Class of 2010 Abstract / OBJECTIVES: The purpose of this study was to demonstrate that an increase in INR is associated with a hemorrhagic event in patients taking the oral anticoagulant warfarin. METHODS: A retrospective review of data from 18 patients previously stable on warfarin therapy with an elevation in INR at the time of a hemorrhagic event. Patients were receiving warfarin treatment in the anticoagulation clinic at the Southern Arizona VA Healthcare system from April 2008 to December 2009. Primary outcome measures included a comparison of INR, warfarin dose, and hematocrit at baseline, within 7 days of the event, and during follow-­‐up. RESULTS: A significant increase in INR was observed from baseline to the event (2.5 +/-­‐ 0.36 vs 6.2 +/-­‐ 3.2; p = 0.0002) but differences in INR during all periods of follow-­‐up did not differ from baseline (p = 0.35 – 0.99). When compared with baseline, differences in warfarin dose reached statistical significance when all 12 weeks of follow-­‐up were included (34.4 +/-­‐ 13.8 mg vs 32.4+/-­‐ 15.5 mg; p = 0.01) but were not significant when only the last 8 weeks (p = 0.06) or 4 weeks (p = 0.16) were included. Hematocrit values decreased significantly following hemorrhage (39.8 +/-­‐ 3.63 vs 33.5 +/-­‐ 5.72; p = 0.0002) before trending toward baseline (39.85 +/-­‐ 3.63 vs 37.13 +/-­‐ 4.72; p = 0.007). CONCLUSIONS: Hemorrhagic events were associated with an increased INR in previously stable warfarin patients. The mean weekly warfarin dose required to maintain a therapeutic INR returned to baseline within 8 weeks of the hemorrhagic event.

Class of 2010 Abstract / OBJECTIVES: To compare the INR-based results of pharmacist anticoagulation management services to non-pharmacist managed anticoagulation therapy. METHODS: A meta-analysis was performed using studies that reported on pharmacists’ services and interventions in anticoagulation. Two reviewers independently assessed each record retrieved by the literature search, and studies were eliminated if both reviewers agreed that the study did not meet the inclusion criteria. The analysis found eight studies that were eligible for inclusion. The primary independent variable was the presence or absence of pharmacist services. The primary dependent variables were the proportion of patients within INR range, the duration of time within that range, and the time required to achieve that range. Extracted data were pooled and entered into the meta-analysis, and a forest plot was constructed. The a-priori alpha level was 0.05. RESULTS: The eight studies were divided into two groups: The INR group consisted of four studies which used INR test data points as the unit of analysis. The Patient group included four studies which measured the patient’s INR only at the end of the study. The INR group demonstrated a significant difference favoring pharmacist services, with a p-value of 0.02 for the group. There was no significant difference between pharmacist services and the control group with respect to the Patient group. When all eight studies were pooled together, the overall forest plot did demonstrate significant favorability for pharmacist services, with an odds ratio of 1.58, indicating that pharmacist provided services improved care by 58% (Z = 2.8;p p = 0.01). CONCLUSIONS: The advantage of a pharmacist service in reaching goal INR was significant compared to the control group of non- pharmacist care.

Introduction: It is recommended to place all the vacuum tubes directly on a sample cradle after vein puncture to prevent analytic error. This recommendation is not always easy to follow because the samples are taken by different professionals under different situations.  The three most common analyses, platelets count, haemoglobin and prothrombin time were tested.  Therefore, it was interesting to compare results from the three most common analyses with or without sample cradle, to evaluate the influence of this step on the result. Methods: Three analyses were preformed, using blood from 50 different persons. Each person gave two vacuum tubes, each contained 4.5mL of venous blood for the study. Tubes containing EDTA were used for platelet counts and measurement of haemoglobin and tubes containing citrate were used for prothrombin time-analysis. One of the tubes was placed, as recommended, directly on the sample cradle while the other tube was placed flat on a bench for 10 minutes before it was placed on the sample cradle. Results: There was a clear difference in platelet counts with and without immediate cradling but only minor difference between the results for haemoglobin and International Normalized Ratio. Conclusion: Some analyses seem to be more sensitive for variation in cradling than others. For platelet count it was important to immediately rock the tubes but for determination of prothrombine time and hemoglobin it had a small impact. The small impact on the results is probably due to the efficiency of the anticoagulant in the vacuum tubes.

Background: Vitamin-K antagonists (VKA) are a class of oral anticoagulant medications used to prevent blood clots. The anticoagulant intensity of VKAs is measured with a blood test known as the International Normalized Ratio (INR). Traditionally, international guidelines have recommended INR tests every 4 weeks for all patients. However, adherence to these guidelines has never been investigated in real world settings. The objectives of this study were to describe adherence to INR testing in Saskatchewan among patients receiving VKA medications, and to identify predictors of optimal adherence. Methods: This was a retrospective cohort study of VKA users in Saskatchewan captured in the administrative data between 2003 and 2010. Physician claims for anticoagulation monitoring were used as a proxy for INR testing. Adherence to INR testing was measured using the Continuous, Multiple-Interval Measure of Medication Gaps (CMG). Individuals were considered adherent if adherence by the CMG was at least 80%. Hierarchical (random effects) logistic regression models were developed to identify important predictors of optimal INR monitoring. Individual physician identification was considered a random effect in these models. The dependent variable was the achievement of optimal adherence, defined as ≥80% adherence to the 4-week test interval. Results: Among 17,388 VKA users, 42% resided in rural areas and virtually all (99%) were monitored by a general practitioner. During a median follow-up of 514 days, 50% of patients exhibited at least 74% adherence to INR testing if a 4-week interval was used as the reference standard. However, the estimated median adherence increased dramatically to 98% when the benchmark for optimal testing was lengthened to every 12 weeks. The most prominent risk factors for poor adherence to INR monitoring appeared to be rural residence (rural vs. urban OR 0.55, 95% CI 0.47-0.64 among subjects age ≥75 years) and duration of VKA therapy (≥731 vs. 35-90 days OR 0.04, 95% CI 0.03-0.05). Discussion: Adherence to INR testing appeared to be acceptable for most VKA-treated patients in Saskatchewan. However, this data indicated that adherence might be more problematic in the subgroup of rural residents. Possible explanations include reduced access to testing facilities or the shortage of physicians in rural areas. Further research is required to understand if poor access is the underlying cause of non-adherence to INR testing in the rural population.

Anticoagulantes orais são amplamente indicados para prevenção de eventos tromboembólicos. No entanto, nem sempre os pacientes atingem a faixa terapêutica recomendada. Os objetivos desse estudo foram avaliar a associação entre periodontite e níveis de anticoagulação (fase 1) e o efeito do tratamento periodontal nos níveis de anticoagulação (fase 2) em pacientes que faziam uso do anticoagulante oral varfarina. O exame clínico incluiu índice CPO-D, índice de placa, sangramento à sondagem, profundidade de bolsa e nível de inserção clínica. Coeficiente normalizado internacional (INR), níveis de albumina, proteína C-reativa (PCR) e fibrinogênio foram avaliados no dia zero e até 180 dias após tratamento periodontal. Na fase 1 do estudo foram examinados 62 pacientes (42 mulheres e 20 homens, com idade média de 50,8 9,2 anos). Observamos uma correlação negativa entre extensão e severidade da doença periodontal e índice de placa com valores de INR. Não houve associação entre diagnóstico periodontal e níveis de anticoagulação. Dentre os pacientes fora do alvo terapêutico, 87% apresentavam diagnóstico de periodontite, enquanto no grupo na faixa terapêutica apenas 56%. Participaram da fase 2 do estudo 26 pacientes com periodontite severa (15 mulheres e 11 homens, com idade média de 51,3 9,2 anos). O tratamento periodontal resultou em melhora significativa de todos os parâmetros periodontais e dos níveis de anticoagulação 30, 60 90 e 180 dias após conclusão da terapia periodontal. Não houve alteração significativa na dose semanal da varfarina. Foi observada redução significativa entre níveis séricos de albumina dos dia 90 e 180 após a terapia periodontal, quando comparado aos valores do dia 0 (p < 0,05). De acordo com o alvo terapêutico estabelecido, observamos que no dia 0 doze pacientes (46,15%) estavam fora dessa faixa. Esse percentual foi reduzido significativamente após tratamento periodontal, sendo 26,1% e 29,2% nos dias 60 e 90, respectivamente. Embora tenha ocorrido melhora nos níveis de anticoagulação, não houve alteração significativa nos níveis de PCR e fibrinogênio. Sendo assim, pacientes com periodontite severa podem apresentar dificuldade para atingir a faixa terapêutica e o tratamento periodontal pode resultar em benefícios na busca da anticoagulação plena. Novos estudos são necessários para avaliar se formas menos severas de doença periodontal também podem interferir com a varfarina. / Oral anticoagulants are widely indicated to prevent thromboembolic events. However, sometimes patients are not in optimal therapeutic range. The aims of this study were to evaluate the association between periodontitis and anticoagulant therapy (phase 1) and the effect of periodontal treatment on anticoagulant levels (phase 2) in patients using oral anticoagulant warfarin. Clinical examination included DMFT index, visible dental plaque, bleeding on probing, probing pocket depth and clinical attachment loss. International Normalizer Ratio (INR), levels of albumin, C-reactive protein (CRP) and fibrinogen were analyzed at baseline and up to 180 days after periodontal therapy. At phase 1, 62 patients were examined (42 women and 20 men, mean age 50,8 9,2 years). A negative correlation was observed between extension and severity of periodontal disease and visible dental plaque and INR values. There was no association between periodontal diagnosis and anticoagulant levels. Among patients out of the therapeutic range, 87% have periodontitis while in the group on optimal anticoagulant level only 56% have periodontitis. 26 patients with severe periodontitis were enrolled on phase 2 (15 women and 11 men, age mean 51,3 9,2 years). Periodontal treatment resulted in improvement of all periodontal parameters and of the anticoagulant levels 30, 60 90 and 180 days after periodontal therapy. There was no significant change in varfarin weekely dose. On days 90 and 180, there was a significant reduction on sera albumin as compared to day 0 values (p < 0,05). Twelve patients (46,15%) were under therapeutic range at baseline. There was a significant reduction of this frequency after treatment, 26,1% and 29,2% on days 60 and 90, respectively. Although there was no improvent on anticoagulant levels, no significant change on CRP and fibrinogen levels was observed. Severe periodontitis patients may present some difficulty to achieve therapeutic anticoagulant level and periodontal therapy may result in benefits in anticoagulation. Other studies are necessary to evaluate if less severe forms of periodontal disease can also interfere with warfarin.

Anticoagulantes orais são amplamente indicados para prevenção de eventos tromboembólicos. No entanto, nem sempre os pacientes atingem a faixa terapêutica recomendada. Os objetivos desse estudo foram avaliar a associação entre periodontite e níveis de anticoagulação (fase 1) e o efeito do tratamento periodontal nos níveis de anticoagulação (fase 2) em pacientes que faziam uso do anticoagulante oral varfarina. O exame clínico incluiu índice CPO-D, índice de placa, sangramento à sondagem, profundidade de bolsa e nível de inserção clínica. Coeficiente normalizado internacional (INR), níveis de albumina, proteína C-reativa (PCR) e fibrinogênio foram avaliados no dia zero e até 180 dias após tratamento periodontal. Na fase 1 do estudo foram examinados 62 pacientes (42 mulheres e 20 homens, com idade média de 50,8 9,2 anos). Observamos uma correlação negativa entre extensão e severidade da doença periodontal e índice de placa com valores de INR. Não houve associação entre diagnóstico periodontal e níveis de anticoagulação. Dentre os pacientes fora do alvo terapêutico, 87% apresentavam diagnóstico de periodontite, enquanto no grupo na faixa terapêutica apenas 56%. Participaram da fase 2 do estudo 26 pacientes com periodontite severa (15 mulheres e 11 homens, com idade média de 51,3 9,2 anos). O tratamento periodontal resultou em melhora significativa de todos os parâmetros periodontais e dos níveis de anticoagulação 30, 60 90 e 180 dias após conclusão da terapia periodontal. Não houve alteração significativa na dose semanal da varfarina. Foi observada redução significativa entre níveis séricos de albumina dos dia 90 e 180 após a terapia periodontal, quando comparado aos valores do dia 0 (p < 0,05). De acordo com o alvo terapêutico estabelecido, observamos que no dia 0 doze pacientes (46,15%) estavam fora dessa faixa. Esse percentual foi reduzido significativamente após tratamento periodontal, sendo 26,1% e 29,2% nos dias 60 e 90, respectivamente. Embora tenha ocorrido melhora nos níveis de anticoagulação, não houve alteração significativa nos níveis de PCR e fibrinogênio. Sendo assim, pacientes com periodontite severa podem apresentar dificuldade para atingir a faixa terapêutica e o tratamento periodontal pode resultar em benefícios na busca da anticoagulação plena. Novos estudos são necessários para avaliar se formas menos severas de doença periodontal também podem interferir com a varfarina. / Oral anticoagulants are widely indicated to prevent thromboembolic events. However, sometimes patients are not in optimal therapeutic range. The aims of this study were to evaluate the association between periodontitis and anticoagulant therapy (phase 1) and the effect of periodontal treatment on anticoagulant levels (phase 2) in patients using oral anticoagulant warfarin. Clinical examination included DMFT index, visible dental plaque, bleeding on probing, probing pocket depth and clinical attachment loss. International Normalizer Ratio (INR), levels of albumin, C-reactive protein (CRP) and fibrinogen were analyzed at baseline and up to 180 days after periodontal therapy. At phase 1, 62 patients were examined (42 women and 20 men, mean age 50,8 9,2 years). A negative correlation was observed between extension and severity of periodontal disease and visible dental plaque and INR values. There was no association between periodontal diagnosis and anticoagulant levels. Among patients out of the therapeutic range, 87% have periodontitis while in the group on optimal anticoagulant level only 56% have periodontitis. 26 patients with severe periodontitis were enrolled on phase 2 (15 women and 11 men, age mean 51,3 9,2 years). Periodontal treatment resulted in improvement of all periodontal parameters and of the anticoagulant levels 30, 60 90 and 180 days after periodontal therapy. There was no significant change in varfarin weekely dose. On days 90 and 180, there was a significant reduction on sera albumin as compared to day 0 values (p < 0,05). Twelve patients (46,15%) were under therapeutic range at baseline. There was a significant reduction of this frequency after treatment, 26,1% and 29,2% on days 60 and 90, respectively. Although there was no improvent on anticoagulant levels, no significant change on CRP and fibrinogen levels was observed. Severe periodontitis patients may present some difficulty to achieve therapeutic anticoagulant level and periodontal therapy may result in benefits in anticoagulation. Other studies are necessary to evaluate if less severe forms of periodontal disease can also interfere with warfarin.

Submitted by Fabiana Gonçalves Pinto (benf@ndc.uff.br) on 2015-12-14T13:43:05Z No. of bitstreams: 1 Maria Cecilia Pereira Bosa.pdf: 2708979 bytes, checksum: 3b6806151684db7e144dbe27a092377c (MD5) / Made available in DSpace on 2015-12-14T13:43:05Z (GMT). No. of bitstreams: 1 Maria Cecilia Pereira Bosa.pdf: 2708979 bytes, checksum: 3b6806151684db7e144dbe27a092377c (MD5) Previous issue date: 2012 / Mestrado Profissional em Enfermagem Assistencial / Trata-se de uma pesquisa desenvolvida no Programa de Mestrado Profissional de Enfermagem Assistencial da Escola de Enfermagem Aurora Afonso Costa – EEAAC, da Universidade Federal Fluminense – UFF. Estudo não experimental, observacional, tipo caso controle com abordagem quantitativa para análise da ocorrência dos desfechos tromboembólicos e hemorrágicos de pacientes cardiopatas portadores fibrilação atrial crônica em uso de varfarina sódica, acompanhados no ambulatório de anticoagulação oral do Instituto Nacional de Cardiologia no município do Rio de Janeiro. Objetivo geral: avaliar o efeito das intervenções de enfermagem na adequação do Coeficiente Internacional Normatizado (INR) alvo, segundo variáveis demográficas e clínicas relacionadas ao uso da terapia de anticoagulação oral (TAO). Objetivos específicos: identificar eventos trombóticos ou hemorrágicos; correlacionar possíveis intercorrências clínicas a fatores como adesão e compreensão ao tratamento; analisar a o processo do conhecimento e aprendizado do paciente através das orientações contidas na cartilha de anticoagulação oral. Método: caso controle amostra não probabilística de conveniência limitada ao recorte temporal de seis meses a partir da segunda consulta no período de agosto de 2011 a fevereiro de 2012, após Consentimento Informado (CI), através entrevistas individuais e consulta ao banco de dados do referido ambulatório. O projeto foi submetido ao Comitê de Ética em Pesquisa do Instituto Nacional de Cardiologia do Ministério da Saúde e aprovado em 09/08/2011 sob n° 0341/21-06-2011. O tratamento dos dados estará baseado em estatística descritiva e cálculo de risco relativo. O ambulatório de Anticoagulação Oral (ACO) desta Instituição tem como proposta minimizar estas intercorrências clínicas através de acompanhamento específico deste paciente. Utilizando um Protocolo criado e Normatizado por equipe interdisciplinar da Instituição (Anexo II), que permeia o fluxo do atendimento e as intervenções. Principais resultados, e conclusão A pesquisa deverá contribuir com a prática da enfermagem dirigida a estes clientes, fornecendo subsídios teóricos científicos para a assistência de enfermagem, de modo a delinear as ações de avaliação e do cuidado de enfermagem, numa prática de cuidado singular, diferenciado e humanizado. Vislumbrando a minimização dos agravos decorrentes da TAO / Non-observational study, experimental, prospective cohort type with quantitative approach to analysis of occurrence of hemorrhagic and thromboembolic events outcomes of cardiopatas patients with chronic atrial fibrillation in use of warfarin, accompanied in oral anticoagulation clinic of the National Institute of Cardiology in the municipality of Rio de Janeiro. General Purpose: evaluate the impact of nursing Consultation guidelines regarding the occurrence of hemorrhagic or thrombotic effects, according to demographic and clinical variables related to the use of oral anticoagulation therapy (TAO), through the International Standardised coefficient evaluation (INR). Specific objectives: identify the association between the presence of complications by use of TAO to possible factors such as membership and understanding to treatment; evaluate effectiveness of nursing interventions through an educational process in the construction of knowledge and leaINRng from patient and in TAO. Method: prospective cohort of non-probability convenience sample limited to temporal clipping of six months from the second query in the period August 2011 to January 2012, after informed consent (CI), through individual interviews and database query of that clinic. The project was submitted to the Committee of ethics in research of the National Institute of Cardiology of the Ministry of health passed in 8/9/2011 under n° 0341/6/21/2011. The data controller is based on descriptive statistics and calculation of relative risk. The ambulatory Oral Anticoagulation (ACO) this institution has as a proposal to minimize these uneventful clinics through specific monitoring of the patient. Using a protocol created and Regulated by an interdisciplinary team of the institution (Annex II), which permeates the flow of care and interventions. The research should help with the practice of nursing addressed to these clients, providing theoretical grants for scientific nursing assistance, so as to delineate the actions of assessment and nursing care, in a singular, differentiated care practice and humanized. Envisioning the minimisation of grievances arising from the TAO