Bivalirudin: a review of the pharmacology and clinical application.

Among the current agents in the class of direct thrombin inhibitors, bivalirudin (Angiomax(®), The Medicines Company, NJ, USA) has seen increased use in cardiovascular medicine over the past decade through its primary indication as an anticoagulant used during percutaneous coronary interventions. Bivalirudin has been further investigated and used as the anticoagulation strategy in the setting of cardiac and endovascular surgical procedures and is frequently utilized in the management of patients with heparin-induced thrombocytopenia. In comparison with heparin, bivalirudin exhibits a low immunogenic profile and provides similar or reduced major bleeding rates as well as a predictable degree of anticoagulation that is dose related. Bivalirudin primarily undergoes dual elimination via proteolytic cleavage and renal elimination, and requires dose adjustment in the setting of severe renal dysfunction. Given the body of supportive data, bivalirudin is likely to continue to figure prominently as a reliable and efficient anticoagulation strategy. Additional agents in the class of direct thrombin inhibitors are under investigation and may find increasing clinical use.

Ranolazine-related dyspnea on exertion.

BACKGROUND: Ranolazine is increasingly being prescribed for the treatment of chronic stable angina. This report describes an adverse effect that may be related to ranolazine. CASE SUMMARY: A 77-year-old white man with chronic renal insufficiency was evaluated for moderate dyspnea on exertion (DOE). Cardiac and pulmonary workup revealed nonobstructive coronary artery disease and mild obstructive lung disease. The patient had been taking ranolazine 500 mg daily for possible angina for the past 2 months. Given the temporal association of his symptoms with drug initiation, ranolazine was discontinued during the hospitalization. One month after discontinuing ranolazine, the patient's DOE had completely resolved; the only intervention had been discontinuation of ranolazine. The patient's Naranjo algorithm score was 3, indicating a possible adverse drug reaction. CONCLUSIONS: No previous cases of ranolazine-related DOE requiring drug cessation have been published. Ranolazine may be associated with DOE in this elderly man.

Development of a deployment course for graduating military internal medicine residents.

Graduates of military internal medicine residency programs are required to have the necessary knowledge and skills to function as internists, military physicians, and military medical leaders. The global war on terrorism has increased the role internists are playing in combat theaters as they fill multiple different military medical positions including battalion, brigade, and division surgeons as well as physicians in echelon I, II, and III medical facilities. Along with general internists, internal medicine subspecialists, pediatricians, and family physicians also fill these roles. Although internal medicine training provides a broad-based knowledge to care for adults, it does not provide significant training in combat casualty care, detainee health care, or environmental health. To overcome many of these perceived shortfalls, we developed the 3-day deployment course for graduating internal medicine residents outlined in this article. Through a combination of didactic and hands-on training, militarily relevant medical knowledge and skills necessary to function at echelon I and II levels of care were provided. Residents uniformly accepted the course with measurable increase in their fund of knowledge at the completion of the course.

The effect of semipermeable dressings on smallpox vaccine site evolution.

BACKGROUND: Many hospital systems in the United States are contemplating the implementation of a smallpox vaccination program. The Centers for Disease Control and Prevention and other organizations recommend use of occlusive dressings over the vaccination site of health care workers in contact with patients. Minimal data are available on the impact of an occlusive dressing on the evolution of the vaccinia inoculation site. METHODS: We conducted a prospective observational study in which subjects were instructed to cover their vaccination site with either a semipermeable dressing over gauze or gauze alone. We recorded the duration of semipermeable dressing use and parameters pertaining to vaccination site evolution, to include time until scab separation. RESULTS: The increased use of a semipermeable dressing is associated with increased time until scab separation (n = 41, r =.48, P =.001 by regression analysis). This analysis predicts a 9-day difference in time until scab separation between patients that wore semipermeable dressings 100% of the time versus not at all. No significant correlation was observed between semipermeable dressing use and size of maximum erythema, time until maximum erythema, size of erythema on day 6 or 8, nor time until pustule formation. CONCLUSION: Semipermeable dressing use appears to prolong the time until scab separation and possibly the duration of infectivity and risk of secondary transmission. Health care organizations may wish to consider this information when instituting a smallpox vaccination program.