Evaluation of an Initiation Regimen of Warfarin for International Normalized Ratio Target 2.0 to 3.0

Background: he number of patients on warfarin therapy is rising steadily. Although warfarin is beneficial, it carries a high risk of bleeding, especially if the international normalized ratio (INR) values exceed 3.0. Currently, no warfarin initiation regimens have been developed for the Asian population, especially for Malaysians. Objective: This article describes the efficacy and safety of a new initiation regimen for warfarin among warfarin-naive patients. Method: Data were retrospectively collected from the ambulatory and inpatient settings. Results: A total of 165 patients who each had a target INR of 2.0 to 3.0 were included in the study. The mean age was 57.2 years and 94 patients were male. A total of 108 patients used Regimen 1 (5 mg/5 mg/3mg) and the rest of the patients used Regimen 2 (5 mg/3 mg/3 mg). Most patients used warfarin either for atrial fibrillation (52.1%) or for venous thromboembolism (29.7%). Overall, 88 of the patients had INR values above 50% from the baseline on Day 4. Additionally, 13 patients had INR values of >3.2, which required withholding and lower dose of warfarin. The predicted weekly maintenance warfarin dose (23 ± 0.5 mg/week) was found to have correlated closely with the actual maintenance dose (22.8 ± 0.5 mg/week; r² = 0.75). Nearly two thirds (70.3%) of the patients achieved the target INR on Day 11. Conclusion: The warfarin initiation regimens in this study was simple, safe, and suitable to be used in both ambulatory and inpatient settings for managing warfarin therapy.     

Hyper-use of the ED

Objectives

This study aims to describe the population that averages one or more emergency department (ED) visits per month and compare them to the general ED population to determine if there are associated characteristics.

Methods

A retrospective cohort study conducted in a teaching hospital between January 1, 2001, and December 31, 2004, identified all patients with more than 35 visits. This hyper-user (HU) cohort (n = 49) was compared to a randomly selected group of non-HU patients (n = 50) on the following measures: age, sex, insurance coverage, primary medical doctor (PMD), dwelling location, chief complaint, comorbidities, and disposition.

Results

The HU group was significantly older (mean, 49.45 years) than the non-HU group (37.32 years) with a P < .0001. There was no difference between the groups in sex, insurance coverage, PMD, dwelling location, and disposition. A univariant logistical regression found that previous cardiovascular, genitourinary, or psychiatric disease were predictors of hyper-use.

Conclusions

The HU group is older and more likely to have a history of cardiovascular, genitourinary, and psychiatric disease but is similar to the non-HU group in other measured parameters. The HU group appears to have equal access to a PMD and is not more likely to be admitted to the hospital than the non-HU group.     

A prospective double-blind study of nasal sumatriptan versus IV ketorolac in migraine

We conducted a study to compare the efficacy in migraine headache of nasal sumatriptan and intravenous ketorolac. The study was a prospective, double-blind study done with a convenience sample of 29 patients presenting to the emergency department (ED) with acute migraine. Patients received either 20 mg of nasal sumatriptan or 30 mg of intravenous ketorolac. Patients scored the severity of their headache on a 100-mm visual analog scale (VAS) of pain prior to medication, and again 1 hour after medication. Differences between initial and 1-hour scores were analyzed. Before treatment, no difference existed between the groups in the intensity of headache. One hour after medication, the sumatriptan group had a decrease in pain score of 22.937 mm and the ketorolac group a decrease of 71.462 mm on the VAS. The decrease in pain score with ketorolac was significantly greater than that with sumatriptan (P < 0.001). The study therefore showed that both sumatriptan and ketorolac effectively reduced the pain associated with acute migraine headache, but that intravenous ketorolac produced a greater reduction in pain than did nasal sumatriptan.     

Ventricular premature contraction after repair of tetralogy of Fallot--the influence of postoperative factors, particularly the right ventricular regional wall motion

The presence and severity of ventricular premature contraction (VPC) in 35 patients with tetralogy of Fallot (TF) were studied, 5 to 10 years after intracardiac repair (ICR), using treadmill exercise testing and 24-hour ambulatory monitoring. VPCs were observed in 24 patients (68.6%). The patients were classified into two groups according to the types of VPCs: group A (23 patients) without VPCs or with VPCs of Lown's grade 1 and group B (12 patients) with VPCs of Lown's grade 2, 3 or 4. Group B patients were found to have significantly higher right to left ventricular peak-systolic pressure ratios and higher right ventricular peak systolic pressures than those of group A. But there were no significant differences between the two groups in operative age, the time lapse between ICR and evaluation, the duration of exercise and so on. Group B patients also showed significantly decreased right ventricular regional wall motions in the right ventricular outflow tracts (ROTs), indicating akinetic or paradoxical movements than group A patients. It is thought that postoperative right ventricular hypertension and the akinetic or paradoxical wall movement of the ROT may have some effect on the genesis of postoperative VPCs after repair of TF.     

Proximal Splenic Artery Embolization In Blunt Splenic Trauma

Abstract Background:   Proximal embolization of the splenic artery (PSAE) has recently been reported for traumatic splenic injury. The suggested mechanism of action entails a decrease in the splenic blood pressure without ischemia due to collateral blood supply. The main complications of selective embolization are continuous bleeding, splenic infarcts and splenic abscesses. The main complications of observation alone are continuous bleeding and formation of splenic pseudoaneurysms. Our aim was to assess the efficacy of PSAE in the cessation of bleeding without formation of pseudoaneurysms, and the outcome of the spleen after such intervention. Methods:   A prospective observational study of all patients undergoing PSAE for traumatic splenic injury in our institution over a 33-month period. Clinical and Doppler sonographic examinations were performed to assess cessation of bleeding, splenic blood flow, and formation of splenic pseudoaneurysms, infarcts or abscesses. Results:   During 33 months, 11 patients with blunt abdominal trauma and tomographic evidence of either high grade or actively bleeding splenic injuries were treated by PSAE. During follow-up, no patient underwent surgery or repeated embolization. Preserved blood flow was found on Doppler sonography in 82% of the patients and no pseudoaneurysms were demonstrated. A perisplenic collection was found in one patient and responded well to percutaneous drainage. Conclusions:   Proximal embolization of the splenic artery for severe splenic injury is highly successful in cessation of bleeding while preserving splenic architecture. There were minimal complications in this series demonstrated by clinical and Doppler examinations.