Warfarin management using point-of-care testing in a university-based internal medicine resident clinic.

INTRODUCTION: The primary endpoint was to determine whether point-of-care (POC) International Normalization Ratio (INR) testing would increase the percentage of patients in the therapeutic range. The secondary endpoint was to determine how POC Testing (POCT) would affect the time to intervention (the amount of time it took to contact a patient who had an INR outside the therapeutic range and make the appropriate warfarin adjustment). METHODS: Over an 11-month time period, the authors implemented an anticoagulation-focused quality improvement initiative based on the internal medicine resident continuity clinic. The initiative was designed as a single site before and after study. RESULTS: The proportion of INR values within the therapeutic range before the implementation of POCT (predesign phase) was 25%. After the implementation of POCT (postdesign phase), the percentage of therapeutic INR was 50% (P = 0.005). The time to intervention in the predesign phase was 4 days while intervention was accomplished during the same visit that the blood was sampled in the postdesign phase of this study. The number needed to treat was 4 to obtain a therapeutic INR. CONCLUSION: The results of this quality improvement study showed significant improvement in the percentage of patients who were in the therapeutic range with the use of POCT. Time to intervention was also markedly improved with the addition of POCT. The authors believe that this is the first study showing such results in an internal medicine academic clinic.

Overview and management of obesity in adults.

Teaching Points. The prevalence of overweight or overtly obese adults in the United States is growing and associated with significant morbidity and mortality. Office evaluation of the overweight or obese adult includes a thorough history and physical examination complemented by several laboratory tests that evaluate for co-morbid conditions. Treatment of the overweight or obese adult requires a step-wise approach beginning with lifestyle modification followed by pharmacologic or surgical interventions in selected patients. Treatment decisions should take into consideration body mass index, waist circumference and the presence of comorbidities or obesity-associated risk factors.

Microbiological, biological, and chemical weapons of warfare and terrorism.

Microbiological, biological, and chemical toxins have been employed in warfare and in terrorist attacks. In this era, it is imperative that health care providers are familiar with illnesses caused by these agents. Botulinum toxin produces a descending flaccid paralysis. Staphylococcal enterotoxin B produces a syndrome of fever, nausea, and diarrhea and may produce a pulmonary syndrome if aerosolized. Clostridium perfringens epsilon-toxin could possibly be aerosolized to produce acute pulmonary edema. Ricin intoxication can manifest as gastrointestinal hemorrhage after ingestion, severe muscle necrosis after intramuscular injection, and acute pulmonary disease after inhalation. Nerve agents inhibit acetylcholinesterase and thus produce symptoms of increased cholinergic activity. Ammonia, chlorine, vinyl chloride, phosgene, sulfur dioxide, and nitrogen dioxide, tear gas, and zinc chloride primarily injure the upper respiratory tract and the lungs. Sulfur mustard (and nitrogen mustard) are vesicant and alkylating agents. Cyanide poisoning ranges from sudden-onset headache and drowsiness to severe hypoxemia, cardiovascular collapse, and death. Health care providers should be familiar with the medical consequences of toxin exposure, and understand the pathophysiology and management of resulting illness.