Dalteparin as periprocedure anticoagulation for patients on warfarin and at high risk of thrombosis.

BACKGROUND: Patients taking warfarin and at high risk for thromboembolic complications have traditionally been hospitalized for two to three days to receive standard treatment with intravenous heparin both prior to and following procedures while their international normalized ratio (INR) is subtherapeutic. OBJECTIVE: To assess the feasibility of protocol implementation for outpatient anticoagulation with low-molecular-weight heparin to eliminate or reduce the length of hospital admission needed solely for anticoagulation. METHODS: Patients included were receiving warfarin for a prosthetic heart valve, mitral valve disease with atrial fibrillation, or recent episode of venous thromboembolism. Warfarin was discontinued four days prior to the procedure. Subcutaneous dalteparin 200 units/kg was given on the two mornings prior to the procedure and restarted 12-24 hours after the procedure until the INR was in the therapeutic range. Warfarin was reinitiated on the evening of surgery. RESULTS: Twenty-four patients underwent 26 procedures. There were two minor bleeding complications, and one patient experienced a transient ischemic attack. Patients received a median of five days of dalteparin. The INR returned to the therapeutic range on the median postoperative day 4. All patients avoided two days of hospitalization prior to the procedure (i.e., no patients needed to be admitted preoperatively for anticoagulation). A median of four days would have been required for the sole purpose of postoperative anticoagulation. CONCLUSIONS: Outpatient perioperative anticoagulation with dalteparin for high-risk patients requiring long-term oral anticoagulation appears feasible and warrants further study.

Identifying and mapping community vulnerability.

Disaster vulnerability is socially constructed, i.e., it arises out of the social and economic circumstances of everyday living. Most often discussed from the perspective of developing nations, this article extends the argument using American demographic trends. Examples from recent disasters, Hurricane Andrew in particular, illustrate how certain categories of people, such as the poor, the elderly, women-headed households and recent residents, are at greater risk throughout the disaster response process. Knowledge of where these groups are concentrated within communities and the general nature of their circumstances is an important step towards effective emergency management. Emergency planners, policy-makers and responding organisations are encouraged to identify and locate high-risk sectors on Community Vulnerability Maps, integrating this information into GIS systems where feasible. Effective disaster management calls for aggressively involving these neighbourhoods and groups at all levels of planning and response, as well as mitigation efforts that address the root causes of vulnerability.

What's gender "got to do with it"?

PIP: Disaster researchers are accumulating clear evidence that, as a group, women are likely to respond, experience, and be affected by disasters in ways which are qualitatively different. At the same time, it is important to recognize and document women's diversity. Clearly, not all women experience disasters uniformly. For example, a White, middle-class professional woman in an American town will be affected differently by disaster than will a sub-Saharan women in seclusion or a disabled Brazilian elder. Privilege is relative to one's location in a given set of social, economic, political, and religious circumstances, of which gender is only 1 major factor. However, understanding how gender relates to the complex interplay of power, resources, privilege, and stratification will increase the effectiveness of emergency and disaster management efforts.^ieng