My name is Jassmin Robinson and I am a 14-year old female from Ohio. I was correctly diagnosed with May-Thurner Syndrome (MTS) on January 1, 2008. MTS is a disease caused when the left iliac vein is compressed by the right iliac artery, increasing the risk of deep vein thrombosis in the left extremity. This is my story:
The purpose of this discussion is to examine new trends in how vitamin K may be used to modulate the control of the International Normalized Ratio (INR) in warfarin-treated patients. Specifically, the following areas will be addressed; the use of vitamin K to:
1. Reverse an excessively elevated INR.
2. Increase the rate of decline in the INR and thereby minimize the need for pre-procedure “bridging” with low molecular weight heparin.
3. Help stabilize the INR (as measured by the percent of time in the therapeutic range – or “TTR”) during chronic warfarin therapy.
Two years ago I experienced a nearly life-terminating series of pulmonary emboli. As a preventive cardiologist I surely should have seen the signs. In this article I share my somewhat embarrassing yet illuminating story, as a case report of what many of us might come upon, but overlook in our own daily practices. Before doing so, let me set the stage with a few sobering statistics and comments that will establish deep vein thrombosis (DVT) and pulmonary embolism (PE) as the underrecognized, underappreciated, and sorely undertreated disorders they are.
Pulmonary arterial hypertension treatment
The treatment of PAH has advanced dramatically in the last decade through the results of several well-designed clinical trials demonstrating the efficacy of several therapies that target specific abnormalities present in PAH 31 – 33. Currently, standard treatment including diet, oral anticoagulation, diuretic and digoxin, are part of the modern therapeutic approach.
Pulmonary Arterial Hypertension Clinic
Unidad de Investigación Clínica en Medicina S.C., Monterrey, NL, Mexico
The term pulmonary arterial hypertension (PAH) refers to conditions that share common isolated elevations in pulmonary arterial pressure defined as at resting mean pulmonary arterial pressure > 25 mmHg with a normal pulmonary capillary or left atrial pressure (<15 mmHg)1. PAH remains a challenging condition to diagnose and manage. In 1991, estimates from the US Department of Health and Human Services National institutes of Health Registry painted a grim portrait of survival in patients with pulmonary hypertension, establishing primary pulmonary hypertension with one, three, and five year survival rates of 68%, 48% and 34%, respectively 2.
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Today, as a hospital employee, words like Deep Vein Thrombosis (DVT) and Pulmonary Embolism (PE) are a part of my daily vocabulary. However, my first experience with DVT happened 13 years ago, when my dad was diagnosed with a DVT in his leg. I remember the day it happened, I came home from school and there was at least ten new voicemails on the phone from my Dad saying, “Linda (my mom) it’s Ross, you need to call me.” My Mom arrived home shortly after and called my Dad, which is when he told her, he was admitted to the hospital for a blood clot. I remember how scary it was going to visit my dad in the hospital and how worried my Mom was.
Abstract
The medical community is challenged to quickly develop a picture of what distinguishes influenza A (H1N1) from seasonal Influenza A. Recent articles on the international and national experience and from radiology provide valuable clues about populations at risk of severe infection, preventable/treatable comorbidities and the need for additional data collection. The experience in Michigan provides valuable data on the potential increased risk of thromboembolic events adding to the severe infection and Acute Respiratory Distress Syndrome (ARDS) picture. The purpose of this report is to highlight unusual features identified in the critically ill patients, specifically the high rate of obesity in those severely infected and the increased rate of VTE (50%) in critical care patients, as documented in Michigan. Related questions for clinicians are the appropriateness of VTE prophylaxis of inpatients, the appropriate dosing given the high rate of obesity and morbid obesity and multiorgan dysfunction and the need for empiric treatment when definitive testing is limited in the critical care setting. Additional data collection on the rate of VTE in-hospital and after discharge is needed.
Abstract
The optimal utilization of glycoprotein IIb/IIIa inhibitors in patients with non-STelevation acute coronary syndromes remains unclear, particularly in regard to timing of infusion. The EARLY-ACS trial was designed to evaluate the clinical benefits of early infusion of eptifibatide (upstream) versus delayed, provisional eptifibatide in high-risk patients with non-ST-segment elevation acute coronary syndromes. The primary efficacy endpoint was a composite of death/myocardial infarction (MI)/recurrent ischemia (RI) leading to urgent revascularization (UR)/thrombotic bailout (TBO) within 96 hours. The secondary efficacy endpoint was a composite of death/MI at 30 days. The key safety endpoints included bleeding events (both GUSTO and TIMI scales) and need for transfusion. There was no difference in the primary endpoint between the treatment groups, with rates of 9.3% and 10.0% in the patients randomized to routine, early eptifibatide and delayed, provisional eptifibatide, respectively (p = 0.23) . There was a statistical trend toward a reduction in the secondary endpoint of death or MI through 30 days with routine, early eptifibatide (11.2% vs 12.4%, p = 0.08). There was a significant increase in bleeding events in the routine early eptifibatide group as compared to the delayed provisional group (TIMI moderate/severe bleeding 5.7% vs. 3.4%, p<0.001). The results of EARLY ACS do not support a strategy of routine, early eptifibatide use in high-risk NSTE ACS patients managed with an invasive strategy. Early eptifibatide may be indicated in certain subgroups of this population with a higher likelihood of benefit and lower risk of bleeding, but this will require further investigation.
Deep vein thrombosis (DVT) is often thought of as a condition that mostly affects the elderly and adults. Many doctors and lay individuals do not realize or understand the potential danger DVT poses for children and teenagers. When I was diagnosed with DVT at age 19, my doctors estimated that I had been misdiagnosed for 10 years! My experience reveals that deep vein thrombosis does not discriminate against age.
By now, most DVT/PE survivors are aware of the new oral anticoagulants undergoing Phase III Trials. Are these medications going to be a replacement for Coumadin/warfarin or are they in the near future, going to target a specific treatment? This update will address all three medications:
1. Rivaroxaban (Bayer/Ortho-McNeil Pharmaceuticals) – In the U.S., rivaroxaban is the closest to being approved by the Food and Drug Administration (FDA) of the three new oral anticoagulants. Rivaroxaban (Xarelto) has received its license in the European Union and Canada for prevention of DVT following hip and knee replacements. In the U.S., it is also being reviewed for knee and hip replacement anticoagulation. This past spring, rivaroxaban was reviewed by a FDA panel hearing which recommended it for approval. The FDA has sent the manufacturer a letter asking for more information regarding the medication before it receives any further evaluation. It is estimated that this product, once approved, will be available sometime in early 2010 for use in the U.S. Rivaroxaban proved to be superior to enoxaparin in prevention of DVT. Other trials being conducted are for atrial fibrillation, DVT/PE prophylaxis for medical and cancer patients, and treatment of DVT/PE…
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