By W. Lukar. University of Denver.

Warfarin is given to children after cardiac surgery to pre- • Cilostazol is probably safe to use in clients with mild or vent thromboembolism cheap penisole 300mg free shipping, but doses and guidelines for safe discount penisole 300mg overnight delivery, moderate renal impairment. Accurate drug ad- pairment alters drug protein binding and increases blood ministration, close monitoring of blood coagulation tests, levels of metabolites. Antiplatelet agents and warfarin are used for long-term pre- • Ticlopidine may be more likely to cause bleeding in vention or management of thromboembolism and are often clients with renal impairment because the plasma drug taken at home. For prevention, antiplatelet agents and warfarin concentration is increased and elimination is slower. Dosage must be reduced INR, and notifies the prescriber, who then prescribes the ap- by approximately 50%. The risk of bleeding has lessened in recent years because of lower doses of warfarin. In addition, bleed- Use in Hepatic Impairment ing during warfarin therapy may be caused by medical condi- tions other than anticoagulation. Little information is available about the use of most anticoag- Heparin may also be taken at home. Standard heparin may ulant, antiplatelet, and thrombolytic drugs in clients with im- be taken subcutaneously, but LMWHs for home management paired liver function. However, such drugs should be used very of venous thrombosis are becoming standard practice. Enoxa- cautiously because these clients may already be predisposed to parin is approved by the Food and Drug Administration for bleeding because of decreased hepatic synthesis of clotting fac- outpatient use. Additional considerations include the following: needed if the client or a family member is unable or unwill- • Warfarin is more likely to cause bleeding in clients with ing to inject the medication. Platelet counts should be done liver disease, because of decreased synthesis of vitamin K. Heparin In addition, warfarin is eliminated only by hepatic me- should be discontinued if the platelet count falls below tabolism and may accumulate with liver impairment. Clients and family members should be educated disease because of high risks of excessive bleeding. When anagrelide is given, blood tests when indicated, and taking safety precautions.

You can do this while doing other things buy generic penisole 300 mg on-line, such as riding a bicycle proven 300 mg penisole, lying in bed or taking a bus. But set a deadline because at some point you will need to put some- thing down on paper (see brief setting). Salami publication The practice of undertaking one piece of research and then cutting slices off it for publishing in various journals. Editors take the view that the role of scientific publishing is to record and validate science, and therefore there is no reason to slice large studies into smaller bits. My advice to writers is to approach the matter from a different direction entirely. Once you have collected the data, define the message you want to give and match it to a journal (see brief setting). If you find, having written this article, that you have enough unused material that would support a different message suitable for another journal, then go ahead and write it. However, there has been a steady stream of cases over the last few decades, ranging from the slight (but nevertheless dishonest) massaging of figures to the lengthy discussion of patients that never existed. Such cases tend to rock the scientific community, and there is now a widespread belief that the tradition of trusting other gentleman scientists is no longer enough. Editors are sensitive to the problem, and to the dangers of being required to spend more and more time policing science rather than communicating it. Academic institu- tions, therefore, are beginning to realize that they need to adopt explicit procedures if the integrity of researchers is to be accepted. Writers should adopt the following principle: do not at any time put your name to a paper unless you are sure that everything in it is true – and that you could prove it if necessary in front of lawyers.