INR result 2.9 as at 27 April 2012

I would prefer it to be a little lower really, though it is apparently going in the right direction. I suppose ideally I should talk to the anticoagulant clinic. We can't really do anything over the weekend though. Remind me where you go to the anticoagulant clinic please and I will see if I can make contact on Monday or Tuesday. JB

I did see Janet on Friday at Royal Vic Folkestone (she mentioned that she had a clinic on Thursaday at Canterbury) who advised that I ring 01227 783157 haemophilia centre number once I had heard from you about possible adjustment to my warfarin. I go for the blood tests at Royal Vic Folkestonefor convenience having been referred from the ambulatory ward at William Harvey where Laine was the point of contact.
My next appointment for review is 18th May in Folkestone and this is based on continuing at 5mg warfarin daily which is what I have been taking since 13th April.
Obviously to lower the INR presumably this dose will need adjusting but by who and how much I do not know.
If you are able to contact someone about this I would be very grateful.
If you need any more details please let me know
178110 seems to be the patient number used in the yellowbook

PS I have spoken to Mum on the phone just now and her right hand is extremely painful so much so that she is contemplating going for the operation but hopefully an injection as soon as is viable will help.
Many thanks for your reply

Angela

I have spoken to the anticoagulant clinic and they will be calling to advise a reduction of dose for a day or two so you can drop in on Thursday morning and we will inject it and discuss the matter further. JB

That's great - thank you so much for contacting them. They have rung and advised reduced doses for the next 3 days.

Is there any particular time on Thursday ? From my own work point of view the earlier the better but I appreciate that this may not fit in with you! Rest assured she will be there - thank you again - Angela.

Turn up anytime between about 9:15 and 12:00 noon. You may have to hang about a bit as the Thursday morning clinic is generally a bit of a madhouse - people with CTS overflowing out of the doors! We will try to fit it in as soon as we can once we know you are there however, just let reception know when you arrive. JB

Thank you so much for seeing Mum today.

She reports that :

the wrist on the other side of the injection feels somewhat like a sprain
there is no pain in the thumb or palm
the tingling in the fingers has gone but the numbness of the tips of the index and middle fingers remain
it will be interesting to see how the hand is tomorrow bearing in mind that this is the first time that she has had an injection while the hand is 'tiresome'

I will update again tomorrow !

Thanks again
AL

I would expect the numbness to be slower to respond than the tingling. We don't often get day by day reports so it is interesting to hear how the symptoms evolve. JB

update as at Monday 7th May

" The early morning spasms have not occurred since the injection but during the day the palm can be painful particularly when playing the accordion .
The tips of the fingers are still numb, the tingling in the fingers is slight and the electric shock feeling is in the palm.
Whereas before the hand has been fine all day the hand is not tiresome at night but painful in the day like an electric shock sensation in the palm which was not present before. ""

Dr Bland - she is complaining of fleeting pain so does not think that painkillers will help as she does not have constaant aching .Whereas before there was instant relief this time the hand is a bit poorly - is there anything else we can do please ? she wonders whether the site of the injection has made a difference as it was on the thumb side this time whereas previously it was on the ring finger side of the wrist .

Pain in the palm on playing the accordion may not be the CTS but some patients do seem to get electric shock like spasms which may be what is being described. I see these even after surgery and I am not sure quite what they represent but they usually seem to settle in time.

I am pretty much expecting the numbness not to change very quickly - it would generaly be slow to improve even after surgery starting from grade 5 CTS - I think the challenge is trying to decide whether it is improving or deteriorating, rather than suddenly disappearing.

I don't think the injection site makes much difference as long as you are somewhere near the wrist. There are no directly comparative studies but all of the various published series of injection treated patients report more or less the same initial success rate regardless of the exact site chosen for injection by the different authors.

I would suggest sitting tight for the moment, perhaps lay off the accordion for a few days. Let me know how it is at a week and if it persists to 2 weeks we might think about trying the method used in Spain of two injections in quick succession. Other than that the only other real option of course is surgery. JB

Thanks for the reply , have already backed off the accordion and will sit tight and update after the weekend. LJ

Fantastic news !

Mum reports no recurrence of pain or disturbance in day or night ! Aside from slight numbness in tip of RH middle finger BOTH hands behaving brilliantly.
Absolutely thrilled - I have just returned from visiting her - she has been repotting plants , tidying and cooking etc and then serenaded me on the accordion while I changed the bedding ! What a difference a week has made -thank you !!
AL

Good to hear that. We'll see how long it lasts now. JB

Dear Dr Bland ,

Mum has asked me to contact you regarding return of symptoms in right hand particularly in early morning .The thumb, index and middle finger are all affected and she is also getting the electric shock through the palm intermittently. This has apparently been occurring since the end of last month and she has been taking paracetamol to ease the pain.
She would like to see you or have another injection - can you please let me know what can be done to help ?

Many thanks
Angela

I will arrange an appointment in the next few weeks. It's not long since the last injection but I guess she is probably still not keen on surgery? JB

It's hard to tell whether or not she would consider the surgery - she could be persuaded I think if there was more of a chance that the outcome is likely to be more successful than the injections.
Certainly up until the last injection she would not have seen the need but if the effect of future injections produce diminishing returns then we may need to reconsider. She is not concerned about having more injections although I am not sure whether this is viable on a long term basis . Health wise , aside from the warfarin treatment (which will continue until November and then be reviewed )she is in pretty good shape for a ninety year old.
Do we need to fill out another questionnaire ?

Well there is no doubt that surgery would offer a better chance of a long term remission of symptoms - but it is also more inconvenient and riskier, and it is the trade off between those things which makes decisions difficult. We can continue with injections indefinitely as long as the nerve is not deteriorating and durations of remissions after each injection seem to be pretty random. I would however be happy to arrange surgery for her anytime. JB

Mum received a phone call yesterday with an appointment time . Having broached the subject of surgery she was adamant that she would prefer to stick with the injection option as surgery would only be worthwhile if she was going to be around for another 10 years and therefore get a telegram from the Queen!
However , this morning she rang me to advise that , having given it some thought overnight she would be amenable to having the operation ( RH only ) and was now concerned about her INR reading ( which is currently about 2.2). Having explained that there is a waiting list for the op of possibly 6 months we have resolved to read up on the pros and cons and perhaps stick with an injection in the meantime and discuss further at her appointment ? I believe that currently her main concern is loss of use of of the fingers.

It's pretty rare for people to entirely lose the use of their fingers purely from CTS though the disorder can certainly make fine manipulative tasks a lot more difficult. Hopefully we can discuss it again shortly. JB