ABSTRACT
PURPOSE: Older adults treated with warfarin are prone to complications, and high-quality monitoring is essential. The aim of this case history based study was to assess the quality of warfarin monitoring in a routine situation, and in a situation with an antibiotic-warfarin interaction, before and after receiving an electronic alert. MATERIALS AND METHODS: In April 2014, a national web-based survey with two case histories was distributed among Norwegian nursing home physicians and general practitioners working part-time in nursing homes. Case A represented a patient on stable warfarin treatment, but with a substantial INR increase within the therapeutic interval. Case B represented a more challenging patient with trimethoprim sulfamethoxazole (TMS) treatment due to pyelonephritis. In both cases, the physicians were asked to state the next warfarin dose and the INR recall interval. In case B, the physicians could change their suggestions after receiving an electronic alert on the TMS-warfarin interaction. RESULTS: Three hundred and ninety eight physicians in 292 nursing homes responded. Suggested INR recall intervals and warfarin doses varied substantially in both cases. In case A, 61% gave acceptable answers according to published recommendations, while only 9% did so for case B. Regarding the TMS-warfarin interaction in case history B, the electronic alert increased the percentage of respondents correctly suggesting a dose reduction from 29% to 53%. Having an INR instrument in the nursing home was associated with shortened INR recall times. CONCLUSIONS: Practical advice on handling of warfarin treatment and drug interactions is needed. Electronic alerts as presented in electronic medical records seem insufficient to change practice. Availability of INR instruments may be important regarding recall time.
Subject(s)
Anticoagulants/adverse effects , Clinical Competence , Drug Monitoring , International Normalized Ratio , Physicians , Reminder Systems , Warfarin/adverse effects , Adult , Aged , Aged, 80 and over , Anti-Bacterial Agents/therapeutic use , Anticoagulants/therapeutic use , Blood Coagulation , Drug Interactions , Female , General Practitioners , Humans , Male , Middle Aged , Nursing Homes , Warfarin/therapeutic useABSTRACT
BACKGROUND: Reactivation of varicella-zostervirus (VZV) can manifest as infection of the central nervous system. The detection of VZV DNA in cerebrospinal fluid by polymerase chain reaction has extended our knowledge about the frequency of various clinical manifestations in the immunocompetent host, also without the typical rash of shingles. MATERIAL AND METHODS: Over a period of three years, 1999 through 2001, we performed VZV polymerase chain reaction in cerebrospinal fluid in 364 patients with suspected infection of the central nervous system. RESULTS: We detected VZV DNA in the cerebrospinal fluid in five patients. Four of the patients had reactivated VZV infection. Meningitis was seen in two young immunocompetent individuals; one of them without shingles. One patient had myelitis without shingles and one had zoster radiculitis. One patient was a child with encephalitis and primary infection. INTERPRETATION: Our results are similar to results from other investigators that have found VZV DNA in the cerebrospinal fluid in immunocompetent patients with meningitis or encephalitis as the most common clinical manifestation, with or without shingles.
