Protamine sulfate for the reversal of enoxaparin associated hemorrhage beyond 12 h.

Clinical practice guidelines recommend protamine sulfate for reversal of enoxaparin associated bleeds dependent on the time from last administration and dose of enoxaparin. We present a case of a hemodynamically unstable patient with an enoxaparin induced abdominal wall hematoma/hemorrhage and the previous enoxaparin administration 21.5 h prior to presentation with a therapeutic anti-Xa assay (0.8 IU/mL) upon assessment in the emergency department. Along with resuscitative efforts, an interdisciplinary team collaborated to administer protamine sulfate 50 mg intravenous once (0.5 mg per 1 mg of enoxaparin) to reverse the therapeutic anticoagulation. Our case demonstrates the importance of monitoring renal function and the potential for accumulation of enoxaparin in patients with renal dysfunction leading to prolonged therapeutic anti-Xa assays. With the availability of anti-Xa assays, future reversal recommendations of enoxaparin associated bleeds using protamine sulfate should include the initial anti-Xa assay as a guide for the dosing regimen.

The Role of Nonvitamin K Antagonist Oral Anticoagulants (NOACs) in Stroke Prevention in Patients with Atrial Fibrillation.

Anticoagulation is important in stroke prevention in patients with atrial fibrillation. Until recently, heparins and vitamin K antagonists were the only available therapy for stroke reduction in atrial fibrillation (AF) patients. Non-vitamin K antagonist oral anticoagulants (NOACs) including direct thrombin inhibitor (dabigatran) and direct factor Xa inhibitors (rivaroxaban, apixaban and edoxaban) are now available and offer new options for stroke prevention. This article reviews the available data on the use of NOACs for primary and secondary stroke prevention in AF patients and describes specific patient populations to guide clinician in making the informed decision regarding appropriate use of those agents. It also addresses the use of NOACs early after acute stroke and use of thrombolysis while on NOAC.

The nature of the pandemic: Exploring the negative impacts of the COVID-19 pandemic upon recreation visitor behaviors and experiences in parks and protected areas.

The COVID-19 pandemic dramatically affected parks and protected areas and overall recreation visitation across the United States. While outdoor recreation has been demonstrated to be beneficial, especially during a pandemic, the resulting increase in recreation visitation raises concerns regarding the broader influence of social, situational, ecological, and behavioral factors upon overall visitor experiences. This study investigated the extent to which recreation visitors' behaviors and experiences have been impacted by the COVID-19 pandemic within the White Mountain National Forest (WMNF). A modified drop-off pick-up survey method was employed to collect population-level data from WMNF visitors from June to August of 2020 (n=317), at the height of the pandemic. Results from this mixed-method study suggest social factors (e.g., crowding and conflict), situational factors (e.g., access and closures), ecological factors (e.g., vegetation damage), behavioral factors (e.g., substitution), and sociodemographic factors (e.g., gender and income) significantly influenced overall visitor decision-making and experience quality within the WMNF. For example, more than one-third of visitors indicated the pandemic had either a major or severe impact upon their WMNF recreation experience. A more nuanced investigation of qualitative data determined that the majority of pandemic-related recreation impacts revolved around the themes of social impacts, general negative recreation impacts, situational and ecological impacts, and behavioral adaptation impacts. Moreover, historically marginalized populations (e.g., low-income households and females) within the sample reported significantly higher recreation experience impacts during the pandemic. This study demonstrates the influence of the pandemic upon outdoor recreation visitor experiences and behaviors and considers outdoor recreation as a central component within the broader social-ecological systems framework. This study demonstrates the influence of the pandemic upon outdoor recreation visitor experiences and behaviors and considers resource users a central component within the broader social-ecological systems conceptual framework. Management implications: This study found that during the peak of the COVID-19 pandemic, social, situational, ecological, behavioral, and sociodemographic factors significantly influenced overall visitor decision-making andexperience quality:· Social and general recreation impacts were most common, with approximately 56% of the sample reporting these issues.· Results suggest significant crowding and conflict impacts stemmed from interactions between in-state and out-of-state visitors, largely based upon perceived violations of pandemic protocols.· Moreover, historically marginalized populations stated unique recreation impacts during the pandemic. For instance, visitors from low-income households reported significantly less substitution options as opposed to high-income visitors.· Female visitors perceived significantly more pandemic-related conflict than male visitors.Study findings suggest visitor crowding and conflict should be prioritized by resource managers, especially amongst historically marginalized populations. Resource managers should consider adopting a broader social-ecological systems approach to parks and protected areas management, particularly during a global pandemic.

Back to the future: The potential relationship between leisure and education.

There is a long, documented history of the relationships among leisure, recreation, and education dating back to Greek philosophy.Originally there was little differentiation among the terms as they were presented as a unified process for youth and human development. Over time, each of these fields has developed, and their definitions have been shaped and reshaped. Using some of the original conceptions from Aristotle and Plato, coupled with foundational premises suggested by Dewey, this article frames current youth development efforts in a historical context. The authors suggest that perhaps what the separate professions might define as high-quality leisure, recreation, and educational experiences still maintain links among each. They further suggest that planned experiences with increasing levels of coordination can strengthen these links and develop an "education-for-leisure" perspective among participating youth and the choices they make. Self-determination theory (SDT) refers to the autonomy in choosing a particular behavior or action. Youth development opportunities that make connections between the content of a regular school day and choice of activity during out-of-school time can inculcate self-determined leisure choices that are productive. Planned and intentional educational experiences expand the possibilities for productive recreational choices. This article therefore proposes a framework for increasing levels of coordination among educational and recreational entities so that participating youth can develop and adopt an education-for-leisure disposition.

A competency-based approach to preparing staff as recreation and youth development leaders.

Youth development professionals and parks and recreation professionals often are charged with providing services to youth. However, the approach of each can be quite different as recreation is a primary focus for recreation professionals and part of many services offered by youth development specialists. Despite the differences, these two groups of professionals can learn a great deal from each other. This article examines youth development and staff training with examples from the field and suggests how youth development professionals can learn from recreation professionals and vice versa. It suggests that parks and recreation professionals can strengthen degree programs, accreditation, certification, and continuing education by incorporating specific youth development competencies established by the National Collaboration for Youth. For their part, youth development professionals can learn from parks and recreation professionals how to enhance recreation programming as part of their services by gaining an understanding of program design, program and activity leadership, and administrative practices. With much debate over whether more education or more experience is a better path for those working with youth, the authors suggest that a combination of both will adhere to the quality of staff. Staff gain further knowledge and skill from academic preparation at the undergraduate and graduate levels, field-based training through jobs and internships, and continuing education courses specializing in youth development competencies and recreation-based competencies set within a youth development environment.

COVID-19 pandemic: Challenges and solutions from the cardiology pharmacist's perspective.

The recent coronavirus disease 2019 (COVID-19) pandemic caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) challenges pharmacists worldwide. Alongside other specialized pharmacists, we re-evaluated daily processes and therapies used to treat COVID-19 patients within our institutions from a cardiovascular perspective and share what we have learned. To develop a collaborative approach for cardiology issues and concerns in the care of confirmed or suspected COVID-19 patients by drawing on the experiences of cardiology pharmacists across the country. On March 26, 2020, a conference call was convened composed of 24 cardiology residency-trained pharmacists (23 actively practicing in cardiology and 1 in critical care) from 16 institutions across the United States to discuss cardiology issues each have encountered with COVID-19 patients. Discussion centered around providing optimal pharmaceutical care while limiting staff exposure. The collaborative of pharmacists found for the ST-elevation myocardial infarction patient, many institutions were diverting COVID-19 rule-out patients to their Emergency Department (ED). Thrombolytics are an alternative to percutaneous coronary intervention (PCI) allowing for timely treatment of patients and decreased staff exposure. An emergency response grab and go kit includes initial drugs and airway equipment so the patient can be treated and the cart can be left outside the room. Cardiology pharmacists have developed policies and procedures to address monitoring of QT prolonging medications, the use of inhaled prostacyclins, and national drug shortages. Technology has allowed us to practice social distancing, while staying in close contact with our teams, patients, and colleagues and continuing to teach. Residents are engaged in unique decision-making processes with their preceptors and assist as pharmacist extenders. Cardiology pharmacists are in a unique position to work with other pharmacists and health care professionals to implement safe and effective practice changes during the COVID-19 pandemic. Ongoing monitoring and adjustments are necessary in rapidly changing times.

Dobutamine-induced eosinophilia.

A man with dilated cardiomyopathy presented with decompensated heart failure and marked eosinophilia. After extensive clinical and laboratory evaluation for hypereosinophilic syndrome, including a myocardial biopsy, it was determined by means of rechallenge (second dobutamine infusion) that the patient was afflicted with dobutamine-induced eosinophilia. This report is important because of the high utilization rate of this drug in a sick population. Simply discontinuing it or switching to another agent can avert the high cost and risk of the evaluation for hypereosinophilic syndrome in this compromised group of patients.

Eptifibatide-associated acute, profound thrombocytopenia.

OBJECTIVE: To describe 3 cases of eptifibatide-associated acute, profound thrombocytopenia. CASE SUMMARIES: A 40-year-old black female received eptifibatide 180-microg/kg double bolus followed by a continuous infusion of 2 microg/kg/min for percutaneous coronary intervention (PCI). The platelet count decreased from 308 x 10(3)/mm3 to 2 x10(3)/mm3 4 hours after initiation of eptifibatide. Eptifibatide was discontinued and platelets were transfused. The patient developed a hematoma and petechiae. A 67-year-old white female received the same dosage regimen of eptifibatide for PCI with no serious adverse effects, with the treatment repeated one month later. At that time, she developed chest and back pain, dyspnea, wheezing, and hypotension after the first bolus. Her platelet count decreased from 334 x10(3)/mm3 to 6 x10(3)/mm3 24 hours after initiation. Eptifibatide was discontinued and platelets were transfused. The patient died due to shock. A 72-year-old white male received eptifibatide 180-microg/kg double bolus followed by a continuous infusion of 2 microg/kg/min for acute coronary syndrome. His platelet count decreased from 189 x10(3)/mm3 to 17 x10(3)/mm3, and eptifibatide was discontinued. Eptifibatide was readministered with bivalirudin for PCI once the platelet count increased to 94 x10(3)/mm3. Sixteen hours later, the platelet count decreased to 1 x 10(3)/mm3. Eptifibatide was discontinued and platelets were transfused. The patient developed a hematoma. DISCUSSION: Acute, profound thrombocytopenia is a rare complication of glycoprotein IIb/IIIa inhibitor therapy characterized by a precipitous decline in platelet count to <20 x10(3)/mm3 within 24 hours of therapy. An objective causality assessment revealed that the adverse drug event was probable in 2 cases and possible in the other. CONCLUSIONS: Increasing use of the glycoprotein IIb/IIIa inhibitors and enhanced recognition of the potential for acute, profound thrombocytopenia reinforce the need for more vigilant monitoring and alternative management strategies.