This chapter about hemorrhagic complications of anticoagulant treatment is part of the seventh ACCP Conference on Antithrombotic and Thrombolytic Therapy: Evidence Based Guidelines. Bleeding is the major complication of anticoagulant therapy. The criteria for defining the severity of bleeding varies considerably between studies, accounting in part for the variation in the rates of bleeding reported. The major determinants of vitamin K antagonist-induced bleeding are the intensity of the anticoagulant effect, underlying patient characteristics, and the length of therapy. There is good evidence that vitamin K antagonist therapy, targeted international normalized ratio (INR) of 2.5 (range, 2.0 to 3.0), is associated with a lower risk of bleeding than therapy targeted at an INR > 3.0. The risk of bleeding associated with IV unfractionated heparin (UFH) in patients with acute venous thromboembolism (VTE) is < 3% in recent trials. This bleeding risk may increase with increasing heparin dosages and age (> 70 years). Low molecular weight heparin (LMWH) is associated with less major bleeding compared with UFH in acute VTE. UFH and LMWH are not associated with an increase in major bleeding in ischemic coronary syndromes, but are associated with an increase in major bleeding in ischemic stroke. Information on bleeding associated with the newer generation of antithrombotic agents has begun to emerge. In terms of treatment decision making for anticoagulant therapy, bleeding risk cannot be considered alone, ie, the potential decrease in thromboembolism must be balanced against the potential increased bleeding risk.

(CHEST 2004; 126:287S-310S)

Key words: anticoagulant; bleeding; complications; heparin

Abbreviations: AMS = anticoagulation management services; APTT = activated partial thromboplastin time; ASPECT = Anticoagulants in the Secondary Prevention of Events in Coronary Thrombosis; CARS = Coumadin-Aspirin Reinfarction Study; CHAMP = Combination Hemotherapy and Mortality Prevention; CI = confidence interval; DVT = deep vein thrombosis;

Reproduction of this article is prohibited without written permission from the American College of Chest Physicians.

Correspondence to: Mark N. Levine, MD, MSc, Room 104, First Floor, Henderson Research Centre, 711 Concession St, Hamilton, Ontario L8V 1C3 INR = international normalized ratio; IST = International Stroke Trial; LMWH = low molecular weight heparin; NSAID = nonsteroidal anti-inflammatory drug; OR = odds ratio; RCT = randomized controlled trial; SPAF = Stroke Prevention in Atrial Fibrillation; SPIRIT = Stroke Prevention in Reversible Ischemia Trial; SPORTIF = Stroke Prevention Using an Oral Thrombin Inhibitor in Atrial Fibrillation; TIMI = Thrombolysis in Myocardial Infarction; UFH = unfractionated heparin; VTE = venous thromboembolism; WARIS = Warfarin-Aspirin Reinfarction Study.

Thus, ximelagatran therapy is a promising alternative to warfarin therapy for stroke prevention in this population. With no need for coagulation monitoring, ximelagatran is more convenient than warfarin, a feature that may increase anticoagulant use in high-risk patients with atrial fibrillation.

Parenteral anticoagulants continue to have a role in the treatment of acute coronary syndromes. The results of the REPLACE-2 trial suggest that bivalirudin obviates the need for GPIIb/IIIa antagonists in the majority of patients with low-to-moderate risk who are undergoing percutaneous coronary interventions, thereby reducing the risk of bleeding.

Fondaparinux and DX9065a have yet to find a place in the treatment of acute coronary syndromes, but further studies are planned. Likewise, NAPc2 is undergoing evaluation for these indications. Although most of the attention has focused on the use of parenteral anticoagulants for short-term treatment, rapidly acting, orally active agents also may have a role in long-term therapy. There is mounting evidence that, despite initial treatment, patients with acute coronary syndromes remain at risk for recurrent ischemic attacks for months after the index event. Some studies have indicated that long-term treatment with the combination of aspirin and clopidogrel is more effective at reducing the risk of recurrent ischemia than aspirin alone. Likewise, long-term warfarin therapy also appears to be effective. We do not yet know whether therapy with aspirin plus clopidogrel is as effective as warfarin therapy, or whether treatment with all three agents can be safely administered on a long-term basis. However, recent results with warfarin raise the possibility that ximelagatran therapy may be useful for this indication, either alone or in combination with antiplatelet agents.

Another unanswered question is the utility of ximelaga-tran in patients with mechanical heart valves. With no need for anticoagulation monitoring, ximelagatran has the potential to streamline the care of these patients, particularly those living in remote areas who cannot access a coagulation laboratory. The anticoagulation management of women with mechanical heart valves during pregnancy also remains a major challenge. If the use of ximelagatran is safe in this setting, treatment would be simplified.

Summary

With a large number of new anticoagulant agents in advanced stages of development, our armamentarium of treatment options is likely to soon be expanded. Particularly promising are new oral anticoagulant agents because they have the potential to streamline the long-term prevention and treatment of patients with venous and arterial thrombosis.

We have previously proposed the BAP-65 (elevated BUN, altered mental status, pulse > 109 beats/min, age > 65 years) system for application in AECOPD. This system is designed to only use information that is generally available to physicians at the time of patient presentation. BAP-65 assigns points based on BUN level, mental status, pulse, and age. In an earlier analysis of nearly 90,000 patients with AECOPD, we demonstrated that BAP-65 correlated with both the need for MV and in-hospital mortality.

In the present study we sought to validate the BAP-65 system in a separate and more recent cohort of patients with AECOPD. We also aimed to explore the usefulness of BAP-65 in a broader population to include AECOPD in patients suffering from acute respiratory failure at the time of presentation. Finally, we attempted to determine how the BAP-65 score correlated with measures of resource use, such as length of stay (LOS) and hospital costs.

Subjects and BAP-65 Classes

We included all people > 40 years of age (to minimize potential patients with asthma) in the analysis with either (1) a principal International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) discharge code of COPD with acute exacerbation (491.21, 491.22, or 496.XX) or (2) a principal ICD-9-CM discharge code of acute respiratory failure (518.81) along with a secondary discharge code of COPD. We further restricted the eligible population to diagnosis-related groups (DRGs) (version 27) 190, 191, 192 (COPD), or DRG 189 (pulmonary edema or respiratory failure), or any of the four DRGs indicating that MV was performed in the index hospitalization (DRG 207, 208, 3, or 4). The analytic units were admissions.

The BAP-65 system is based on information available on initial hospital presentation. For patients who have none of the three main risk factors (BUN level > 25 mg/dL, altered mental status, or pulse > 109 beats/min), those < 65 years of age are designated as class I, whereas patients with no risk factors who are >65 years of age are classified as class II.

Diabetes is a metabolic disorder in which the body does not properly process sugar. While diabetes often runs in families, its onset and course cannot be predicted or prevented. But, with medication, proper nutrition and exercise, diabetics live healthy lives.

Uncontrolled, however, it can cause heart and blood vessel disorders that may lead to blindness, gangrene, kidney disease, and even death.

There are two basic types of diabetes.

• Type I, the more severe, is caused by a deficiency of the hormone insulin.
• With Type II, or noninsulin-dependent diabetes, there may be enough insulin, but the body’s cells have trouble using it.

In either form, excess sugar builds up in the blood because insulin is unable to regulate it. The sugar then “spills” into the urine, where it is excreted from the body. Frequent urination or excessive thirst often signals high blood sugar levels.

Having diabetes means you need to eat foods from each food group. Include breads and cereals, milk products, vegetables, fruits, meat and fish, nuts and legumes, and fats and oils.

Minimize sugars and fats while maximizing starches and proteins. The old standard of avoiding carbohydrates no longer applies. In fact, a diet in which 50 to 60% of total calories is obtained through complex carbohydrates is recommended. Keep fat to 30% of calories.

Control your caloric intake; being overweight makes diabetes worse. Weight management, especially in Type II diabetes, is crucial. Losing even a small amount of weight can improve or even normalize blood sugar levels in older diabetics.

Type I diabetics must eat meals on a regular schedule in order to balance their injections of insulin. All diabetics need to space their meals throughout the day so as to minimize extreme highs and lows of blood sugar levels.

If you haven’t been physically active, start slowly and build the intensity. Consult your doctor before starting your exercise program. Be aware that strenuous exercise can throw you out of balance by lowering blood glucose too much; this could lead to hypoglycemia.

Moderate exercise helps lower blood sugar by “burning” it off, making tissues more responsive to insulin and reducing weight. It also reduces fat and cholesterol in the bloodstream and lowers blood pressure. This is important because diabetics are at high risk for heart and vascular diseases.

Babies born to diabetics have a greater risk of birth defects than others. To minimize the risk:

• Get your body in the best possible condition three to six months before you conceive. If you must lose weight, do it under supervision of your doctor.
• Choose a doctor trained to care for diabetic mothers and their babies.
• Closely monitor your blood glucose before and during your pregnancy.
• Breastfeeding is good for both you and the baby, but it will set up new conditions for controlling blood sugar.

Coffee is one of the popular beverages in the world. Nobody knows where coffee began its journey and probably, it all began in Ethiopia. Strangely enough, the greatest coffee drinking countries are those which do not produce them. The only exception is Brazil which is the leading producer of coffee and the second largest consumer in the world. Colombia is the second largest producer of coffee. The leading consumer is the USA which is believed to consume 25% of the coffee produced in the world. 54% of the Americans over the age of 18 are coffee drinkers. America spends nearly $40 billion in coffee consumption. Coffee is the second commonly traded commodity after oil. Around 53 countries grow coffee and most of them lie along the equator.

Each year around 7 million tons of green beans are produced worldwide. Arabica and Robusta are the most popular varieties. Coffee contains hundreds of chemicals and for decades, scientists have been trying to portray it as a villain. In spite of spending millions of dollars, nobody has succeeded in producing concrete evidence that coffee is bad for health. Instead, good news about the beneficial effects of coffee is pouring in.

Coffee supplies antioxidants

It has been shown that drinking three to four cups of coffee a day can reduce the risk for heart disease by 45%. However, when the consumption is over six cups, the beneficial effects decrease. Chlorogenic acid present in coffee is an antioxidant. In addition, caffeine also has been shown to be an antioxidant. HDL whose levels are elevated by coffee consumption is also an antioxidant. The antioxidants protect by preventing the initiation of inflammatory reactions. The antioxidants prevent the accumulation of dangerous free radicals which are believed to be responsible for the onset of several diseases like diabetes.

Coffee decreases diabetes risk
Diabetes is a metabolic disorder characterized by abnormal body metabolism. Just about every part of the body is affected. Coffee contains significant quantities of magnesium. Magnesium helps to prevent the onset of diabetes because it promotes the actions of insulin. For example, one of the actions of insulin is to promote the utilization of glucose within the cells. The first step in the glucose utilization is catalyzed by an enzyme called hexokinase and this enzyme shows an obligatory requirement for magnesium.

The protein called sex hormone-binding globulin is concerned with the binding of sex hormones and has been implicated in the onset of diabetes. The level of this protein in the circulation falls during diabetes. High circulating levels of this protein is believed to protect against the onset of type 2 diabetes. Drinking four cups of coffee a day has been shown to increase the blood levels of sex hormone-binding globulin. Therefore coffee can reduce the risk for diabetes. Coffee also protects the heart because diabetes increases the risk for coronary heart disease.

If you are diabetic, you need to be particularly careful when you buying shoes to avoid foot injuries. However this is not implying that you can only wear ugly, clunky or large shoes. In the event that you are not really experiencing lack of feeling in your feet, you can just ensure that you are wearing well-designed and the right fitting shoes. The following will highlight some of the things to consider when you are shopping for diabetic shoes.

Here are some of the things to consider:

The shoes should have 3/8-1/2 inch space at the ending of your longest toe and the shoe. This space must be enough so that your finger can fit inside the back of your shoes and you should also have sufficient wiggle room for your toes

Look for shoes with leather upper material and comfortable, cushioned soles and insoles.

Shoes must be comfortable from the moment you put them on, instead of expecting that it will stretch to fit or that your foot can easily break into it afterward.

You should try to avoid the pointed-toe shoes styles.

Shoes must be firm at the back to support your heels without being too tight.

If you are unable to resist high heel shoes, you should ensure that you are only wearing them for a limited time. The poor fitting shoes can easily lead to many foot problems such as sores, bunions, calluses, hammertoes, blisters and wounds, which you might not feel if you have lost all the sensation in your feet. The best protective footwear will have deep boxes for your toes to prevent rubbing and cramping; a soft lining and a lack of seams at vital spots in the shoe.

In case your podiatrist suggests special footwear, you should follow this guidance at all time to prevent foot problems. A recent research was carried with individuals who have foot problems and were at higher risk for amputation, which indicates that those who wore the protective footwear had fewer amputations as a group.

Many people actually wear the wrong size shoes without realizing it. Generally, this will happen if you are unaware that your size has evolved or if you cannot feel your feet and will not know whether the shoe is tight or not. When you are shopping at certain shoes store, you can get help from trained professionals who are knowledgeable about shoes style, function and fit as well as orthotics products like heel inserts or pads. Ultimately, you can get the help to find footwear that will enhance the function and health of your ankle or foot.

Diabetes is a widespread disease, the frequency of which increases with that of obesity. The importance of nutrition in the onset and course of diabetes is undisputed scientific fact. Overeating, dietary excesses and overloads with carbohydrates and fats increase the risk of diabetes, especially in persons who have an inherited predisposition to disease.

Diabetes mellitus is a disorder of carbohydrate metabolism resulting in insulin deficiency or impaired insulin action.

There is chronic hyperglycaemia (high blood sugar) due to a shortage of insulin, the inability to achieve insulin effects, or both.

Symptoms of untreated diabetes include excessive thirst, increased urine output, increased appetite, and poor wound healing.

Cardiovascular complications are a major cause of death in most diabetics, but also common among them are kidney disease, stroke, infections, eye diseases, neurological disorders, gangrene and others.

Type 1 diabetes is characterized by lack of insulin production of b-cells of islets of Langerhans of the pancreas. This is the type of diabetes that often occurs in children, especially those aged 10-14 years. Absolute insulin deficiency in these patients have his permanent injection imports. Therefore, this type of diabetes is referred to as insulin dependent diabetes mellitus.

Type 2 diabetes develops as a result of impaired sensitivity of cells to insulin action (insulin resistance), together with the delay or lack of insulin secretion. This insulin resistance leads to increased insulin requirements, which most individuals are unable to produce.

Sixty percent of patients with type 2 diabetes can maintain normal blood sugar levels by diet, physical activity, antidiabetic agents, which are taken orally, without insulin. This diabetes is insulin-type. It occurs mainly in people aged 40 However, in recent years have seen an increase in incidence among younger obese individuals. There is a direct correlation between obesity and insulin resistance in type 2 diabetes.
Orientations and behavior in diabetes.

As for the near and distant prognosis for this disease, the most important have good blood sugar control. Secondly, mandatory measures to regulate lipid metabolism (blood fat) and achieve a healthy weight.

Nutrition in diabetic patients plays a crucial role in their treatment.

Over the past 50 years has radically changed the views on this issue and present recommendations for nutrition of diabetic patients virtually inAdvice for diabetics:

• Control and optimization of body weight are particularly important.
• Attention is drawn to both quantitative and qualitative composition of the carbohydrates in food.
• Recommended mostly complex sugars and dietary fiber. Carbohydrates should supply 55% of daily food energy (E%).
• The recommended intake of fiber is at least 20-35 g / day.
• Moderate exercise improves insulin efficiency and energy consumption.
• Proteins should provide 10-20% E.
• The intake of fat should be less than 30 E%, sufficient import of polyunsaturated fatty acids (about 10% E).distinguishable from those of healthy people
• Eat a varied diet
• Increase consumption of whole grain bread, vegetables and fruits
• Maintain a healthy weight
• Reduce consumption of fat and saturated fatty acids
• Limit salt intake
• If you drink alcohol, do so in moderation
• Eat more fish
• Preserving the nutritional value and safety of food.

What exactly is the cause of diabetic foot problems? In most cases it is damage to the nerves that affect the legs and feet. This is called Diabetic Neuropathy. There is deterioration of these nerves due to high blood sugar levels in the body. Other factors are high blood fat, and high blood pressure. If you suffer from diabetics and are overweight or over 40 years of age there must be constant vigilance in keeping these levels down and also by checking your feet and legs daily.

The most common condition resulting from Foot Problems in a type 2 diabetic is called Peripheral Neuropathy. It is a loss of sensation which begins at the very tips of the toes and worms it way up the legs. It can result in infections and foot ulcers because there is no feeling. If there’s no feeling, you won’t be able to tell if you have injured your feet. If the infections are not treated it can lead to amputations. That is why a daily regime of foot and leg examinations is so important.

There are things that you can do every day to lessen the risk of infections in the feet of a diabetic. Wash your feet with warm water and soap, and gently dry them with a soft towel. To help with dry skin utilize a good lotion, but not between your toes. Keep your toenails trimmed with rounded edges. If you wear socks, then get seamless socks or ones with soft-flat seams. The important thing is to protect your feet, so wear shoes or slippers, even if you’re at home or enjoying the beach.

Because of the loss in sensitivity, a diabetic may not be able to feel a pebble or other debris in their shoes. It is a very good habit for any diabetic with foot numbness to shake their shoes out before putting them on. In the case where there is a break in the skin: a blister, rash, bruise, or redness, instead of trying to tend it yourself it is better to make an appointment with your physician as soon as possible. It is also highly suggested that any diabetic, especially those with foot problems have a thorough foot examination that will check your skin, muscles, bones and blood circulation, plus, a monofilament test to inspect the nerves in your feet at least once a year.

If you, or someone you know is a known diabetic and has begun to lose sensitivity in their feet to tell their doctor immediately. This is a very serious issue that can easily result in amputation.