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There is no clear preference for any of the currently available NOACs over VKA for patients with both AF and CAD. A joint European consensus document endorsed by the Heart Rhythm Society and Asia-Pacific Heart Rhythm Society refutes the concern that dabigatran may increase the risk of acute myocardial infarction. 11 Moreover, the large FDA Medicare analysis found no evidence of an increased risk of myocardial infarction in patients taking dabigatran compared with warfarin. 12

Based on our interpretation of available data, we suggest

Only limited data are available on the use of NOACs as antithrombotic therapy in patients with peripheral artery disease (PAD). Patients with PAD in ROCKET AF (5.9%) did not have a significantly higher risk of stroke or systemic embolism than did patients without PAD, and outcomes in patients treated with rivaroxaban and warfarin paralleled those in the trial as a whole. There was a significant interaction for major or non-major clinically relevant bleeding in patients with PAD treated with rivaroxaban compared with warfarin (hazard ratio, HR: 1.40, 95% confidence interval, CI: 1.06–1.86) and those without PAD (HR: 1.03, 95% CI: 0.95–1.11; interaction P = 0.037). 13 Randomized trials of edoxaban and rivaroxaban in patients with PAD are currently underway. 14

Based on our interpretation of available data we suggest:

Patients with AF and an acute coronary syndrome or stable CAD may require percutaneous coronary intervention with stenting. In these patients, the need for OAC treatment to prevent stroke and for dual antiplatelet therapy to prevent stent thrombosis must be balanced against the increased risk of bleeding (particularly intracranial haemorrhage) with dual or triple antithrombotic therapy.

The use of VKAs in this setting has been the subject of observational studies and one completed randomized trial, 15 and is currently under investigation in comparison with NOACs in additional trials. All phase III trials of NOACs allowed the concomitant use of aspirin (≤100 mg/day) for patients undergoing percutaneous coronary interventions, but only the RE-LY trial included a substantial number of patients on concomitant clopidogrel with or without aspirin. 10 Ongoing trials will provide additional data for NOACs or warfarin in combination with aspirin and/or P2Y12 inhibitors (clopidogrel, prasugrel, or ticagrelor) (REDUAL-PCI for dabigatran NCT02164864, PIONEER-AF-PCI for rivaroxaban NCT01830543, AUGUSTUS for apixaban NCT02415400).

Management of these patients was recently addressed in the joint European consensus document. 11 The document suggested a period of triple therapy (OAC plus aspirin plus clopidogrel), followed by a period of dual therapy (OAC plus single antiplatelet agent, preferably clopidogrel). Once the patient is stable, after 1 year, an OAC alone can be given. When an OAC is prescribed, this can be either controlled VKA therapy [time in therapeutic range (TTR) of >70%; preferred international normalized ratio (INR) range 2.0–2.5] or an NOAC. When an NOAC is combined with dual antiplatelet therapy, the lower dose tested for stroke prevention in AF is recommended.

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says:
August 15, 2011 at 9:21 am

Hi Martina, U.S. law and our federal contract require us to have a system to keep donor and patient information confidential for at least the first year after transplant. After that time, if both the donor and recipient sign consent forms agreeing to share their contact information, they can meet. Some donors and recipients are eager to make contact, but others choose not to, for a variety of personal reasons. In addition, some centers do not allow donors and recipients to have contact at any time. For a little more information, see: http://www.marrow.org/DONOR/After_You_Donate/index.html Thanks, Be The Match

Reply
says:
August 13, 2011 at 7:31 am

I have been on the list for years. I have been contacted twice. The first time I was contacted and told that someone else was a better match for the individual. The second time I went through donating the blood to be tested but never heard back. I tried to contact the center, but still never got a response.

Reply
says:
August 14, 2011 at 12:24 pm

I have been on the registry for years and never been contacted. I pray that someday I will be and can help another person.

Reply
says:
August 14, 2011 at 8:07 pm

I have been on the list probably 15-20 years and not contacted, but concerned about the comment about “aging out”. At what age am not longer “viable” to donate?

Reply
says:
August 15, 2011 at 9:24 am

Hi Paula, Registry members are eligible to donate marrow up till their 61st birthday. Thanks, Be The Match

Reply
says:
August 15, 2011 at 12:32 pm

I’m do not always check my email everyday. If I am a potential match I would hope to be contacted by telephone in addition to email

Reply
says:
August 15, 2011 at 12:53 pm

Thank you for your comments and for offering insightful feedback to help us improve our service to potential donors.

As a little more background, there are currently two scenarios in which we contact potential donors:

1) Donors who a patient’s doctor has requested for additional testing. If a donor requested for additional testing is not selected to proceed to donation, they will receive a letter telling them so within 60 days of the initial request.

2) Donors identified as a potential match in the preliminary search process — as described in this article. Though we do let donors know they may or may not be asked to proceed to the next step, there is currently no written follow-up sent to let them know they will not be asked to proceed. This is complicated by the wide variation in when a patient’s doctor may request donors for further testing. In some cases, a patient’s doctor requests donors the same day and in some cases donors are requested more than 200 days after the preliminary search request. The typical experience for donors is to be requested 20 days following the preliminary donor search contact. But in some cases, patients choose not to proceed with transplant at all.

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Americans work more than anyone in the industrialized world.

More than the English, more than the French, way more than the Germans or Norwegians. Even, recently, more than the Japanese.

And Americans take less vacation, work longer days, and retire later, too.

That much most people agree on. What's harder to pin down is exactly how much Americans are working. It may be more than our industrialized competitors, but is it more than we have ever worked before?

The short answer, according to the government, is that it is only slightly more and not so much that most people should really notice.

Numbers from the Bureau of Labor Statistics show a very gradually rising trend through the 1990s that has only just recently tapered off, hovering somewhere just north of 40 hours weekly.

A Month More a Year?

The long answer is, of course, more complicated. It depends who you ask, and about whom you're asking.

Author Juliet Schor, who wrote the best-selling book The Overworked American in 1992, concluded that in 1990 Americans worked an average of nearly one month more per year than in 1970.

There are also volumes of surveys that ask people if they're working more than they used to. Generally, people say yes, of course they are. And they also estimate almost 10 more hours a week than the government does.

A Bunch of Whiners?

Critics pooh-pooh such studies, saying self-estimators are exaggerators, although most of those studies echo the same general trend as governmental figures — a bit of a rise through the '90s with a slight dip recently.

Dissenters to overworked-American theories say it's better to base studies on employers' reports of worker hours, which is what the government does, but that leaves out overtime hours worked by salaried employees.

Critics also point to what they say is a growing number of part-time jobs. How can people be working more if they are not working full-time?

Here's where you have to ask which workers we're really talking about.

Measuring Past the Punch Clock

That's what Schor's book tries to do, as well as two recent releases: The White-Collar Sweatshop by Jill Andresky Fraser, and The Working Life by Joanne B. Ciulla.

All those books have been embraced by a large part of the public that apparently feels harassed by the pressures of the workplace.

The authors all find evidence that many Americans are overstressed and overworked in trends that are not necessarily measured with a punch clock; trends such as road rage, workplace shootings, the rising number of children in day care and increasing demands for after-school activities to occupy children whose parents are too busy or still at work.

They aren't the only ones finding long hours in at least certain parts of the workforce. According to a Bureau of Labor Statistics report released last year, more than 25 million Americans — 20.5 percent of the total workforce — reported they worked at least 49 hours a week in 1999. Eleven million of those said they worked more than 59 hours a week.

Sweat Under the White Collar

Who are these people? Fraser, after four years of interviews, concludes they are white-collar workers, who do not punch a clock and whose hours therefore are the most difficult to track.

The other evidence often pointed to that people are not really working as much as they say is the increasing number of part-time jobs. How can people be working more if more people are not working full-time?

But the anecdotal evidence presented by Fraser, Schor and Ciulla — and met by millions of people everyday — is that many Americans feel they are working more than ever.

An ABCNEWS.com poll released Monday found only 26 percent of Americans feel they work too hard. Although far more feel the opposite, that's still a lot of people and it's twice as many as the 13 percent who told a Harris Poll in 1960 that they felt overworked. And the percentage rises to about a third of people with kids, or people between 35 and 54 years old.

What Happened to 'The Little Woman'?

Even for people who are not actually working longer hours than they used to, there's an explanation for why some of them might feel over-burdened anyway, particularly men.

Experts who accept some of the arguments of both sides of the working-longer debate often focus less on individuals' hours worked, instead looking at household hours on the job.

In Overworked and Underemployed, a study in The American Prospect, Barry Bluestone and Stephen Rose argue that to really understand the situation Americans face, you need to look beyond individuals and numbers.

The overall figures for how many hours a week the average American works have been held down by the increasing number of part-time service and retail jobs in the economy. But since many of the part-time jobs have been filled by the increasing number of women in the workforce, and many of these women had previously been housewives, there are fewer hours when anyone is taking care of household chores.

Instead of coming home to find the refrigerator and cupboards stocked, dinner ready, the table set, the clothes washed, the house clean and the children entertained, men are coming home and finding they have to chip in, because their wives aren't "the little woman," anymore. They are now sharing duties as breadwinner, which means men have to share household chores. The situation is exaggerated when both spouses work full-time — particularly if they don't earn enough to hire help.

If people aren't spending quite as many more hours at work as they think they are, the fact that they aren't allowed as much leisure time once they're off work might account for the apparent illusion.

Authors like Fraser, Schor and Ciullo, though, argue that there is no illusion, and the case made by the harried Americans who fill their books — and fill commuter trains and highways — is hard to discount.

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Last, N.S. used Excel to derive/calculate the results, which D.S. checked. We also conducted a sensitivity analysis, which aimed to see whether the difference in the number and variety of reasons captured by our systematic review versus the most comprehensive included publication was preserved when Types of Reason were more broadly individuated: we merged similar narrow Types of Reason, and recounted the numbers of reasons identified by our systematic review versus the most comprehensive publication. Table 1 shows which Types of Reason were merged (see the last note under the table).

Table 1.

Broad and narrow Types of Reasons

Notes: • This table lists all the mentioned reasons why PTA should or need not be ensured, including those that were rejected, or neither rejected nor endorsed. Given that reasons will in any case need to be appraised, it better aids the decision-maker to err on the side of comprehensiveness. • Finer-grained data is available on request. • No colour background: reason used just for the view that PTA should be ensured; number in square brackets with no colour background is number of reason mentions used for the view that PTA should be ensured. • Grey background: reason used just for the view that PTA need not be ensured or with unclear implications; number in square brackets with grey colour background is number of reason mentions used for the view that PTA need not be ensured. • Red background: some reason mentions were for the view that PTA should be ensured and some for the view that it need not be ensured, or implications for PTA were left unspecified. • Note that, for many broad Types of Reason, the number after the broad type (e.g. Avoid exploitation) is more than the sum of numbers after the narrow types because, for colourless or grey reasons the number given excludes the few reason mentions with unclear implications. • Round parentheses: reasons followed by the same number in parentheses were merged in the sensitivity analysis.

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Table 1.

Broad and narrow Types of Reasons

Notes: • This table lists all the mentioned reasons why PTA should or need not be ensured, including those that were rejected, or neither rejected nor endorsed. Given that reasons will in any case need to be appraised, it better aids the decision-maker to err on the side of comprehensiveness. • Finer-grained data is available on request. • No colour background: reason used just for the view that PTA should be ensured; number in square brackets with no colour background is number of reason mentions used for the view that PTA should be ensured. • Grey background: reason used just for the view that PTA need not be ensured or with unclear implications; number in square brackets with grey colour background is number of reason mentions used for the view that PTA need not be ensured. • Red background: some reason mentions were for the view that PTA should be ensured and some for the view that it need not be ensured, or implications for PTA were left unspecified. • Note that, for many broad Types of Reason, the number after the broad type (e.g. Avoid exploitation) is more than the sum of numbers after the narrow types because, for colourless or grey reasons the number given excludes the few reason mentions with unclear implications. • Round parentheses: reasons followed by the same number in parentheses were merged in the sensitivity analysis.

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Disagreements and problems that arose in the selection of publications and the data extraction and analysis were resolved by frequent discussion and not by deference to the second author; we did not need to appeal to a third person. Details of the types of data extracted and types of results are given in Strech and Sofaer, How to write a systematic review of reasons, manuscript).

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