Comparison of a portable capillary whole blood coagulation monitor and standard laboratory methods for determining international normalized ratio.

The international normalized ratio (INR) is the current standard for monitoring anticoagulation therapy. Although simple to determine, it normally requires venipuncture and extensive laboratory resources for specimen handling and analysis. The portable capillary whole blood coagulation monitor is an alternative to laboratory venipuncture. Its promoted advantages are: it obtains a blood sample by finger-stick versus venipuncture; rapid turnaround time for results; resultant dosage adjustments (as appropriate) performed in minutes versus hours or days after testing; relative ease of use by nonlaboratory personnel; and potential for home monitoring. This project compared the results of INRs obtained through the venipuncture/laboratory process to INRs obtained by the portable monitoring process at the National Naval Medical Center. A correlation coefficient of 0.97 was determined. The difference in the mean INR results of the two testing methods was not clinically significant (p = 0.269). The portable monitor was determined to be a viable alternative to laboratory testing.

Suspected chromium picolinate-induced rhabdomyolysis.

Rhabdomyolysis results from skeletal muscle injury and release of muscle cell contents into plasma. A number of etiologic factors have been reported for the condition, including strenuous exercise, weight lifting, trauma, seizure, sepsis, and alcohol and drug abuse. Hundreds of drugs also reportedly cause rhabdomyolysis. A 24-year-old body builder developed the disease after ingesting 1200 microg of chromium picolinate (6-24 times the daily recommended allowance of 50-200 microg) over 48 hours. We believe this to be the first reported case of chromium-induced rhabdomyolysis.

Treatment of vancomycin-resistant enterococci, with a focus on quinupristin-dalfopristin.

Enterococci are the second most common cause of hospital-acquired infections, and drug resistance among these organisms is a growing problem. Vancomycin-resistant enterococci (VRE) now account for 7.9% of the nosocomial enterococcal infections. There is no standard therapy for VRE. Although some agents have shown in vitro activity alone or in combination, including ciprofloxacin, doxycycline, novobiocin, teicoplanin, chloramphenicol, and rifampin, treatment options are limited to combinations of drugs with marginal efficacy against the pathogens. Quinupristin-dalfopristin is a new investigational agent with activity against gram-positive cocci, including VRE.

Oral antibiotic therapy in infective endocarditis.

The mortality of IE remains fairly high despite the aggressive use of intravenous antibiotics. Oral treatment of IE is an intriguing concept with many potential advantages over conventional intravenous therapy. Unfortunately, there are insufficient data to justify predominantly oral regimens for the treatment of IE. Trials have shown that oral therapy may have a role in follow-up to short courses of parenteral antibiotics, but these trials are limited by the small number of patients studied. It is important to note that most data for oral treatment of IE have been obtained from studies in patients with histories of IVDA and right-sided S. aureus endocarditis. As mentioned previously, the course of IE in this patient population tends to be less severe, which makes extrapolation of these data to the general population difficult. A need exist for the development of oral antimicrobials with the properties previously mentioned, making them appropriate for use in IE. Currently available oral agents require further study before general recommendations regarding their use in patients with IE can be made. Although successful oral treatment of prosthetic valve endocarditis has been reported, such patients in general should not be considered as appropriate candidates for oral therapy. For now, oral antimicrobial therapy may be appropriate only as follow-up to short-course intravenous therapy, or use in combination with intravenous therapy for IE in select populations whose disease course is less severe or in whom prolonged intravenous therapy is impractical (i.e., intravenous drug users).