Background: Multiple factors influence warfarin metabolism and can significantly affect the risk of adverse events. The extent to which patients understand the modifiable factors that impact on warfarin safety and efficacy is unclear. Methods: A 52-item questionnaire related to knowledge of warfarin was administered to patients with atrial fibrillation in a face-to-face interview with a dietitian. Results were compiled based on five categories: general warfarin knowledge, compliance, drug interactions, herbal or vitamin interactions, and diet. Results: 100 patients were surveyed. Stroke risk factors included hypertension (57%), heart failure (36%), age >75 years (33%), diabetes (22%), and prior stroke/transient ischemic attack (29%). The majority were either high-school (49%) or college graduates (27%). Ten (10%) had a stroke while on warfarin, 11 (11%) had a blood transfusion, and 26 (26%) had at least one fall. The percentages correct for questionnaire items in the five categories were as follows: general knowledge (62%), compliance (71%), drug interactions (17%), herbal or vitamin interactions (7%), and diet (23%). Neither education level nor duration of therapy correlated with warfarin knowledge. Patients at highest risk of stroke had very low knowledge scores in general. Discussion: Patients on warfarin have a poor general understanding of the medication, particularly those at highest risk of stroke.
SUMMARY Two children (aged 10 and 12 years) were admitted unconscious to a neurosurgical department after traffic accidents. Both developed a 6th nerve paralysis on the next day. One patient was able to communicate from the 2nd day and died on the 8th day in an anuric state without major neurological deficit. The second patient remained deeply comatose, tetraplegic, and required intermittent artificial respiration: She died of pneumonia on the 26th day. Neuropathological examination revealed a ponto-medullary rent in each case; additionally there was avulsion of small arteries over the pyramids, haemorrhage and small focal infarcts in the distribution of perforating arteries in the medulla and pons, and abundant retraction balls in longitudinal fibre tracts of the brain stem. The cases show for the first time that traumatic ponto-medullary tears are not always rapidly fatal, and demonstrate that primary focal brain stem trauma may occur in the absence of diffuse trauma of the white substance.Tears at the ponto-medullary junction as a result of severe cranio-cervical injury are well-recognised,'-5 but they are usually associated with almost instantaneous death. Accordingly, it has been argued by Adams and his group6-8 that primary damage to the brain stem as a result of a non-missile head injury does not occur in patients who survive their injury long enough to be transferred to a neurosurgical unit, and there is always diffuse damage to the white matter in such cases. The two cases documented in this paper, however, show that patients with primary traumatic ponto-medullary rents may survive for days or weeks after injury.
Case reportCase 1 This 10-year-old girl was found unconscious fastened in a safety belt after a 100 m crash down a steep slope sitting in a Lada Taiga car. On admission she was unconscious but reacted to pain. Extension spasms, bilateral extensor plantar responses and gaze deviation to the right were observed. She had a haematoma of the occiput and multiple bruises on her body. Radiographs and CT scan of the head were normal. On the cervical spine film there was a suspicion of an atlanto-axial subluxation. On the second day the child was able to communicate and now had paralysis of the 6th cranial nerve on the right side. One
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