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Kristoffersen A.-H.,University of Bergen | Thue G.,University of Bergen | Ajzner E.,Central Laboratory | Claes N.,Hasselt University | And 16 more authors.
Thrombosis Research | Year: 2012

Introduction: Standardisation of treatment with vitamin K antagonists (VKAs) is still an issue after 60 years of use. The study aimed to explore aspects of VKA monitoring in primary and secondary care. Methods: Two case histories were distributed to physicians in 13 countries. Case history A focused on a patient with atrial fibrillation on stable anticoagulation (latest INR 2.3). Physicians were asked about frequency of INR measurement, when to change the VKA dose, and the patient's annual risk of ischemic stroke and bleeding. Case history B focused on a patient with an unexpected INR of 4.8, asking for the patient's 48-hour bleeding risk, the immediate dose reduction and time until a repeat INR. Results: Altogether, 3016 physicians responded (response rate 8 - 38%), of which 82% were from primary care and 18% from secondary care. Answers varied substantially within and between countries regardless of level of care and VKA used. Median number of weeks between INR measurements was 4 - 6 weeks. Median threshold INR for increasing or decreasing the VKA dose was 1.9 and 3.1, respectively. Risk of ischemic stroke and bleeding were overestimated 2 - 3 times. In case history B, the median dose reduction the two first days was 75% for GPs and 55% for specialists, irrespective of estimates of bleeding risk; with one week to a repeat INR. Conclusion: Variation in VKA monitoring is substantial implying clinical consequences. Guidelines seem either unknown or may be considered impracticable. Further efforts towards standardisation of VKA management are needed. © 2012 Elsevier Ltd. Source


Watine J.,Center Hospitalier la Chartreuse | Mokaddem W.,Unite dAngiologie et dExplorations Fonctionnelles Vasculaires | Carriere P.,Unite dAngiologie et dExplorations Fonctionnelles Vasculaires | Couaillac J.-P.,Center Hospitalier Of Cahors | And 3 more authors.
Annales de Biologie Clinique | Year: 2013

Using a questionnaire, we have evaluated how VKA and INR are handled by medical doctors in Quercy-Rouergue. This evaluation is part of an international post-analytical quality assessment survey in laboratory medicine supervised by Noklus (http://www.noklus.no/). The original questionnaire designed by Noklus has been adapted to our local practices in replacing warfarin by fluindione. The ≪ Centre de référence et d'éducation aux antithrombotiques d'Ile de France ≫ (Creatif) also participated. Of 282 medical doctors who were sent the questionnaire 109 filled it in, 62% of them being general practitioners. For a target INR at 2.5, the thresholds used to change the dose of VKA range between 1.3 and 2.3 for low values, and between 2.8 and 4 for high values. The bleeding or ischemic risks of being under VKA, versus of not being under VKA, are largely overestimated. INR measurements also tend to be too frequent in stable, and even more so in overdosed, patients. In case of INR at 4.8 only 59% of the participants implement the recommendation of la Haute autorité de santé (HAS) and le Groupe d'étude sur l'hémostase et la thrombose (GEHT) which consists of skipping one dose of VKA, and the attitudes also diverge regarding the importance of the VKA dose reduction, and the number of days under reduced dose before the next INR measurement, the attitude of the Creatif being barely predominant among the participants, and slightly different from that recommended by the HAS and the GEHT. In conclusion, despite the limitations of our methods (the analysis of a questionnaire being less close to the truth than an analysis of actual practices), our evaluation points to the heterogeneity in the knowledge about, and in handling, VKA and INR regarding more particularly management of overdosing, and the estimation of bleeding or ischemic risks, despite the availability of supposedly clear and simple practice guidelines. © Copyright 2007 John Libbey Eurotext - All rights reserved. Source


Kristoffersen A.H.,University of Bergen | Kristoffersen A.H.,Norwegian Quality Improvement of Primary Care Laboratories NOKLUS | Ajzner E.,Central University of Costa Rica | Rogic D.,Clinical Institute of Laboratory Diagnostics | And 7 more authors.
Thrombosis Research | Year: 2016

Introduction Clinical algorithms consisting of pre-test probability estimation and D-dimer testing are recommended in diagnostic work-up for suspected venous thromboembolism (VTE). The aim of this study was to explore how physicians working in emergency departments investigated patients suspected to have VTE. Materials and methods A questionnaire with two case histories related to the diagnosis of suspected pulmonary embolism (PE) (Case A) and deep venous thrombosis (DVT) (Case B) were sent to physicians in six European countries. The physicians were asked to estimate pre-test probability of VTE, and indicate their clinical actions. Results In total, 487 physicians were included. Sixty percent assessed pre-test probability of PE to be high in Case A, but 7% would still request only D-dimer and 11% would exclude PE if D-dimer was negative, which could be hazardous. Besides imaging, a D-dimer test was requested by 41%, which is a "waste of resources" (extra costs and efforts, no clinical benefit). For Case B, 92% assessed pre-test probability of DVT to be low. Correctly, only D-dimer was requested by 66% of the physicians, while 26% requested imaging, alone or in addition to D-dimer, which is a "waste of resources". Conclusions These results should encourage scientific societies to improve the dissemination and knowledge of the current recommendations for the diagnosis of VTE. © 2016 Elsevier Ltd. All rights reserved. Source


Grimaldi-Bensouda L.,LA SER | Grimaldi-Bensouda L.,French National Conservatory of Arts and Crafts | Grimaldi-Bensouda L.,French Institute of Health and Medical Research | Alperovitch A.,French Institute of Health and Medical Research | And 55 more authors.
Annals of the Rheumatic Diseases | Year: 2015

Background: Gout therapy includes xanthine oxidase inhibitors (XOI) and colchicine, which have both been associated with decreased cardiovascular risk. However, their effects on major cardiac events, such as myocardial infarction (MI), need to be investigated further. Objectives: To investigate whether XOIs and colchicine are associated with decreased risk of MI. Methods: This case-control study compared patients with first-ever MI and matched controls. Cases were recruited from the Pharmacoepidemiological General Research on MI registry. Controls were selected from a referent population (n=8444) from general practice settings. Results: The study sample consisted of 2277 MI patients and 4849 matched controls. Use of allopurinol was reported by 3.1% of cases and 3.8 of controls, and 1.1% of cases and controls used colchicine. The adjusted OR (95% CI) for MI with allopurinol use was 0.80 (0.59 to 1.09). When using less stringent matching criteria that allowed for inclusion of 2593 cases and 5185 controls, the adjusted OR was 0.73 (0.54 to 0.99). Similar results were found on analysis by sex and hypertension status. Colchicine used was not associated with a decreased risk of MI (aOR=1.17 (0.70 to 1.93)). Conclusions: Allopurinol may be associated with a reduced risk of MI. No decreased risk of MI was found in colchicine users. Besides its urate-lowering property, allopurinol might have a cardioprotective effect. Source


Milleret G.,Center Hospitalier la Chartreuse | Benradia I.,Center Collaborateur Of Loms | Guicherd W.,Center Hospitalier la Chartreuse | Roelandt J.L.,Center Collaborateur Of Loms
Information Psychiatrique | Year: 2014

In order to better understand the practices of general practitioners (GP) in relation to mental health disorders and their expectations of mental health participants, the WHO Collaborating Centre (Lille) and La Chartreuse Hospital (Dijon) carried out research regarding the "Place of Mental Health in General Medicine". A total of 101 psychiatric sectors participated in the study and 2,076 questionnaires were collected. The main obstacles to effective co-operation between GP and mental health services were related to the difficulties of referral, stigma and reluctance of patients, as well as the high cost of psychotherapy in the private sector. The optimization of joint action by the GP and psychiatric professionals requires an improvement in communications, training and mental health care in the primary care system. Source

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