#doac

[terrafey]

true crime has nothing on listening to people talk about scientific fraud and failing businesses. stop harrassing victims and their families and start clowning on CEOs. go watch two hours of a video essay talking about a guy who got his phd taken away for his poor behavior

[soulinkpoetry]

This is too funny not to post. This is James Sexton , a divorce lawyer on the DOAC diary of a CEO podcast.

Love truly blinds us. Once those feel good chemicals start to run through your veins, all logic goes out the window. 😆

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[xxxsimplyhookedxxx]

Cole Sprouse: My Narcissistic Mum Sacrificed My Childhood For Fame! | E229

[mcatmemoranda]

Anticoagulation Lecture 6/21/23

Factor Xa inhibitors = rivaroxaban, apixaban (Eliquis)

Direct thrombin inhibitor = dabigatran

Vitamin K inhibitor = warfarin

Apixaban has the lowest bleeding risk compared to the other Direct Oral Anticoagulants (DOACs); avoid in pts with BMI greater than or equal to 40 or weight more than 120 kg. Avoid dual inhibitors or inducers of CYP3A4 and P-gp.

VTE/PE tx = 10mg bid x7 days, then 5 mg bid

AFib = 5 mg bid (reduce to 2.5 mg bid if Cr greater than or equal to 1.5 or weight less than 60 kg or age greater than 80

Rivaroxaban (Xarelto) = once daily dosing compared to Eliquis

VTE/PE: 15 mg bid x21 days; then 20 mg qd

AFib: 20 mg qd with food to increase absorption

PAD/CAD: 2.5 mg bid (+antiplatelets if at increased risk)

Avoid with CYP3A4 inhibitors or inducers and P-gp

Edoxaban (Savaysa) – not used in pts with CrCl greater than 95

VTE/PE = parenteral anticoagulation for 5-10 days, then PO

VTE/PE/AFib = 60 mg qd

Does not have reversal agent like other DOACs do (which are reversed with Kcentra or andexanet)

Dabigatran (Pradaxa)

AFib: 150 mg bid; consider 110 mg bid if bleeding risk

VTE/PE: 5 days IV, then 150 mg bid

VTE ppx after THA/TKA: initial 110 mg once, then 220 mg qd x10-35 days

5-10 day bridge required for PE/VTE

Caution in pts greater than 75 years due to increased bleeding risk

Has own reversal agent (praxbind; idarucizumab)

C/I in pts with prosthetic heart valve

Store in original bottle and discard if unused after 4 months

Eliquis and Xarelto can be crushed and given via feeding tubes.

Warfarin (Coumadin)

Dosing is pt specific. Goal INR is 2-3. (2.5-3.5 if mechanical mitral valve).

Slow onset; slow time to steady state means dose taken today may not be reflected in INR for several days (2-4 days).

So many drug-drug interactions!

Metabolized by CYP pathways

Vitamin K antagonist

Dosing: recommend taking at night because INR is taken during the day, makes it easier to adjust dose.

Warfarin’s therapeutic steady state is based on half-lives of clotting factors. At least 5 days of consecutive warfarin needed for pt to be fully anticoagulated (this is why you use heparin until they get to this point).

Usually start with 5 mg qd. If bleeding risk, start with 2.5 mg qd. For obese pts or otherwise healthy/young can start with 7.5 mg qd. You go to maintenance protocol on 7th day.

Pts on VTE/PE tx are not anticoagulated the first 5 days, so use heparin IV or LMWH outpt. Once anticoagulated x24 hours, d/c heparin.

Start with 5 mg warfarin for first 3 days, then follow up with warfarin clinic on day 4. Typically, pt goes for weekly INRs. Then when at goal INR for 2 weeks, can spread out how often they f/u on their INR levels. Eventually they can go q6-8 weeks to check INR level.

VTE/PE – always bridge

AFib – risk assess to see whether heparin bridging is needed (assess bleeding risk [HASBLED]; CHA2DS2VASc for thrombotic risk).

Every 10 years, the dosing needed will decrease by 10%, so as pts age, the dose of warfarin needed will decrease.

DOACs = no INR monitoring, no dietary interactions, lower rates of bleeding, limited availability of reversal agent; contraindicated in pts with mechanical heart valves

AFib – AC (anticoagulate) indefinitely

1st VTE or PE that is provoked – AC for 3 months

1st episode of VTE/PE in setting of cancer – 3 months of AC (LMWH is better than DOAC or warfarin--new research shows DOAC may actually be more effective, so can use DOAC now; LMWH not preferred)

1st episode of VTE/PE unprovoked (no idea what caused it) – AC more than or equal to 3 months

2nd VTE – AC indefinitely

Heparin reversal – protamine (max dose is 50 mg), to reverse enoxaparin, give 1 mg protamine for each 1 mg of Lovenox

Warfarin reversal – vit K; 4 factor prothrombin compex (KCentra); FFP (if KCentra not available); KCentra is for life-threatening bleeding or if pt needs surgery for life-threatening condition

Apixaban/Rivaroxaban reversal – Kcentra (life threatening bleed or need emergency surgery; has thrombotic risk); FFP (Fresh Frozen Plasma); Andexanet Alfa. KCentra can cause clotting in 5% of pts; don’t give if you don’t need to.

Dabigatran reversal – idarucizumab (Praxbind); dosed as 5 g IV given 2.5 mg no more than 15 minutes apart)

Heparin lasts 2 hours

LMWH is preferred in pts who are pregnant (avoid warfarin). ESRD on dialysis – warfarin or Eliquis (avoid Xarelto). Obese pts – DOACs or warfarin. Cancer – use LMWH; recent study shows Eliquis is equal to or superior to LMWH in cancer pts who need anticoagulation.

Pregnancy = lovenox better, doesn’t cross placenta; UFH (unfractionated heparin) is an alternative in pts with poor renal function.

Stop heparin gtt and give Eliquis now or give 2 hours after stopping heparin gtt. Give loading dose Eliquis even if the pt was on heparin gtt.

[patricemcbride]

🗓 M A R C H 🗓 #DJ #NearDarkEnt @neardarkent #casino #nightlife #nightclub #party #winter #winter2023 #philly #philadelphia #atlanticcity #doac #jerseyshore 📸: @aidenscott / @t.do___ (at Trenton, New Jersey) https://www.instagram.com/p/CpVHa2TL1tj/?igshid=NGJjMDIxMWI=

[unfoldingmoments]

Does Talking About Problems Make Them Worse?

Talking about our problems can absolutely make things worse

Talking Isn't Always Healing: The common belief that talking about your problems is automatically beneficial is misleading. For talking to be helpful, there needs to be an emotional catharsis—a kind of breakthrough where suppressed or dormant emotions are intensely felt, processed, and released. This isn’t just a venting session but a therapeutic experience that allows for deeper emotional healing.

Emotional Catharsis: This term refers to a moment of significant emotional release or breakthrough in therapy. It’s more than just recounting problems—it’s re-experiencing and processing those emotions in a way that leads to a shift in understanding or emotional relief. Freud described this as essential to therapy, where deeply held emotions emerge and are confronted.

Venting vs. Healing: Venting—releasing negative emotions by talking about them—can provide temporary relief by reducing the intensity of those emotions in the moment. However, the problem with venting is that while it may make you feel better short-term, it can reduce the emotional energy needed for real change. Negative emotions like fear, anger, or frustration can motivate action and transformation. If you vent without addressing the root causes of your problems, you risk staying stuck without resolving anything.

Negative Emotions as Motivation: Negative emotions are signals that something is wrong and need to be addressed. For example, fear signals danger, and anger may indicate that boundaries are crossed. These emotions are powerful motivators for change. If you vent away all your negative emotions without using them to drive change, you may lose the energy or motivation to make improvements in your life.

The Downside of Constant Venting: Constant venting, without taking action or seeking resolution, can lead to a cycle where people complain but don't make changes. These individuals may remain in the same patterns of frustration and negativity because they don’t channel their negative emotions into constructive change.

Therapy Beyond Venting: Effective therapy should involve more than just talking or venting. It should help individuals confront and process their emotions in a way that leads to actionable change and personal growth. If therapy becomes just a session for venting without deeper exploration, it may fail to produce the desired results.

In summary, while talking about problems can sometimes help, it only leads to positive change when it involves emotional catharsis and results in meaningful insights or actions. Venting alone can make things worse by reducing the motivational drive needed for real change.

Dr K: We Are Producing Millions Of Lonely, Addicted, Purposeless Men & Women! https://www.youtube.com/watch?v=P1ALkQMfkjc

Healthy way talking about your problems

Talking about problems can sometimes feel like it makes them worse, but generally, discussing problems is a healthy way to process and manage them. Here’s why:

1. Releasing Stress: Talking about your problems can help relieve the emotional weight they carry. By expressing your thoughts and feelings, you can release pent-up stress, which can help prevent it from building up and causing more significant issues.

2. Gaining Perspective: When you talk about a problem, especially with someone who listens well, you can gain new insights and perspectives. Others might offer solutions you hadn’t considered or help you see the issue in a different light.

3. Strengthening Relationships: Sharing your problems can bring you closer to others, especially if they can empathize or relate to your situation. It helps create emotional bonds and reminds you that you’re not alone.

4. Problem Solving: Verbalizing your problems can help clarify your thoughts and enable you to approach the situation more objectively. Sometimes, simply talking through the issue can lead to solutions you might not have thought of on your own.

That said, there are times when talking about a problem can feel like it’s making things worse, such as:

• Ruminating: If you find yourself going over the same issues repeatedly without moving toward a solution, this can lead to rumination, which might amplify negative feelings and make the problem seem larger.

• Unhelpful Reactions: If the person you’re talking to responds negatively—by dismissing your concerns or adding to your worry—it might feel like talking about it made things worse. In these cases, it’s important to choose supportive people who genuinely listen and offer constructive feedback.

Ultimately, talking about problems is most beneficial when done with the intention to process, gain perspective, and seek support. It can be a valuable tool for healing and growth when balanced with actions to address the underlying issues.

[thisblogisnotcursed]

Diary of a CEO is really going hard on the click bait.

[xxxsimplyhookedxxx]

Josh Peck: The Surprising Truth Behind The 127lb Weight Loss | E238

[rockbottomfuckthis]

Have conversations with self.

'Reframe challenges to voluntarily demonstrate your capacity. 'HERE WE GO!'.

'All you can do to have a conversation with yourself that holds firmness and compassion together. That's the best you've got.'

'What's you're chasing is to feel calm l, smart and proud of yourself.'

Example: Taking an unhealthy snack away from a child that got used to that snack.

Compassion: you'd expect the kid to cry. She is used to something. You'd make her life as comfortable as possible and do it until she realizes she come out unscaved.

'I know why you feel this way, of course you feel this way, you deserve to feel this way, you can scream/cry as much as you want.

Doesn't mean I'm going to give you the snack.'

[thedanneary]

FRI - The Event Horizon - Gypsy Bar - Borgata - Atlantic City - 11pm SAT - The Event Horizon - Midland Brew House - Saddle Brook, NJ - 10:30pm ����🏻🎶 📸: @loridollphotos #rocknroll #danneary #guitaristsofinstagram #guitarsolo #guitarvideo #guitarreels #hardrock #rocknroll #guitarplayer #rocker #rockon #musicislife #rockband #guitarcover #musiciansofinstagram #gibsonguitars #stagephoto #rocker #lespaul #doac #atlanticcity #newjersey #jerseyshore #nyc #vintagevibes #hollywood #nashville #guitarposts #musicvideo #guitarsdaily (at New Jersey) https://www.instagram.com/p/CoFjKE6u7IE/?igshid=NGJjMDIxMWI=

[patricemcbride]

🗓 J A N U A R Y 🗓 #DJ #NearDarkEnt @neardarkent #casino #nightlife #nightclub #party #winter #winter2023 #philadelphiaeagles #flyeaglesfly #gobirds #philly #philadelphia #atlanticcity #doac #jerseyshore 📸: @slimbojimboyo / @t.do___ https://www.instagram.com/p/CnE7ybJrp0A/?igshid=NGJjMDIxMWI=