PURPOSE: Regional thrombolysis in the recanalization of peripheral vascular occlusive disease is an increasingly accepted therapeutic modality. Efficacy and complication rate are major issues in thrombolytic therapy. This prospective study was undertaken to determine if locally delivered recombinant tissue plasminogen activator (r-TPA) is safe and effective in clot lysis at non-weight-adjusted doses. PATIENTS AND METHODS: Twenty patients (undergoing 21 infusions) from two centers underwent fibrinolytic therapy with use of r-TPA, at a dose rate of 2 mg/h. The mean duration of arterial occlusion was 27.2 days (range, 1-117 days). Concomitant intravenous heparin anticoagulation was administered to all patients. A coaxial infusion delivery system was employed. Hematologic parameters and angiographic follow-up were evaluated at 4-hour intervals during thrombolytic infusion. The chosen maximum r-TPA dose of 40 mg could be extended at investigator discretion. RESULTS: Complete clot lysis was achieved in 18 of 21 (85.7%) infusions at a mean total dose of 38.9 mg (range, 8-84 mg). The mean infusion duration was 19.7 hours. In 16 of 19 (84.2%) infusions, in which the nadir fibrinogen level was recorded, it remained greater than 65% of baseline. Three of 21 (14.3%) infusions resulted in three major bleeding complications, one of which resulted in death. CONCLUSION: In this two-center trial, catheter-directed r-TPA infusion at 2 mg/h is effective for clot lysis. When combined with concomitant heparin administration, this treatment may result in an unacceptably high frequency of bleeding complications.

Adult↗

PubMedDate not supplied

Cefepime versus ceftazidime for treatment of pneumonia.

Consecutive patients with pneumonia, treated with cefepime (n = 66) or ceftazidime (n = 132), were evaluated in a retrospective, observational study. There was no significant difference between the two treatment groups with respect to age, underlying diseases, acute physical and chronic health evaluation score, intensive care unit admission, presence of sepsis, community or hospital acquisition, causative organism, duration of therapy, death, cure or improvement in infection, adverse events, superinfections, presence of vancomycin-resistant enterococcus (VRE) and resistance to therapy. Post-therapy hospitalization (days) and vancomycin co-administration were significantly lower, and time to vancomycin initiation significantly higher, in the cefepime compared with the ceftazidime group. The results suggest a trend towards less resistance on therapy, less VRE, reduced vancomycin use and shorter post-therapy hospitalization in patients treated with cefepime compared with ceftazidime. The clinical outcomes for hospitalized patients treated for serious pneumonia were similar between the two groups.

Anti-Bacterial Agents↗

PubMedDate not supplied

Effect of immediate hemoglobin A1c results on treatment decisions in office practice.

OBJECTIVE: To assess the effect of an immediately available hemoglobin A1c (HbA1c) result on glycemic control and physician decisions about pharmacologic therapy in an office practice. METHODS: In a 1-year retrospective review of medical records, HbA1c results were analyzed in 115 patients beyond the age of 65 years, who had type 2 diabetes and were referred for the first time to a private endocrinology practice between April 1, 1997, and March 31, 1998. These patients were classified into two groups: group A (N = 93, insured by standard Medicare) had immediate HbA1c results (during the patient encounter) and group B (N = 22, insured by Medicare health maintenance organization [HMO]) had commercial laboratory HbA1c results available within 2 to 3 days. We reviewed the changes in the HbA1c level during the 12-month period and the presence or absence of a change in therapy at each visit. HbA1c levels were measured by ion-exchange low-pressure liquid chromatography in group A and by one of three capitated commercial laboratories (depending on HMO contracts) in group B. RESULTS: At the end of the 12 months, the mean HbA1c decrease was 1.03 +/- 0.33% in group A and 0.33 +/- 0.83% in group B. During the first visit, 52% of the patients in group A had pharmacologic treatment interventions, whereas only 27% in group B had such interventions. CONCLUSION: Rapid availability of the HbA1c results during the clinical encounter improves the ability of the physician to make appropriate therapeutic decisions and results in improved glycemic control.

Aged↗