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A multicenter randomized controlled trial of home uterine monitoring: active versus sham device. The Collaborative Home Uterine Monitoring Study (CHUMS) Group.

OBJECTIVE: Our purpose was to determine the efficacy of a home uterine activity monitoring system for early detection of preterm labor and reduction of preterm birth. STUDY DESIGN: A randomized, controlled, double-blinded trial was performed in which pregnant women between 24 and 36 weeks' gestation and at high risk for preterm labor or birth were assigned to receive twice daily nursing contact and home uterine activity monitoring with either active (data revealed) or sham (data concealed) devices. Study end points included mean cervical dilatation and its mean change from a previous visit at preterm labor diagnosis, preterm birth rate, and infant outcomes. Analysis of variance or logistic models including terms for site and group-by-site interaction effects were constructed for all variables. RESULTS: Of 1355 patients enrolled, 1292 were randomized, 1165 used home uterine activity monitoring devices, and 842 (72.3%) completed the study. Both device groups had similar demographics, enrollment and delivery gestational ages, discontinuation rates, risk factors, birth weights, cervical dilatation at enrollment and at preterm labor diagnosis, change in cervical dilatation at preterm labor diagnosis, rates of preterm labor and birth, and neonatal intensive care requirements. Power to detect a difference in cervical dilatation > or = 1 cm at diagnosis of preterm labor was 0.99 for all risk factors. CONCLUSIONS: Uterine activity data obtained from home uterine activity monitoring, when added to daily nursing contact, were not linked to earlier diagnosis of preterm labor or lower rates of preterm birth or neonatal morbidity in pregnancies at high risk for preterm labor and birth.

Adult↗

Recurrent ischemia during continuous 12-lead ECG-ischemia monitoring in patients with acute coronary syndromes treated with eptifibatide: relation with death and myocardial infarction. PURSUIT ECG-Ischemia Monitoring Substudy Investigators. Platelet glycoprotein IIb/IIIa in Unstable angina: Receptor Suppression Using Integrilin Therapy.

Computer-assisted continuous monitoring of the ST-segment allows detection and quantification of recurrent ischemia in patients with acute coronary syndromes. In a substudy of the PURSUIT (Platelet glycoprotein IIb/IIIa in Unstable angina: Receptor Suppression Using Integrilin Therapy) trial, this technique was used to evaluate the effects of the glycoprotein IIb/IIIa inhibitor eptifibatide on the incidence and severity of recurrent ischemia, and to investigate the relationship between recurrent ischemia and the occurrence of subsequent death or myocardial (re)infarction. A total of 258 patients with unstable angina or evolving myocardial infarction without ST elevation were monitored for 24 hours during infusion with either eptifibatide or placebo with a computer-assisted 12-lead ECG-ischemia monitoring device. Recurrent ischemic episodes were identified by an automated computer algorithm. Two hundred and sixteen patients (84%) had ECG recordings suitable for analysis. Ischemic episodes were detected in 35 (33%) of the 105 eptifibatide patients and in 32 (29%) of the 111 placebo patients (not significant). No difference in ischemic burden was apparent between both treatment groups. Patients who exhibited 2 or more episodes of recurrent ischemia more frequently died or suffered a myocardial infarction, both at 7 and 30 days, as well as through the 6-month follow-up. A greater ischemic burden was significantly related to adverse outcome during the 6-month follow-up period. Real-time computer-assisted continuous multilead ECG-ischemia monitoring may help to identify patients with unstable coronary syndromes at increased risk of adverse outcome and, thus, allow for better prognostic triage and more appropriate selection of therapeutic strategies. Integration of these systems in coronary care units and emergency wards should, therefore, be recommended.

Adult↗

Evaluation of the Paratrend 7 intravascular blood gas monitor during cardiac surgery: comparison with the C4000 in-line blood gas monitor during cardiopulmonary bypass.

OBJECTIVE: To evaluate the performance of the Paratrend 7 intravascular blood gas monitor (Biomedical Sensors, High Wycombe, UK, Ltd) during cardiac surgery and compare it with that of an in-line blood gas monitor placed in the arterial limb of an extracorporeal circuit during cardiopulmonary bypass. DESIGN: A prospective study. Consecutive patient enrolment. SETTING: In the cardiac surgical intensive care units at a tertiary referral center. INTERVENTION: Insertion of the Paratrend 7 intravascular sensor through the radial arterial catheter after induction of anesthesia. MEASUREMENTS AND MAIN RESULTS: Simultaneous measurements of pH, PCO2, and PO2 were made from the sensor and the blood gas analyzer, and the bias and precision were calculated on all the measured parameters. The bias and precision of the intravascular sensor during bypass for pH, PCO2, and PO2 were 0.01 and 0.06 pH units, 0.5 and 2.5 mmHg (2% and 8%), and 3 and 45 torr (0.5% and 14%), respectively. The bias and precision for the prebypass and the postbypass phases were comparable. The bias and precision of the extracorporeal monitor for pH, PCO2, and PO2 were 0.04 and 0.1 pH units, -0.3 and 4 mmHg (-1% and 15%) and 8 and 48 mmHg (4 and 18%), respectively. There were no instances of any complications attributable to the intravascular sensor. CONCLUSIONS: The intravascular sensor used in this study functioned well during cardiopulmonary bypass and the postbypass phase. The performance of the intravascular sensor was better than the in-line blood gas monitor during cardiopulmonary bypass.

Adult↗

Symptom monitoring in childhood asthma: a randomized clinical trial comparing peak expiratory flow rate with symptom monitoring.

BACKGROUND: Accurate symptom evaluation is a critical component of asthma management. Limited data are available about the accuracy of symptom evaluation by children with asthma and their parents, or the impact of various symptom-monitoring strategies on asthma morbidity outcomes. OBJECTIVE: The purpose of this randomized clinical trial was to evaluate the effect of three different intensities of symptom monitoring on asthma morbidity outcomes. METHODS: One hundred sixty-eight children (ages 6 to 19) of diverse racial, geographic, and socioeconomic backgrounds were randomized to 1 of 3 treatment groups (subjective symptom evaluation, symptom-time peak expiratory flow rate (PEFR) monitoring, daily PEFR monitoring) in this longitudinal, clinical trial. Outcome measures included a summary asthma severity score, forced expiratory volume in 1 second, symptom days, and health care utilization. RESULTS: Children who used PEFR meters (PFMs) when symptomatic had a lower asthma severity score, fewer symptom days, and less health care utilization than children in the other two treatment groups. Minority and poor children had the greatest amount of improvement using PFMs when symptomatic. Results were much less striking in white families. Thirty percent of families in the PFM treatment groups discontinued use entirely by 1 year postexit, whereas the majority of families who continued use (94%) used them only when symptomatic to inform symptom interpretation and management decisions. CONCLUSIONS: Not every child with asthma needs a PFM. Children and families facing extra challenges as a result of illness severity, sociodemographic, or health care system characteristics clearly benefited most from PFM use.

Adolescent↗

Cerebral state monitor, a new small handheld EEG monitor for determining depth of anaesthesia: a clinical comparison with the bispectral index during day-surgery.

BACKGROUND AND OBJECTIVE: The cerebral state index (CSI) derived from a new small handheld electroencephalogram monitor was studied during routine day surgical anaesthesia titrated according to the bispectral index (BIS). The objective was to determine the degree of agreement between the two monitors. METHODS: Anaesthesia was induced with propofol and fentanyl (0.1 mg) in 38 patients undergoing general anaesthesia for routine day-surgery. Maintenance anaesthesia (sevoflurane (20/38), desflurane (10/38) or propofol (8/38)) titrated by BIS XP (Aspect Medical, Natwick, MA, USA) and BIS and CSI (cerebral State Monitor, Danmeter; Odense, Denmark) index values were recorded every minute. No patient received muscle relaxation. Observer's Assessment of Alertness/Sedation rating scale was used to assess level of sedation. RESULTS: Pair-wise recordings (914) of CSI and BIS were collected. The indices showed similar pattern and decreased with increasing level of sedation, however with large ranges for each level of sedation. Median indices were similar during surgery (BIS: 50 (14-89); CSI: 51 (7-88)) and both indices increased (P 20% from BIS-index in 24% of readings, and on rare occasions CSI indices deviated >100% from the BIS reading. When BIS < 40, CSI decreased slower than BIS and with wider spreading. CONCLUSIONS: When used for day-surgery anaesthesia without muscle relaxation, CSI and BIS show similar patterns and numerical values but with the incidence of occasionally large discrepancies between pair-wise readings. Which monitor is the more dependable remains to be established and cannot be implied from this initial explorative study.

Adult↗

Therapeutic concordance of two portable monitors and two routine automatic oral anticoagulant monitoring systems using as reference the manual prothrombin time technique.

Two models of capillary blood prothrombin time (PT) monitoring systems were evaluated for analytical performance and then compared with two routine PT systems using the reference manual technique and a high-sensitivity thromboplastin. Two sets of 60 and 80 plasmas were analyzed from anticoagulated patients stabilized over 3 months in an INR range 2-3.5 for therapy. Capillary PT determination was performed in two portable monitors, CoaguChek S and CoaguChek PT (Roche Diagnostics), and plasma automatic methods were Neoplastine/STA (Diagnostics Stago) and PT-FibrinogenHsPlus/ACL7000 (Instrumental Laboratories). Thromboplastin Bilbao (TBi), an in-house high-sensitivity rabbit thromboplastin (ISI=1.08), recommended as the reference reagent by an External Spanish Oral Anticoagulant Quality Assessment, was used in the PT manual technique. The two monitors' coefficients of correlation with the reference system were 0.74 for CoaguChek S and 0.81 for CoaguChek PT. The automatic routine systems showed a correlation of 0.92 (Neoplastine/STA) and 0.91 (PT-FbHsPlus/ACL7000). Clinical agreement expressed as the percentage of simple correlation ranged between 75.0% (CoaguChek S) and 88.9% (Neoplastine/STA). The systems having the best kappa index with the manual technique were CoaguChek PT (71.9%) and the Neoplastine/STA system (73%). The routine PT management systems exhibited better correlation and percentage of concordance when using the TBi/manual technique than did the portable monitors, which moreover performed unequally in this regard.

Anticoagulants↗

[The continuous monitoring of hepatic venous oxygen saturation in patient monitoring following hemihepatectomy].

UNLABELLED: Increasing numbers of liver tumours and liver metastases from other tumours are treated by liver resection. During resection the ligamentum hepatoduodenale is occluded and the liver is exposed to warm ischemia. Duration and intensity of resulting liver ischemia can not be evaluated without special monitoring devices. A fiberoptic catheter placed in a liver vein facilitates continuous recording of the hepatic-venous oxygen saturation (ShvO2). CASE REPORT: We present a case where such a catheter was placed perioperatively in a patient undergoing hemihepatectomy. The liver venous catheter was positioned by guidance of the saturation curve and X-ray. The preoperative oxygen saturation in this liver vein was 80%. During the whole operation, the ShvO2 was continuously monitored. Blood for blood gas analyses was drawn before, during and after the occlusion of the ligamentum hepatoduodenale. Hemodynamic parameters were documented at the same time. The ShvO2 already decreased in the preparation period before the actual occlusion of the ligamentum hepatoduodenale. During the occlusion the ShvO2 dropped to an average of 30% with the lowest value being 13%. After reopening of the hepatic hilus the ShvO2 increased rapidly but did not reach preoperative values which were recorded not earlier than at the end of the operation. CONCLUSION: Duration and intensity of the decreased ShvO2 were recognized early by the liver venous catheter. It was demonstrated that desaturation of the hepatico-splanchnic region already occurred during the period of liver preparation before the ligamentum hepatoduodenale was occluded. Interventions to protect the liver from ischemia should therefore be applied some time before occlusion of the liver hilus. However, clearly defined indications for this invasive monitoring cannot be given at this time. In situations of extended liver resection or in cases of expected technical difficulties a continuous monitoring of the liver-venous oxygen saturation might be beneficial.

Adult↗

[Fetal monitoring sub partu in West Germany. II. Effect of clinic size and clinic type on monitoring practice].

Data from 690 clinics concerning obstetric management and intensive monitoring of the fetus sub partu were classified according to the type of hospital (e. g., municipal clinic, district hospital...) and the size of the hospital based on the number of births per year. On the basis of the annual number of births four groups (I-IV) were formed, each with 172 clinics. While the average number of surgical deliveries (cesarean, forceps, vacuum) is not related to the hospital (Table 3), it is related to the type of hospital (Table 6): the average number of cesarean deliveries is highest in university clinics (n = 24; 14.9%), and on average more forceps (6.5%) than vacuum extractions (5.7%) are performed. In all other hospitals vacuum extraction is clearly preferred (7-8%). The quotient Q of the annual number of births per CTG unit is not constant, but increases with the size of the clinic: In large hospitals (Group IV) significantly more births are monitored with a CTG unit (maximum 607, average 215), so that there is a numerical "monitoring deficit" as compared to smaller departments. The monitoring capability is numerically highest in the university clinics (Q = 147) and lowest in the academic teaching hospitals (Q = 192). The larger the clinic, the more frequently fetal blood is analyzed: the figure in large clinics is 40%. Small clinics are less familiar with this method (approx. 16%). The larger the clinic, the more often intrauterine catheters are used to measure labor; the figure rises from 7% to 29%.(ABSTRACT TRUNCATED AT 250 WORDS)

Birth Rate↗

Investigation of gastro-oesophageal reflux in patients with an intact stomach: is oesophageal bilirubin monitoring a useful addition to pH monitoring?

OBJECTIVES: Ambulatory bilirubin monitoring has helped to establish the role of duodenal contents in gastro-oesophageal reflux disease. This study aims to define the clinical role of oesophageal bilirubin monitoring in reflux patients with an intact stomach. METHODS: In total, 113 consecutive patients with reflux symptoms were prospectively studied using combined ambulatory oesophageal pH and bilirubin monitoring. Patients were categorized as follows: no pathological reflux, isolated acid reflux, isolated bilirubin reflux, combined acid and bilirubin reflux. RESULTS: Thirty-eight patients (33%) had no pathological reflux, 49 patients (44%) had combined pathological acid and bilirubin reflux, and 17 patients (15%) had isolated pathological acid reflux. Only nine patients (8%) had isolated pathological bilirubin reflux. In these nine, the extent of pathological bilirubin reflux was small (median total bilirubin exposure time 12.2%, range 6.5%-20.7%) and mucosal damage was minimal (five had grade 1 oesophagitis, four had a normal oesophagus). In one patient, symptoms were temporally related to acid reflux, and in none were symptoms temporally related to bilirubin reflux. CONCLUSIONS: Isolated oesophageal bilirubin reflux in patients with an intact stomach is uncommon. In these patients mucosal injury is minimal, and reflux symptoms are not related to bilirubin reflux episodes. Further work is needed to define the role for oesophageal bilirubin monitoring in the investigation of reflux disease in patients with an intact stomach.

Bilirubin↗

The non-contact monitoring of heart and respiratory rates using laser irradiation: an experimental simultaneous monitoring with and without clothes during biochemical hazards.

The purpose of this study is to develop a non-contact method to evaluate the heart and respiratory rates simultaneously using a single optical sensor which can be used without the removal of clothes before a decontamination procedure in biochemical hazards. We measured the heart and respiratory rates with and without clothes to assess the vital sign monitoring before decontamination. In order to monitor the heart and respiratory rates of rabbits simultaneously, the respiratory and cardiac peaks were separated using fast Fourier transform from a 5 mW helium-neon laser (wavelength 632.8 nm) reflected off the chest walls of rabbits. A cloth (50 mm x 50 mm, 2 mm thick) was placed on the chest of the rabbits to simulate the vital sign monitoring with clothes. The heart rate measured using this method agreed with the rate derived from an electrocardiogram (r = 0.82, p<0.05). The respiratory rate correlated with the manually measured respirator rate (r = 0.93, p<0.05). This method appears promising as a non-contact method for monitoring the heart and respiratory rates of patients under biochemically hazardous conditions.

Animals↗

Noninvasive automatic blood pressure monitoring does not attenuate nighttime hypotension. Evidence from 24 h intraarterial blood pressure monitoring.

Automatic ambulatory blood pressure monitoring makes use of repeated cuff inflations throughout the day and night. This may interfere with the cardiovascular effects of sleep and thus alter the 24 h blood pressure profile. The possibility that intermittent automatic blood pressure measurements prevent nocturnal hypotension was examined in 17 mild or moderate essential hypertensive patients in whom blood pressure was recorded intraarterially for 48 h by the Oxford technique. During the first or the second 24 h period, blood pressure was also monitored noninvasively by the SpaceLabs (Redmond, WA) 5300 (n = 10) and by the Sandoz Pressure System SPS 1558 (Lavanchy Electronique, Prilly, Switzerland) (n = 7) devices, automatic measurements being performed at 15 min intervals during the day and at 30 min intervals during the night. Separate computer analysis of 24 h intraarterial tracings obtained in absence and in concomitance of contralateral automatic blood pressure monitoring showed that the occurrence of automatic measurements had not interfered with the day-night intraarterial blood pressure and heart rate profiles. Thus the frequent cuff inflations that characterize automatic blood pressure monitoring do not attenuate nighttime hypotension and bradycardia. This finding supports use of the noninvasive approach in assessing blood pressure profiles.

Adult↗

Standards of evidence for the safety and effectiveness of critical care monitoring devices and related interventions. Coalition for Critical Care Excellence: Consensus Conference on Physiologic Monitoring Devices.

OBJECTIVE: To devise alternatives to randomized, controlled, clinical trials that clinicians and research experts might find acceptable for approval of devices used in critical care medicine. DATA SOURCES: The Coalition for Critical Care Excellence (Coalition) of the Society of Critical Care Medicine organized a consensus conference in which recognized critical care researchers gave testimony to a panel of experts regarding the process for testing and approval of monitoring devices. DATA SELECTION: The expert panel used testimony from the presenters as the basis of discussions on the testing and approval process. Guiding principles and specific recommendations were made based on the testimony given. MAIN RESULTS: The panel determined the main constituents of the medical device approval process to be the Food and Drug Administration (FDA), the research and clinical community, and the device manufacturers. Distinctions were made between monitoring and interventional device categories. This document addresses only monitoring devices. Potential alternatives to randomized, blinded, controlled study designs for device testing are: a) nonblinded, randomized, management protocol-driven study; b) crossover study (n-of-one design); c) cluster-randomization (randomized by care unit); d) case-matched controls; e) mixed design; f) on/off design (before-after); and g) historical controls. CONCLUSIONS: The panel agreed on the following major recommendations: a) the FDA should accelerate publication of specific guidances for physiologic monitoring products with the assistance of the Coalition (priorities and content); b) more multidisciplinary research should be incorporated into new device studies; c) commonly accepted clinical tools may not need to be tested for clinical utility--these accepted tools should be identified by the Coalition; and d) an independent council of researchers and clinicians should make themselves available to serve as consultants to manufacturers regarding appropriate study design for the testing of devices.

Case-Control Studies↗

Monitoring monitors.

A centralized, remote alarm system was implemented to alert nursing personnel when patient monitors located in isolation rooms go into alarm. The design includes a method of confirming the ON/OFF status of individual monitors to avoid operator error. This system utilizes low-cost individual patient monitors and includes interface devices, an alarm panel, and indicator panels. The design logic is based on the need for nursing personnel to also be alerted in the event of any abnormality associated with the patient monitors, the alarm panel itself, or with the interconnections. The system will also accommodate infusion pumps, respirators, or any other devices equipped with a remote alarm (nurse call) output.

Equipment Failure↗

Airflow-based PCO2 monitoring delivers O2 and removes CO2 from the monitored environment.

Previous investigation has suggested that the use of airflow-based gastrointestinal intraluminal PCO2 (GI PiCO2) monitoring systems may affect the local tissue microenvironment, making it not representative of the organ system as a whole. Therefore, we investigated the effects of using an airflow-based PCO2 monitoring system in a sealed environment. A 250-mL Erlenmeyer flask was filled with 10% CO2/90% N2 and was sealed with probes in place. Using a fiber-optic (Neotrend, Diametrix Medical, St. Paul, MN) system, the PCO2 and PO2 were continuously monitored with and without the airflow-based (Tonocap, Tonometrics, Datex-Ingstrom, Helsinki, Finland) system operating. PCO2 and PO2 remained constant when the airflow-based system was not in operation. PCO2 decreased 25.3 mmHg and PO2 increased 30 mmHg from a starting value of 0 mmHg when the airflow-based system was in operation for 12 h. The use of airflow-based methods for determining GI PiCO2 may influence the values obtained. Nonsample removing techniques such as fiber-optic methods for monitoring GI PiCO2 are preferable because they neither deliver O2 to nor remove CO2 from the local microenvironment.

Carbon Dioxide↗

Intracranial pressure monitoring: why monitor?

Evidence suggests that the mortality and morbidity of acquired brain injury could be reduced if clinicians used an aggressive intracranial pressure guided approach to care. Despite nearly 50 years of evidence that intracranial pressure monitoring benefits patient care, only about half of the patients who could benefit are monitored. Some clinicians express concerns regarding risks such as bleeding, infections, and inaccuracy of the technology. Others cite cost as the reason. This article discusses the risks and benefits of intracranial pressure monitoring and the current state of evidence of why patients should be monitored.

Calibration↗

Monitor: an expert system that validates and interprets time-dependent partial data based on a cystic fibrosis home monitoring program.

The use of health diaries to monitor patients with chronic diseases has often been complicated by difficulties encountered in data quality assurance and interpretation. An expert system, Monitor, has been developed to predict the health status of cystic fibrosis patients based on daily home measurements of pulse, respiratory rate, weight, inspired vital capacity, and a check list of symptoms of acute illness. This system ensures data reliability beyond what can be achieved in most current automatic error detection procedures by validating inputs against patient-specific expectations. Its explicit representation of the time dimension and the hierarchical structure of its knowledge base facilitate the abstraction of trends and relationships among the time-dependent data. Dynamically imposed expectations also lend flexibility to the interpretation process by allowing the processing of partial (incomplete) data. Monitor correctly classified 86 percent (three-category classification) and 94 percent (two-category classification) of 111 cases. This demonstrates that expert systems can be a feasible approach in building more robust diary monitoring systems.

Cystic Fibrosis↗

Addition of esophageal impedance monitoring to pH monitoring increases the yield of symptom association analysis in patients off PPI therapy.

BACKGROUND: The additional yield of esophageal impedance monitoring in identification of reflux as the cause of reflux symptoms is unknown. OBJECTIVES: To compare the yield of symptom-reflux association analysis of combined esophageal pH-impedance data with the yield of analysis of pH data alone. METHODS: In 60 patients with symptoms of heartburn and regurgitation combined, 24-h pH-impedance monitoring was performed. Acid-suppressive medication was stopped 1 wk in advance. Patients (48) with at least one symptom during the measurement period were selected for further analysis. Patients were instructed to note the time and nature of their symptoms. Eleven types of reflux episodes were defined, based on combinations of magnitude of the pH drop, nadir pH, and nature of the refluxate (gas and liquid) on impedance tracings. Symptom association analysis-symptom index, the symptom sensitivity index, and the symptom association probability (SAP)-was performed for each definition of reflux. RESULTS: The proportion of patients with a positive SAP (> or =95.0%) varied between 62.5% and 77.1%, depending on the definition of reflux episodes. When both pH and impedance parameters were used to identify reflux, a higher proportion of patients had a positive SAP than with pH alone (77.1%vs 66.7%, p < 0.05). Symptom association analysis for acidic and weakly acidic reflux separately did not result in a higher yield than analysis with all reflux episodes pooled, regardless of pH. CONCLUSION: In patients off proton pump inhibitor, the addition of impedance monitoring to esophageal pH monitoring leads to an increase in the proportion of patients in whom an association between reflux episodes and symptoms can be identified.

Adult↗

Accuracy and clinical utility of the CoaguChek XS portable international normalised ratio monitor in a pilot study of warfarin home-monitoring.

AIM: To evaluate the accuracy of the CoaguChek XS international normalised ratio (INR) monitor compared with the laboratory method. METHODS: The accuracy and ease of use of the recently marketed CoaguChek XS portable INR monitor was evaluated in 17 patients involved in a trial of warfarin home monitoring. INR results from the monitor were compared with those from the laboratory method. Clinical applicability was measured by discrepant INR values, defined in the literature by expanded and narrow agreement criteria, and by the proportion of INR values differing by >15% and by >20% from those derived by the laboratory method. RESULTS: Participants provided 59 comparison INR measurements for analysis. The paired results were highly correlated (r = 0.91). Expanded and narrow agreement between paired INR values occurred 100% of the time. Only three CoaguChek XS (5.1%) results differed by >15% compared with the laboratory method; no results differed by >20% or were discrepant by >0.5 INR units. CONCLUSIONS: In the hands of patients the CoaguChek XS showed good correlation with laboratory determination of INR and compared well with expanded and narrow clinical agreement criteria. Both patients and doctors were highly satisfied with the accuracy and ease of use of the CoaguChek XS.

Aged↗