Safe and cost effective use of alteplase for the clearance of occluded central venous access devices.

PURPOSE: To determine whether cryopreserved solutions of the thrombolytic agent alteplase could be used as a safe, effective, and economically reasonable alternative to urokinase in patients presenting with occluded central venous access devices (CVADs). MATERIALS AND METHODS: Alteplase has been reported as an efficacious alternative to urokinase for treatment of occluded CVADs. However, the practicality of using alteplase as the thrombolytic of choice for this indication remained conjectural. To make this approach economically feasible, alteplase was diluted to 1 mg/mL and 2.5-mL aliquots were stored at -20 degrees C until use. A need to confirm that the cryopreserving and thawing of the reconstituted solution did not compromise the safety and efficacy reported from prior trials was recognized. A quality assessment initiative was undertaken to concurrently monitor the safety and efficacy of this approach. Patients presenting with occluded CVADs received a sufficient volume of the thawed alteplase solution to fill the occluded catheter(s). Data, including efficacy, adverse reactions, dwell time, and catheter type, were collected over a 5-month period. RESULTS: One hundred twenty-one patients accounting for 168 attempted clearances were assessable for safety and efficacy. One hundred thirty-six (81%) of the 168 catheter clearance attempts resulted in successful catheter clearance (95% confidence interval, 74% to 86%). No adverse events were reported. CONCLUSION: Cryopreserved 1-mg/mL aliquots of alteplase are safe and effective in the clearance of occluded CVADs when stored at -20 degrees C for 30 days. The ability to cryopreserve alteplase aliquots makes it an economically reasonable alternative to urokinase in the setting of CVAD occlusion.

Thiamine status in patients receiving long-term home parenteral nutrition.

OBJECTIVES: Clinical thiamine deficiency can occur in patients receiving total parenteral nutrition (TPN) without thiamine supplementation. Because considerable breakdown of thiamine may occur in the presence of bisulfite-containing amino acid solutions, subclinical thiamine deficiency may develop with the use of these solutions, even with appropriate thiamine supplementation. The current American Medical Association-Food and Drug Administration approved injectable multivitamin formula contains 3 mg of thiamine. This study was undertaken to determine whether this quantity of thiamine is sufficient to avoid clinical thiamine deficiency in long-term home TPN patients with negligible oral thiamine absorption and in the presence of bisulfite-containing amino acid solutions. METHODS: Twenty-four long-term home TPN patients with oral caloric intakes below the norm were evaluated. Seventeen patients suffered from short bowel syndrome or radiation enteritis, and another three had draining gastrostomies that precluded all intestinal absorption. The duration of TPN therapy ranged between 1 and 164 months. Thiamine status was assessed by assaying thiamine pyrophosphate, transketolase activity, and blood thiamine levels. RESULTS: All thiamine pyrophosphate and erythrocyte transketolase activity levels were within the normal range. CONCLUSIONS: This study demonstrates that the currently recommended 3 mg of thiamine hydrochloride added to TPN solutions is adequate to maintain normal thiamine status. This should prevent the development of thiamine deficiency even in patients with compromised intestinal thiamine absorption, and in the presence of bisulfite-containing amino acid solutions.

L-glutamine supplementation in home total parenteral nutrition patients: stability, safety, and effects on intestinal absorption.

A study was conducted to determine safety and efficacy of L-glutamine when added to total parenteral nutrition (TPN) solutions of patients receiving TPN in the home. Stability studies were first performed on various concentrations of L-glutamine in TPN solutions mixed by the Pharmix method. These showed that glutamine was stable in home TPN solutions for at least 22 days. The daily home TPN solutions of seven stable patients were then supplemented with glutamine at a dose of 0.285 g/kg of body weight for 4 weeks. The glutamine-TPN solutions were prepared weekly. Five patients received the full 4 weeks of glutamine-TPN. In two patients, administration of glutamine-TPN mixtures was stopped at the end of week 2 and week 3 because of elevations in liver enzymes. A third patient's liver enzymes rose at the end of week 4. These abnormalities subsided after discontinuation of the glutamine-TPN solution. Plasma levels of glutamine increased during the first 3 weeks of supplementation but these increases were not statistically significant. D-Xylose absorption studies performed before and after the administration of glutamine-TPN did not reveal any improvement in small-bowel absorptive capacity. In conclusion, stable glutamine-TPN solutions for use by home TPN patients can be formulated. However, supplementation of home TPN solutions at this dose was associated with apparent hepatic toxicity and did not demonstrate a beneficial effect on intestinal absorptive capacity as measured by D-xylose absorption. Therefore, on the basis of this study, routine supplementation of home TPN solution with glutamine cannot be recommended.

Battered wives and female alcoholics: a comparative social and psychiatric study.

In this study 49 women seeking hospital treatment for wife battering injuries were compared with 49 female alcoholics and a control group consisting of 49 women treated in hospital for accidents. At one time or another two-thirds of the female alcoholics had been battered and the majority of these women showed the same pattern of severe, prolonged abuse as the 49 women seeking hospital treatment for wife battering injuries. The women in these groups were also similar in that many of them had experienced violence in their own childhood environment, in that they had cohabited with more men than the women in the control group and in that the frequency of depressive symptoms was high. An analysis restricted to the battered women in each of the three groups revealed similarities between them. The battered women in the control group did not, however, show any signs of more severe psychopathology or alcoholism. It is concluded that mental health is of crucial importance for the woman's ability to break away from an abusive male.

Aetiological and precipiating factors in wife battering. A psychosocial study of battered wives.

Forty-nine women who attended a surgical emergency department after being battered are the subjects of this prospective study. The childhood and adolescence of the women had been marked by abuse and violence in the parental home. Most of the women had suffered prolonged, repeated battering. Fifty-one per cent of the women and 88% of their male assailants were considered to be heavy consumers of alcohol and in over half of the cases of battering both the man and the women had been drinking. In most cases the women's own children were present when the mother was beaten. One third of the women stated that they were highly dependent on the man in question emotionally. It is concluded that social heredity, heavy consumption of alcohol and emotional dependence on the male assailant are major reasons for the woman's inability to break away from a relationship characterized by repeated battering.

Battered women--their susceptibility to treatment.

During an eight-month period a trial was made of a special therapeutic programme focused on the diagnosis and treatment of battered women who sought treatment for physical injuries at a surgical emergency department. Forty-nine women agreed to undergo the treatment programme, the aim of which was to provide social and psychological support. The women were treated as inpatients at the department of surgery. After their discharge from the hospital, contact on an out-patient basis was difficult to maintain. Nearly half of the women dropped out during the first month and only 22 women (45%) completed the programme. The causes of the high drop-out rate were analysed considering the women's backgrounds of repeated battering, high alcohol consumption and psychiatric morbidity. It is concluded that battered women need long-term and individualized support and that more attention should be focused on the possibility of carrying out the suggested treatment. Prolonged ambulatory treatment within the frame of medical care does not, however, seem to be the right method for helping and supporting battered women.

Psychiatric morbidity and personality characteristics of battered women.

Forty-nine battered women attending a surgical emergency department were studied with regard to prior and current psychiatric morbidity, substance abuse and personality characteristics, and were compared with a control group. More battered women than controls had consulted a psychiatrist and half of them were classified as heavy consumers of alcohol. One third of the assaulted women were found to be depressed, compared to 6% of the controls. The groups also differed in respect of muscular tension, aches and pain, and autonomic disturbances, the battered women having more pronounced symptoms. It is important for psychiatrists to recognize the symptoms that battered women often exhibit. With better early diagnosis, these women could be offered more appropriate psychosocial therapy.