[Improvement of knowledge of patients treated with an oral anticoagulant after a pharmaceutical interview at the hospital]. / Amélioration des connaissances des patients traités par un anticoagulant oral après avoir bénéficié d'un entretien pharmaceutique à l'hôpital.

OBJECTIVES: Patients treated with oral anticoagulants need an adapted education in order to optimize the management of these treatments. The objective was to assess the knowledge of patients before and after a pharmaceutical interview carried out by pharmacy students on digital tablets at the hospital. METHODS: A prospective study took place in the cardiology department, with a first phase from December 2016 to June 2018. Patient's knowledge were assessed during a pharmaceutical interview; additional informations were done for unacquired concepts. The second phase took place in October 2018, and patient's knowledge were assessed during a phone call for patients who had at least given one wrong answer on the four selected questions. RESULTS: Sixty-eight and twenty-two patients were included respectively for phases 1 and 2 (mean age=70±3.4; treatments number=8.2±0.9). 36 patients were treated by Vitamin K antagonists and 32 by direct oral anticoagulants. 57% of patients with oral anticoagulants gave a good answer for principles of the treatment and the surveillance during phase 1, and 33% for signs of overdose. A significant improvement for the 22 patients with poor knowledge was observed in phase 2 (1.73 vs. 2.5; P=0.006). CONCLUSIONS: The playful interview improves the patient's knowledge over time. Developing the relationship between the hospital and community pharmacists would allow us to optimize the patient follow-up.

[Follow-up of patients treated by VKA: Interest of a pharmaceutical link between the hospital and the retail pharmacies]. / Suivi des patients traités par AVK : intérêt d'un relais pharmaceutique entre l'hôpital et la ville.

Vitamin K antagonists (VKA) are used by 1,7% of the French population. Patient education and monitoring can decrease the number of iatrogenic hospitalizations due to VKA. We assessed the impact of a communication between hospital and retail pharmacists about patient's knowledge on VKA. The aim of our study has been to evaluate the value added by the link between the hospital pharmacist and the community pharmacist on the follow-up of patients treated by vitamin K antagonist. Patient information about VKA treatment is offered to inpatients in our hospital. An information form is filled for each patient treated by VKA. Patient's knowledge is assessed on the document (Name of VKA, cause of treatment, monitoring, risks of overdose, compliance…). This form is sent to the community pharmacist after the training when the patient leaves the hospital (by fax or by email). The form is sent back by the community pharmacist after the second training. Sixty-eight patients received the training, 48 forms have been sent to the retail pharmacists and 43 forms have been sent back to the hospital. Seven retail pharmacists replied spontaneously. Twenty-eight patients increased their knowledge (in average+21%) and 12 patients stabilized their knowledge. The best-known concepts were the INR target, the time of drug intake, the risks of overdose and the information of the family. The improvement of knowledge is significant for the name of VKA, the cause of treatment, efficacy assessment and signs of overdose. The implementation of a communication between the hospital and the retail pharmacies is time-consuming but the follow-up of those patients seems essential to keep a good knowledge.

[Recurrent pyoderma gangrenosum-like ulcers induced by oral anticoagulants]. / Ulcérations récidivantes à type de pyoderma grangrenosum induites par les antivitamines K.

BACKGROUND: Other than the classic skin necrosis induced by oral anticoagulants (OAC) in patients with protein C and S deficiencies, other types of OAC induced-skin ulcers are little known. Herein, we describe an original case of recurrent pyoderma gangrenosum (PG)-like ulcers induced by OAC. PATIENTS AND METHODS: A 70-year-old female heart-transplant recipient presented deep, hyperalgesic and quickly-spreading necrotic ulceration of the right leg 6 weeks after starting oral anticoagulant therapy with fluindione. Histological analysis revealed dermal infiltrate containing polynuclear neutrophils, which accords with the histopathological diagnosis of leukocytoclastic vasculitis or PG. Infectious, autoimmune and thrombophilic causes were ruled out. Fluindione was withdrawn and the ulcer healed completely within a month. Six months later, right leg ulceration recurred two weeks after the patient resumed fluindione but healed within 1 month of discontinuation of the drug. An OAC from another chemical family (warfarin) was then introduced, with further recurrence of ulceration after 2 weeks of treatment. DISCUSSION: The chronology of events and the negativity of aetiological explorations allowed a diagnosis to be made of OAC-induced skin ulcer, a rare complication of which the pathophysiology is unclear. This is the first case of PG-like ulcers induced by OAC.

[Evaluation of the quality of long-term anticoagulation therapy with antivitamin-K in atrial fibrillation]. / Évaluation de la qualité de l'anticoagulation au long cours par antivitamine-K dans la fibrillation auriculaire.

AIM: To assess the quality of long-term anticoagulation therapy with antivitamin-K in patients with atrial fibrillation by measuring the TTR and to determine the factors associated with a good TTR. PATIENTS AND METHODS: This is an observational study conducted over a period of three years (from January 2013 until December 2015) in the outpatient clinic of cardiology of Farhat Hached hospital of Sousse, Tunisia. Pre-established individual plugs were used for data collection. The data analysis was performed using the SPSS Software, version 20. RESULTS: Overall, 200 patients were eligible. Half of the patients did not know the risks of AVK and 29.1% were unaware of their interest. The average TTR was 57.3±18.2%. Good control of anticoagulation was obtained in 24.5% of patients. Those with a≥70% were more autonomous, observant, of urban origin, living in Sousse and Kairouan, with good knowledge about AVK and having a small left atrium. The factors associated negatively with TTR were hypertension, diabetes, old AF, hematological diseases, high number of medications taken daily and the presence of mitral insufficiency, mitral valve replacement, a tricuspid insufficiency or a tricuspid plasty. CONCLUSION: The quality of AVK anticoagulation in AF patients is insufficient. Improving this indicator would reduce the morbidity and mortality associated with AVK treatment.

Quality of life in children participating in a non-selective INR self-monitoring VKA-education programme.

BACKGROUND: The quality of life (QoL) of children receiving vitamin K antagonist (VKA) treatment has been scarcely studied. AIM: To assess QoL of children, and its evolution, throughout our non-selective international normalized ratio (INR) self-monitoring education programme. METHODS: Children and parents completed QoL questionnaires (Qualin, PedsQL) during education sessions. Scores were compared with those from controls. RESULTS: A total of 111 children (mean±standard deviation age 8.7±5.4 years) were included over a 3-year period. Indications for VKA treatment were congenital heart diseases (valve replacement [42.3%], total cavopulmonary connection [29.7%]), myocardiopathy (11.7%), coronary aneurysm (7.2%), venous/intracardiac thrombosis (4.5%), pulmonary artery hypertension (1.8%), arrhythmia (0.9%) and extra-cardiac disease (1.8%). Eighty children, 105 mothers and 74 fathers completed the QoL questionnaires. QoL was good among children aged 1-4 years and moderately impaired in those aged between 5 and 18 years. There was no significant relationship between self-reported QoL and patient's sex, type of VKA, number of group sessions attended, disease duration or time of diagnosis (prenatal or postnatal). QoL scores were significantly lower among children with congenital heart diseases compared with other diseases. There were few differences in QoL between children under transient VKA treatment and those treated for life. Parental proxy QoL scoring correlated well with but was significantly lower than child self-assessments. QoL reported by mothers increased throughout the education programme, independently of any improvement of the health condition. CONCLUSIONS: This QoL study provides original data from a large cohort of children and their parents participating in a formalized INR self-monitoring education programme for VKA treatment.

[Are general practitioners in Paris and surrounding areas reticent about direct oral anticoagulants?] / Les médecins généralistes d'Île-de-France se méfient-ils des anticoagulants oraux directs ?

OBJECTIVE: Determine how familiar general practitioners (GPs) working in Paris and surrounding areas are with prescriptions for direct oral anticoagulants (DOACs). MATERIAL AND METHOD: A questionnaire sent to 189 GP working in Paris and surrounding areas yielded 100 responses. Data collected included a brief summary of sociodemographic items, comparative knowledge about DOACs and vitamin K antagonists (VKAs), and responses to two clinical situations for DOAC prescriptions (renewal of a first prescription). RESULTS: The majority (65%) of the responding GPs were over 50. The GPs were knowledgeable about data in the literature concerning the following items: patient quality of life (72% considered it improved); adherence (55% suggested it was improved); rules for DOAC prescription (88% knew the set doses; 81% knew biological monitoring does not exist; 38% were aware of potential interactions). They were not knowledgeable about the following points: main sites for bleeding risks are the gut and the brain; 44% thought risk was lowered for gastrointestinal bleeding and concerning brain hemorrhages 26% thought there was a lesser risk while 40% had no opinion; cost (20% thought it was lower). For prescription modalities, 90% of the GPs renewed the DOAC previously prescribed for non-valvular atrial fibrillation while 76% preferred a LMWH-VKA scheme for the first prescription for deep vein thrombosis. CONCLUSION: Without being reticent about DOACs, the GPs questioned in this study recognized the usefulness of these medications for their patients' quality of life but were hesitant to use DOACs as the first intention anticoagulant, undeniably due to lack of experience and knowledge about the lower risk of bleeding. Initial training and continuing education should be strengthened on this point with dedicated workshops.

Risk factors associated with a thrombotic or bleeding event in patients treated with vitamin K antagonists.

AIM: To identify, in a case-control study, the risk factors associated with a thrombotic or bleeding event in patients treated with vitamin K antagonists. MATERIALS AND METHODS: We performed a single-centre observational study during a three-month period where we consecutively included patients admitted to the emergency department of a secondary-level hospital and treated with vitamin K antagonists, regardless the reason for admission. Patients admitted for a thrombotic or bleeding event were included as cases and the other patients served as controls. Main thrombotic or bleeding risk factors during vitamin K antagonist therapy were a priori identified in literature and tested in conditional logistic regression. RESULTS: Two hundred and forty subjects were identified, 40 of which (17%) were admitted for a bleeding event, 19 (8%) for a thrombotic event and 181 (75%) for another reason. Over 85% of patients were treated with fluindione. No risk factor was significantly associated with bleeding or thrombotic event in patients treated with vitamin K antagonist. Patients presenting a thrombotic event were however more likely to have a chronic respiratory disease. CONCLUSIONS: In this study, no risk factor significantly associated with a bleeding or thrombotic event in patients treated with vitamin K antagonist were identified. The occurrence of these events supposes other risk factors, including potential genetic polymorphisms that should be considered in future studies.