Factors Associated With Myocardial Infarction in a Rural Population With Peripheral Arterial Diseases.

Peripheral arterial disease (PAD) studies in rural populations are limited. The incidence of myocardial infarction (MI) is higher in patients with PAD. This study examined the association between sociodemographic and clinical risk factors and MI in patients with PAD in Central Appalachia, comprising of 230 counties across six states in the United States. Data from electronic medical records of 13,455 patients with PAD were extracted from a large health system in Central Appalachia. Bivariate and logistic regression analyses were conducted. The final sample consisted of 5574 patients with PAD, of whom 24.85% were also diagnosed with MI. The mean age was 71 ± 11.23 years, and the majority were male (56.40%). After adjusting for confounders, patients with hypertension had three times higher odds of MI (adjusted Odds Ratio [aOR] = 3.21; 95% CI: 2.50-4.14) compared with those without hypertension. The likelihood of MI increased by 51% among patients with diabetes (aOR = 1.51; 95% CI: 1.33-1.71), 34% among ever-smokers (aOR = 1.34; 95% CI: 1.18-1.52), and 45% in males (aOR = 1.45; 95% CI: 1.27-1.65). Hypertension, diabetes, smoking, and male sex were identified as significant risk factors for MI. Screening and effective management of these risk factors in rural areas could potentially prevent MI incidence among patients with PAD.

COVID-19 vaccine hesitancy and health literacy in US Southern states.

OBJECTIVES: COVID-19 vaccination in the United States has stalled, with some of the lowest rates in the South. Vaccine hesitancy is a primary contributor and may be influenced by health literacy (HL). This study assessed the association between HL and COVID-19 vaccine hesitancy in a population residing in 14 Southern states. STUDY DESIGN: Cross-sectional study using a web-based survey conducted between February and June 2021. METHODS: The outcome was vaccine hesitancy, and the main independent variable was HL, assessed as an index score. Descriptive statistical tests were performed, and multivariable logistic regression analysis was conducted, controlling for sociodemographic and other variables. RESULTS: Of the total analytic sample (n = 221), the overall rate of vaccine hesitancy was 23.5%. Vaccine hesitancy was more prevalent in those with low/moderate HL (33.3%) vs those with high HL (22.7%). The association between HL and vaccine hesitancy, however, was not significant. Personal perception of COVID-19 threat was significantly associated with lower odds of vaccine hesitancy compared with those without perception of threat (adjusted odds ratio, 0.15; 95% CI, 0.03-0.73; P = .0189). The association between race/ethnicity and vaccine hesitancy was not statistically significant (P = .1571). CONCLUSIONS: HL was not a significant indicator of vaccine hesitancy in the study population, suggesting that general low rates of vaccination in the Southern region may not be due to knowledge about COVID-19. This indicates a critical need for place-based or contextual research on why vaccine hesitancy in the region transcends most sociodemographic differences.

Examining Disparities in Current E-Cigarette Use among U.S. Adults before and after the WHO Declaration of the COVID-19 Pandemic in March 2020.

This paper aims to estimate the prevalence of e-cigarette use before and after the COVID-19 pandemic declaration and to delineate disparities in use across subpopulations. Data were derived from the 2020 Health Information National Trends Survey (N = 3865) to conduct weighted multivariable logistic regression and marginal analyses. The overall prevalence of current e-cigarette use increased from 4.79% to 8.63% after the COVID-19 pandemic declaration. Furthermore, non-Hispanic Black people and Hispanic people had lower odds of current e-cigarette use than non-Hispanic White people, but no significant differences were observed between groups before the pandemic. Compared to heterosexual participants, sexual minority (SM) participants had higher odds of current e-cigarette use after the declaration, with insignificant differences before. People who had cardiovascular disease conditions, relative to those without, had higher odds of current e-cigarette use after the declaration, but no group differences were found before the declaration. The marginal analyses showed that before and after the pandemic declaration, SM individuals had a significantly higher probability of using e-cigarettes compared to heterosexual individuals. These findings suggest the importance of adopting a subpopulation approach to understand and develop initiatives to address substance use, such as e-cigarettes, during pandemics and other public health emergencies.

Setting Patient-Centered Priorities for Cardiovascular Disease in Central Appalachia: Engaging Stakeholder Experts to Develop a Research Agenda.

The disproportionate burden of cardiovascular diseases (CVD) and associated risk factors continues to exist in the Central Appalachian Region (CAR) of the United States. Previous studies to gather data about patient-centered care for CVD in the region were conducted through focus group discussions. There have not been any studies that used a collaborative framework where patients, providers, and community stakeholders were engaged as panelists. The objective of this study was to identify patient-centered research priorities for CVD in the CAR. We used a modified Delphi approach to administer questionnaires to forty-two stakeholder experts in six states representing the CAR between the fall of 2018 and the summer of 2019. Their responses were analyzed for rankings and derived priorities by research gaps. Six of the fifteen research priorities identified were patient-centered. These patient-centered priorities included shorter wait times for appointments; educating patients at their level; empowering patients to take responsibility for their health; access to quality providers; heart disease specialists for rural areas; and lifestyle changes. The participants' commitments to identify patient-centered research priorities indicate the potential to engage in community-based collaboration to address the burden of CVD in the CAR.

The prevalence of metabolic conditions before and during the COVID-19 pandemic and its association with health and sociodemographic factors.

BACKGROUND: There is a dearth of evidence on the relationship between COVID-19 and metabolic conditions among the general U.S. population. We examined the prevalence and association of metabolic conditions with health and sociodemographic factors before and during the COVID-19 pandemic. METHODS: Data were drawn from the 2019 (N = 5,359) and 2020 (N = 3,830) Health Information National Trends Surveys on adults to compare observations before (2019) and during (2020) the COVID-19 pandemic. We conducted weighted descriptive and multivariable logistic regression analyses to assess the study objective. RESULTS: During the pandemic, compared to pre-pandemic, the prevalence of diabetes (18.10% vs. 17.28%) has increased, while the prevalence of hypertension (36.38% vs. 36.36%) and obesity (34.68% vs. 34.18%) has remained similar. In general, the prevalence of metabolic conditions was higher during the pandemic (56.09%) compared to pre-pandemic (54.96%). Compared to never smokers, former smokers had higher odds of metabolic conditions (AOR = 1.38, 95% CI = 1.01, 1.87 and AOR = 1.57, 95% CI = 1.10, 2.25) before and during the pandemic, respectively. People with mild anxiety/depression symptoms (before: AOR = 1.52, 95% CI = 1.06, 2.19 and during: AOR = 1.55, 95% CI = 1.01, 2.38) had higher odds of metabolic conditions relative to those with no anxiety/depression symptoms. CONCLUSION: This study found increased odds of metabolic conditions among certain subgroups of US adults during the pandemic. We recommend further studies and proper allocation of public health resources to address these conditions.

Correction: Perceptions of risk for COVID-19 among individuals with chronic diseases and stakeholders in Central Appalachia.

[This corrects the article DOI: 10.1057/s41599-021-00906-7.].

First evidence for a pharmacist-led anticoagulant clinic in a medicare part A long term care environment.

Anticoagulation risks in older adult, long-term care patients are known to be high, especially in those with frequent transitions between care environments. Introduction of collaborative practice agreements (CPA) in specific settings is encouraged in the United States and has provided an additional option for the care of medically challenging patients. The aim of this study was to investigate the time in therapeutic range (TTR) in a Medicare Part A sponsored long-term care environment managed by pharmacists through a collaborative practice agreement in South-Central Appalachia. A retrospective review of all warfarin patient admissions from a large long-term care pharmacy's anticoagulant clinic was conducted for residents over an 18-month period. For all patients (n = 104), the overall TTR was 46.7% (INR 43% in range). Average management duration was 19.5 days per patient. Further studies are required to optimize CPA and transition strategies for complex, advanced age warfarin patients.

Faculty Applicants' Attempt to Inflate CVs Using Predatory Journals.

Recently, scientific publishing has experienced an expansion of journals and publishers whose primary goal is profit and whose peer review process is virtually non-existent. These "predatory" or "opportunistic" journals pose a threat to the credibility and integrity of legitimate scientific literature, and quality science. Unfortunately, many scientists choose to publish in these journals and/or serve on their editorial boards, either due to ease of rapid publication or naivety. Here, we highlight the extensive use of predatory publications or editorial board involvement by applicants applying for a faculty position in the Pharmaceutical Sciences department at the Bill Gatton College of Pharmacy at East Tennessee State University. We caution search committees at other pharmacy schools to thoroughly examine applicant curricula vitarum (CVs) for predatory publishing.

Comparison of Postoperative Bleeding in Total Hip and Knee Arthroplasty Patients Receiving Rivaroxaban, Enoxaparin, or Aspirin for Thromboprophylaxis.

BACKGROUND: Guidelines recommend the use of multiple pharmacologic agents and/or mechanical compressive devices for prevention of venous thromboembolism, but preference for any specific agent is no longer given in regard to safety or efficacy. OBJECTIVE: To compare postoperative bleeding rates in patients receiving enoxaparin, rivaroxaban, or aspirin for thromboprophylaxis after undergoing elective total hip arthroplasty or total knee arthroplasty. METHODS: This retrospective cohort analysis evaluated patients who received thromboprophylaxis with either enoxaparin, rivaroxaban, or aspirin. All data were collected from the electronic medical record. The primary outcome was any postoperative bleeding. RESULTS: A total of 1244 patients were included with 366 in the aspirin, 438 in the enoxaparin, and 440 in the rivaroxaban arms. Those who received aspirin or enoxaparin were less likely to experience any bleeding compared to those patients who received rivaroxaban ( P < .05). There was also a lower rate of major bleeding in these groups, but the differences were not significant. CONCLUSIONS: Aspirin and enoxaparin conferred similar bleeding risks, and both exhibited less bleeding than patients who received rivaroxaban.

Student Performance in a Pharmacotherapy Oncology Module Before and After Flipping the Classroom.

Objective. To determine if a flipped classroom improved student examination performance in a pharmacotherapy oncology module. Design. Third-year pharmacy students in 2012 experienced the oncology module as interactive lectures with optional case studies as supplemental homework. In 2013, students experienced the same content in a primarily flipped classroom. Students were instructed to watch vodcasts (video podcasts) before in-class case studies but were not held accountable (ie, quizzed) for preclass preparation. Examination questions were identical in both cohorts. Performance on examination questions was compared between the two cohorts using analysis of covariance (ANCOVA), with prior academic performance variables (grade point average [GPA]) as covariates. Assessment. The students who experienced the flipped classroom approach performed poorer on examination questions than the cohort who experienced interactive lecture, with previous GPA used as a covariate. Conclusion. A flipped classroom does not necessarily improve student performance. Further research is needed to determine optimal classroom flipping techniques.

A descriptive investigation of the impact of student research projects arising from elective research courses.

BACKGROUND: Pharmacy academicians have noted the need to develop research skills in student pharmacists. At the Gatton College of Pharmacy, significant focus has been placed on the development of research skills through offering elective research courses. In order to evaluate the impact of participation in the research elective(s), we analyzed college records and surveyed faculty members with regard to the number of poster/podium presentations, published peer-reviewed manuscripts, and funded projects. RESULTS: Student enrollment in the research elective sequence has increased over time and has resulted in 81 poster presentations, 14 podium presentations, and 15 peer-reviewed publications. CONCLUSIONS: Implementation of a research elective sequence and fostering of a research culture amongst the faculty and students has resulted in increased student engagement in research and related scholarly activities.

Comparison of Postoperative Bleeding in Total Hip and Knee Arthroplasty Patients Receiving Rivaroxaban or Enoxaparin.

BACKGROUND: The Regulation of Coagulation in Orthopedic Surgery to Prevent Deep Venous Thrombosis and Pulmonary Embolism (RECORD) 1 to 4 trials compared rivaroxaban 10 mg daily with commonly used doses of enoxaparin and demonstrated similar rates of VTE and bleeding. OBJECTIVE: To evaluate bleeding events between patients who received enoxaparin or rivaroxaban for prevention of venous thromboembolism (VTE) following total hip arthroplasty (THA) or total knee arthroplasty (TKA). METHODS: Retrospective cohort that compared patients undergoing THA and TKA who received enoxaparin (enoxaparin) with those who received rivaroxaban (rivaroxaban) and also with those who received enoxaparin in the RECORD 1 to 4 trials (enoxaparin RECORD). The primary outcome was any postoperative bleeding, defined as a composite of major and clinically relevant nonmajor bleeding based on the definitions in the RECORD 1 to 4 trials. RESULTS: There was a lower rate of any postoperative bleeding (2.2% vs 6.8%, P = 0.004) in patients who received enoxaparin compared with rivaroxaban, and bleeding rates between the enoxaparin group and the enoxaparin RECORD groups were similar (2.2% vs 2.5%, P = 0.085). Major bleeding in the enoxaparin group (0.2%) was not significantly different from that in the rivaroxaban group (1.4%, P = 0.12) or the RECORD group (0.2%, P = 0.93). Clinically relevant nonmajor bleeding was also lower in the enoxaparin group compared with the rivaroxaban group (2.0% vs 5.5%, P = 0.012). CONCLUSIONS: The use of enoxaparin for VTE prophylaxis following THA and TKA was associated with a lower rate of the primary outcome (any postoperative bleeding) compared with the use of rivaroxaban in a similar cohort of patients.

Retrospective Evaluation of Postoperative Bleeding Events in Patients Receiving Rivaroxaban After Undergoing Total Hip and Total Knee Arthroplasty: Comparison with Clinical Trial Data.

STUDY OBJECTIVE: Although data from the Regulation of Coagulation in Orthopedic Surgery to Prevent Deep Venous Thrombosis and Pulmonary Embolism (RECORD) 1-4 trials have shown a similar postoperative bleeding risk between rivaroxban and enoxaparin in patients undergoing total hip arthroplasty (THA) and total knee arthroplasty (TKA), anecdotal observations from local institutions have suggested that postoperative bleeding rates seemed higher in patients who received rivaroxaban than those reported in the RECORD trials. Thus, the objective of this pilot study was to assess postoperative bleeding events observed in clinical practice in patients receiving rivaroxaban after undergoing THA and TKA and to compare their results with those published in the RECORD trials. DESIGN: Retrospective cohort study with a comparator group of patients from the RECORD 1-4 trials. SETTING: Two institutions within a regional health care system. PATIENTS: Four hundred forty adults who received at least one dose of rivaroxaban 10 mg daily after undergoing THA or TKA in the two institutions between August 2011 and October 2013 (cohort group), and 6183 patients who received rivaroxaban in the RECORD 1-4 trials (comparator group). MEASUREMENTS AND MAIN RESULTS: Postoperative bleeding was assessed in the cohort patients versus the patients in the RECORD trials. The primary outcome, occurrence of any postoperative bleeding, was a composite of major and clinically relevant nonmajor bleeding as defined in the RECORD trials. Any postoperative bleeding occurred in 6.8% of the cohort patients versus 3.2% of the RECORD trial patients (p<0.0001); 1.4% of the cohort patients versus 0.38% of the RECORD trial patients suffered a major bleed (p=0.013). Within defined major bleeding, bleeding leading to reoperation and clinically overt extrasurgical site bleeding resulting in either a hemoglobin level decrease of at least 2 g/dl or transfusion of 2 units or greater of packed red blood cells were reported in 0.68% versus 0.19% (p=0.073) and 0.68% versus 0.13% (p=0.032), respectively, of the cohort patients versus the RECORD trial patients. CONCLUSION: Overall, any postoperative bleeding in the cohort patients occurred significantly more frequently than that observed in the RECORD trial patients. The major bleeding rate was also significantly higher in the cohort patients, influenced by higher rates of bleeding leading to reoperation and clinically overt extrasurgical site bleeding resulting in either a hemoglobin decrease of at least 2 g/dl or transfusion of two units or greater of packed red blood cells. These findings from our pilot study are thought provoking and, thus, invite further investigation.

A Subgroup Analysis of the Impact of Self-testing Frequency on Examination Scores in a Pathophysiology Course.

OBJECTIVE: To determine if the frequency of self-testing of course material prior to actual examination improves examination scores, regardless of the actual scores on the self-testing. METHODS: Practice quizzes were randomly generated from a total of 1342 multiple-choice questions in pathophysiology and made available online for student self-testing. Intercorrelations, 2-way repeated measures ANOVA with post hoc tests, and 2-group comparisons following rank ordering, were conducted. RESULTS: During each of 4 testing blocks, more than 85% of students took advantage of the self-testing process for a total of 7042 attempts. A consistent significant correlation (p≤0.05) existed between the number of practice quiz attempts and the subsequent examination scores. No difference in the number of quiz attempts was demonstrated compared to the first testing block. Exam scores for the first and second testing blocks were both higher than those for third and fourth blocks. CONCLUSION: Although self-testing strategies increase retrieval and retention, they are uncommon in pharmacy education. The results suggested that the number of self-testing attempts alone improved subsequent examination scores, regardless of the score for self-tests.

Aspirin for the prophylaxis of venous thromboembolic events in orthopedic surgery patients: a comparison of the AAOS and ACCP guidelines with review of the evidence.

BACKGROUND: The American Academy of Orthopaedic Surgeons (AAOS) and the American College of Chest Physicians (ACCP) have both developed evidence-based guidelines to prevent venous thromboembolism (VTE) in high-risk orthopedic surgery patients. Recent changes to these documents have brought them into agreement as to the inclusion of aspirin as an appropriate option for VTE prophylaxis in this patient population. OBJECTIVE: To evaluate the appropriateness of aspirin to prevent VTE in high-risk orthopedic surgery patients. DATA SOURCES: Guidelines published by the AAOS in 2011 and the ACCP in 2012 were compared regarding their recommendations on the use of aspirin for the prevention of VTE. A literature search was also conducted to identify clinical trials that evaluated the use of aspirin for the prevention of VTE in this patient population. Search terms included the MeSH terms venous thromboembolism; venous thrombosis; pulmonary embolism; aspirin; arthroplasty, replacement, knee; arthroplasty, replacement, hip; and hip fractures/surgery. STUDY SELECTION AND DATA EXTRACTION: Any study that evaluated aspirin, even in combination with another method of prophylaxis (such as pneumatic compression devices), and had been published during or after 1985 was included. DATA SYNTHESIS: Randomized controlled trials, meta-analyses, and other large pooled and retrospective reviews have failed to consistently arrive at similar conclusions regarding the efficacy and safety of aspirin as an option for VTE prophylaxis in patients undergoing total knee arthroplasty (TKA), total hip arthroplasty (THA), or hip fracture surgery (HFS). Disagreements in the appropriateness of surrogate markers for safety and efficacy have resulted in differing recommendations from the ACCP and AAOS. The primary argument lies in the appropriateness of deep vein thrombosis as a surrogate marker for more serious outcomes such as pulmonary emboli. CONCLUSIONS: Recent changes to both the ACCP and AAOS guidelines are in agreement for those who choose to use aspirin for chemoprophylaxis of VTE. Current surgical care improvement project measures do not include aspirin as an appropriate sole option for the prevention of VTE, but in patients undergoing elective TKA or who have a contraindication to pharmacologic prophylaxis and undergo a THA or HFS, aspirin in conjunction with compression devices as part of a multimodal approach would meet these measures. Data do not support the hypothesis that aspirin is less likely to cause adverse bleeding events than more potent anticoagulants.

Coltsfoot as a potential cause of deep vein thrombosis and pulmonary embolism in a patient also consuming kava and blue vervain.

OBJECTIVE: To report a case of deep vein thrombosis (DVT) with symptomatic pulmonary embolism (PE) possibly associated with the use of coltsfoot, kava, or blue vervain. CASE SUMMARY: A 27-year-old white male presented with leg pain and swelling, tachycardia, and pleuritic chest pain. He had no significant medical history. A medication history revealed extensive herbal medication use including: coltsfoot, passionflower, red poppy flower petals, wild lettuce, blue lily flowers, wild dagga flowers, Diviners Three Burning Blend® (comprised of salvia divinorum, blue lily, and wild dagga), kava-kava, St. John's Wort, blue vervain, and Dreamer's Blend® (comprised of Calea zacatechichi, vervain, Entada rheedii, wild lettuce, and Eschscholzia californica). Lower extremity Doppler ultrasound and computed topography (CT) of the chest revealed DVT and PE. A hypercoagulable work-up was negative. The patient was treated with enoxaparin and warfarin and was discharged home. DISCUSSION: While no distinct agent can be identified as a sole cause of this venous thromboembolic event, coltsfoot could potentially affect coagulation through its effect on vascular endothelial cells as they regulate nitric oxide. Nitric oxide is a known mediator of platelet activity and coagulation, particularly in the pulmonary vasculature. Kava and vervain have estrogenic properties. CONCLUSIONS: Of the medications consumed by this self-proclaimed "herbalist," coltsfoot is a potential cause of venous thromboembolic disease (VTE).

The severity and duration of postoperative pain and analgesia requirements in children after tonsillectomy, orchidopexy, or inguinal hernia repair.

OBJECTIVES: To provide parents of children with accurate information regarding postoperative pain, its management, and functioning following common surgical procedures. BACKGROUND: The increasing prevalence of pediatric day-case procedures demands a more thorough understanding of the recovery profiles associated with these operations. AIM: To document postdischarge pain profiles, analgesia requirements, and functional limitation in children following tonsillectomy, orchidopexy, or inguinal hernia repair (IHR). METHODS: Following hospital discharge, parents were asked to record their children's pain levels, analgesia consumption, and degree of functional limitation each day until complete recovery. Pain and functional limitation were measured using the Parents' Postoperative Pain Measurement (PPPM) scale and Functional Activity Score, respectively. Significant pain was defined as PPPM ≥ 6. RESULTS: One hundred and five patients (50, tonsillectomy; 24, orchidopexy; and 31, IHR) were recruited. Median PPPM was always <6 after IHR, ≥6 only on day 1 after orchidopexy and persisted through to day 8 after tonsillectomy. Mild or severe functional limitation was observed after all surgeries and persisted for 4, 5, and 4 days after median PPPM < 6 after IHR, orchidopexy, and tonsillectomy, respectively. Combination analgesia was commonly administered after orchidopexy and tonsillectomy but less so after IHR. The general practitioner consultation rate following tonsillectomy was 54%. CONCLUSIONS: After tonsillectomy, children experience significant pain and severe functional limitation for 7 days after surgery. For many children, pain and functional limitation persists throughout the second postoperative week. In children undergoing orchidopexy, paracetamol and ibuprofen provide adequate analgesia. Pain begins to subside after the first postoperative day, and normal activity resumes after 7 days. After IHR, children experience mild pain that can be treated with paracetamol and return to normal functioning after 4 days.

Active-learning processes used in US pharmacy education.

OBJECTIVE: To document the type and extent of active-learning techniques used in US colleges and schools of pharmacy as well as factors associated with use of these techniques. METHODS: A survey instrument was developed to assess whether and to what extent active learning was used by faculty members of US colleges and schools of pharmacy. This survey instrument was distributed via the American Association of Colleges of Pharmacy (AACP) mailing list. RESULTS: Ninety-five percent (114) of all US colleges and schools of pharmacy were represented with at least 1 survey among the 1179 responses received. Eighty-seven percent of respondents used active-learning techniques in their classroom activities. The heavier the teaching workload the more active-learning strategies were used. Other factors correlated with higher use of active-learning strategies included younger faculty member age (inverse relationship), lower faculty member rank (inverse relationship), and departments that focused on practice, clinical and social, behavioral, and/or administrative sciences. CONCLUSIONS: Active learning has been embraced by pharmacy educators and is used to some extent by the majority of US colleges and schools of pharmacy. Future research should focus on how active-learning methods can be used most effectively within pharmacy education, how it can gain even broader acceptance throughout the academy, and how the effect of active learning on programmatic outcomes can be better documented.

Pharmacist's role in an interdisciplinary falls clinic.

Falls are caused by many factors in older patients. Medications have been shown to be a risk factor for falls, and studies have shown that patients taking more than five total medications may have a two-fold increased risk of impaired balance. A more recent model suggests only medications with sedating and anticholinergic properties contribute significantly to physical impairment. The authors of this paper helped to develop a multidisciplinary clinic to evaluate the risk of falls in at-risk patients. We present the case of a woman on multiple medications that increased her risk of falling. Of note, this patient was taking a total of 14 prescription medications, seven of which were considered sedating. Based on a comprehensive medication evaluation, six specific changes were recommended to improve this patient's medication regimen and reduce her risk of falling.

Recurrent deep vein thrombosis despite warfarin therapy in a patient with Crohn's disease.

Patients with inflammatory bowel disease (IBD) are known to have an increased propensity for thromboembolic events. Like any patient with a high risk of event recurrence, most of these patients can be managed successfully with long-term warfarin therapy. We present the case of a 66-year-old woman with Crohn's disease who, despite careful attention to the management of her international normalized ratio, developed a new deep vein thrombosis and required inferior vena cava filter placement in addition to ongoing warfarin therapy to prevent recurrent pulmonary emboli. This report serves as a reminder to physicians to have a low threshold for diagnosing thromboembolic events in patients with IBD, even if they are presumed to be adequately anticoagulated. Known and theoretical contributing factors to this increased clotting tendency are also reviewed.