Podcasts about lmwh

New! Download the JournalFeed iPhone app!The JournalFeed podcast for the week of March 3-7, 2025.These are summaries from just 2 of the 5 articles we cover every week! For access to more, please visit JournalFeed.org for details about becoming a member.Monday Spoon Feed:Guidelines recommended low molecular weight heparin (LMWH) for most patients with acute pulmonary embolism (PE), but we often choose unfractionated heparin (UFH). Here's why...Friday Spoon Feed:This pre-planned secondary analysis compared OHCA patients who received a single dose of epinephrine to standard ACLS epinephrine dosing and found mixed results in the outcomes of ROSC and survival to hospital discharge. Strap in for this nuanced article summary.

Venous thromboembolism (VTE), which includes deep vein thrombosis and pulmonary embolism, is responsible for 9–30% of pregnancy-related mortality in high resource countries and remains a significant, increasing cause of severe maternal morbidity. Peripartum, 50% of VTE events occur in the postpartum interval, which has a 6-fold higher risk compared to antepartum. There is wide variation in LMWH pharmacological postpartum prophylaxis guidance. The RCOG, for example, recommends 10 days of LMWH for all postop CS patients unless it was elective, and additional risk factors exist. The ACOG uses a more selective approach. However, on Jan 16, 2025, a new multicenter retrospective study from the US is raising questions about the efficacy of postpartum VTE pharmacologic therapy. Is there really no need for pp VTE pharmacologic therapy? Or does the answer lie in the reality of VTE as a “low frequency, high acuity” event? Listen in for details!

Everyone understands that VTE (DVT and/or VTE) requires life-saving anticoagulation. That's simple. No controversy there. But what about pregnancy-associated superficial thrombophlebitis (AKA superficial venous thrombosis) in an extremity? Does that need anticoagulation? We have been traditionally taught that superficial venous issues are benign and do not require LMWH. Is that correct? The answer is NOT as straightforward as you would think. In this episode, we will review the 2018 ASH guidelines and contrast them to the 2022 published consensus statement from the Balkan Working Group. Plus, we will highlight a May 2023 Danish population based study from the Lancet Hematology that reminds us that superficial venous disease is not always benign in its course. Listen in for details,

The SMFM, ACOG and RCOG all recommend screening for Antiphospholipid Antibody Syndrome (APS) in women with Recurrent Pregnancy Loss (RPL). However, once identified, there has been controversy historically regarding the best TIME to initiate low dose aspirin and prophylactic LMWH. The main controversy regarding this is whether to begin treatment before a confirmed pregnancy, right after a positive pregnancy test, or only after an ultrasound confirms a viable fetus; with some studies suggesting potential benefits from starting earlier, while others debate the optimal timing due to lack of conclusive evidence and potential risks associated with early anticoagulation. Nonetheless, we DO HAVE current guidance here to make an evidence-based plan of care for these patients. In this episode, we will summarize a recent Clinical Expert Series from the ACOG (May 2024) and the RCOG (June 2023). PLUS, we will highlight some persistent controversies surrounding APS and RPL.

Haemodialysis (HD) requires safe and effective anticoagulation to prevent clot formation within the extracorporeal circuit during dialysis treatments to enable adequate dialysis and minimise adverse events, including major bleeding. Low molecular weight heparin (LMWH) may provide a more predictable dose, reliable anticoagulant effects and be simpler to administer than unfractionated heparin (UFH) for HD anticoagulation, but may accumulate in the kidneys and lead to bleeding. in this latest episode fo the podcast Edmund Chung, Knowledge and Information Decimation Editor of the Cochrane Kidney Transplant Group. Edmund is Joined by the lead author on this article Patricia Natale Sydney School of Public Health, The University of Sydney. 

The JournalFeed podcast for the week of July 29 – August 2, 2024.These are summaries from just 2 of the 5 articles we cover every week! For access to more, please visit JournalFeed.org for details about becoming a member.Thursday Spoon Feed:This retrospective study found increased use of unfractionated heparin (UFH) relative to low-molecular weight heparin (LMWH) and direct oral anticoagulants (DOACs) over time, despite guidelines recommending LMWH or DOACs as first-line treatment for most patients with acute pulmonary embolism (PE).Friday Spoon Feed:Anticoagulation is the cornerstone of managing acute pulmonary embolism (PE), but initial management strategies in the intensive care unit (ICU) for sicker patients* with acute PE lack consensus guidelines. This reviews the available evidence and provides guidance.

Trial of the Week: UFH v. LMWH for Trauma VTE Prophylaxis Special Guest: Brandon Hobbs, PharmD, BCPS, BCCCP, FCCM Brandon Hobbs joins to discuss the landmark article “A comparison of low-dose heparin with low-molecular-weight heparin as prophylaxis against venous thromboembolism after major trauma” published in the New England Journal of Medicine.  We review the history of VTE prophylaxis in trauma, what this study ultimately found, how long did it impact practice, what regimen is guideline-recommended today, practices from other centers across the country, and much, more. Reference list: https://pharmacytodose.files.wordpress.com/2023/09/vte-ppx-tow-references.pdf PharmacyToDose.Com  @PharmacyToDose  PharmacyToDose@Gmail.com Learn more about your ad choices. Visit megaphone.fm/adchoices

2:38  Labiotech news4:23  APSFA20:59 University of MichiganJune is Antiphospholipid Syndrome (APS) Awareness Month. APS is a rare autoimmune disorder in which the body recognizes certain normal components of blood and/or cell membranes as foreign substances and produces antibodies against them. There are two known forms. APS may occur in people with systemic lupus erythematosus, other autoimmune disease, or in otherwise healthy individuals.APS is also referred to as APLS or APLA in the U.S., and formerly Hughes Syndrome or Sticky Blood in the U.K.On the podcast this week, we spoke with Tina Pohlman, who suffers from APS, and who is president of the APSFA, about the disease and the organization.The APS Foundation of America, Inc. (APSFA) was founded in 2005, and is the only U.S. nonprofit health agency dedicated to bringing national awareness to APS, a major cause of multiple miscarriages, thrombosis, young strokes and heart attacks. The APSFA's Medical Advisory Team includes nationally & internationally recognized experts on Antiphospholipid Syndrome.We also had a conversation with APS researcher Dr Jason Knight, Marvin and Betty Danto Research Professor of Connective Tissue Research and Associate Professor, Division of Rheumatology at the University of Michigan.Current APS trialsThere are currently several clinical trials being undertaken with respect to APS. University Hospital, Clermont-Ferrand, France, is looking to assess the effect of injectable anticoagulants (unfractionated heparin (UFH), low molecular weight heparins (LMWH), fondaparinux, danaparoid, and argatroban) on lupus anticoagulant testing assays over broad anti-Xa activity ranges and to establish their potential for causing false-positive or false-negative results.David Ware Branch, from the University of Utah, is also undertaking a trial with results expected in 2024. The treatment trial is evaluating the addition of an anti-tumor necrosis factor-alpha drug,certolizumab, compared to the usual treatment (a heparin agent and low-dose aspirin) in pregnant women with APS and repeatedly positive tests for lupus anticoagulant (LAC) to determine if this regimen will improve pregnancy outcomes. All enrolled patients will receive certolizumab, and pregnancy outcomes will be compared to those of women with APS and repeatedly positive tests for LAC enrolled in a previous study by the investigators.Another study, in China, also with results anticipated in 2024, is being run by Zhang Lei. The study aims to evaluate the safety and efficacy of zanubrutinib in the treatment of APS with secondary thrombocytopenia in 10 patients.The University of Turin in Italy is sponsoring BLAST (belimumab antiphospholipid syndrome trial), which is expecting to see results in 2025. BLAST aims to evaluate the safety and tolerability of belimumab for up to 24 months in patients with persistent aPL positivity and clinical features attributable to aPL that are resistant to warfarin and/or heparin.

Today we are joined by Dr. Brian Locke, recently graduated pulmonary-critical care fellow, who takes us on a journey of avoiding statistical fallacies. Does metformin reduce the likelihood of long COVID? Should we give platelet transfusions to thrombocytopenic patients before central line placement? Did the CANVAS trial change practice in cancer associated thrombosis? Should patients with a stroke due to atrial fibrillation start oral anticoagulation earlier or later? We discuss all these questions on more on today's episode. Check it out! Metformin for Long COVIDDefinition of Post Acute Sequelae of Sars-CoV-2 InfectionPlatelet Transfusion before CVC Placement in Thrombocytopenia DOACs vs LMWH in Cancer Associated VTEEarly vs Late Anticoagulation for Stroke with AFMusic from Uppbeat (free for Creators!):https://uppbeat.io/t/soundroll/dopeLicense code: NP8HLP5WKGKXFW2R

In this episode of CLOT Conversations we interview Dr Saskia Middeldorp and Dr Hanke Wiegers, authors of the groundbreaking Highlow study. This open-label, multicenter, randomized controlled trial aimed to determine the optimal dose of low-molecular-weight heparin (LMWH) for pregnant and postpartum women with a history of venous thromboembolism (VTE). Discover the study's findings on the incidence of recurrent VTE, major bleeding, and death from any cause between the intermediate-dose (ID) and low-dose (LD) LMWH groups. The results may surprise you and highlight the need for individualized dosing strategies for pregnant and postpartum women to balance the risks and benefits of anticoagulant therapy. Don't miss this fascinating episode!Dr Saskia Middeldorp is Professor of Medicine and Head of the Department of Internal Medicine of the Radboud University Medical Center in Nijmegen, The Netherlands. Prior to her transfer to Nijmegen in January 2021, she has been a professor of Medicine at Amsterdam University Medical Centers for over 10 years, leading the clinical thrombosis and haemostasis research lines of the Department of Vascular Medicine. Since January 2023, Saskia Middeldorp is one of the 4 Research Domain Leaders in the Radboudumc Research Institution for Medical Innovation.Her present research focuses on several aspects of hereditary and acquired thrombophilia, women's issues in thrombosis and haemostasis, and the clinical evaluation of new anticoagulants and antidotes.Dr Hanke Wiegers is an MD, PhD student, at the department of vascular medicine at the Amsterdam UMC, location AMC. In June 2019 she started her PhD trajectory under the supervision of Prof. Dr. S. Middeldorp as supervisor and focuses particularly on women & thrombosis. On the 17th of March 2023 she will defend her PhD thesis entitled: “Progress in prevention and prediction of venous thromboembolism in women – focus on pregnancy and the postpartum period.”  Hanke Wiegers started as a gynecologist in training on the 1st of January 2023 Bistervels, I. M., Buchmüller, A., Wiegers, H. M., Áinle, F. N., Tardy, B., Donnelly, J., ... & Zelis, M. (2022). Intermediate-dose versus low-dose low-molecular-weight heparin in pregnant and post-partum women with a history of venous thromboembolism (Highlow study): an open-label, multicentre, randomised, controlled trial. The Lancet, 400(10365), 1777-1787 Follow us on Twitter:@thrombosiscan@MiddeldorpSSupport the showhttps://thrombosiscanada.caTake a look at our healthcare professional and patient resources, videos and publications on thrombosis from the expert members of Thrombosis Canada

Dr. Robert O'Toole, Professor of Orthopaedic Trauma, Division Head of Orthopaedic Traumatology, Chief of Orthopaedics at the R Adams Cowley Shock Trauma Center, Program Director of the Orthopaedic Traumatology Fellowship Program, Department of Orthopaedics at the University of Maryland Medical Center discusses the recent METRC study comparing aspirin vs LMWH for DVT prophylaxis in ortho […]

1:03 Labiotech.eu news2:34 Knowledge Gate10:59 Janssen Scientific AffairsThis week, our guests are Viktoriya Vasilenko, Knowledge Gate co-founder and CEO; and Avery Ince, vice president, medical affairs, cardiovascular & metabolism at Janssen Scientific Affairs.Study confirms benefit of XARELTO (rivaroxaban) for secondary prevention of venous thromboembolism in cancer patientsThe Janssen Pharmaceutical Companies of Johnson & Johnson has revealed observational data from eight years of clinical practice showing that the oral Factor Xa inhibitor XARELTO (rivaroxaban) is associated with comparable effectiveness and safety to the Factor Xa inhibitor apixaban for the treatment of cancer-associated thromboembolism (CAT) in a broad cohort of patients with various cancer types. Patients with CAT are at a higher risk of venous thromboembolism (VTE), which is the second-leading cause of death in people with cancer.Data from the observational study in cancer-associated thrombosis for rivaroxaban (OSCAR) found XARELTO showed non-inferiority for the composite outcome of recurrent VTE or any bleeding resulting in hospitalization for treatment of patients with CAT. Janssen said the study adds to the evidence for XARELTO, with more than 300,000 patients having been evaluated since its initial approval in the U.S. in 2011.VTE occurs when a blood clot forms in a vein, affecting between 300,000 to 600,000 Americans each year, commonly triggered by surgery, cancer, immobilization and hospitalization. VTE is a common cause of morbidity and mortality, and people with cancer are at a higher risk for developing VTE than people without cancer.Cancer is known to increase the risk of VTE, with cancer patients having a four to seven times increased risk of developing VTE. These patients also have a higher risk of recurrent VTE and of bleeding.Previous studies such as SELECT-D and CONKO-11 demonstrated that changing from a low molecular weight heparin (LMWH) to XARELTO was associated with a reduction in risk of recurrent thrombosis and improved patient satisfaction.Knowledge GateKnowledge Gate Group provides a key opinion leader online platform. Based in Copenhagen, Denmark, the company bridges the gap between businesses and life science experts. The artificial intelligence platform connects those looking to innovate with the key opinion leaders who can provide valuable insights. It covers a broad range of therapy area experts in the life sciences, and features automated management of all contractual, compliance and confidentiality requirements.SponsorInterested in sponsoring one or more episodes of the podcast? Learn more here!Leave a review on Apple podcastsReviews are hugely important because they help new people discover this podcast. If you enjoyed listening to this episode, we would love to hear your feedback!Connect with uslabiotech.euSubscribe to our newsletter

In this episode have a conversation with Dr Michelle Sholzberg on her recent publication from the British Medical Journal entitled Effectiveness of therapeutic heparin versus prophylactic heparin on death, mechanical ventilation, or intensive care unit admission in moderately ill patients with covid-19 admitted to hospital: RAPID randomised clinical trial (BMJ 2021; 375 doi: https://doi.org/10.1136/bmj.n2400) which was co-authored by an international team on behalf of the RAPID trial investigators.Dr. Sholzberg received her MDCM and residency training in Internal Medicine at McGill University, completed additional postgraduate training in Hematology at the University of Toronto and a research hemostasis fellowship in Toronto and internationally. Dr. Sholzberg has a Master of Science from the University of Toronto in Clinical Epidemiology and Health Care Research and was awarded the Claire Bombardier award for career promise as a scientist. She is a clinician-investigator with a focus on coagulation, the Division Head of Hematology-Oncology and the Medical Director of the Coagulation Laboratory at St. Michael's Hospital. She is also the Director of the Hematology-Oncology Clinical Research Group and Co-director of the Hematology-Immunology Translational Research Theme of the Li Ka Shing Knowledge Institute. Dr. Sholzberg is the associate editor for illustrated materials at Research and Practice in Thrombosis and Haemostasis. Currently, she is involved in the study of: prediction tools for perioperative and traumatic bleeding, the intersection of women's health and bleeding disorders, treatments for iron deficiency anemia, new treatments for immune thrombocytopenia and the management of COVID-19 coagulopathy. Follow us on Twitter:Dr Michelle Sholzberg: @sholzbergThrombosis Canada: @ThrombosisCan Reference:Sholzberg M, Tang GH, Rahhal H, AlHamzah M, Kreuziger LB, Áinle FN, Alomran F, Alayed K, Alsheef M, AlSumait F, Pompilio CE. Effectiveness of therapeutic heparin versus prophylactic heparin on death, mechanical ventilation, or intensive care unit admission in moderately ill patients with covid-19 admitted to hospital: RAPID randomised clinical trial. BMJ. 2021 Oct 14;375.  Support the showhttps://thrombosiscanada.caTake a look at our healthcare professional and patient resources, videos and publications on thrombosis from the expert members of Thrombosis Canada

A grab bag of stuff gleaned from the DHM crew @ SHM in Nashville. All sources in this episode can be found in the April 2022 CKC dispatch e-mail dated 4/19/2022. | 00:00 Intro | | 00:39 TOC | | 01:27 HFrEF management | | 02:42 AC monotherapy in stable CAD+Afib | | 03:28 Upper GI bleed management | | 04:15 ID updates (GNR Bacteremia and MRSA) | | 05:22 Ascites, SBP, HRS in Cirrhosis | | 06:23 Post-op complications in elective surgery done peri-COVID | | 07:00 Peri-op LMWH bridging | | 08:03 Midodrine and vasovagal syncope | | 09:05 Closing | [The appearance of external hyperlinks does not constitute endorsements by UCSF of the linked websites, or the information, products, or services contained therein. UCSF does not exercise any editorial control over the information found therein, nor does UCSF make any representation of their accuracy or completeness.]

In this episode we are joined by Dr Vicky Tagalakis and Dr Marc Carrier, two of the authors of a recently published review paper entitled Treatment Algorithm in Cancer-Associated Thrombosis: Updated Canadian Expert Consensus. The paper was published in Current Oncology (Curr. Oncol. 2021, 28, 5434–5451. https://www.mdpi.com/1718-7729/28/6/453). The authors speak about why this update was undertaken and discuss many of the challenging scenarios encountered with this patient group and the recommendations for managing them. Join us for this insightful discussion that can help you in managing patients with cancer at risk of thrombosis.Dr. Vicky Tagalakis, is an Associate Professor of Medicine at McGill University and an attending in the Department of Medicine of the Jewish General Hospital. She is Director of the Division of General Internal Medicine at McGill University. She is a Research Scientist in the Centre of Epidemiology and Community of Studies, Lady Davis Institute for Medical Research, Jewish General Hospital. She holds several peer-reviewed grants. She is Co-Lead of the Quality Improvement Platform of CanVECTOR), a CIHR funded national research network on venous thromboembolism (VTE).Dr. Marc Carrier, is the Head of the Division of Hematology at The Ottawa Hospital, a Professor in the Faculty of Medicine, Department of Medicine and Senior Scientist in the Clinical Epidemiology Program of The Ottawa Hospital Research Institute. He holds a Tier 1 Research Chair in Venous Thromboembolism and Cancer from the Faculty of Medicine at the University of Ottawa. Dr. Carrier is also president of Thrombosis Canada.Related Thrombosis Canada resources:Downloadable PDF Algorithm: https://thrombosiscanada.ca/cat-treatment-algorithm-2021/DOAC Drug-Drug-Interaction tool: Download HereThrombosis Canada Cancer-associated Thrombosis (CAT) Clinical Guide: Download HereThrombosis Canada Clinical Guides: Visit HereFor other relevant resources, education programs and patient materials visit https://thrombosiscanada.caSupport the showhttps://thrombosiscanada.caTake a look at our healthcare professional and patient resources, videos and publications on thrombosis from the expert members of Thrombosis Canada

Pregnancy is a hypercoagulable state associated with increased risk of thromboembolism. Managing anticoagulation during pregnancy has implications for both the mother and the fetus. CardioNerd Amit Goyal joins Dr. Akanksha Agrawal (Cardiology Fellow at Emory University), Dr. Natalie Stokes (Cardiology Fellow at UPMC and Co-Chair of the Cardionerds Cardio-Ob series), and Dr. Katie Berlacher (Program Director of the Cardiovascular Disease Fellowship and Director of the Women's Heart Program at UPMC) as they discuss the common indications for anticoagulation and their management before, during, and after pregnancy. In this episode, we focus on management of pregnant patients with mechanical valves and venous thromboembolism. Audio editing by CardioNerds Academy Intern, Dr. Maryam Barkhordarian. Pearls • Notes • References • Guest Profiles • Production Team CardioNerds Cardio-Obstetrics Series PageCardioNerds Episode PageCardioNerds AcademyCardionerds Healy Honor Roll CardioNerds Journal ClubSubscribe to The Heartbeat Newsletter!Check out CardioNerds SWAG!Become a CardioNerds Patron! Pearls- Pregnancy and Anticoagulation Pregnancy is a hypercoagulable state. Pregnancy-associated VTE is a leading cause of maternal morbidity and mortality.The use of anticoagulation requires a balance between the risks and benefits to the mother and her fetus.The agent of choice for anticoagulation during pregnancy depends on the indication, pre-pregnancy dose of vitamin K antagonist (VKA), and the trimester of pregnancy. For instance, patients with mechanical heart valves, warfarin is generally recommended in the first trimester if the daily dose is less than 5 mg and as the first option for all patients with mechanical valves in the 2nd and 3rd trimester. Use of direct oral anticoagulants (DOACs) has not been systematically studied, they do cross the placenta and their safety remains untested.Warfarin crosses the placenta but is not found in breast milk. LMWH does not cross the placenta and is not found in breast milk. Thus, both these agents can be used by a lactating mother. Quatables - Pregnancy and Anticoagulation “[We] can't highlight enough that good communication and documentation is vital in such situations” says Dr. Berlacher while discussing the role of a multidisciplinary team including cardiologists, obstetricians and fetal medicine physicians in taking care of a pregnant patient on anticoagulation. “What I love about cardio-obstetrics is that we really can help women in a time that is so important in their life…this is one of the most memorable times in their life..” says Dr. Berlacher when asked what makes your heart flutter about cardio-obstetrics. “Knowledge is power...not just for providers, but also for the patients” says Dr. Berlacher emphasizing the importance of clear communication between physicians and patients. Show notes - Pregnancy and Anticoagulation 1. What makes pregnancy a hypercoagulable state? Pregnancy is a hypercoagulable state associated with higher risk of thromboembolic phenomenon. The three components of Virchow's triad: hypercoagulability, stasis, and endothelial injury are all present during pregnancy. This leads to a 5-fold increased risk of venous thromboembolism (VTE) during pregnancy that persists for 12 weeks postpartum. The risk for VTE seems to be highest in the first 6 weeks postpartum, with a higher prevalence of clot in the left lower extremity.There are additional risk factors for developing VTE in the postpartum period besides pregnancy itself, and this includes but is not limited to preeclampsia, emergent c-section, hypertension, smoking, and postpartum infection.Choosing anticoagulant therapies during pregnancy involves a fine balance between the risks and benefits to both the mother and fetus. A multidisciplinary team involving the obstetrician, cardiologist, and maternal-fetal medicine team is critical to guide anticoagulation in pregnanc...

Ever wonder why some bariatric patients received extended VTE prophylaxis and others do not? Or what the ideal chemical VTE prophylaxis is for bariatric patients? All of your questions answered in this journal review discussion! Journal articles: A single-center comparison of extended and restricted thromboprophylaxis with LMWH after metabolic surgery: https://pubmed.ncbi.nlm.nih.gov/31641983/ Risk factors for postdischarge venous thromboembolism among bariatric surgery patients and the evolving approach to extended thromboprophylaxis with enoxaparin: https://pubmed.ncbi.nlm.nih.gov/33814315/

In this episode, we discuss the recently published major updates in the 9th edition of the anticoagulation guidelines from CHEST. These new recommendations range from initiation of therapy, secondary prevention, and management of post-thrombotic syndrome. Key Concepts Among patients with cancer-associated VTE, DOACs are preferred over low molecular weight heparins (LMWH) EXCEPT in patients with GI cancers. The preferred anticoagulant in those with GI cancers is either LMWH or apixaban. Among patients with antiphospholipid antibody syndrome, warfarin (INR goal 2-3) is preferred over DOAC therapy. In the extended phase of treatment (secondary prevention after 3 months of treatment), lower anticoagulant doses should be used (such as apixaban 2.5 mg BID or rivaroxaban 10 mg daily). In patients with a DVT, IVC filters should only be used when anticoagulation therapy is contraindicated. IVC filters reduce the risk of PE but do not alter the risk of DVT extension or future DVTs. Compression stockings are not recommended for prevention of post-thrombotic syndrome nor for recurrent DVT prevention.

In this episode we get together with Dr. Tess Fitzpatrick @TessFitzNeuro (first author on a recent paper on this topic: Quality of anticoagulation using intravenous unfractionated heparin for cerebrovascular indications) and Dr. Katherine Sawicka @KatherineSawic1 (our resident guru in Clinical Epidemiology and lover of all things research methods) to discuss challenges with anticoagulation using unfractionated heparin infusions. This is not to be confused with the fact that this agent provides a very good modality to providing anticoagulation and has very specific uses, but in the real world setting, IV infusion of this agent causes issues with the quality of anticoagulation achieved. We discuss how there may be better alternatives specifically low molecular weight heparin (LMWH) when it comes to use cases in stroke. Anticoagulating a patient with acute stroke is always a challenging topic, and there are nuances to be considered, to reduce the risk of hemorrhage, and therefore we looked back at the use of unfractionated heparin infusion in stroke and talk about how some considerations are very important to keep in mind. As usual - please note our disclaimer.

Expert: Stephan Rauh, Hospital Center Emile Mayrisch, Esch-sur-Alzette, Luxembourg Questions: 1- What would be your approach to patients for whom anticoagulation is of uncertain benefit, for example with active malignant disease in pelvis creating continuous venous compression and conditions for recurrent or progressive thrombosis? 2- In a cancer patient with creatinine clearance bellow 30 mcmol/ l what would be your anticoagulant of choice for the treatment of a tromboembolic event (DVT/PE)? 3- In a patient with a chemotherapy- induced trombocytopenia bellow 50 x 10^9/l and active PE what would be your choice of LMWH? 4- Due to Covid pandemic there is a shortage of LMWHs in our country. If LMWHs were unavailable, what would be your first choice of alternative anticoagulant for the prophylaxis or treatment of thromboembolic events in cancer patients? 5- In a premenopausal women diagnosed with estrogen receptor positive high risk early breast cancer (node positive with more than 4 involved lymph nodes) with a high risk for thromboembolic events (history of thrombophilia) who opt for a pregnancy and do not tolerate LHRH analogs in combination with aromatase inhibitors? Would tamoxifen be an option with or w/o anticoagulant prophylaxis?

Valeo Pharma is already a successful, revenue generating, small cap Canadian pharmaceutical company that acquires the Canadian rights to commercialized drugs in other parts of the world that don't have Canada on their radar as a target market. This "in-license" business model is ingenious because it means ZERO developmental or clinical risk, which is the downfall of most small cap pharma companies. This model has resulted in the following success: 2020 net revenues of $7.5 million 2021 is expected to double to $15 million Commercializing Novartis Asthma Therapies In Canada Closed $6.6 Million Financing With Insiders Taking ~ 40% If that was all Valeo had, most investors would be happy to sit back and watch the Company grow. But then came Redesca. We are going to save you the science and tell you that Redesca belongs to a class of anticoagulant medications (blood thinners) called LMWH. The size of the Canadian LMWH market is over $200M per year and Valeo believes they can capture 15-20% of this market. If you're doing back of napkin math, that equates to $30,000,000 - $40,000,000 per year in revenues. But how does a new product capture that much market share? Glad you asked because we asked CEO Steve Saviuk the same question. Competition is tough in all markets and they don't let someone take 15-20% market share without one hell of a fight. Saviuk agreed and gave the following 3 reasons: 1. Redesca has an 8-year international track record of safety and efficacy. It is already well known 2. Redesca is flat out cheaper, which is music to the ears of Provincial Health Ministries whose budgets have been stretched to the max this year no thanks to COVID-19. Vaelo is so confident that it stated "This is great news for the Canadian healthcare system .... and is expected to help provide significant savings to provincial healthcare systems." More than just lip service, $VPH just announced that Redesca is now listed on the Ontario Public Drug Program, which means the government will cover its costs for all public use. Moreover, $VPH expects additional Provinces to follow. If you love revenue generating, growing and blue sky potential small cap companies, then this Valeo interview is a must watch.

Time for round 2 with Pat are very generous trainee who's offered to be quizzed on our podcast.Here are the questions from this round:Stem 51.     How does heparin work?2.     How about low molecular weight heparin?3.     Why do we monitor unfractionated heparin but not low molecular weight heparin? Due to lower binding to plasma proteins and to cell surfaces, the plasma anti Xa activity generated by a given dose of LMWH is more predictable than for UH. 4.     How do we monitor unfractionated heparin's effect?5.     How is the clearance of unfractionated heparin different to that of low molecular weight heparin? Stem 61.     What are the main differences between intracellular and extracellular ion concentrations?2.     What is the function of potassium?3.     What is the NERST potential?4.     What are the ECG changes in hyperkalaemia?5.     What is the treatment for hyperkalaemia? Stem 71.     What are the functions of the placenta?2.     How is the placenta different to the lung?3.     How are substances transferred across the placenta?4.     What are the factors that affect transfer of O2 across the placenta?5.     What are the factors that affect placental blood flow? Stem 81.     During anaesthesia, you notice a difference between the End Tidal CO2 and Arterial CO2. What can you do to minimise this difference?2.     How do you measure physiological dead space?3.     How do you measure anatomical dead space?4.     What increases anatomical dead space?5.     What is closing capacity? Please rate, post a review and subscribe!Check out https://anaesthesiacollective.com/education/first-part-exam/ for general information and a collection of model answersand sign up to the ABCs of Anaesthesia facebook group https://www.facebook.com/groups/2082807131964430and check out the ABCs of Anaesthesia YouTube channel for more contenthttps://www.youtube.com/c/ABCsofAnaesthesiaIf you have any questions, please email Lahiruandstan@gmail.com  Disclaimer:The information contained in this podcast is for medical practitioner education only. It is not and will not be relevant for the general public.This contains general information about medical conditions and treatments. The information is not advice and should not be treated as such. The medical information is provided “as is” without any representations or warranties, express or implied. The presenter makes no representations or warranties in relation to the medical information on this episode. You must not rely on the information as an alternative to assessing and managing your patient with your treating team and consultant.You should seek your own advice from your medical practitioner in relation to any of the topics discussed in this episode'Medical information can change rapidly, and the author/s make all reasonable attempts to provide accurate information at the time of filming. There is no guarantee that the information will be accurate at the time of viewingThe information presented here does not represent the views of any hospital or ANZCA.These podcasts are solely for training and education of medical practitioners, and are not an advertisement. They were not sponsored and offer no discounts, gifts or other inducements. 

In questo podcast si parla dei tempi da rispettare tra la sospensione dei principali farmaci Anticoagulanti, Antiaggreganti e Fibrinolitici e le tecniche di Anestesia Neuroassiale (Anestesia Subaracnoidea o spinale, peridurale, combinata). I tempi di sospensione sono tratti dagli Special Article del 2018: Interventional Spine and Pain Procedures in Patients onAntiplatelet and Anticoagulant Medications (Second Edition)Guidelines From the American Society of Regional Anesthesia and Pain Medicine, the European Society of Regional Anaesthesia and Pain Therapy, the American Academy of Pain Medicine, the International Neuromodulation Society, the North American Neuromodulation Society, and theWorld Institute of Pain (Reg Anesth Pain Med 2018;43: 225–262)Regional Anesthesia in the Patient ReceivingAntithrombotic or Thrombolytic TherapyAmerican Society of Regional Anesthesia and Pain Medicine Evidence-Based Guidelines (Fourth Edition) (Reg Anesth Pain Med 2018;43: 263–309)I farmaci trattati sono: coumadin, acenocumarolo, eparina non frazionata, eparine a basso peso molecolare, fondaparinux, rivaroxaban, apixaban, edoxaban, dabigatran, eptifibatide e tirofiban, abciximab, clopidogrel, prasugrel, ticagrelor, , cangrelor, ticlopidina, desirudina e bivalirudina, aspirina e i fibrinolitici alteplase e tenecteplase.Questo video costituisce solo uno strumento di studio e di ripasso di un argomento molto mnemonico. Non esaurisce l'argomento. NON SOSTITUISCE IL PARERE DI UN MEDICO. È dedicato a tutti gli Specializzandi di Anestesia, Rianimazione, Terapia Intensiva e del Dolore.

In today's episode we discuss: —Adjusting Practice During COVID-19: A team of cardiologists and pharmacists from hospitals in Shanghai and Wuhan, China assessed the association between mortality in hospitalized COVID-19 patients (n=535) and low molecular weight heparin (LMWH) use between January 26-March 26, 2020. They found overall adjusted odds ratio for mortality was lower in the LMWH-users vs non-users (0.20; 95% CI, 0.09-0.46), specifically in severe (0.08; 95% CI, 0.01–0.62) and critically ill cases (0.32; 95% CI ,0.10–0.996). Authors suggest LMWH appears correlated with a survival benefit in hospitalized COVID-19 patients, especially those severely and critically ill. --- Support this podcast: https://anchor.fm/covid19lst/support

Today I do a quick review of the COVID-19 thrombosis literature from the last year to try to answer some of the following questions: Why does COVID-19 cause thrombosis? How many patients with COVID-19 develop thrombotic complications? Why do patients with COVID-19 on VTE prophylaxis still develop blood clots? Should we use intermediate dosing of anticoagulation for prophylaxis? What about full dose therapeutic anticoagulation (no!) What do the guidelines say? Lots of papers:JAMA IM Review Autopsy Findings and VTE in Patients with COVID-19Klok et al Helms et alShah et alPiazza et alPorfidia et alKunutsor et alDutt et alStessel et alParanjpe et alFraisse et alMusoke et alPatel et alISTH GuidelinesACCP GuidelinesTake home points:COVID-19 is associated with an elevated risk of thrombosis. Observational data suggests that ICU patients are likely to develop thrombotic complications even on standard VTE prophylaxis. This number seems to be round 25%. Ward patients are also at higher risk (around 8-9%). Critically ill patients commonly develop heparin resistance, and this may partially explain why some patients with COVID develop thrombotic complications despite prophylaxis. Some have suggested intermediate dosing of anticoagulation for prophylaxis, but there are no randomized controlled trials published at this time, and observational data are limited. Some have suggested therapeutic dosing of anticoagulation for critically ill patients, but observational data show high rates of bleeding and other complications, and the three largest randomized controlled trials have stopped enrolling critically ill patients into the therapeutic anticoagulation arm due to safety concerns and futility. Some have suggested targeting a certain anti-Xa activity level, but no one really knows what that should be, and there aren’t any guidelines recommending it. ISTH and ACCP have both put out guidelines which are overall pretty similar.Make sure your patient has VTE prophylaxis, preferably a LMWH, and keep an eye out for thrombotic complications so you can treat them in a timely manner. Music from https://filmmusic.io"Sneaky Snitch" by Kevin MacLeod (https://incompetech.com)License: CC BY (http://creativecommons.org/licenses/by/4.0/)

Valeo Pharma is already a successful, revenue generating, small cap Canadian pharmaceutical company that acquires the Canadian rights to commercialized drugs in other parts of the world that don’t have Canada on their radar as a target market. This “in-license” business model is ingenious because it means ZERO developmental or clinical risk, which is the downfall of most small cap pharma companies. This model has resulted in the following success: $5.3M in revenues in the first 9 months of 2020 (ending July 31, 2020) 9 products currently in the market with an annual estimated peak sales of $40M/year 7 products in the pipeline with an annual estimated peak sales of $45M/year In fact, capital markets confidence is so high that Valeo secured $8.6M in financing in the last half of the year with: $6.9M Bought Deal financing at $1.20/shares A $1.7M Oversubscribed debenture (non-convertible) If that was all Valeo had, most investors would be happy to sit back and watch the Company grow. But then came Redesca. We are going to save you the science and tell you that Redesca belongs to a class of anticoagulant medications (blood thinners) called LMWH. The size of the Canadian LMWH market is over $200M per year and Valeo believes they can capture 15-30% of this market. If you’re doing back of napkin math, that equates to $30,000,000 – $60,000,000 per year in revenues. But how does a new product capture that much market share? Glad you asked because we asked CEO Steve Saviuk the same question. Competition is tough in all markets and they don’t let someone take 15-30% market share without one hell of a fight. Saviuk agreed and gave the following 3 reasons: 1. Redesca has an 8-year international track record of safety and efficacy. It is already well known 2. Redesca is flat out cheaper, which is music to the ears of Provincial Health Ministries whose budgets have been stretched to the max this year no thanks to COVID-19. Vaelo is so confident that it stated “This is great news for the Canadian healthcare system …. and is expected to help provide significant savings to provincial healthcare systems.” Well there you have it. Valeo is a great story. Watch the video. HOLD ON. THERE’S MORE … A LOT MORE In addition to being used primarily for treating and preventing deep vein thrombosis and pulmonary embolism, LMWH are also now increasingly used as a first line of defense tool in the fight against Covid-19. The World Health Organization’s (“WHO”) issued guidance regarding the prophylaxis use of LMWH to help prevent complications in the clinical management of severe acute respiratory infections when COVID-19 infection is suspected. The Canadian market for LMWH was already at a healthy $200M + per year when Valeo started down the Redesca path 4 years ago. Now it gets the added kicker of Redesca being a first line of defense to fight COVID-19. Now you have it. That’s the Valeo story as it applies to Redesca. There is a whole lot more to the story given their pipeline of products but we couldn’t cover it all in this great interview with CEO Steve Saviuk. If you love revenue generating, growing and blue sky potential small cap companies, then this Valeo interview is a must watch.

The Landmarks in OncoPharm series returns to discuss the practice-changing CLOT trial of a LMWH vs. a vitamin K antatogist for treating cancer-associated VTE. CLOT: https://www.nejm.org/doi/full/10.1056/nejmoa025313

Episode 25: Autism [Music to start: Grieg’s Morning Mood (https://www.youtube.com/watch?v=-rh8gMvzPw0) The sun rises over the San Joaquin Valley, California, today is August 28, 2020. The Journal of the American Board of Family Medicine recently published the characteristics of primary care physicians (PCPs) associated with prescribing potentially inappropriate medication (PIM) for elderly patients. Medicare data from more than 100,000 PCPs was analyzed. The sample included specialists in family medicine, internal medicine, geriatrics and general practice. PCPs more likely to prescribe PIMs were on average older, male, DO, practicing in the South, and have a smaller Medicare patient panel. The study also found that PIM rates have been decreasing over time (1). So, don’t forget to review your Beers Criteria (2) when prescribing meds to your elderly patients. Cancer and VTE normally means low molecular weight heparin, LMWH aka Lovenox®, right? But direct oral anticoagulants (DOACs) are being used more frequently in patients with acute venous thromboembolism (VTE) and active cancer. Studies comparing their safety and efficacy with LMWH are limited. In a recent, randomized trial of 1170 patients with cancer and VTE, the DOAC apixaban resulted in similar rates of recurrent VTE when compared with the LMWH dalteparin (Fragmin®) (5.6 versus 7.9 percent) without any impact on major bleeding events. Apixaban is now considered a suitable alternative to LMWH for treatment of VTE in patients with active cancer (3). So, good point for Eliquis®.  [Music mixes with country Chris Haugen - Cattleshire - Country & Folk https://www.youtube.com/watch?v=WiYqHkH4Tnc&list=PLYo1YtVKirP-LAZ3AjpIiJNW9KIe1MJLw&index=7]Welcome to Rio Bravo qWeek, the podcast of the Rio Bravo Family Medicine Residency Program, recorded weekly from Bakersfield, California, the land where growing is happening everywhere.The Rio Bravo Family Medicine Residency Program trains residents and students to prevent illnesses and bring health and hope to our community. Our mission: To Seek, Teach and Serve. Sponsored by Clinica Sierra Vista, Providing compassionate and affordable care to patients throughout Kern and Fresno counties since 1971. [Music continues and fades…] ____________________________[MUSIC]“By three methods we may learn wisdom: First, by reflection, which is noblest; Second, by imitation, which is easiest; and third by experience, which is the bitterest.” –Confucius Spanish refrains don’t make sense, but here I have one to see if it makes sense: “Nobody learns on someone else’s brain”. It means, you learn better by experience. Dear residents, how do you want to learn wisdom? By reflection, by imitation or by experience?  Question number 1: Who are you?  This is Steven Saito. I am a former Navy doctor, having spent 6.5 years in the service primarily working out of a branch clinic having taken on a variety of additional duties including prior department head and senior medical officer. I am also a recent graduate from RBFM and have come back as faculty Tag line: I’m here to give you your weekly suppository of information. Relax and let it in.  Question number 2: What did you learn this week?  What I actually encountered was a need for follow up from podcast #9 vaccine hesitancy.  There were follow on questions for autisms and what we can be doing as primary care providers. I’m going to start with some basics of autism. Diagnostic Criteria The current DSM criteria states that a child must have persistent deficits in 3 areas of social communication/interaction and at least 2 of 4 types of restricted/repetitive behaviors.  It’s important to understand these criteria as not every child who has difficulty with eye contact falls on the spectrum. A: Areas of social communication and interactionDeficits in social-emotional reciprocity, ranging, for example, from abnormal social approach and failure of normal back-and-forth conversation; to reduced sharing of interests, emotions, or affect; to failure to initiate or respond to social interactions.Deficits in nonverbal communicative behaviors used for social interaction, ranging, for example, from poorly integrated verbal and nonverbal communication; to abnormalities in eye contact and body language or deficits in understanding and use of gestures; to a total lack of facial expressions and nonverbal communication.Deficits in developing, maintaining, and understand relationships, ranging, for example, from difficulties adjusting behavior to suit various social contexts; to difficulties in sharing imaginative play or in making friends; to absence of interest in peers.B: Restricted, repetitive patterns of behavior, interests, or activities, as manifested by at least two of the following, currently or by history (examples are illustrative, not exhaustive; see text):Stereotyped or repetitive motor movements, use of objects, or speech (e.g., simple motor stereotypes, lining up toys or flipping objects, echolalia, idiosyncratic phrases).Insistence on sameness, inflexible adherence to routines, or ritualized patterns of verbal or nonverbal behavior (e.g., extreme distress at small changes, difficulties with transitions, rigid thinking patterns, greeting rituals, need to take same route or eat same food every day).Highly restricted, fixated interests that are abnormal in intensity or focus (e.g., strong attachment to or preoccupation with unusual objects, excessively circumscribed or perseverative interests).Hyper- or hyporeactivity to sensory input or unusual interest in sensory aspects of the environment (e.g. apparent indifference to pain/temperature, adverse response to specific sounds or textures, excessive smelling or touching of objects, visual fascination with lights or movement).C: Symptoms must be present in the early developmental period (but may not become fully manifest until social demands exceed limited capacities, or may be masked by learned strategies in later life).D: Symptoms cause clinically significant impairment in social, occupational, or other important areas of current functioning.E: These disturbances are not better explained by intellectual disability (intellectual developmental disorder) or global developmental delay. Intellectual disability and autism spectrum disorder frequently co-occur; to make comorbid diagnoses of autism spectrum disorder and intellectual disability, social communication should be below that expected for general developmental level.Hey. Hey you.  The poor resident and or medical student that just sat through a bunch of raw criteria.  I’m sorry. A real quick aside, we have already covered some of the basics of epidemiology in a prior podcast (that’s Podcast #9 which dealt with vaccine hesitancy) Let me expand that discussion a little bit, we know that boys are about 4x as likely as girls to have it, there does seem to be a genetic component as noted in twin studies.  As far as impact it falls somewhere around 1 in 40 and 1 in 500 people.  There may be environmental factors that act as a second hit, but again see our prior podcast- studies have shown time and again no significant correlation between vaccines and autism.    There are some things which have been shown to cause a greater relative risk such as older parents, chromosomal abnormalities (such as fragile X), and certain medications taken during the prenatal period (such as valproic acid)Symptoms can present prior to 18 months, but they are most typically fully noted at 18 to 24 months when symptoms exceed the capacities of the patient. Let’s talk about something that you might need to wake up for.  Wake up. Wake up. Wake up.  The role of Primary Care is not necessarily to make the diagnosis.  Comprehensive evaluation by appropriate tools is still best left to specialists who are well trained in the field.  Most commonly developmental pediatricians, pediatric psychologist/psychiatrists, or pediatric neurologist.  However, it is very important that we recognize the signs and symptoms of autism and that we perform appropriate screening.   So, what constitutes appropriate screening? For children who appear neurotypical in whom parents are not concerned, routine screening should be implemented at ages 18 and 24 months using any of the standardized tools. The M-CHAT R/ F is validated as a first tier screening.  It is available in multiple languages through their official website.  Importantly for the primary care provider it can be completed in under 5 minutes and at least for the initial questionnaire can be completed by the parent before the visit eg either in the waiting room if given while awaiting or if the appropriate underlying electronic health record / email service is in place, the questionnaire can be given online prior to the visit.  For F component of the M-CHAT R/F is a structured set of follow up questions that should be done prior to referral.  For example, the first question: “If you point at something across the room, does (your child) look at it?”    Prompts the question, what does your child typically do?  There is a list of 7 items that are typical examples.  A child might still pass for example if he were to point at the object.  A greater concern might be when the child ignores the parent or looks at the finger instead of the object. Please note that there are other standardized questionnaires for example the Autism Spectrum Screening Questionnaire.  Most still require additional studies or are potentially better at finding other issues (such as general intellectual disability)  Resources for parentsIf the child is less than 3 years old, the Early Childhood Technical Assistance Center may be of use (especially if I am talking to people outside of my local jurisdiction)  Their website located at ectacenter.org has a contact list for coordinators that may be connect parents with services.Locally, we have the Kern Regional Center    For those 3 and older, you can contact the local public school system even for those not currently enrolled in school.For those of us in California, the Lanterman Act is very important.  The Lanterman act is the California law that gives people with developmental disabilities the right to the services and supports they need to live a more independent and normal life.  In particular, your patient may be eligible for Medi-Cal even if they might otherwise not be eligible, and they may be entitled top additional services.  Furthermore, it allows them to access for additional services through the Regional Center.  As an example, their diagnosis may entitle the family to Respite services. Now that we have identified the patient with autism, what are some of the ways that we can improve their care in our primary care.First remember that these children still need routine primary care preventive services and screening.  Anticipatory guidance may need to adapted to include some additional safety recommendations for example discussing elopement  Those with autism may have some difficulty with change, and so unfamiliar settings eg things that are not done everyday and per routine, may be more difficult.  If the patient is already in ABA therapy they may already be getting social stories or a visual board to orient the child as to expectations.  Allow additional time if possible (or manipulate your schedule to have easier / shorter appointments adjacent to this visit) to give more time to allow the patient to adapt.     Question number 3: Why is that knowledge important for you and your patients?   Question number 4: How did you get that knowledge? (learning habits)  As a general rule, I refer to multiple online sources like UpToDate to read articles and get suggestions for primary source citation. eg check the bibliography from UTD to see there sources and see if you agree with their evidence for your evidence-based medicine and primary sources.   However, for this talk I wanted to get some additional sources to discuss.  My usual go to locations for additional broad information is to first start with important medical institutions including the Center for Disease Control, World Health Organization, and AAFP. Question number 5: Where did that knowledge come from? (cite source)  I used a variety of references.  Primarily I used  UpToDate, but I also used the DSM, as well as information from the Center for Disease Control and the World Health Organization Rights Under the Lanterman Act https://www.disabilityrightsca.org/publications/rula-rights-under-the-lanterman-act-complete-manual Date of access 8/18/2020 Caldwell, Nicole. Going to the Doctor http://www.positivelyautism.com/downloads/DoctorVisit_Story.pdf “Autism” Center for Disease Control, https://www.cdc.gov/ncbddd/autism/index.html  Date of access 8/18/2020American Psychiatric Association. Autism spectrum disorder. In: Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, American Psychiatric Association, Arlington, VA 2013. p.50World Health Organization. The ICD-10 Classification of Mental and Behavioural Disorders. Clinical descriptions and diagnostic guidelines. www.who.int/classifications/icd/en/bluebook.pdf (Accessed on March 28, 2018).Augustyn, Marilyn MD. “Autism spectrum disorder: Terminology, epidemiology, and pathogenesis” UpToDate, https://www.uptodate.com/contents/autism-spectrum-disorder-terminology-epidemiology-and-pathogenesis Date of access 8/18/2020Weissman, Laura MD “Autism spectrum disorder in children and adolescents: Pharmacologic interverventions” UpToDate https://www.uptodate.com/contents/autism-spectrum-disorder-in-children-and-adolescents-pharmacologic-interventions  Date of access 8/18/2020Augustyn, Marilyn MD and von Hahn, L Erik MD. “Autism spectrum disorder: Clinical Features” UpToDate, https://www.uptodate.com/contents/autism-spectrum-disorder-clinical-features   Date of access 8/18/2020Augustyn, Marilyn MD. “Autism spectrum disorder in children and adolescents: Overview of management” UpToDate, https://www.uptodate.com/contents/autism-spectrum-disorder-in-children-and-adolescents-overview-of-managementDate of access 8/18/2020 Handleman, J.S., Harris, S., eds. Preschool Education Programs for Children with Autism (2nd ed). Austin, TX: Pro-Ed. 2000.National Research Council. Educating Children with Autism. Washington, DC: National Academy Press, 2001.  ____________________________[Music] Speaking Medical: Anosognosia by Cameron Anderson, MS4When someone rejects a diagnosis of mental illness, it’s tempting to say that he's “in denial.” But someone with acute mental illness may not be thinking clearly enough to consciously choose denial. They may instead be experiencing “lack of insight” or “lack of awareness.” The formal medical term for this condition is anosognosia, from the Greek meaning “to not know a disease.”As humans, we are consistently updating our reality and perception. Think about it this way: when you get a sunburn because you spent your weekend at the beach you expect yourself to look red when you look in the mirror. You have updated your perception of what your reality is. You now expect to appear more red. This update requires a functioning frontal lobe of the brain. When that is not working properly you can lose your ability to update what is real. Everyone else can tell you received a sunburn but you are unable to recognize you have one. In essence, this is anosognosia.This lack of insight into the disease is fairly common in those with schizophrenia and bipolar disorder. When a person is in this state they become very difficult to treat because they believe their perceptions of reality are what we should be experiencing. These people frequently will stop taking their medications because in their mind there is no reason to continue them because there is no disease.People with anosognosia often fluctuate with how aware they are of their disease. This can also cause a strain on their support system and relationships with friends and families. Since our perceptions feel accurate, we conclude that our loved ones are lying or making a mistake. If family and friends insist they're right, the person with an illness may get frustrated or angry, or begin to avoid them. When maintaining a relationship with a person with anosognosia, it is important to realize that their perception of reality is as real to them as our reality is to us.  Remember the word anosognosia.____________________________[Music]  Espanish Por Favor: Cansancioby Dr Claudia CarranzaHi this is Dr Carranza on our section Espanish Por Favor. This week’s word is cansancio. Cansancio means tiredness or fatigue. The verb “cansar” comes from the Latin word “campsare” which means to deviate or bend from a path or trajectory. Interestingly, back in the day cansancio began to be used to describe taking a break from a trip, taking a break due to exhaustion, or to rest because you’re tired. Patients can come to you with the complaint: “Doctor, tengo cansancio” or “Doctor, estoy cansado” which means: “Doctor, I am tired” or “I feel tired”. Cansancio is a very common complaint in clinic but it’s not very specific. So, the question “¿Se siente cansado?” “Are you feeling tired?” normally is answered with a yes, more so if you are a resident. Feeling tired may be physiologic, but feeling tired continually, with no relief after rest, and with no identifiable cause can lead you to start an investigation. Ask if this cansancio is new or chronic, think of differentials such as thyroid disease, anemia, sleep apnea, acute viral illness and continue with your work up. Now you know the Spanish word of the week, cansancio. ___________________________[Music]For your Sanity: Medical Jokesby Dr RAVA[SURAJ, PLEASE EDIT]I used all my sick days, so I called in dead.Statistically, 9 out of 10 injections are in vein.PMS jokes aren't funny; period.He was wheeled into the operating room, and then had a change of heart.I don't find health-related puns funny anymore since I started suffering from an irony deficiency (5). [Music to end: Jeremy Blake - Stardrive - Rock | Bright ]Now we conclude our episode number 25 “Autism with Saito”. Dr Saito explained the key features of Autism Spectrum Disorder and reminded us to screen at 18 and 24 months by using M-CHAT. Health care of patients with ASD requires a multidisciplinary team, and you can be part of that team. For some reason, we decided to expand on the word anosognosia (explained in episode 14). Cameron explained that anosognosia (UH NO SO NOGSIA) may fluctuate in intensity causing difficulty in relationships with family and friends. Dr Carranza gave us a good explanation about cansancio, which means tiredness, a good word to describe how we feel after a busy shift like today. Tomorrow the sun will rise again over the San Joaquin Valley and we’ll continue to learn and grow.This is the end of Rio Bravo qWeek. We say good bye from Bakersfield, a special place in the beautiful Central Valley of California, United States, a land where growing is happening everywhere.If you have any feedback about this podcast, contact us by email RBresidency@clinicasierravista.org, or visit our website riobravofmrp.org/qweek. This podcast was created with educational purposes only. Visit your primary care physician for additional medical advice. _____________________Our podcast team is Hector Arreaza, Lisa Manzanares, Steven Saito, Roberto Velazquez, Audio edition: Suraj Amrutia. See you soon! _____________________References:Avanthi Jayaweera, Yoonkyung Chung and Yalda Jabbarpour, The Journal of the American Board of Family Medicine July 2020, 33 (4) 561-568; DOI: https://doi.org/10.3122/jabfm.2020.04.190310American Geriatrics Society 2019 Updated AGS Beers Criteria® for Potentially Inappropriate Medication Use in Older Adults By the 2019 American Geriatrics Society Beers Criteria, Update Expert Panel, https://qioprogram.org/sites/default/files/2019BeersCriteria_JAGS.pdfAgnelli G, Becattini C, Meyer G, et al. Apixaban for the Treatment of Venous Thromboembolism Associated with Cancer. N Engl J Med 2020. 382:1599-1607. https://www.nejm.org/doi/full/10.1056/NEJMoa1915103Stokes, Andrew, PhD; Dielle J. Lundberg, MPH; Bethany Sheridan, PhD; et al, Association of Obesity With Prescription Opioids for Painful Conditions in Patients Seeking Primary Care in the US, April 2, 2020, JAMA Netw Open. 2020;3(4):e202012. doi: 10.1001/jamanetworkopen.2020.2012, https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2763785https://aimseducation.edu/blog/medical-puns-jokes-and-one-liners

Dr. Eric Ley from Cedars-Sinai Medical Center joins us on Rounds to discuss the recently published Western Trauma Association's Critical Decisions Algorithm for reducing VTE in trauma patients. Early risk stratification, timing and initial dose of LMWH, weight-based dosing, and surveillance screening are just a few of the key topics we discuss on this episode.

Are you trying to keep up with the COVID literature but by the time you've read one article you realise it was from one month ago and therefore is currently irrelevant?Here we have the Brilliant Professor Beverley Hunt to help us wade through the literature, learn from her experience and figure out how we should be treating our COVID-19 patients relating to their bloody sticky blood.Don't forget to subscribe to the podcast, and get regular emails by signing up on our website. Also on our website are the awesome Podpoint Graphics by Kosta for this episode and others!www.JournalSpotting.com01:00 Introduction to hosts / what we are talking about03:30 Professor Beverley explains her role in COVID crisis05:00 Why the blood is so sticky06:40 How we have come to understand this08:50 Rates & Cause of thrombosis - immunothrombosis11:10 Why Dexamethasone helps12:50 What thromboses do we see in patients?15:10 Which patients are most at risk16:35 And in pregnancy?18:45 Which blood tests are useful? And the D-Dimer?24:25 Which dose of LMWH? Call for trials27:50 Rates of bleeding with LMWH29:45 Are the thrombosis rates higher than other conditions?30:45 OP / discharge Tx33:20 Key Take Home Points for Bloody COVID - Thromboprophylaxis on D1 admission! - Enter your patients into trials - Don't over treat with LMWH - Sometimes the best is what existed before and had good evidence35:00 An OBE for COVID?35:15 Thank yous and sign offsWant more info on Professor Hunt? Just google her name or find her on Twitter @bhwords.Follow us on twitter @JournalSpotting, Facebook or Instagram.Subscribe to regular JournalSpotting emails on our website!

In this episode we cover the work horses we use daily in critical care patients: anticoagulants: Unfractionated heparin (UFH), LMWH, fondaparinux, argatroban, and bivalirudin. We also cover BID dosing of LMWH prophylaxis and the essential section here is on heparin resistance. Enjoy!

Does heparin - LMWH or unfractionated heparin - benefit the patient with a pretty good story for angina with a bump in their troponin and some ST depression in the lateral leads? We’re expected to routinely give heparin for all these NSTEMI and unstable angina patients with any ischemic changes seen on the ECG, right? And for STEMI too. But should we?.... The post Journal Jam 16 Heparin for ACS and STEMI appeared first on Emergency Medicine Cases.

Matt Kalaycio, MD, of the Cleveland Clinic joins Blood & Cancer host David H. Henry, MD, of Pennsylvania Hospital, Philadelphia, to preview the potentially practice changing research that will be reported at the 2019 annual meeting of the American Society of Hematology. Plus, in Clinical Correlation, Ilana Yurkiewicz, MD, of Stanford (Calif.) University, addresses the isolation that comes from dealing with a serious chronic illness, especially around the holidays. *  *  *  Help us make this podcast better! Please take our short listener survey: https://www.surveymonkey.com/r/podcastsurveyOct2019 *  *  *  FDA approves atezolizumab combo as first line for advanced NSCLC Atezolizumab is a monoclonal antibody and is already approved for adults with metastatic NSCLC with disease progression. By Laura Nicolaides The Food and Drug administration as approved atezolizumab in combination with paclitaxel and carboplatin chemotherapy for first-line treatment of adults with metastatic, nonsquamous non-small cell lung cancer with no EGFR or ALK genomic tumor aberrations.  *  *  *  ASH abstracts discussed in the podcast: Abstract 1: Post-transplantation cyclophosphamide after allogeneic hematopoietic stem cell transplantation: Results of the prospective randomized HOVON-96 trial in recipients of matched related and unrelated donors. Abstract 261: Superior survival with post-remission pediatric-inspired chemotherapy compared to myeloablative allogeneic hematopoietic cell transplantation in adolescents and young adults with Ph-negative acute lymphoblastic leukemia in first complete remission: Comparison of CALGB 10403 to patients reported to the CIBMTR. Abstract 322: Nonmyeloablative allogeneic transplantation confers an overall survival benefit with similar nonrelapse mortality when compared with autologous stem transplantation for patients with relapsed follicular lymphoma. Abstract 6: Mosunetuzumab induces complete remissions in poor prognosis non-Hodgkin lymphoma patients, including those who are resistant to or relapsing after chimeric antigen receptor T-cell therapies, and is active in treatment through multiple lines. Abstract LBA-5: Validation of BCL11A as therapeutic target in sickle cell disease: Results from the adult cohort of a pilot/feasibility gene therapy trial inducing sustained expression of fetal hemoglobin using posttranscriptional gene silencing. Abstract LBA-6: Carfilzomib, dexamethasone, and daratumumab versus carfilzomib and dexamethasone for the treatment of patients with relapsed or refractory multiple myeloma: Primary analysis results from the randomized, open-label, phase 3 study Candor. Abstract 1588: A randomized trial of EPOCH-based chemotherapy with vorinostat for highly aggressive HIV-associated lymphomas: Updated results evaluating the impact of diagnosis-to-treatment interval and pre-protocol systemic therapy on outcomes. Abstract 940: Elucidating the role of IL6 in stress erythropoiesis and in the development of anemia under inflammatory conditions. Abstract 57: Patient harm from repetitive blood draws and blood waste in the ICU: A retrospective cohort study. Abstract 59: Impact of iron supplementation on patient outcomes in women undergoing gynecologic procedures: Systematic review and meta-analysis of randomized trials. Abstract 126: Polatuzumab vedotin plus obinutuzumab and lenalidomide in patients with relapsed/refractory follicular lymphoma: Primary analysis of the full efficacy population in a phase Ib/II trial. Abstract 168: Risk of hemorrhage in patient with polycythemia vera exposed to aspirin in combination with anticoagulants: Results of a prospective, multicenter, observational cohort study (REVEAL). Abstract 326: Safety and effectiveness of apixaban, LMWH, and warfarin among venous thromboembolism patients with active cancer: A retrospective analysis using four U.S. claims databases. Abstract 327: Safety and effectiveness of apixaban, LMWH and warfarin among venous thromboembolism patients with active cancer: A subgroup analysis of VTE risk scale. Abstract 566: Phase II study of oral rigosertib combined with azacytidine as first line therapy in patients with higher-risk myelodysplastic syndromes.   For more MDedge Podcasts, go to mdedge.com/podcasts Email the show: podcasts@mdedge.com Interact with us on Twitter: @MDedgehemonc David Henry on Twitter: @davidhenrymd Ilana Yurkiewicz on Twitter: @ilanayurkiewicz

 Alok Khorana, MD, of the Cleveland Clinic joins Blood & Cancer host David H. Henry, MD, of Pennsylvania Hospital, Philadelphia, to break down the latest recommendations from the American Society of Clinical Oncology on venous thromboembolism (VTE) prophylaxis in cancer patients. Plus, in Clinical Correlation, Ilana Yurkiewicz, MD, of Stanford (Calif.) University, shares her answer to a frequent question from cancer patients: What should I eat? This Week in Oncology What is the role of thromboprophylaxis in patients with cancer in the outpatient setting?  Key change in ASCO recommendations: Thromboprophylaxis with apixaban, rivaroxaban, or low-molecular-weight heparin (LMWH) may be offered to select high-risk outpatients with cancer. Prophylactic anticoagulation should not be given to every patient with malignancy. Khorana score predicts the venous thromboembolism in patients with malignancy. Influenced by type of malignancy, hemoglobin, platelet count, leukocyte count, and BMI. High risk = Khorana score of 2 or higher may be offered prophylaxis. Patients with pancreatic cancer and gastric cancer are particularly coagulopathic. Does the presence of a CNS lesion(s) preclude anticoagulation for a DVT/PE? All CNS lesions have a risk of hemorrhage. A CNS lesion hemorrhage is not significantly greater when anticoagulated Among high-risk cancer patients who undergo surgery, is there a role for postoperative prophylaxis with LMWH? Data show a persistent risk of VTE up to 4 weeks following abdominal/pelvic surgery.   Show notes by Emily Bryer, DO, resident in the department of internal medicine, University of Pennsylvania, Philadelphia.   References: Venous thromboembolism prophylaxis and treatment in patients with cancer: ASCO Clinical Practice Guideline Update ascopubs.org/doi/pdf/10.1200/JCO.19.01461 Rivaroxaban for thromboprophylaxis in high-risk ambulatory patients with cancer nejm.org/doi/full/10.1056/NEJMoa1814630 Apixaban to prevent venous thromboembolism in patients with cancer nejm.org/doi/full/10.1056/NEJMoa1814468   For more MDedge Podcasts, go to mdedge.com/podcasts Email the show: podcasts@mdedge.com Interact with us on Twitter: @MDedgehemonc Ilana Yurkiewicz on Twitter: @ilanayurkiewicz  

Avatrombopag's FDA-approval prompts discussion of both the indication and drug itself. Finally, the publication of the SELECT-D study allows us to dig deeper into the data of a DOAC vs. LMWH in cancer-associated VTE.

Prof Khorana talks to ecancertv at ASH 2015 about current practice patterns and patient persistence on anticoagulant treatments for cancer-associated thrombosis. In the interview he describes a study that looked at almost 3,000 patients with cancer who were newly diagnosed venous thromboembolism (VTE) and had received anticoagulant treatment in the outpatient setting. Guidelines recommend that 3–6 months of a low-molecular-weight heparin (LMWH) be given, but it is not clear if this should be continued beyond 6 months. In this real-world practice setting 25% of patients were treated with a LMWH and 18.7% received LMWH or warfarin. A further 29% had been given warfarin and 24.1% had been given the newer oral anticoagulant rivaroxaban. On average the median duration of treatment was 3.29 months for LMWH, 7.76 months for LMWH/warfarin, 8.12 months for warfarin, and 7.92 months for rivaroxaban. Persistence to the initial therapy were a respective 37%, 60%, 62%, and 61% at 6 months, dropping to 21%, 37%, 34%, and 36% at 12 months. In addition more patients initially taking LMWH were found to have switched to another anticoagulant compared to patients who had been started on warfarin or rivaroxaban.

Dr Soff talks to ecancertv at ASH 2015 about a quality assessment initiative that looked at the use of the oral anticoagulant rivaroxaban for treating cancer-related thrombosis. The current standard of care for treating patients with cancer who develop venous thromboembolism (VTE) is injected low molecular weight heparin. Rivaroxaban has been approved in the United States for the treatment for VTE since the end of 2012 but clinical trials did not specifically look at its use in cancer patients, Dr Soff explains in the interview. It was therefore decided to take a look at patients being treated with rivaroxaban for VTE according to the product’s label and make note of which of these patients also had cancer and what effects could be seen. The risk of major bleeding, which is always a concern with anticoagulant therapy, was found to be low (1.6% of patients) and recurrent thrombosis occurred in 4.4% of patients. A randomized trial is the optimal approach to establish non-inferiority or superiority of rivaroxaban to LMWH for cancer-associated thrombosis but results of the quality assessment provide guidance and reassurance for rivaroxaban use in cancer patients.

Dr Soff talks to ecancertv at ASH 2015 about the results of a study that prospectively assessed the efficacy and safety of an algorithm for reducing the dose of low molecular weight heparin (LMWH) in patients with cancer-associated thrombosis who develop chemotherapy-induced thrombocytopenia (CIT). CIT is a common problem in anticoagulated cancer patients and the current recommendation on how to amend LMWH is based on expert opinion rather published evidence, Dr Soff explains. The present study therefore aimed to address this knowledge gap and considered all 15,000 cancer patients treated with LMWH (enoxaparin) at Memorial Sloan Kettering Cancer Center over a 3-year period. There were 143 patients who developed CIT and results showed that holding anticoagulant therapy was an appropriate approach if platelet levels fell below 25,000/mcL. Halving the dose of LMWH was appropriate if the platelet count was 25,000/mcL to 50,000/mcL and continuing LMWH at full dose if the platelet count was more than 50,000/mcL.

Dr Chai-Adisaksopha talks to ecancertv at ASH 2015 about his study that looked at the efficacy and safety of switching patients with cancer-related thrombosis to warfarin after completing 6 months of anticoagulant treatment. Extended (3–6 months) anticoagulant treatment with low-molecular-weight heparin (LMWH) is now generally recommended for patients who develop venous thromboembolism (VTE) secondary to their cancer, but not all patients tolerate this in the long term, Dr Chai-Adisaksopha says in the interview. His research suggests, however, that switching to the old standard of warfarin is just as good as continuing LMWH for preventing recurrent VTE (7.2% vs 6.0%, p = NS) with no increase in major bleeding (2.6% versus 2.7%, p = NS). Dr Chai-Adisaksopha acknowledges that this was a retrospective study and so a prospective study is needed, but the results suggest that switching to warfarin may be an option for some patients.

In today's VETgirl online veterinary continuing education podcast, we review the use of enoxaparin, a low molecular weight heparin (LMWH) in dogs with primary immune-mediated hemolytic anemia (IMHA). Do you see a lot of dogs with primary IMHA in your practice? Do you have an anticoagulation protocol that you like to use in treating them? Does it involve aspirin? Clopidogrel? Unfractionated heparin? What about LMWH?

In today's VETgirl online veterinary continuing education podcast, we review the use of enoxaparin, a low molecular weight heparin (LMWH) in dogs with primary immune-mediated hemolytic anemia (IMHA). Do you see a lot of dogs with primary IMHA in your practice? Do you have an anticoagulation protocol that you like to use in treating them? Does it involve aspirin? Clopidogrel? Unfractionated heparin? What about LMWH?

Neurocritical Care Society and Society for Critical Care Medicine recommendations for reversal of antithrombotic agents in patients with intracranial hemorrhage Guideline for Reversal of Antithrombotics in Intracranial Hemorrhage : A Statement for Healthcare Professionals from the Neurocritical Care Society... - PubMed - NCBI http://www.ncbi.nlm.nih.gov/pubmed/26714677 Antithrombotic: Timing, Antidote, Factor Replacement, antifibrinolytics Vitamin K antagonists (warfarin) If INR > 1.3 then Vitamin K 10 mg IV, plus 3 or 4 factor PCC IV (dosing based on weight, INR and PCC type) OR FFP 10–15 ml/kg IV if PCC not available Direct factor Xa inhibitors: activated charcoal (50 g) within 2 h of ingestion, activated PCC (FEIBA) 50 units/kg IV OR 4 factor PCC 50 units/kg IV Direct thrombin inhibitors (dabigatran): Activated charcoal (50 g) within 2 h of ingestion, AND Activated PCC (FEIBA) 50 units/kg IV OR 4 factor PCC 50 units/kg IV Idarucizumab 5 g IV (in two 2.5 g/50 mL vials) consider hemodialysis or idarucizumab redosing for refractory bleeding after initial administration if 1) dabigatran was taken with 3-5 half lives and NO evidence of renal insufficiency or 2) dabigatran was taken beyond 3-5 half lives WITH renal insufficiency For other DTIs: Activated PCC (FEIBA) 50 units/kg IV OR 4 factor PCC 50 units/kg IV Unfractionated heparin: Protamine 1 mg IV for every 100 units of heparin administered in the previous 2–3 h (up to 50 mg in a single dose) LMWH Enoxaparin: Dosed within 8 h: Protamine 1 mg IV per 1 mg enoxaparin (up to 50 mg in a single dose) Dosed within 8–12 h: Protamine 0.5 mg IV per 1 mg enoxaparin (up to 50 mg in a single dose) Minimal utility in reversal >12 h from dosing Dalteparin, Nadroparin and Tinzaparin: Dosed within 3–5 half-lives of LMWH: Protamine 1 mg IV per 100 anti-Xa units of LMWH (up to 50 mg in a single dose) OR rFVIIa 90 mcg/kg IV if protamine is contraindicated Danaparoid: rFVIIa 90 mcg/kg IV Pentasaccharides: Activated PCC (FEIBA) 20 units/kg IV or rFVIIa 90 mcg/kg IV Thrombolytic agents (plasminogen activators): Cryoprecipitate 10 units IV OR antifibrinolytics (tranexamic acid 10–15 mg/kg IV over 20 min or e-aminocaproic acid 4–5 g IV) if cryoprecipitate is contraindicated Antiplatelet agents: DDAVP 0.4 mcg/kg x 1, if neurosurgical intervention, transfuse one apheresis unit

Editor's Audio Summary by Howard Bauchner, MD, Editor in Chief of JAMA, the Journal of the American Medical Association, for the August 18, 2015 issue

In Part 2 of this Episode on Acute Coronary Syndromes Risk Stratification & Management, the evidence for various medications for ACS, from supplemental oxygen to thrombolytics are debated, and decision making around reperfusion therapy for STEMI as well as NSTEMI are discussed. Finally, there is a discussion on risk stratification of low risk chest pain patients and all it's attendant challenges as well as disposition and follow-up decisions. Dr. Eric Letovsky, the Head of the CCFP(EM) Program at the University of Toronto, Dr. Mark Mensour & Dr. Neil Fam, an interventional cardiologist answer questions like: What is the danger of high flow oxygen in the setting of ACS? When, if ever, should we be using IV B-blockers in AMI patients? How can you predict, in the ED, who might go on to have an urgent CABG, in which case Clopidogrel is contra-indicated? Which anticoagulant is best for unstable angina, NSTEMI and STEMI - unfractionated heparin (UFH), low molecular weight heparin (LMWH), or fonduparinux? Is there currenly any role for Glycoprotein 2b3a Inhibitors in ACS in the ED? When is thrombolysis better than PCI for STEMI? When should we consider facilitated angioplasty and rescue angioplasty? Which low risk chest pain patients require an early stress test? CT coronary angiography? Stress Echo? Admission to a Coronary Decision Unit (CDU)? and many more.......

In Part 2 of this Episode on Acute Coronary Syndromes Risk Stratification & Management, the evidence for various medications for ACS, from supplemental oxygen to thrombolytics are debated, and decision making around reperfusion therapy for STEMI as well as NSTEMI are discussed. Finally, there is a discussion on risk stratification of low risk chest pain patients and all it's attendant challenges as well as disposition and follow-up decisions. Dr. Eric Letovsky, the Head of the CCFP(EM) Program at the University of Toronto, Dr. Mark Mensour & Dr. Neil Fam, an interventional cardiologist answer questions like: What is the danger of high flow oxygen in the setting of ACS? When, if ever, should we be using IV B-blockers in AMI patients? How can you predict, in the ED, who might go on to have an urgent CABG, in which case Clopidogrel is contra-indicated? Which anticoagulant is best for unstable angina, NSTEMI and STEMI - unfractionated heparin (UFH), low molecular weight heparin (LMWH), or fonduparinux? Is there currenly any role for Glycoprotein 2b3a Inhibitors in ACS in the ED? When is thrombolysis better than PCI for STEMI? When should we consider facilitated angioplasty and rescue angioplasty? Which low risk chest pain patients require an early stress test? CT coronary angiography? Stress Echo? Admission to a Coronary Decision Unit (CDU)? and many more....... The post Episode 15 Part 2: Acute Coronary Syndromes Management appeared first on Emergency Medicine Cases.

Thrombozyten von Patienten mit disseminierter Arteriosklerose wie bei pAVK zeigen eine erhöhte Reaktivität. In vorherigen Arbeiten wurde gezeigt, daß diese Aktivitätserhöhung postoperativ nach Gefäßeingriffen weiter ansteigt, weshalb es vermehrt zu Komplikationen auf dem kardiovaskulären Gebiet bzw. peripher zu Restenosierungen kommen kann. In dieser Dissertation soll mittels der SPAA-Methode geprüft werden, wie sich Thrombozyten von Patienten mit pAVK im Vergleich zu gesunden Kontrollen bei Inkubation mit verschiedenen Substanzen zur Thromboseprophylaxe verhalten. Aufgrund der Eigenschaften von Thrombozyten kann hinsichtlich einer Adhäsion der Thrombozyten an der Gefäßwand, in unserem Fall der Glasoberfläche und einem Haften der Thrombozyten untereinander, was als Aggregation bezeichnet wird, unterschieden werden. Das SPAA-Modell kann diese beiden Ereignisse mit hoher Sensitivität und Spezifität messen. Es zeigt sich, daß die Adhäsionsausgangswerte der pAVK-Patienten doppelt so hoch sind, wie die der Kontrollgruppe. Ebenso tritt bei diesen im Gegensatz zu den gesunden Kontrollen, bei denen keine spontane Aggregation nachweisbar ist, bereits vor den Inkubationsversuchen in 37% der Fälle eine spontane Thrombozytenaggregation auf. Das bestätigten die Ergebnisse vorangegangener Untersuchungen, daß Thrombozyten von pAVK Patienten hyperreaktiv sind. Dieses Phänomen ist nicht nur bei den Ausgangswerten mit plättchenreichem Plasma, sondern in besonderem Maße bei Zugabe von Substanzen, die in den Gerinnungsablauf eingreifen. Dabei fällt auf, wie besonders nach Zugabe von Heparinen bei Patienten eine Steigerung der Adhäsion auftritt. Auf UFH reagieren sogar Kontrollplasmen mit erhöhten Adhäsionswerten. Ein dämpfender Effekt zeigt sich bei Substanzen, die frei von Heparinfragmenten sind. Ebenso führen alle Heparine (UFH, LMWH) zu einer gesteigerten Aggregation sowohl bei Patienten als auch Kontrollen, als Ausdruck einer akuten Aktivierung. Wiederum haben von Heparinfragmenten freie Substanzen auch hier einen dämpfenden Effekt auf die Thrombozytenaggregation. Es stellt sich somit die Frage, ob für pAVK-Patienten nicht Wirkstoffe, die nicht mit Thrombozyten reagieren, von größerem Nutzen sind.