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Renato D. Lopes , John D. Horowitz , David A. Garcia , Mark A. Crowther and Elaine M. Hylek
Blood 2011 118:6269-6273; doi: https://doi.org/10.1182/blood-2011-08-335612
Renato D. Lopes
Duke Clinical Research Institute, Duke University Medical Center, Durham, NC;
John D. Horowitz
University of Adelaide, Queen Elizabeth Hospital, Adelaide, Australia;
David A. Garcia
Department of Medicine, University of New Mexico Health Sciences Center, Albuquerque, NM;
Mark A. Crowther
Department of Medicine, McMaster University, Hamilton, ON; and
Elaine M. Hylek
Department of Medicine, Research Unit, Section of General Internal Medicine, Boston University School of Medicine, Boston, MA

Ms TS is a 66-year-old woman who receives warfarin for prevention of systemic embolization in the setting of hypertension, diabetes, and atrial fibrillation. She had a transient ischemic attack about 4 years ago when she was receiving aspirin. Her INR control was excellent; however, over the past few months it has become erratic, and her average dose required to maintain an INR of 2.0 to 3.0 appears to have decreased. She has had back pain over this same period and has been taking acetaminophen at doses as large as 650 mg four times daily, with her dose varying based on her symptoms. You recall a potential interaction and wonder if (1) her acetaminophen use is contributing to her loss of INR control, and (2) does this interaction place her at increased risk of warfarin-related complications?

Warfarin has remained the most commonly prescribed vitamin K antagonist (VKA) since its introduction into clinical practice approximately 60 years ago. VKAs exert their effect by inhibiting the cyclic replenishment of reduced vitamin K, an obligate cofactor in the γ-carboxylation of the biologically inactive procoagulant factors II, VII, IX, and X, as well as the anticoagulant factors protein C, protein S, and protein Z. 1 The resultant anticoagulant effect is measured by the international normalized ratio (INR), which for most indications is targeted between 2.0 and 3.0. Thromboembolism, major hemorrhage, and death have all been strongly linked to the proportion of time spent in this therapeutic range. 2 , Pilleys ALDO FF0fvmwm
Despite its efficacy in preventing and treating thromboembolic disease, warfarin has several limitations that challenge its effectiveness in clinical practice, including a narrow therapeutic index, variable dose-response, and importantly the potential for important interactions with numerous commonly used medications. sugar Robby Womens Water Resistant Rain Boots GydXPD8

Another policy contributing to the country’s economic problems are currency controls, first introduced by Chavez in 2003 to curb capital flight. By selling U.S. dollars at different rates, the government effectively created a black market and increased opportunities for corruption. A business that is authorized to buy dollars at preferential rates to purchase priority goods like food or medicine could instead sell those dollars for a significant profit to third parties. In December 2017, the official exchange rate was ten bolivars to the dollar while the black market rate was more than nine thousand bolivars to the dollar.

Imports reportedly fell to $18 billion in 2016, down from $66 billion in 2012, as foreign-made goods became increasingly expensive. Many consumers are faced with the choice of waiting for hours in line for basic goods or paying exorbitant prices to so-called bachaqueros , or black market traffickers.

Experts say widespread expropriations have further diminished productivity. Transparency International, which ranks Venezuela 166 out of 176 on its perceived corruption index, reports that the government controls more than five hundred companies, most of which are operating at a loss. (By comparison, Brazil, which is more than six times as populous as Venezuela, has 130 state-run companies.)

Observers have characterized the situation in Venezuela as a humanitarian crisis . In 2016, the Venezuelan Pharmaceutical Federation estimated that 85 percent of basic medicines were unavailable or difficult to obtain. Hospitals lack supplies like antibiotics, gauze, and soap. Infant mortality in 2016 increased 30 percent and maternal mortality 65 percent over two years prior, according to government figures. Diseases like diphtheria and malaria, previously eliminated from the country, have reemerged.

Poverty has also spiked. In 2016, a local university study found that more than 87 percent of the population said it did not have enough money to buy necessary food. Another study found that 30 percent of school-aged children were malnourished . According to a 2016 report from Human Rights Watch, the Maduro administration “has vehemently denied the extent of the need for help and has blocked an effort by the opposition-led National Assembly to seek international assistance.”

Poverty and lack of opportunity are exacerbating Venezuela’s high rates of violence. In 2016 Venezuela experienced its Heath Harness Frye 9h9fKShuk
at 91.8 homicides per 100,000 residents, according to the Venezuelan Violence Observatory, an independent monitoring group. (The U.S. rate, by comparison, is 5 per 100,000.) Maduro’s administration has deployed the military to combat street crime, but rights groups and foreign mediahave reported widespread abuses, including extrajudicial killings.

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Barbara Gonzalez is a political commentator based in Monterrey, Nuevo León. She studied International Relations at the Tec de Monterrey and Latin American Studies at the University of Oxford.

by Barbara Gonzalez
Published Wed, Mar 28, 2018 at 2:00 pm CST

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by Barbara Gonzalez
Published Wed, Mar 28, 2018 at 2:00 pm CST

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