Joseph F McGuire, M.A., Ph.D.

• Assistant Professor of Psychiatry and Behavioral Sciences

https://www.hopkinsmedicine.org/profiles/results/directory/profile/10004044/joseph-mcguire

The drop in performance quality during this period was thought to result from disruption of motor coordination and the inefficiency of Earth-learned motor skills to control the spacecraft in weightlessness cat allergy treatment uk cheap alavert 10mg online. This inefficiency was manifested by frequent allergy testing kits for physicians cheap alavert 10 mg with visa, jerky motions instead of smooth controlling motions allergy medicine you can take when pregnant generic alavert 10 mg without a prescription. Later in flight cat allergy treatment uk cost of alavert, allowing more than 30 days to elapse between trials produced further decrements in simulated berthing and docking skills, with the degree 22 of decrement directly related to the duration of the interval. The greatest declines were present in accuracy and time; after more than 30 days, operators tended to forget components of the performance algorithm as well. However, another study revealed no change in logical or computational ability, nor in complex sensorimotor 30 reactions during flight. Cosmonauts and astronauts were able to process a great deal of information under time pressure; to discriminate between similar signals; to shift attention rapidly; to recognize problems promptly; and to implement appropriate solutions. Thus, humans in space flight retain their ability to perceive, comprehend, and 4 Vl 4 Ch 11 Psychological Analysis and Monitoring of Crew Performance Myasnikov et al. This measure, quantified in arbitrary stress units, is closely linked to the difficulty of the task being performed. Stress levels increased substantially once that cosmonaut reached the station exterior (Fig. Later peaks in the stress indicator were associated with the cosmonaut freeing himself from the tether anchor (0. Another concept showing great promise for psychological analysis of cosmonaut performance is that of an onboard 33 multipurpose psychophysiological complex (Fig. The configuration of that complex facilitates the solution of many problems, such as: • acquiring, processing, analyzing, and storing psychophysiological information; • issuing commands to select and present the operator with test material and various types of operator tasks; • creating a data bank and expert system representing a set of programs, allowing diagnostic information to be used to predict operator reliability and crew-spacecraft system efficiency; • simulating work tasks for monitoring, supporting, and recovering skills for controlling the spacecraft and evaluating crew performance; • implementing and optimizing the state of the operator with biofeedback and psychotherapy techniques; and • supporting conditions for embedding test information in game or work-simulation forms, which substantially increases the motivation to perform well on psychological tests. The psychophysiological complex also provides confidentiality in data collection, a dialogue mode, graphic representation of results, and other features necessary for its effective use. This concept has met with the support and approval of several discussion groups, including one held in March 1991 with the European Space Agency. Enhancing the Efficiency of the Crew-Spacecraft System During Its Design, Production, and Use From a mathematical perspective, efficiency is a scalar quantity representing the quality of crew performance divided by expenditure of time and resources. The efficiency of a crew-spacecraft system can be associated with the probability that the crew will perform some stipulated function(s) during a period defined by the flight program. Other considerations can include the quantity of products or quality of the services performed by the crew in a given time. At the current state of crewed space flight, enhancements of the efficiency of the crew-spacecraft system can be grouped into 5 major categories: (a) optimal allocation of functions between the spacecraft and ground-control crews, between the crew and the onboard spacecraft hardware, and among crewmembers; (b) appropriate design of the spacecraft layout and interior according to ergonomic principles and functional comfort; (c) well-organized and planned in-flight work schedules; (d) the use of selection and training to create crews that have the most important qualities for work performance; and (e) psychological support measures to ensure the readiness. Allocation of Functions Allocation of functions in human-machine systems is an extraordinarily complex issue. Aspects of this problem are addressed from an ergonomics/engineering perspective in Chapter 10, and from a psychological point of view in the following paragraphs. One example concerns whether the balance of spacecraft-control functions are allocated to the flight control center on Earth vs. Decentralized flight control also is needed when the spacecraft is out of radio contact with Earth, whether from orbital pattern or from problems with the communication lines. The importance of decentralized flight control in maintaining the efficiency of the crew-spacecraft system has been amply demonstrated throughout the history of crewed space flight. Allocation of functions among members of a flight crew is based on principles of command authority, collegiality, and specialization. Within a crew, the commander is responsible for the safety of the crew and orbital complex, as well as the completion of the flight program. The flight engineer is responsible for the use and maintenance of the onboard systems. Mission and payload specialists, if present, are responsible for specified tasks and the use of associated hardware. Responsibilities among crews are alloacated and defined as the orbital complex is being planned. While onboard systems and methods of controlling them are being developed, functions are allocated to crewmembers in more detail, at the level of flight operations and modes of operation of onboard systems. More detailed allocations take place both while the crews train with the training simulators (see Chapters 2 and 10) and during actual work according to individual strengths and skills. From a psychological perspective, the role of human operators in the current crew-spacecraft system is less than ideal. Space-hardware developers strive for maximum automation of all functions, following the principle that all the major flight operations should be performed automatically, without crew involvement. Crews, as a rule, are assigned secondary functions, and serve as a back-up for automated operations. This situation diminishes the active participation by crews and as a consequence decrease their readiness to act in cases of equipment failure or other emergencies. Effective interactions among crews and hardware can be fostered through an integrated systems approach to spacecraft design, which substitutes the design of a unified human operator-hardware system for the design of individual hardware components. In this approach, the crew is treated as the major, active, defining component of the system, and the spacecraft systems controlled by the crew are treated as passive components. For operational tasks and control functions that do not affect crew safety, crew-hardware functions can be allocated on the basis of cost effectiveness, i. For control functions that do affect crew safety or could threaten the operation of the spacecraft, this principle is not acceptable. All available resources should be used to provide maximum reliability, which in some cases means maximizing the level of automation. Special training methods and programs are now being developed that can support active crew involvement with highly automated station control. Spacecraft Architecture and Interior Design Another way of enhancing the efficiency of the crew-spacecraft system is to improve the functional comfort or habitability of working conditions for its human operators. Such improvements, based on principles of architectural and interior design, aim to provide variety in volumes, forms, and colors of working and living modules, compartments, areas interiors, panels, and work stations. Ideally, these areas could be reconfigured as needed over 34,35 the course of a flight. From the standpoint of functional comfort, the interior architecture and configuration of Mir is greatly constrained, being determined by the configurations of the spacecraft hull. From both psychological and architectural perspectives, Mir is a highly dynamic and symmetrical living environment that is densely saturated with specialized equipment. In general, its design represents an appropriate balance between hardware and working conditions for the crews in terms of maximizing productivity, maintaining 6 Vl 4 Ch 11 Psychological Analysis and Monitoring of Crew Performance Myasnikov et al. The success of this balance is demonstrated by the reliability and efficiency of the crew-spacecraft system during missions lasting up to 1 year. Planning Mission Tasks Planning can have an enormous influence on the efficiency with which a wide variety of tasks are performed on board a spacecraft. Appropriate planning organizes the work of the crew (both temporally and spatially), defines the direction of that work, and establishes the amount of effort needed to complete the work so as to meet the goals and objectives of the mission. In a sense, planning is part of the cyclic process by which space flights are controlled. The essence of planning is the identification of a sequence of actions that will achieve mission objectives through transforming information about the status of the spacecraft and the environment. During the process of planning, the order of flight operations and their temporal relationships to each other are established. The result of the planning process is the creation of a flight plan by which mission objectives are achieved and the safety of the crew is maintained. In the Russian space program, three levels of planning correspond to three types of plans: the overall flight plan, the detailed flight plan, and the schedule of flight operations. The overall flight plan for crewed space stations covers periods lasting 10–12 days, and includes the list and sequence of flight operations performed on each day. The detailed flight plan covers 24-hour periods and provides a schedule for crew activities (see Section D below), operation of onboard systems, and exchanges of information between the crew and other components of the flight control system (e. The schedule of flight operations contains instructions on how to monitor the operation of onboard systems and how to change the activity schedule if contingency situations arise. Flight planning begins at the phase of spacecraft design and continues until the flight is completed. The extent to which crews are involved in planning during the course of the flight depends on the autonomy of the spacecraft and the allocation of this function between the crew and the Mission Control Center. Work-Rest Schedule As described above, planning is one way in which both the efficiency of the crew-spacecraft system and crew performance can be enhanced.

You must seek medical advice quickly if you develop symptoms of an infection and you should carry a card to say that you have had your spleen removed in case you are in an accident allergy shots high blood pressure discount generic alavert canada. Like steroids allergy medicine prednisone 10 mg alavert visa, it stops the immune system destroying platelets allergy forecast georgetown texas purchase 10 mg alavert, but it has fewer side effects than steroids allergy medicine cvs order online alavert. It is a manufactured antibody (developed by a medicines company) which affects the white blood cells. Rituximab is given as an infusion through a drip (a small tube into a vein in your arm), once a week for four weeks. It usually takes a few weeks for rituximab to work, although some people respond many months after treatment. If rituximab works well for you, the treatment can be repeated months or years later, if needed. Around two out of three people given rituximab will have some increase in their platelet count. The most common problem is a reaction to the infusion (such as a fast heart rate or breathlessness), but you will be monitored closely while it is given. Although rituximab works by stopping the white cells from making antibodies, you arent likely to have any problems with infections. There is an extremely rare viral infection which can affect the nervous system, which a few people treated with rituximab have had. Romiplostim (Nplate™) is given by an injection under the skin, usually once per week. It cant be absorbed by the gut if there is calcium nearby, so you must not eat foods high in calcium for four hours before or after you take it. Most people fnd it easiest to take the medication early in the morning or just before going to sleep. Foods high in calcium include dairy products, cereals, tinned fsh with bones and green leafy vegetables. They do not cure the underlying problem, they just tell your body to make more platelets to replace the ones that are being destroyed. Some people get headaches and a few people taking romiplostim have developed scarring of the bone marrow. The scarring of the bone marrow doesnt appear to stop the bone marrow from working properly. There may be a small risk of blood clots (which can be in the legs or lungs, or cause heart attacks or strokes) in people whose platelet count goes up to high levels. Your doctor will monitor your platelet count carefully while you are on this medication, to help avoid this. Sometimes your platelet count can go up and down a lot when you start these medications. This means that you will need frequent blood tests and clinic visits when you start to take this medicine. They are used less often now, as they are thought to have more side effects than the newer treatments. However, they can stop bone marrow from working properly, which can lead to anaemia and low white blood cell counts. Some of these drugs can also affect the kidneys, so you will be closely monitored while you are taking them. All are given as a tablet, except vincristine, which is given as an injection into a vein. Improvements of platelet count following treatment of the infection are not always permanent, but the treatment is very safe and so may be recommended by your doctor. It is not really known how it works, but it appears to dampen down the autoimmune process, which can stop your body from attacking your platelets. About 50% of people (50 in 100) who have already had steroids and rituximab will respond to dapsone. However less than half of these people will still have a good platelet count after 6 months. However, it can only work for people who are rhesus positive or more correctly, D positive and who have not had a splenectomy. The platelets made by your bone marrow are healthy and it is only because your immune system is destroying them that you have a low platelet count. If you were to receive other peoples platelets (given by transfusion) they would also be destroyed by your immune system. Platelets transfused to you would only last minutes or hours before being destroyed. Platelet transfusions can be useful as an emergency treatment if you have severe bleeding, as they can help you to form a clot, but they are not useful for long term prevention of bleeding. Tranexamic acid is a medication which helps blood clots to last longer once they have formed. It can sometimes cause indigestion, which may get better if you take a lower dose. You should discuss any questions you might have about these treatments with your doctor, so you can make a decision together about which one would be appropriate for you. If you need to make an appointment to discuss this information with your doctor, please phone the Haematology Secretaries: Tel: 01865 235 882 (9. A purple rash, usually on the ankles and legs, which does not fade when you press it, can also be a sign of a low platelet count. If you have excessive bleeding or bruising, you must go to the Emergency Department at your nearest hospital. You can also use it to request leafets on specifc topics (such as splenectomy): Website: www. Copyright © 2011 European Group for Blood and Marrow Transplantation Contents Chapter 1: Overview of immune thrombocytopenia 3 Chapter 2: Identifying immune thrombocytopenia 7 Chapter 3: Managing patients with immune thrombocytopenia 11 Chapter 4: Immune thrombocytopenia – patient considerations 19 Glossary 23 References 25 Additional resources 27 Appendix: Case examples 28 Chapter 1. Overview of immune thrombocytopenia 3 and suboptimal bone marrow production of platelets. They are phagocytosed by macrophages mainly in the spleen, but also in the liver and bone marrow Chapter 1. Mucosal bleeding and petechiae • Petechiae or purpura (Figure 5) images courtesy of Drew Provan. A peripheral blood smear one survey, report experiencing fatigue, which has a signifcant can exclude pseudothrombocytopenia, which is an in-vitro impact on their quality of life. The medical history and physical examination are used to characterise the type, severity Table 2. Life-threatening bleeding, however, rarely occurs in patients with platelet counts above 10 x 109/L. Consequences of low platelet counts Platelet count (x 109/L) Symptoms >50 None 30–50 Excessive bruising with minor trauma 10–30 Spontaneous petechiae or bruising <10 At risk of internal bleeding Data taken from Cines & Blanchette. Risk of bleeding increases with age 100 Fatal bleed Major nonfatal bleed 80 60 40 20 0 <40 40–60 >60 (n=571) (n=240) (n=183) Age group (years) Adapted with permission from the Archives of Internal Medicine. Corticosteroids prevent the destruction of consensus group,25 to refect the introduction of new treatments, platelets by macrophages within the spleen and liver thereby the greater understanding of the disease, and the availability of 35 increasing platelet levels. If there is no response recommendations are mainly based on expert opinion rather than after 4 weeks, treatment is considered to have failed and should evidence based, due to the paucity of randomised controlled trials be stopped. The choice of treatment(s) term treatment (3–4 weeks) because long-term use leads to should be individualised and depends on a number of factors signifcant side effects that outweigh the benefts of reducing including the individuals signs, symptoms and comorbidities, the risk of serious bleeding. Patients receiving long-term Who and when to treat corticosteroids (>6 months) require bone density monitoring or prophylactic treatment to avoid osteoporosis, particularly if they Patients with a platelet count above 50 x 109/L usually do are over 60 years of age. When to treat They are produced by collecting antibodies from human Platelet count (x 109/L) Treatment plasma and, therefore, carry the potential risk of transmitting infectious diseases. The latter has been withdrawn from the European mg/kg/day) for patients at higher risk of haemorrhage (e. Vary with length of administration: mood As high as 50–80% 40 mg daily for (several days–weeks) swings, weight gain, anger, anxiety, insomnia, reported during 4 days every Cushingoid face, dorsal fat, diabetes, fuid 2–5 years of follow-up 2–4 weeks for retention, osteoporosis, skin changes (e. Transient: neutropenia, renal insuffciency, 2–4 weeks following 24 hours, typically aseptic meningitis, thrombosis, fushing, treatment, although 2–4 days) fever, chills, fatigue, nausea, diarrhoea, blood occasionally can pressure changes and tachycardia persist for months • Occasional: anaphylactoid reactions in patients with IgA defciency *Note: Intravenous anti-D was voluntarily withdrawn from the European market in August 2009 owing to safety concerns.

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Urticaria Dosing in each patient varied from 300 mg/kg to 2 g/kg allergy symptoms no allergies buy discount alavert 10 mg line, and Chronic urticaria is a disorder that is often difficult to treat allergy forecast in tampa florida generic alavert 10 mg on-line, duration ranged from 6 to 39 months allergy testing nj buy generic alavert 10 mg online. Time to response seen although advances in the understanding of the underlying was 3-6 months allergy symptoms to tylenol 3 order alavert 10mg. Significant decreases in serum IgE and mechanisms have provided new insights and therapeutic ratio eosinophils were seen at the 3-month time point, and the 304 nale. An autoimmune process is implicated in about one third of decrease in serum IgE persisted after discontinuation. Slight improvement in skin disease was observed in 6 trial; one third of the enrolled patients experienced remission, patients; no improvement, in 2 patients; and worsening, in 1 another third experienced some benefit, and the rest did not patient. The cause of provided conflicting results, and the majority of successful reports illness remains unknown but several clinical, laboratory, and were case series. Long-term benefits following discontinuation of may be associated with even better outcomes, but these data 314 treatment are conflicting, and additional randomized, placebo have been challenged. All patients should be given a single 315 controlled studies with longer follow-up are needed. Another meta-analysis of data from >3400 patients for which no specific chemotherapy exists. Age, duration of illness, immunoglobulin products with high concentrations of specific neutrophil and platelet counts, elevated aspartate aminotrans antibodies to pathogens such as those causing tetanus, ferase and C-reactive protein, and hyponatremia have been pro 322-325 rabies, and diphtheria have been made available in the United posed to predict resistance to treatment. A larger-scale study in 3493 infants receiving not responding to initial dosing within 48-72 hours (ie, when antibiotics for the treatment of sepsis did not show differences in neutrophil counts, C-reactive protein, and N-terminal of the mortality or major disability at 2 years between patients who prohormone brain natriuretic peptide, which are independent 343 received immunoglobulins and those who received placebo. Immunoprophylaxis with 5 332 coccal disease in newborns, streptococcal toxic shock/invasive monthly doses of palivizumab is an effective intervention that 333-337 338 streptococcal syndromes, postoperative sepsis, trauma has been reported to reduce hospitalization by 39-82% among 339 340 351 associated sepsis, and neonatal sepsis. Category Ib evidence exists to support the retrospective study, in 9 of 14 patients with refractory C. Those probably beneficial in the treatment of neonatal sepsis (Ia), but not studies were of relatively small sample size and used different in prophylaxis of infection. It is thought to result from 369,370,373,374 371 were common and treatment failures did occur, immunologic destruction of myelin or Schwann cells within the but the latter approach was associated with long-term eradication peripheral nervous system. None of the treatments significantly reduced mor tients with autonomic instability. Nonetheless, a randomized, placebo-controlled 414 remain unclear, although genetic factors may play a role. A retrospective chart review of data from 53 patients 416-418 conduction block or Medical Research Council scores. Limited but moderate to high-quality ev now the recommended therapy for this neurologic disease. A similar response and lack of serious and other centralnervous system syndromes) that is associated with adverse events have been reported in additional case reports and autoantibodies against the astrocyte water channel called aqua 443-445 461 uncontrolled trials. It may thus be used as an alternative prine, mycophenolate mofetil, or rituximab, based on retrospective treatment in patients who fail to respond or do not tolerate other and prospective open-label studies only. When larger doses were tried (1 g/kg/d for Intractable childhood epilepsy 2 days at 4-week intervals), 65% (of 25 patients) had no There is some evidence that an aberrant immune response is 449 exacerbations in 6 months versus 35% of the control group. However, event suggesting demyelinating disease significantly lowered the there are 2 randomized placebo-controlled trials that have been 450 prevalence of a second attack and reduced disease activity. However, further randomized, double-blind studies are 4 days, then once each in weeks 2, 3, and 6, 6 month 6) reduced 452 needed to confirm these findings. A multicenter, randomized, double-blind, placebo immunomodulatory treatment in resistant cases. Another study reported increased plasma anti– 475,483 there are contraindications of steroid use. It was also b-amyloid antibody concentrations associated with decreased reported to improve acute disseminated encephalomyelitis b-amyloid peptide levels in the cerebrospinal fluid following 484 following pertussis in an infant. These changes at the molecular level were 496-499 case series that included 6 patients with steroid-dependent accompanied by improved cognitive function. Case reports and series extend to preg 510 512 513 conditions nant, adolescent, and infant patients. A consensus statement 517 ness in a number of disorders of the peripheral and central from the American Academy of Dermatology on the use of nervous systems. The blistering skin diseases group as adjuvant therapy in combination with an immunosuppressive of autoimmune disorders includes pemphigus vulgaris, bullous agent. A review of data from >200 additional patients contained in anec syndrome are potentially fatal disorders. This finding is especially relevant corticosteroids) in these disorders also showed a trend toward in light of the teratogenic effects of the other forms of available earlier resolution and reduced mortality, although results were therapies. A few recent small-scale, covered elsewhere in this review: psoriasis, pyoderma gangreno uncontrolled studies have suggested a benefit of standard or 522 sum, pretibial myxedema, and Mucha-Habermann disease. Some argue that when patients are selected for 525 More recent reports also include dystrophic calcinosis cutis the occurrence of other autoimmune phenomena, the effective 526 546,547 and scleromyxedema. Between typical chronic fatigue syndrome, as demonstrated in a 552 2% and 10% of patients with cystic fibrosis have hypogamma double-blind, placebo-controlled trial. Some studies do not suggest any associated be associated with specific viral infections, such as parvovirus 532 additional morbidity due to hypogammaglobulinemia, while (erythrovirus) B19. Autistic children reportedly may have mild abnor 535 stabilization and delayed progression of loss of renal function. However, at least 1 report has described neural antigens may be found in subsets of these patients. Likewise, immunoglobulin is unlikely to 560 compulsive and tic disorders in some children. There may be be beneficial in autism, except in the cases of comorbid bona fide cross-reaction between microbial and brain antigens, although antibody deficiency. The the immune-based therapies should be used only in cases in safe and effective use of immunoglobulin requires attention to which it is clear that the neuropsychiatric symptoms are related numerous issues that relate to the both the product and the patient. It becomes crucial for the prescribing physician to carefully assess and monitor patients receiving immunoglobulin Summary: Immunoglobulin in miscellaneous so that treatment can be optimized. Of mention, guidelines and consensus documents on the use of immunoglobulin, in conjunction with rituximab and other Intravenous immunoglobulin therapy immunosuppressives, in blistering skin diseases have been Products. Modified from Primary Immunodeficiency Committee, American Academy of Allergy, Asthma & Immunology. Failure to base this decision on patient experience and circumstance, and choose the appropriate site of care could place a patient at risk. Adapted from Primary Immunodeficiency Committee, American Academy of Allergy, Asthma & Immunology. The plasma is Research) and Plasma Protein Therapeutics Association: more separated using alcohol-based fractionation procedures to precip than 15,000, but not to exceed 60,000, donors. Excipients, such as sugars (eg, maltose ogen contamination in pools of donor plasma, including donor or D-sorbitol) or amino acids, (eg, glycine and L-proline) are added screening, donor testing for viral pathogens, and pooled plasma to prevent aggregation of purified IgG, which can cause adverse testing by sensitive nucleotide testing. Cold ethanol fractionation, the first step in the process of readings due to interference by the maltose. The investigators suggested more intensive therapy according to the ability of a given regimen to maintain an to maintain higher serum IgG trough levels, >700 mg/dL. Other acceptable clinical effect, such as keeping the patient infection 565 studies have echoed these findings. Immune Deficiency Foundation found that 44% report experi An acceptable starting point for maintenance dosing is 400 encing adverse reactions, and that this rate was unrelated to rate 600 mg/kg every 3-4 weeks and is consistent with majority 578 of infusion. The rates of reactions in clinical practice are practice by focused immunologists in the United States and higher than observed in clinical studies and highlight the 568,569 Europe. However, physicians reactions are rate-related, are mild, and occur in only 5-15% of should be aware of weight changes in growing children and adjust infusions. They should be obtained whenever a pain, nausea, breathing difficulties, chills, flushing, rash, anxiety, significant infection occurs or when the clinical response to 572,579 low-grade fever, arthralgia, myalgias, and/or headache. After the fifth infusion, a Slowing or stopping the infusion for 15-30 minutes will steady state will have been achieved, and the dose or dosing reverse many reactions. Oral hydration prior to the infu increase over baseline IgG level has been shown to significantly sion is often helpful.

The intensity of anticoagulation treatment also needs to be controlled closely due to the narrow therapeutic range of warfarin allergy testing boston ma alavert 10mg low cost, the potentially life-threatening effects of both over allergy medicine bag order alavert canada, and under-dosing allergy mask purchase 10mg alavert with visa, and its interaction with other drugs or foods like leafy green vegetables allergy symptoms ginger purchase alavert without prescription. Several other factors may affect the patients? response to warfarin control including compliance to therapy, underlying liver or kidney diseases, infections, diet, and others. The test is easy to perform but its results may widely vary between institutions, and even within the same institution. These monitors require only a finger stick whole blood rather than the citrated venous blood, and the patients can perform it at home. Patients need to operate the machine, and self-sample blood, they have to be free from any major visual problems, tactile dysfunction, or severe tremors to be able to mechanically handle self-testing, they also have to be reliable and complying with the dosage algorithm. Without prophylaxis, the rate of deep vein thrombosis or pulmonary embolism in these patients range from 40% to 84% and is the most common cause of death. The currently available methods of thromboprophylaxis include intermittent pneumatic calf compression, elastic compression stockings, or the use of pharmacological agents. The duration of thromboprophylaxis is controversial and varies widely between practices, ranging from 1-12 weeks 2002 Kaiser Foundation Health Plan of Washington. Back to Top Date Sent: 3/24/2020 512 these criteria do not imply or guarantee approval. This, together with the shorter durations of hospitalization, extending the use of antithrombotic prophylaxis for up to 5 weeks is becoming more common (Schuringa 1999, Geerts 2001, Frederick 2003, He Xing 2008. The intensity of anticoagulation treatment needs to be controlled closely due to the narrow therapeutic range of warfarin, its interaction with several other drugs and foods, and the potentially life-threatening effects of both over and under-dosing of the drug. These monitors may be used at home and only require a fingerstick whole blood rather than the citrated venous blood. Personal self-testing with or without self-management is however is not suitable for everyone. Patients have to be reliable and free from any major visual problems, tactile dysfunction, or severe tremors to be able to mechanically handle self-testing. The trial also showed that significantly more measurements were in the therapeutic range among patients in the self management group. This difference was only statistically significant at three months of follow-up but not after six month. It also showed that a higher proportion of measurements among patients in the self-management group were in the therapeutic range vs. Eldor?s study on elderly patients with atrial fibrillation was too small, non randomized and had insufficient power to detect any difference between the groups. The other studies had insufficient sample sizes, and follow-up durations to study that outcome. It is worth noting that the studies were conducted among selected groups of patients and cannot be generalized to all patients with mechanical heart replacement. The purpose of this review is assessing the home use of the monitors for patients with mechanical heart valves, or atrial fibrillation, and not for evaluating the portable systems that have been in use since 1987 (known as point of service. Trials conducted among patients with mechanical heart valves, or atrial fibrillation were selected. International Normalized Ratio self-management after mechanical heart valve replacement: is an early start advantageous? A structured teaching and self-management program for patients receiving oral anticoagulation. A Prospective Controlled Trial Comparing Weekly Self-Testing and Self-dosing with the Standard Management of Patients on Stable Oral Anticoagulation. Back to Top Date Sent: 3/24/2020 513 these criteria do not imply or guarantee approval. Self-management of oral anticoagulants with a whole blood prothrombin-time monitor in elderly patients with atrial fibrillation. Clinical endpoints for studies on self-management of anticoagulation therapy would be bleeding and thromboembolic complications. Six hundred patients (50% of the randomized sample) were included in the analysis, dropouts and deaths were not included, and analysis was not based on intention to treat. It also showed that significantly more measurements were in the therapeutic range among patients in the self-management group. It is an ongoing trial and the published articles only present the interim analysis with data on 55% of the total sample size. There was no difference between them the in thromboembolic rates, and the difference in the bleeding rates did not reach statistical difference. Articles: the search yielded 20 newer articles many of which were reviews and editorials. The purpose of this review is to assess the home use of the monitors for patients with mechanical heart valves or atrial fibrillation, and not for evaluating the portable systems that have been in use since 1987 (known as point of service. Low-dose International normalized ratio self-management: A promising tool to achieve low complication rates after mechanical heart valve replacement. All studies were conducted among selected groups of patients and the results might not be generalized to all patients with mechanical heart replacement. Heneghan et al?s recent meta-analysis (2006) assessed the effects of self-monitoring with/ or without or self-management of 2002 Kaiser Foundation Health Plan of Washington. Back to Top Date Sent: 3/24/2020 514 these criteria do not imply or guarantee approval. Criteria | Codes | Revision History anticoagulation compared with standard monitoring. The meta-analysis had valid methodology, was well conducted, and 10 out of the 14 studies it included were judged to be of good quality. The authors also performed a sensitivity analysis by excluding the studies with the lowest quality. However, the control groups in the trials received their routine care in different settings. The results of a recent meta-analysis (van Walraven, 2006) showed that the study setting has a major influence on anticoagulation control. Moreover, the majority of the trials included in Heneghan?s meta-analysis, provided education and training sessions only to the patients randomized to self-testing, not to the entire study population. Education increases awareness, motivation, and may modify the patient?s attitude and behavior. The education and training were given after randomization, and those who could not complete the training sessions or were incapable of self testing and/or self-management either left the study or were transferred to the routine care group. This resulted in a high dropout rate (20% to > 30%) in the intervention groups, and intention to treat analysis was not conducted in all the trials, which could overestimate the observed results. Ideally, training would be performed prior to randomization to eliminate those who are unable to complete it, and/or are incapable of self testing or self-management, from participating in the trial. The results of this meta-analysis indicate that the thromboembolic events, major bleeds, and death rates were significantly lower in the self-monitoring groups versus the controls who were managed by their personal physicians, anticoagulation management clinics, or managed service. Those who both self-tested and self adjusted their therapy dose had significantly lower thromboembolic events and mortality rates but a non significant reduction the rate of hemorrhage. The difference in thromboembolic event rates was not significant between the intervention and control groups in the pooled results of the 3 trials conducted among patients with mechanical heart valves. The authors did not report on the difference in major hemorrhage or death rate among these patients, and no subgroup analysis was provided for patients with atrial fibrillation. Fitzmaurice, et al?s (2005) study was a relatively large, multicenter, randomized, and controlled trial. Less than 25% of the eligible patient agreed to participate in the trial and were actually randomized to the study groups. Training on self-testing was given after randomization and only to the intervention group not to the entire population, which resulted in a higher dropout rate (43%) in the self-management group compared to 11% of those in the routine care group. Those who were considered incapable of self managing withdrew from the trial or were returned to the routine care group. The study population who self-selected to enroll was younger and included more men than the eligible population. Patients in the routine care group were managed in a variety of models including anticoagulation clinics, hospital outpatient clinics, and primary care clinics which may have an influence on their anticoagulation control, and outcomes. The study participants were highly motivated, mainly younger, willing to take and complete a structured training course on self-management, and capable of performing self-testing correctly and reliably.