Change In Therapeutic Strategy Research Articles

Antibiothérapie des infections urinaires basses: bases cliniques, microbiologiques et pharmacologiques

While uncomplicated lower urinary tract infection (UTI) in young women is a common and very frequent disorder, change and progress in the infection’s management, choice of antimicrobial agents and whether or not it is necessary to perform urine cultures and antibiotic susceptibility testing, are not precluded. Among the factors supporting use of urine cultures, the increasing emergence of antibiotic-resistant bacteria may theoretically pose an argument for use of this test. And yet, epidemiological studies on urinary tract infections have investigated the predominant uropathogens and their antibiotic sensitivity: the results for several years of data show the stable incidence of Escherichia coli, Proteus mirabilis, Klebsiella spp or Staphylococcus saprophyticus; the investigations’ results also demonstrate low resistance rates to the most frequently used antimicrobial agents, with the exception of beta-lactams, represented mainly by aminopenicillins. The availability of several new classes of antibiotics and the development of antibiomicrobial agents specific to urinary infections are factors allowing empirical treatment of uncomplicated lower UTIs. In this case, the use of urine culture to diagnose urinary tract infections is called into question, the clinical presentation and use of urine dip-sticks being adequate. Finally, the change in therapeutic strategy towards shorter treatment regimens with an optimum 3-day course of therapy, is manifested by treatment with fluoroquinolones, which are broad-spectrum antimicrobial agents that are mainly excreted in the urine. This latter pharmacokinetic parameter makes it possible to ensure bacterial eradication when high doses (cause of poor safety profile) of the selected compound are not necessary, when this compound is weakly bound to plasma proteins, undergoes little metabolism and maintains high urinary concentrations of the product in unchanged form that persist after the end of treatment.

Application, Feasibility, and Efficacy of a Combined Intravascular Ultrasound and Stent Delivery System: Results from a Prospective Multicenter Trial

Intravascular ultrasound (IVUS) is the reference method for in vivo assessment of vessel dimensions and coronary plaque composition, which can influence device selection as well as stent sizing. The objective of this prospective multicenter-study was to test the application, safety, and feasibility of a new combined IVUS and stent delivery system. A total of 32 patients with planned direct stent implantation under IVUS guidance were included in the study. Procedural as well as angiographical and IVUS characteristics of the stent implantation with the combined IVUS and stent delivery system were assessed and compared to a historical control cohort where IVUS-guided stenting was performed with a separate IVUS catheter. Direct stent placement was successfully performed in all patients and no malfunctions of the system were noted. A post-interventional IVUS assessment was possible in 27 (87%) of the 31 patients. The IVUS information led to a change in therapeutic strategy in 16 (50%) of the 32 patients. In the study group, both the procedural time and the amount of contrast dye were significantly lower than in the historical IVUS-guided stenting control group. A clinical 12-month follow-up revealed a 89% event-free survival and a target vessel revascularization rate of 7%. The use of a combined IVUS and stent delivery device is safe, easy to handle, and can provide helpful additional information to guide a percutaneous coronary interventions procedure. Beyond angiography, these informations had significant impact on the interventional strategy in these patients, which resulted in a low rate of major adverse cardiac events. The concept of combining IVUS information and a stent delivery system may be increasingly attractive with evolving imaging modalities like virtual histology or a combination with drug-eluting stents.

Accuracy, utility and complications of continuous glucose monitoring system (CGMS) in pediatric patients with type 1 diabetes

To evaluate the accuracy, utility and complications of continuous glucose monitoring system in children and adolescents with type 1 diabetes.This retrospective study assessed 16 type 1 diabetic patients (16.12+/-4.41 years) submitted to continuous glucose monitoring system (Medtronic; Northridge, CA) for 72 hours. The following parameters were analyzed: mean capillary glucose level and mean glucose value measured by the continuous glucose monitoring system; glucose excursions (continuous glucose monitoring system vs. capillary glucose measurement), postprandial hyperglycemia (NR < 140 mg/dl), nocturnal hypoglycemia, complications (trauma, local infection, disconnection) and therapeutic management after continuous glucose monitoring. A1c levels were measured at the beginning and after 3 months of the study.The mean capillary glucose values were 214.3+/-66.5 mg/dl vs. 207.6+/-54.6 mg/dl by continuous glucose monitoring system, with a significant correlation (p = 0.001). The correlation coefficient and mean absolute error were 0.86+/-0.21 and 12.6% of the median, respectively. The continuous glucose monitoring system was significantly more efficient in detecting glucose excursion than fingerstick capillary blood sampling (p = 0.04; W = 74), and postprandial hyperglycemia was identified in 60% of type 1 diabetic patients with a median value of 157 mg/dl (< 140 mg/dl). Nocturnal hypoglycemia was detected in 46.7% of these patients. The evaluation of A1c levels in eight (50%) patients before continuous glucose monitoring and after 3 months showed a significantly lower level of A1c in this population (8.18+/-1.5 vs. 7.28+/-1.3; p = 0.034). The therapeutic management of type 1 diabetes was changed in 100% of patients. No complications were detected in 93.7% of patients.The continuous glucose monitoring system showed to be a very safe, well-tolerated and highly accurate method, with a low complication rate. It is a good method to identify glucose excursion and postprandial hyperglycemia, and to improve metabolic changes in therapeutic strategies, with a significant impact on the A1c levels of pediatric diabetic patients. The efficacy of the continuous glucose monitoring system in detecting hypoglycemia is still unclear in the medical literature.

Acurácia, utilidade e complicações da monitorização subcutânea contínua da glicose (CGMS) em pacientes pediátricos com diabetes tipo 1

To evaluate the accuracy, utility and complications of continuous glucose monitoring system in children and adolescents with type 1 diabetes. This retrospective study assessed 16 type 1 diabetic patients (16.12+/-4.41 years) submitted to continuous glucose monitoring system (Medtronic; Northridge, CA) for 72 hours. The following parameters were analyzed: mean capillary glucose level and mean glucose value measured by the continuous glucose monitoring system; glucose excursions (continuous glucose monitoring system vs. capillary glucose measurement), postprandial hyperglycemia (NR < 140 mg/dl), nocturnal hypoglycemia, complications (trauma, local infection, disconnection) and therapeutic management after continuous glucose monitoring. A1c levels were measured at the beginning and after 3 months of the study. The mean capillary glucose values were 214.3+/-66.5 mg/dl vs. 207.6+/-54.6 mg/dl by continuous glucose monitoring system, with a significant correlation (p = 0.001). The correlation coefficient and mean absolute error were 0.86+/-0.21 and 12.6% of the median, respectively. The continuous glucose monitoring system was significantly more efficient in detecting glucose excursion than fingerstick capillary blood sampling (p = 0.04; W = 74), and postprandial hyperglycemia was identified in 60% of type 1 diabetic patients with a median value of 157 mg/dl (< 140 mg/dl). Nocturnal hypoglycemia was detected in 46.7% of these patients. The evaluation of A1c levels in eight (50%) patients before continuous glucose monitoring and after 3 months showed a significantly lower level of A1c in this population (8.18+/-1.5 vs. 7.28+/-1.3; p = 0.034). The therapeutic management of type 1 diabetes was changed in 100% of patients. No complications were detected in 93.7% of patients. The continuous glucose monitoring system showed to be a very safe, well-tolerated and highly accurate method, with a low complication rate. It is a good method to identify glucose excursion and postprandial hyperglycemia, and to improve metabolic changes in therapeutic strategies, with a significant impact on the A1c levels of pediatric diabetic patients. The efficacy of the continuous glucose monitoring system in detecting hypoglycemia is still unclear in the medical literature.

67Ga-SPECT/CT with a hybrid system in the clinical management of lymphoma

The purpose of this study was to investigate the added value of co-registered fusion imaging using a hybrid system in patients with lymphoma. Twenty-four lymphoma patients underwent (67)Ga-SPECT/CT using a hybrid tomograph consisting of a dual-head, variable-angle gamma camera and a low-dose X-ray tube. Results were compared with those of SPECT alone. Forty-five lesions were identified by SPECT alone, while 49 were detected by SPECT/CT. Forty out of the 45 lesions observed on SPECT were confirmed as lymphoma, but five were due to other causes (thoracic aorta blood pool activity, sialoadenitis in the submandibular gland, bowel activity, rib fracture and bone marrow activation due to radiotherapy). SPECT/CT identified nine more neoplastic lesions compared with SPECT alone: four areas of radiopharmaceutical accumulation were observed in para-aortic lymph nodes, three in the spleen, one in the liver and one in para-iliac lymph nodes. In five cases, SPECT/CT provided additional anatomical information over SPECT alone. In four patients, four large areas of (67)Ga uptake (one mediastinal, two supraclavicular and one para-aortic) were better characterised; in one subject uptake was localised in the seventh thoracic vertebra only by SPECT/CT. Hybrid imaging provided additional data in 13 patients (54.2%), thus inducing oncologists to reconsider the therapeutic approach in eight subjects (33.2%): unnecessary treatment was avoided in four (16.6%) while therapy was altered in another four (16.6%). SPECT/CT hybrid system is able to provide information not obtained by SPECT alone. It allows the anatomical localisation of lymphoma and physiological radiopharmaceutical uptake, facilitates the diagnosis of tumours located in the abdomen (subdiaphragmatic lesions) and provides information that may cause a change in therapeutic strategy.

Clinical Use and Pathogenetic Basis of Laboratory Tests for the Evaluation of Primary Arterial Hypertension

This review focuses on the laboratory biochemical tests that are useful in the diagnostic approach to the hypertensive patient. A “minimal” diagnostic laboratory work-up, including a small number of tests that are simple and relatively inexpensive, is first described. Because these tests provide basic information on the presence of major cardiovascular (CV) risk factors and target organ damage, and might give some clues to the presence of a secondary form of hypertension (HT), they should be performed on all patients presenting with HT. Other tests that are aimed at assessing the overall CV risk, a major determinant of prognosis that dictates the therapeutic strategy in the individual HT patient, are then discussed. They allow identification of major CV risk factors and associated clinical conditions which, if present, lead to a substantial change of therapeutic strategy. The role of C-reactive protein as a marker of atherosclerosis and its predictive value for CV events are also discussed. Finally, a section is devoted to tests that are currently confined to research purposes, such as markers of endothelial function including endothelin-1, homocysteine and genetic analysis.

Das Mannheimer Schlaganfallprojekt

Stroke and its consequences are under medical, sociologic and socioeconomic aspects one of the biggest contemporary challenges. Due to the demographic development the importance of this disease will further increase. Nonetheless acute therapy of ischemic stroke up to now was marked by therapeutic nihilism and adherence to empiric therapeutic procedures. Only the admission of rt-Pa in the USA in 1996 for the systemic thrombolysis in ischemic insults less then 3 hours old led to a change in therapeutic strategies. The good profit-risk-ratio of early thrombolysis with rt-Pa could be confirmed by further studies lately. In the meantime this therapy was officially recommended by the AHA in the importance of grade A recommendation. In Europe thrombolysis is equally promoted as the procedure of choice. At present only few patients receive such a treatment. A thrombolytic therapy can only be provided by a minority of centers due to high requirement in infra-structure. Furthermore clinic admission often appears with immense loss of time. Unfortunately also within the clinics there are relevant latencies until therapeutic intervention. Therefore fundamental requirements for thrombolytic therapy are the indentification of potentially suitable patients and the rapid transfer to an appropriate clinic.

Projecting future drug expenditures—1994

The use of information on inflation, generic competition, market introduction of new drug entities, institution-specific drug-use patterns, and federal legislation to project drug expenditures is discussed. Inflation of pharmaceutical prices has been decreasing over the past few years. Increases in the producer price index for drugs and pharmaceuticals diminished from 6.9% in 1991 to 4.3% in the first half of 1993; the specter of government regulation may be one reason. Pharmacy group purchasing organizations (GPOs) predicted that in 1994 expenditures would increase an average of 2.1% for contracted drug items and 8.3% for noncontracted items. Expenditures for biotechnology drugs in January through July 1993 increased 16% over the same period in 1992; such agents are now hospital pharmacies' third most costly drug category, at 10% of total expenditures. Future price competition by generic drug products can be predicted from information on patent or market-exclusivity expiration. To predict the market release of new drug products, new-drug applications filed with FDA can be monitored. The most important component in projecting drug expenditures is a specific institution's pattern of use of high-cost drugs. Mechanisms that can be used to monitor changes in therapeutic strategies and drug-use protocols include drug cost indexes, assessment of drug-use patterns by outside companies, and computerized models for specific high-cost drugs. Drug expenditures can be affected by legislative changes such as the Medicaid rebate provisions of the Omnibus Budget Reconciliation Act of 1990 and the Medicare outpatient drug benefit in the proposed American Health Security Act. The accuracy of projections of drug expenditures can be improved by examining inflation, generic competition, the introduction of new drug entities, institution-specific drug-use patterns, and legislative issues. Pharmacy managers need better methods for estimating institution-specific use of high-cost drugs.

Recent advances in pulmonary medicine (1).

Traditionally a discipline based on physiology for the functional assessment of patients with lung disease, pulmonary medicine has been moving over the past decade into the realm of cellular and molecular biology in an attempt to unravel mechanisms of disease. Advances in understanding the pathogenesis of diseases such as cystic fibrosis, alpha1-antitrypsin deficiency, and asthma have resulted in changes in therapeutic strategy as well as new and promising forms of treatment. At the same time, more sophisticated imaging methods have opened up a new world of structural characterization of disease. On the other hand, the respiratory complications of . . .

On the causes of the inadequate protection afforded by Lightning Rods, in some cases, and the means of insuring their perfect competency: also, a refutation of the prevalent idea, that Metals are peculiarly attractive of Electricity

The outcome of desmoid-type fibromatosis (DTF) is unpredictable. Currently, a wait-and-see approach tends to replace large en bloc resection as the first therapeutic approach. Nevertheless, there are no validated factors to guide the treatment choice.We conducted a prospective study of 771 confirmed cases of DTF. We analysed event-free survival (EFS) based on the occurrence of relapse after surgery, progressive disease during the wait-and-see approach, or change in therapeutic strategy. Identification of prognostic factors was performed using classical methods (log-rank test and Cox model).Overall, the 2-year EFS was 56%; this value did not differ between patients undergoing an operation and those managed by the wait-and-see approach (53% versus 58%, p = 0.415). In univariate analysis, two prognostic factors significantly influenced the outcome: the nature of diagnostic sampling (p = 0.466) and primary location (p = 0.0001). The 2-year EFS was only 32% after open biopsy. The 2-year EFS was 66% for favourable locations (abdominal wall, intra-abdominal, breast, digestive viscera and lower limb) and 41% for unfavourable locations. Among patients with favourable locations, the 2-year EFS was similar in patients treated by both surgery (70%) and the wait-and-see approach (63%; p = 0.413). Among patients with unfavourable locations, the 2-year EFS was significantly enhanced in patients initially managed with the wait-and-see approach (52%) compared with those who underwent initial surgery (25%; p = 0.001).The location of DTF is a major prognostic factor for EFS. If these findings are confirmed by independent analysis, personalised management of DTF must consider this easily obtained parameter.