Studying and Learning Psychology During the COVID-19 Pandemic: A Mixed-Methods Approach on Students' Perspectives of Psychological Well-being and Adjustment to Studying Online.

Background: The challenges presented by coronavirus disease 2019 (COVID-19) in higher education pressured learners and instructors to incorporate online emergent learning which presented several well-being and academic challenges to students. Objective: The purpose of this study is to examine the impact of studying online to students' well-being. Methods: A mixed methods approach was followed for this study. Eighty students completed an online survey that measured their stress level of studying online, and 13 semistructured interviews were conducted at Queen's University Belfast. Results: Findings suggest that online learning under such circumstances increased students' level of stress due to a number of perceived factors. Our findings also reveal the journey of student adjustment to online learning, reflecting the flexibility of blended learning as a long-term pedagogical strategy in universities, necessary for University's survival. Conclusion: As demonstrated in this study, after the initial difficulties of moving to online learning which had negative impacts on students learning and well-being, students subsequently adjusted to the online learning environment documenting students' adaptability to a new learning environment and highlighting student resilience.

General Aviation Accidents Involving Fixed-Wing Aircraft on the Ground.

BACKGROUND: Accidents during start-up and shut-down procedures of aircraft can lead to fatalities or destroyed aircraft. Start-up procedures for propeller aircraft include the possibility of hand-propping, which may increase the occurrence of injuries from propeller strikes.METHODS: A set of 142 accidents from a 10-yr period were selected from the U.S. National Transportation Safety Board online database. Only fixed-wing aircraft in the "standing" phase of flight were included in the dataset. The significance of differences was determined using Pearson's Chi-squared analysis.RESULTS: The severity of the injuries sustained in the accidents were inversely related to the amount of damage to the aircraft. Hand-propping without properly securing the aircraft was more likely to result in substantial damage to the aircraft. Pilots with less than a thousand hours of flight experience were significantly more likely to use an incorrect hand-propping procedure.CONCLUSIONS: It is recommended to make the advisory on hand-propping a regulatory article of the Federal Aviation Administration so that pilots' knowledge of this procedure is mandatory and part of their initial training, especially securing the aircraft during hand-propping. Highlighting throttle positions in both regular and hand-propping procedures may optimize checklist design and further mitigate accidents during start-up procedures.de Voogt AJ, Kalagher H, Burns S. General aviation accidents involving fixed-wing aircraft on the ground. Aerosp Med Hum Perform. 2022; 93(7):597-600.

Evolution of Investigating Informed Assent Discussions about CPR in Seriously Ill Patients.

CONTEXT: Outcomes after cardiopulmonary resuscitation (CPR) remain poor. We have spent 10 years investigating an "informed assent" (IA) approach to discussing CPR with chronically ill patients/families. IA is a discussion framework whereby patients extremely unlikely to benefit from CPR are informed that unless they disagree, CPR will not be performed because it will not help achieve their goals, thus removing the burden of decision-making from the patient/family, while they retain an opportunity to disagree. OBJECTIVES: Determine the acceptability and efficacy of IA discussions about CPR with older chronically ill patients/families. METHODS: This multi-site research occurred in three stages. Stage I determined acceptability of the intervention through focus groups of patients with advanced COPD or malignancy, family members, and physicians. Stage II was an ambulatory pilot randomized controlled trial (RCT) of the IA discussion. Stage III is an ongoing phase 2 RCT of IA versus attention control in in patients with advanced chronic illness. RESULTS: Our qualitative work found the IA approach was acceptable to most patients, families, and physicians. The pilot RCT demonstrated feasibility and showed an increase in participants in the intervention group changing from "full code" to "do not resuscitate" within two weeks after the intervention. However, Stages I and II found that IA is best suited to inpatients. Our phase 2 RCT in older hospitalized seriously ill patients is ongoing; results are pending. CONCLUSIONS: IA is a feasible and reasonable approach to CPR discussions in selected patient populations.

Transition to lanadelumab-flyo from three medications for a hereditary angioedema patient with a variant in the SYTL2 gene: A case report.

Non-SERPING1 gene variant hereditary angioedema patients often need to take progesterone, attenuated androgens, and antifibrinolytics to control symptoms. These drugs may need to be tapered to extinction or reduced as lanadelumab-flyo reaches maximum concentration.

Miscarriage determination in first trimester based on alpha-fetoprotein extracted from sanitary pads.

OBJECTIVE: To determine if high alpha-fetoprotein (AFP) level in vaginal blood collected on a sanitary pad can assist with detecting an active miscarriage. DESIGN: A prospective cohort study. SETTING: Academic medical center. PATIENT(S): Five groups were evaluated: women with active miscarriage, pregnancy of unknown location, completed miscarriage or extrauterine pregnancy (EUP), ongoing pregnancy, and undergoing elective dilation and curettage (D&C). INTERVENTION(S): None. MAIN OUTCOME MEASURE(S): For each patient, AFP level in the vaginal blood collected on a sanitary pad was quantified. RESULT(S): The vaginal blood AFP median levels (and their ranges) were 3.7 IU/mL (0.5-739.2) and 4,542 IU/mL (15.6-100,000) in the active miscarriage (n = 16) and the elective D&C (n = 24) groups, respectively. Alpha-fetoprotein was detected in all elective D&C and active miscarriage cases except in 1 case. In the ongoing pregnancy group (n = 35), only 2 of 35 specimens showed detectable AFP levels. In the pregnancy of unknown location (n = 12) and the completed miscarriage or EUP (n = 10) groups, no AFP was detected. Receiver operating characteristic analysis demonstrated 93.7% sensitivity and 97.8% specificity for the detection of an active miscarriage (cutoff 0.61 IU/mL; area under the curve 0.96). CONCLUSION(S): Alpha-fetoprotein can be extracted from vaginal blood collected on sanitary pads. A high level of vaginal AFP can assist with the same-day detection of an active miscarriage. This novel test is useful in differentiating active miscarriages from ongoing pregnancies, completed miscarriages, and EUPs and, therefore, it reduces uncertainty, anxiety level, and number of repeat office visits.

A step towards the automation of intracytoplasmic sperm injection: real time confirmation of mouse and human oocyte penetration and viability by electrical resistance measurement.

OBJECTIVE: To evaluate if oocyte penetration and viability can be confirmed by an electrical resistance increase. Automated (robotic) intracytoplasmic sperm injection (ICSI) requires confirmation of oolemma penetration before sperm injection. Visual assessment using image processing algorithms have been developed but remain unreliable. We hypothesized that an increase in electrical resistance upon oolemma piercing during ICSI can serve as an objective tool to confirm oocyte penetration and viability. DESIGN: Experimental study. SETTING: Research laboratory in an academic center. PATIENTS/ANIMALS: Oocytes from female mice and women undergoing oocyte retrieval procedure. INTERVENTION: Oolemma piercing attempts with the ICSI pipette were performed by advancing the pipette towards mature (metaphase II) oocytes collected from 6 to 12-week-old mice and immature (germinal vesicle stage and metaphase I) oocytes donated by women who underwent oocyte retrieval. Electrical resistance was measured using a conventional electrophysiological setup that includes an electrical resistance meter and two electrical wires located in the lumina of the holding and ICSI pipettes. MAIN OUTCOME MEASURE(S): The measure of interest was the change in electrical resistance (ΔR) before and after advancing the ICSI pipette in an attempt to penetrate an oocyte. The experiments of resistance measurements were done in 3 steps: Step 1 (proof of concept), penetrated vs. non-penetrated mouse oocytes. Step 2, mouse oocytes with visually intact oolemma vs. fragmented mouse oocytes. Step 3, human oocytes with visually intact oolemma vs. fragmented human oocytes. For each group, median and range (in parenthesis) of ΔR were determined in MΩ. Mann-Whitney test was performed to compare the two groups in each step. RESULTS: In Step 1, the penetrated mouse oocytes showed a statistically significant resistance increase compared to the non-penetrated ones (n = 20, median ΔR = 7.79 [2.57 - 106.00] vs. n = 15, median ΔR = 0.10 [-0.06 - 0.69], respectively. In Step 2, the mouse oocytes with visually intact oolemma showed a statistically significant resistance increase compared to the fragmented ones (n = 45, median ΔR = 6.5 [0.1 - 191.7] vs. n = 13, median ΔR = 0.1 [-0.3 - 2.2], respectively. In Step 3, the human oocytes with visually intact oolemma showed a statistically significant resistance increase compared to the fragmented ones (n = 96, median ΔR = 1.92 [-0.05 - 6.70] vs. n = 17, median ΔR = 0.11 [0.00 - 0.30], respectively. CONCLUSIONS: An electrical resistance increase can serve as a reliable tool to confirm oocyte penetration and viability, independent of optical visualization. Following further validation and safety assessment, this technology can potentially be integrated into manual and robotic ICSI systems.

Effect of Exercise on Risk Factors of Diabetic Foot Ulcers: A Systematic Review and Meta-Analysis.

The objectives of this study were to examine the effectiveness of different types of exercise on risk factors of diabetic foot ulcers, including glycated hemoglobin, peripheral arterial disease, and diabetic peripheral neuropathy, in people with type 2 diabetes mellitus. PubMed, Web of Science, Cochrane Library, Scopus, and CINAHL were searched from inception to January 2018 for relevant articles. Eligible studies were randomized controlled trials that examined effects of exercise on the selected risk factors. Twenty randomized controlled trials with 1357 participants were included in the meta-analyses. The differences in postintervention values of glycated hemoglobin and ankle brachial index between exercise and control groups were synthesized, yielding mean differences of -0.45% (P < 0.00001) and 0.03 (P = 0.002), respectively; the differences in within-group changes in glycated hemoglobin were synthesized, yielding mean differences of -0.19% (P = 0.1), -0.25% (P = 0.0006), and -0.64% (P = 0.006) for aerobic versus resistance, combined versus aerobic, and combined versus resistance exercise, respectively. Exercise has a significant effect on reducing glycated hemoglobin, whereas combined exercise is more effective compared with aerobic or resistance exercise alone. Exercise also improves ankle brachial index. However, evidence regarding the association between exercise and peripheral neuropathy and risks of diabetic foot ulcers in people with type 2 diabetes mellitus remains insufficient.

Effect of Yoga Breathing (Pranayama) on Exercise Tolerance in Patients with Chronic Obstructive Pulmonary Disease: A Randomized, Controlled Trial.

OBJECTIVE: Pulmonary rehabilitation improves exercise tolerance in patients with chronic obstructive pulmonary disease (COPD). However, many patients do not have access to pulmonary rehabilitation programs. We hypothesized that an alternative to pulmonary rehabilitation to improve exercise tolerance is the practice of pranayama, or yoga breathing, which could be done independently at home. We also sought to determine whether yoga nonprofessionals could adequately teach pranayama to patients. DESIGN: Proof-of-concept, randomized, double-blind, controlled pilot trial. SETTINGS/LOCATION: Two academic pulmonary practices. SUBJECTS: Forty-three patients with symptomatic, moderate-to-severe COPD. INTERVENTIONS: Twelve weeks of pranayama plus education versus education alone. Two yoga professionals trained the research coordinators to conduct all pranayama teaching and monitored the quality of the teaching and the practice of pranayama by study participants. OUTCOME MEASURES: The primary outcome was a change in the 6-min walk distance (6MWD). Secondary outcomes included changes in lung function, markers of oxidative stress and systemic inflammation, and measures of dyspnea and quality of life. RESULTS: The 6MWD increased in the pranayama group (least square mean [95% confidence interval] = 28 m [-5 to 61]) and decreased in the control group (-15 m [-47 to 16]), with a nearly significant treatment effect (p = 0.06) in favor of pranayama. Pranayama also resulted in small improvements in inspiratory capacity and air trapping. Both groups had significant improvements in various measures of symptoms, but no overall differences in respiratory system impedance or markers of oxidative stress or systemic inflammation. CONCLUSION: This pilot study successfully demonstrated that pranayama was associated with improved exercise tolerance in patients with COPD. Lay personnel were able to adequately teach patients to practice pranayama. These results suggest that pranayama may have significant clinical benefits for symptomatic patients with COPD, a concept that needs to be confirmed in future, larger clinical trials.

Quantifying Dynamic Changes in Plantar Pressure Gradient in Diabetics with Peripheral Neuropathy.

Diabetic foot ulcers remain one of the most serious complications of diabetes. Peak plantar pressure (PPP) and peak pressure gradient (PPG) during walking have been shown to be associated with the development of diabetic foot ulcers. To gain further insight into the mechanical etiology of diabetic foot ulcers, examination of the pressure gradient angle (PGA) has been recently proposed. The PGA quantifies directional variation or orientation of the pressure gradient during walking and provides a measure of whether pressure gradient patterns are concentrated or dispersed along the plantar surface. We hypothesized that diabetics at risk of foot ulceration would have smaller PGA in key plantar regions, suggesting less movement of the pressure gradient over time. A total of 27 participants were studied, including 19 diabetics with peripheral neuropathy and 8 non-diabetic control subjects. A foot pressure measurement system was used to measure plantar pressures during walking. PPP, PPG, and PGA were calculated for four foot regions - first toe (T1), first metatarsal head (M1), second metatarsal head (M2), and heel (HL). Consistent with prior studies, PPP and PPG were significantly larger in the diabetic group compared with non-diabetic controls in the T1 and M1 regions, but not M2 or HL. For example, PPP was 165% (P = 0.02) and PPG was 214% (P < 0.001) larger in T1. PGA was found to be significantly smaller in the diabetic group in T1 (46%, P = 0.04), suggesting a more concentrated pressure gradient pattern under the toe. The proposed PGA may improve our understanding of the role of pressure gradient on the risk of diabetic foot ulcers.

Neurofeedback in Hereditary Angioedema: A Single Case Study of Symptom Reduction.

Neurofeedback training was performed consisting of rewarding and encouraging 12-15 Hz brainwaves (SMR), while simultaneously discouraging 4-7 Hz brainwaves (theta) and 22-30 Hz brainwaves (high beta) in the right dorsal posterior quadrant of the brain (T4, P4) for 20 half-hour NFB sessions to determine the impact on cortisol levels, DHEA-S levels, scores on the Symptom Checklist-90-R (SCL-90-R), the quality of life inventory, and acute attack medication usage for a Hereditary Angioedema patient.

Exercise Augmentation of Exposure Therapy for PTSD: Rationale and Pilot Efficacy Data.

Brain-derived neurotrophic factor (BDNF) is associated with synaptic plasticity, which is crucial for long-term learning and memory. Some studies suggest that people suffering from anxiety disorders show reduced BDNF relative to healthy controls. Lower BDNF is associated with impaired learning, cognitive deficits, and poor exposure-based treatment outcomes. A series of studies with rats showed that exercise elevates BDNF and enhances fear extinction. However, this strategy has not been tested in humans. In this pilot study, we randomized participants (N = 9, 8 females, M(Age) = 34) with posttraumatic stress disorder (PTSD) to (a) prolonged exposure alone (PE) or (b) prolonged exposure+exercise (PE+E). Participants randomized to the PE+E condition completed a 30-minute bout of moderate-intensity treadmill exercise (70% of age-predicted HR(max)) prior to each PE session. Consistent with prediction, the PE+E group showed a greater improvement in PTSD symptoms (d = 2.65) and elevated BDNF (d = 1.08) relative to the PE only condition. This pilot study provides initial support for further investigation into exercise augmented exposure therapy.

Preliminary observations on whole-ovary xenotransplantation as an experimental model for fertility preservation.

Ovarian tissue preservation and retransplantation is a promising strategy to restore fertility in cancer survivors. Ischaemia accompanying ovarian tissue grafting, however, can lead to significant follicle loss. Transplantation of the whole ovary by vascular anastomosis has been considered as an alternative to prevent widespread ischaemic damage. In this study, the feasibility and function of transplanting whole ovary with intact vasculature were evaluated, with the goal of developing a xenograft model for studies using donated human ovaries. Whole-swine ovaries with vascular pedicles were perfused and transplanted as intact ovaries by anastomosis into irradiated ovariectomized nude rats (n = 10). The observation period was between 1 and 4 weeks. Fresh swine ovaries served as controls (n = 10). Ovarian stroma and follicle populations were assessed through histological examination in both transplanted and control ovaries. Most of the transplanted whole ovaries (n = 6) maintained stromal quality and all preantral follicle classes were represented, although follicle numbers decreased compared with fresh control. Four transplanted ovaries were fibrotic after 1-4 weeks within the nude rat. Our results demonstrate transplantation of whole-pig ovary into nude rats is possible and support development of this xenograft model system for human studies.

Spontaneous antral follicle formation and metaphase II oocyte from a non-stimulated prepubertal ovarian tissue xenotransplant.

BACKGROUND: Current strategies in cancer treatment have markedly increased the rates of remission and survival for cancer patients, but are often associated with subsequent sterility. While there are various options available to an adult female depending on the patient's particular situation, the only realistic option for preserving fertility in prepubertal females is to cryopreserve ovarian tissue. This is the first report of a morphologically mature oocyte collected from non-stimulated prepubertal ovarian tissue xenotransplants. METHODS: Ovarian tissue from a 6 year old patient suffering from nephroblastoma was removed and cryopreserved for fertility preservation. The frozen-thawed ovarian tissue fragments were xenotransplanted to bilaterally oophorectomized severe combined immunodeficiency (SCID) mice to assess follicle development. RESULTS: Antral follicle formation occurred post-xenotransplantation in a single ovarian fragment without exogenous hormone stimulation. A morphologically maturing oocyte was harvested from these follicles. CONCLUSIONS: Prepubertal human ovarian follicles and oocytes can be matured after xenotransplantation even without exogenous hormone stimulation. These results indicate that tissue collected from prepubertal patients can support fertility in cancer survivors.

Co-morbid infections in Hansen's disease patients in the United States: considerations for treatment.

120 patients attending a Hansen's disease public health satellite clinic were evaluated for selected latent co-morbidities, consisting of strongyloidiasis, Chagas disease, hepatitis B, HIV, and tuberculosis, and potential exacerbation by immunosuppressive therapy. Implications for treatment of Hansen's disease are discussed.

Comparison of changes in heart rate variability and sacral skin perfusion in response to postural changes in people with spinal cord injury.

The current clinical practice has established guidelines to assess influences of severity of autonomic injury on the control of heart and blood pressure following spinal cord injury (SCI). However, the influences of SCI-induced autonomic impairment on microvascular dysfunction have not yet been established. Heart rate variability (HRV) has been shown to be a potential tool for quantifying residual sympathovagal regulation of the cardiovascular system following SCI and may be used to assess the effect of autonomic injury on skin microvascular dysfunction. A total of 26 people were recruited into the study, including 12 people with SCI and 14 nondisabled controls. HRV and sacral skin intervals and sacral skin perfusion were continually recorded during 10 min upright and 10 min prone postures. The sympathovagal balance was defined as the ratio of the power of the low frequency to the high frequency of HRV. The results showed that postural changes of nondisabled people produced significant changes in the sympathovagal balance; lower sympathovagal balance was associated with higher skin perfusion (p < 0.05). People with SCI did not show a significant change of HRV and skin perfusion in response to postural changes. In this study, we have demonstrated that the sympathovagal balance assessed by HRV was associated with the skin vasoconstrictive response to postural changes.

Skin blood flow dynamics and its role in pressure ulcers.

Pressure ulcers are a significant healthcare problem affecting the quality of life in wheelchair bounded or bed-ridden people and are a major cost to the healthcare system. Various assessment tools such as the Braden scale have been developed to quantify the risk level of pressure ulcers. These tools have provided an initial guideline on preventing pressure ulcers while additional assessments are needed to improve the outcomes of pressure ulcer prevention. Skin blood flow function that determines the ability of the skin in response to ischemic stress has been proposed to be a good indicator for identifying people at risk of pressure ulcers. Wavelet spectral and nonlinear complexity analyses have been performed to investigate the influences of the metabolic, neurogenic and myogenic activities on microvascular regulation in people with various pathological conditions. These findings have contributed to the understanding of the role of ischemia and viability on the development of pressure ulcers. The purpose of the present review is to provide an introduction of the basic concepts and approaches for the analysis of skin blood flow oscillations, and present an overview of the research results obtained so far. We hope this information may contribute to the development of better clinical guidelines for the prevention of pressure ulcers.

Anomalous pulmonary venous connections.

Developmental lung anomalies are classified into 3 main categories: bronchopulmonary (lung bud) anomalies, vascular anomalies, and combined lung and vascular anomalies. These anomalies are uncommon, and patients are at times asymptomatic; hence, identifying a developmental lung anomaly in the adult can be a challenge. Pulmonary vascular anomalies include interruption or absence of the main pulmonary artery, anomalous origin of the left pulmonary artery from the right pulmonary artery, anomalous pulmonary venous drainage (partial or complete), and pulmonary arteriovenous malformations. Systemic vascular anomalies comprise persistent left superior vena cava, anomalies of azygos and hemiazygos systems, and anomalies of the thoracic aorta and its major branches. In this article, we present embryology, classification, epidemiology, clinical presentation, and imaging features of anomalous pulmonary venous connections, with special emphasis on multidetector computed tomography and magnetic resonance imaging. These state-of-art imaging techniques have facilitated accurate and prompt diagnosis of these anomalies.

3T magnetic resonance imaging accurately depicts radiofrequency ablation zones in a blood-perfused bovine liver model.

PURPOSE: To determine if noncontrast T1-weighted (T1W) images from 3T magnetic resonance (MR) imaging accurately depict radiofrequency (RF) ablation zones as determined macroscopically and microscopically in a blood-perfused bovine liver model. MATERIALS AND METHODS: Three-dimensional (3D) gradient-recalled echo (GRE) T1W images were obtained on a 3T MR imaging scanner after RF ablations (n = 14) of in vitro blood-perfused bovine livers. The resulting central hypointense and peripheral hyperintense signal regions were measured and compared with the inner tan and outer red zones of the gross specimen. Corresponding ablated hepatic tissue samples were examined microscopically and stained with nicotinamide adenine dinucleotide phosphate (NADPH) to assess for the presence or absence of NADPH diaphorase activity. Bootstrap two-sample hypothesis tests were used to compare MR imaging, gross, and histopathologic measurements. RESULTS: The MR imaging inner ablation zone had a mean radius of 0.80 cm (range 0.33-1.14 cm); the inner zone plus the outer ablation zone had a mean radius of 1.40 cm (range 1.01-1.74 cm). Comparison of the measurements of the inner ablation zone on MR imaging versus the gross specimen showed equivalence (95% confidence interval [CI] -0.122 cm, 0.223 cm). Comparison of the measurements of the outer ablation zone on MR imaging versus the gross and histologic specimens also showed equivalence (95% CI -0.095 cm, 0.244 cm, and -0.146 cm, 0.142 cm). CONCLUSIONS: Noncontrast 3D GRE T1W 3T MR imaging accurately depicts the RF ablation zones in a blood-perfused bovine liver model and can be used as a noninvasive means to assess the 3D morphologic characteristics of RF ablation lesions in the model.

Diagnostic imaging and risk stratification of patients with acute pulmonary embolism.

Pulmonary embolism (PE) is the third most common acute cardiovascular disease after myocardial infarction and stroke. The prompt diagnosis, risk stratification, and treatment of patients with acute PE can reduce mortality. Multidetector row computed tomography pulmonary angiography (CTPA) is the most common study used to make the diagnosis of acute PE. CTPA may additionally identify right heart dysfunction or alternative diagnoses. There is a growing body of evidence that computed tomography signs of right heart failure predict patients at higher risk of mortality. At the same time, CTPA has about a 6-fold greater whole body effective dose than ventilation-perfusion (V/Q) scintigraphy, and a much higher dose to breast tissue in particular. V/Q scintigraphy should be considered for patients with contraindications to iodinated contrast or for patients with normal chest radiographs, especially young women. Compression ultrasonography of the proximal lower extremities, an imaging study without ionizing radiation, should be considered for patients suspected of acute PE with signs of lower extremity deep venous thrombosis or for patients with negative CTPA or V/Q scan with discordant clinical probability. This article reviews factors affecting the selection of the best imaging test for a particular patient suspected of acute PE, performance characteristics of diagnostic imaging tests, and imaging findings that correlate with higher mortality.

Elevated international normalized ratio values associated with concomitant use of warfarin and ceftriaxone.

PURPOSE: The case of a patient receiving long-term warfarin therapy who experienced elevated International Normalized Ratio (INR) values on two occasions after injections of ceftriaxone is reported. SUMMARY: An elderly woman (age, 67 years) with multiple comorbidities who had been receiving warfarin therapy for about 8 years was given an intramuscular injection of ceftriaxone 1 g for the treatment of a urinary tract infection. Four days later, her INR (which had recently ranged from 1.9 to 3.0 at a weekly warfarin dosage of 52.5-54.5 mg) was 10.74. One scheduled warfarin dose was withheld and 5 mg of phytonadione administered; one day later, the INR was 3.4 (goal, 2.5-3.5). INR values remained stable for several weeks until the patient again received a 1-g ceftriaxone injection for an infection (she was also prescribed oral cefuroxime and phenazopyridine); four days later, the INR was 16.99. Again, the scheduled warfarin dose was withheld and 5 mg of phytonadione administered. One day later, the INR had declined to 4.6 but remained above the target range; therefore, warfarin was withheld for a second day, after which the patient received 7.5 mg of warfarin sodium daily for two days, resulting in an INR decrease to 2.1. The patient continued to receive 7.5 mg of warfarin sodium daily, and at one-week follow-up the INR value (2.5) was within the therapeutic range. CONCLUSION: A 67-year-old American Indian woman with previously stable INR values during long-term warfarin therapy after mitral valve replacement surgery had INR elevations on two occasions after receiving ceftriaxone for urinary tract infections.