[Dyspnea in left-sided heart disease]. / Dyspnoe bei Linksherzerkrankungen.

Shortness of breath (dyspnea) is a common symptom in left-sided heart disease but clinically, patient symptoms show a high variability. Echocardiography is the mainstay for evaluating whether left-sided heart disease is the cause of dyspnea. If left-sided heart failure is diagnosed, this symptom complex must then be subjected to further etiological evaluation. Hypertensive, ischemic and valvular heart diseases are common, as well as atrial fibrillation. If the patient does not have angina pectoris, testing for ischemic heart disease should be done non-invasively by coronary computed tomography or testing for regional myocardial ischemia. Coronary revascularization is indicated only when a prognostically relevant ischemia of more than 10 % of the left ventricle is diagnosed. Diuretics are important for the relief of dyspnea but do not improve the prognosis of patients. In patients with reduced left ventricular function, combination therapy with angiotensin-converting enzyme (ACE) inhibitors, beta blockers and aldosterone antagonists improve the symptoms and prognosis. For treatment of heart failure with preserved ejection fraction evidence-based measures are still lacking. In this case the recommended therapy consists of optimal treatment of comorbidities, regulation of heart rate and blood pressure and participation in structured exercise programs. Angiotensin receptor blockers and aldosterone antagonists can be given in patients with more severe symptoms even though the available data are very sparse.

[Percutaneous coronary intervention versus bypass surgery in patients with diabetes and multivessel coronary disease. Coronary revascularization after FREEDOM]. / Perkutane koronare Intervention versus Bypass-Operation bei Patienten mit Diabetes und koronarer Mehrgefäßerkrankung. Koronarrevaskularisation nach FREEDOM.

Is coronary revascularization required in a patient with chronic stable coronary artery disease or can optimized medical therapy (OMT) alone be a sufficient alternative? This question has been controversially discussed for non-diabetics as well as for diabetics since the COURAGE and BARI 2D trials. According to our present knowledge, a patient will benefit from coronary revascularization only when either a non-invasive test method, such as single photon emission computed tomography (SPECT) or positron emission tomography (PET) myocardial scintigraphy, stress echocardiography or stress nuclear magnetic resonance imaging, can detect relevant, objective evidence of ischemia >10% of the left ventricular myocardium or when a pathological fractional flow reserve (FFR) <0.80 can be measured in an invasive procedure for an angiographically detectable coronary stenosis. If similar relevant ischemia can be non-invasively or invasively objectified in a patient with chronic stable multivessel coronary artery disease, the often controversially discussed question arises particularly in diabetics whether a percutaneous coronary intervention (PCI) with implantation of drug-eluting stents or coronary artery bypass surgery should be favored. The FREEDOM study (Future Revascularization Evaluation in Patients with Diabetes Mellitus: Optimal Management of Multivessel Disease), published in November 2012, was the first prospective randomized study to examine this issue in diabetic patients with multivessel coronary artery disease. Despite a higher rate of stroke in the surgical cohort, after an average follow-up time of 3.8 years a significant prognostic advantage in favor of bypass surgery was detected for a combined primary endpoint of all-cause mortality, nonfatal myocardial infarction and nonfatal stroke. Thus, in the new ESC guidelines on diabetes, pre-diabetes and cardiovascular diseases developed with the EASD of the European Society of Cardiology and published in 2013, coronary bypass surgery has a class I, level of evidence A recommendation for patients with diabetes mellitus, chronic stable multivessel coronary disease and a synergy between PCI with taxus and cardiac surgery (SYNTAX) score >22. The decision for or against a PCI/stent implantation or coronary bypass surgery in a diabetic patient with chronic stable multivessel coronary artery disease should therefore be made with the patient only after a detailed informed consent discussion and comprehensive explanation of both treatment options. In controversial cases, particularly with an equivocal SYNTAX score around 22, relevant comorbidities or anticipated method-specific complications, a one-stage ad hoc intervention during the diagnostic coronary angiography should be rejected in favor of a two-stage procedure with prior discussion of both treatment options in the heart team comprising noninvasive cardiologists, interventional cardiologists and cardiac surgeons.

[Prevalence of undetected diabetes mellitus in invasive and interventional cardiology. Silent diabetes in the catheterization laboratory]. / Prävalenz unentdeckter Glukosestoffwechselstörungen in der invasiven und interventionellen Kardiologie. "Silent diabetes" im Herzkatheterlabor.

In most randomized controlled trials on revascularization therapy for patients with ischemic coronary artery disease (CAD), the diabetes prevalence ranges between 15% and 35%. However, the true prevalence of diabetes is probably considerably underestimated in these trials. The European heart survey diabetes and the heart published in 2004 supplied strong evidence that there are many additional cases of undetected prediabetics and diabetics in any cardiology patient cohort. The long-term outcome of newly detected diabetics was found to be comparable to patients with already known diabetes mellitus. With this in mind, the Dresden silent diabetes study investigated the prevalence of undetected diabetes mellitus by oral glucose tolerance testing (OGTT) and comparative HbA1c sampling in 1,015 patients admitted for coronary angiography. Patients with known diabetes were excluded from the study.According to the OGTT only 513 patients (51%) were classified with normal glucose tolerance (NGT), 10 (1%) with isolated impaired fasting glucose (IFG), 349 (34%) with impaired glucose tolerance (IGT) and 143 (14%) were diagnosed with newly detected diabetes mellitus (DM). According to the HbA1c measurements 588 patients (58%) were classified as normal, 385 (38%) as borderline and only 42 (4%) were diagnosed with diabetes (DM). There was a significant correlation between the extent of CAD and glycemic status as defined by the OGTT. The number of patients with IGT and diabetes increased with the extent of CAD (IGT group p<0.001, diabetes group p=0.01). However, no such correlation was observed when glycemic status was defined by HbA1c testing.Based on these results an OGTT should be routinely performed in patients with known or suspected coronary artery disease undergoing coronary angiography for diagnosis of diabetes, as HbA1c measurements alone appear to miss a substantial proportion of patients. These findings are of high clinical relevance with regard to optimal coronary revascularization procedure chosen in catheterization laboratories, preferably drug-eluting stents in cases of diabetes mellitus or newly detected diabetes mellitus and preferably coronary bypass surgery in diabetics with multi-vessel disease and high SYNTAX scores.

Oral glucose tolerance test and HbA1c for diagnosis of diabetes in patients undergoing coronary angiography: [corrected] the Silent Diabetes Study.

AIMS/HYPOTHESIS: The primary aim of this study was to compare the results of HbA(1c) measurements with those of an OGTT for early diagnosis of 'silent diabetes' in patients with coronary artery disease (CAD) undergoing angiography without prediagnosed diabetes. A secondary aim was to investigate the correlation between the extent of CAD and the glycaemic status of the patient. METHODS: Data from 1,015 patients admitted for acute (n = 149) or elective (n = 866) coronary angiography were analysed. Patients with known diabetes were excluded from the study. Using the OGTT results, patients were classified as having normal glucose tolerance (NGT), impaired fasting glucose (IFG), impaired glucose tolerance (IGT) or diabetes. According to the results of the HbA(1c) measurements, patients were classified into three groups: normal (HbA(1c) <5.7% [<39 mmol/mol]), borderline (HbA(1c) 5.7-6.4% [39-47 mmol/mol]) and diabetes (HbA(1c) ≥6.5% [≥48 mmol/mol]). RESULTS: Based on the OGTT, 513 patients (51%) were classified with NGT, 10 (1%) with IFG, 349 (34%) with IGT and 149 (14%) were diagnosed with diabetes. According to HbA(1c) measurements, 588 patients (58%) were classified as normal, 385 (38%) as borderline and 42 (4%) were diagnosed with diabetes. The proportion of patients with IGT and diabetes increased with the extent of CAD (IGT ρ = 0.14, p < 0.001, diabetes ρ = 0.09, p = 0.01). No differences in HbA(1c) were seen among the groups with different extents of CAD (p = 0.652). CONCLUSIONS/INTERPRETATION: An OGTT should be performed routinely for diagnosis of diabetes in patients with CAD undergoing coronary angiography, since HbA(1c) measurement alone appears to miss a substantial proportion of patients with silent diabetes. A limitation of the study is that the OGTT was not performed before the angiography.

Study on dosimetric parameters for stereotactic radiosurgery and intensity-modulated radiotherapy.

This study is an attempt to compare the dosimetric parameters of intensity-modulated radiation therapy (IMRT) and stereotactic radiosurgery (SRS) using patient data. Radiosurgery was delivered through circular tertiary collimators attached to a linear accelerator. Six patients who were treated with SRS were replanned and evaluated with the IMRT planning system. Contouring of all structures, including target volume, was done on the IMRT system to closely match the SRS system. Treatment plans were generated after specifying the goals in the prescription module. The NOMOS BEAK collimator attached to the NOMOS MIMiC delivery device was chosen for treatment delivery. Various parameters such as conformity index, homogeneity index, target volume coverage, nontarget tissue, and brainstem doses were calculated and compared between the IMRT and SRS systems. Patient data were divided into 2 groups based on the complexity of the lesion and the number of isocenters used for radiosurgery. Analysis was done for each group and for the cumulative data. Superior conformality and homogeneous dose distribution in IMRT for multiple isocenter cases were observed. In addition, critical structure volumes for 50%, 70%, and 90% of the prescribed dose were lower in IMRT compared to SRS treatment. However, nontarget tissue received significantly higher doses with IMRT plans. Results show that IMRT treatment modality produces similar results as radiosurgery for small, spherical lesions, whereas it is found to be superior to SRS for irregular lesions in terms of critical structure sparing and better dose homogeneity.

A framework for best practices in the deployment of departmental information systems.

In previous work, we conceptualized a departmental information system as embodying a flexible, but limited, model for the operation of a department, such as a laboratory or diagnostic imaging service. We further recognized these systems as tools that enable data-driven departmental management and function as feeder systems to enterprise management decision-support systems, and also embody a departmental and components of an enterprise management model. Finally, for systems that interact with professionals related to decision support, we note that such systems embody partial cognitive models that must be congruent with the professionals cognitive processes (or professionals cognitive behaviors must alternatively be congruent with the systems cognitive model), if these systems are to be supportive of the professionals thinking and decision making. In this paper, we review this thinking and use it to derive proposed "best practices" in IS management, and system planning, procurement, implementation, and use.

A new architecture for enterprise information systems.

Irresistible economic and technical forces are forcing healthcare institutions to develop regionalized services such as consolidated or virtual laboratories. Technical realities, such as the lack of an enabling enterprise-level information technology (IT) integration infrastructure, the existence of legacy systems, and non-existent or embryonic enterprise-level IT services organizations, are delaying or frustrating the achievement of the desired configuration of shared services. On attempting to address this matter, we discover that the state-of-the-art in integration technology is not wholly adequate, and itself becomes a barrier to the full realization of shared healthcare services. In this paper we report new work from the field of Co-operative Information Systems that proposes a new architecture of systems that are intrinsically cooperation-enabled, and we extend this architecture to both the regional and national scales.

Papillary muscle shortening for mitral valve reconstruction in patients with ischaemic mitral insufficiency.

AIMS: To evaluate the feasibility of papillary muscle shortening in a specific group of high risk patients with ischaemic mitral regurgitation undergoing mitral valve reconstruction. BACKGROUND: From January 1996 to December 1997, 712 (10.1%) out of a total of 7042 open heart patients underwent mitral valve surgery in our hospital. Mitral valve reconstruction was performed in 408 of these patients (57.3%) and valve replacement had to be performed in 304 patients (42.7%). METHODS: A specific technique of papillary muscle reconstruction was performed in 32 patients undergoing valve reconstruction (7.8%). These cases had degenerated and had developed fibrotic elongated papillary muscles, which resulted in prolapses of one or more parts of the mitral valve leaflets. The aetiology in this group of patients was ischaemic, requiring concomitant myocardial revascularization in 28 patients (87.5%) with a mean of 2.7 grafts/patient. All patients underwent papillary muscle shortening using a pericardium pledget-reinforced Polytetrafluoroethylene suture and annuloplasty with a Carpentier-Edwards Physio Annuloplasty Ring. Of these 32 patients, 17 (53.1%) were male, the mean age was 67.1+/-9.7 years (range 41 to 81 years) and all but one were in pre-operative NYHA class III or IV. RESULTS: There were two hospital deaths (6.2%). Postoperative Doppler echocardiography indicated satisfactory mitral valve function in all patients. Within the short mean follow-up period of 9.6+/-5.4 months (3 to 26 months) there was one non-cardiac-related death (3.1%). There was no need for reoperation, and no cases of thromboembolic and bleeding complications in the postoperative period. All patients were in NYHA functional class I or II at the time of follow-up. CONCLUSION: Our results indicate that mitral valve repair is a safe treatment for this group of high risk patients, and that papillary muscle shortening is a valuable tool in these patients with ischaemic mitral regurgitation undergoing surgery.

[Isolated prolapse of the posterior leaflet of the mitral valve. Results of reconstructive surgery]. / Prolapsus isolé du feuillet postérieur de la valve mitrale. Résultats de la chirurgie reconstructrice.

Out of 522 patients undergoing mitral valve reconstruction for mitral regurgitation between 1988 and June 1994, the authors studied 159 cases of isolated mitral regurgitation by prolapse of the posterior mitral leaflet. There were 98 men (62%) and 61 women (38%), with an average age of 58.4 +/- 10.4 years. The functional class and ejection fraction were 2.8 +/- 0.11 and 0.66 +/- 0.2 respectively. In 155 patients, surgery consisted in quadrangular resection of the prolapsed tissue, followed in 83 cases by sliding posterior valvuloplasty and in 72 cases by plicature of the annulus. In 4 cases, the prolapse was treated by implantation of artificial chordae tendinae. A Carpentier-Edwards ring was inserted in all cases. There were no hospital deaths. Echocardiography was performed before discharge from hospital and showed satisfactory mitral valve function in 98% of cases: slight systolic anterior motion (SAM) was observed in one case. All patients were followed up for an average of 3.67 +/- 0.10 years. At six years, survival was 93 +/- 7%; moreover, 93 +/- 7% and 97 +/- 3% of patients had no thromboembolic or haemorrhagic complications. Six patients were reoperated, three of them in the first year of follow-up. At six years, 95 +/- 5% of patients were free of reoperation and 81 +/- 11% were free of all complications. The authors conclude that the excellent medium term survival and the low rate of complications are evidence in favour of conservative surgery for treatment of mitral regurgitation due to prolapse of the posterior mitral leaflet.

Dissolution of gallbladder stones with methyl tert-butyl ether and stone recurrence: a European survey.

Since there are now several ways to treat symptomatic gallstone disease, one is able to select treatment on the basis of the patient's comfort, the practicability, effectiveness, and side effects of the technique, and the relative costs. In order to assess the present status of contact dissolution with methyl tert-butyl ether with regard to these aspects, the present enquiry reports the data of 21 European hospitals. Eight hundred three patients were selected for contact litholysis of cholesterol gallbladder stones using methyl tert-butyl ether. Percutaneous transhepatic puncture of the gallbladder was performed under x-ray or ultrasound guidance. Dissolution rate, side effects, and treatment times of 268 patients from one single center were compared to those of 535 patients from the other 20 centers. Two hundred sixty-four patients were followed for five years to assess stone recurrence. Physicians were asked how they assessed the expenditure of the method, the discomfort to the patients, and the staffing situation. Patients were asked to indicate their acceptance on an analog scale. Puncture was successful in 761 (94.8%) patients. Prophylactic administration of antibiotics was not necessary. Stones were dissolved in 724 (95.1%) patients. In 315 (43.5%) sludge remained in the gallbladder. The most severe complication was bile leakage, which led 12 (1.6%) patients to have elective cholecystectomy. Toxic injuries due to the ether were not reported. Method-related lethality amounted to 0%, 30-day-lethality to 0.4%. Stone recurrence rate was about 40% in solitary stones and about 70% in multiple stones over five years. Patients with multiple stones developed recurrent stones almost twice as often as those with solitary stones. The probability of stone recurrence in patients with sludge in the gallbladder after catheter removal was not statistically significantly different from those without sludge. Seventy to 90% of the centers found the puncture to be simple and not distressing for patients and the relation between expenditure and therapeutic success to be acceptable. The acceptance of contact litholysis by the patients was excellent. Contact litholysis when applied by an experienced team provides real advantages in the treatment of gallstone disease. The method is technically simple, well accepted by the patients, and can be easily applied in community hospitals. Contact litholysis may be of particular value in patients who are not suitable for anesthesia or surgery.

Valve repair for mitral regurgitation caused by isolated prolapse of the posterior leaflet.

BACKGROUND: Although prolapse of the posterior leaflet is the most common abnormality of the mitral valve causing dysfunction, the long-term results of mitral valve repair for this condition are seldom reported. METHODS: From October 1988 to June 1994, 208 patients (mean age, 59.4 years) with mitral regurgitation caused by isolated prolapse of the posterior leaflet underwent mitral valve repair alone or combined with myocardial revascularization (n = 30). The surgical techniques were quadrangular resection (n = 199) followed by annulus plication (n = 101) or sliding leaflet plasty (n = 98), use of artificial chordae (n = 5), or papillary muscle shortening (n = 4). All patients had an annuloplasty with a Carpentier ring. Mean follow-up was 3.4 +/- 0.1 years and total follow-up, 656 patient-years. RESULTS: There were six operative deaths (2.9%). Postoperative Doppler echocardiography found two cases of systolic anterior motion (1%), and echocardiographic studies at follow-up showed satisfactory mitral valve function in 97% of 112 patients. At 6 years, the actuarial survival rate was 87% +/- 7%, and freedom from thromboembolic complications, bleeding complications, and reoperation was 93% +/- 7%, 95% +/- 3%, and 95% +/- 4%, respectively. CONCLUSIONS: Mitral valve repair for regurgitation caused by prolapse of the posterior leaflet provides excellent survival at 6 years and should be considered the method of choice for its surgical treatment.

Human endothelin-converting enzyme (ECE-1): three isoforms with distinct subcellular localizations.

Endothelin-converting enzyme 1 (ECE-1) is a membrane-bound metalloprotease that catalyses the conversion of inactive big endothelins into active endothelins. Two different isoforms (ECE-1a and ECE-1b) have previously been identified for human ECE-1. In the present study we have cloned a novel human ECE-1 isoform, termed ECE-1c, and have thus shown for the first time the existence of three distinct ECE-1 isoforms. The three isoforms differ only in their N-terminal regions and are derived from a single gene through the use of alternative promoters. Ribonuclease protection experiments revealed that, although the relative levels of the three isoform mRNA species vary between human tissues, ECE-1c mRNA is generally the predominant isoform messenger. Immunofluorescence microscopy analysis showed distinct subcellular localizations for the three isoforms: whereas ECE-1a and ECE-1c are localized at the cell surface, ECE-1b was found to be intracellular and showed significant co-localization with a marker protein for the trans-Golgi network. We determined that the three isoforms have similar kinetic rate constants (Km, kcat and Vmax) for the processing of big endothelin 1 and that the big endothelin isoforms 1, 2 and 3 are cleaved with similar relative velocities of 1.0:0.1:0.1 by the three isoenzymes.

[Clinical experiences with mitral valve reconstruction]. / Klinische Erfahrungen mit der Mitralklappenrekonstruktion.

Between October 1988 and December 1993, 433 patients with mitral valve insufficiency underwent mitral valve repair. Patient's age ranged from 13 to 82 years (mean age 59.5 years). Mitral valve insufficiency was due to degenerative disease in 192 patients (44%), ischemic disease in 102 (23%), rheumatic disease in 76 (18%) and other causes in 63 patients (15%). Most of the patients (337) were in functional class III or IV. The patients were divided into 3 functional groups: type I (normal leaflet motion) 141 patients (33%), type II (leaflet prolapse) 265 patients (61%) and type III (restricted leaflet motion) 27 patients (6%). Two patients were lost to follow-up for a total follow-up of 761 patients per year. The operative mortality was 2.5% for the total group, 0.4% for the group with isolated mitral valve insufficiency, 7.5% for the group with mitral valve repair associated with coronary artery bypass grafting and 2.9% for the group associated with tricuspid valve repair. At the time of the discharge, 71% of the patient at Doppler echocardiography showed no mitral regurgitation, 25.5%, 3% and 0.5% showed a mitral regurgitation grade 1,2 or 3 respectively. The 5-year actuarial survival was 84%. At 5 years, 96% of the patients were free from reoperation, 96% free from thromboembolism and 93% free from bleeding complications. Among the survivors 93% of the patients were in functional class I or II.

[Recombinant human erythropoietin in the treatment of anemic patients undergoing chemotherapy for cancer]. / Kemoterápiában részesülö vérszegény daganatos betegek kezelése rekombináns humán erythropoetinnel.

Twenty-seven anemic patients with malignant tumour who received chemotherapy were treated with recombinant human erythropoietin (r-HuEPO). The objective of this study was to evaluate the effect of r-huEPO on hematologic and quality of life parameters as well as on transfusion requirement in patients with anemia secondary to cancer and cyclic chemotherapy. Patient population was allocated into two groups based on the chemotherapeutic regimens: 1. cisplatin containing and 2, non cisplatin containing regimen. Using 2 g/dl increase in haemoglobin levels as the criteria for response, twenty women responded to r-huEPO treatment. The response was more marked in the cisplatin group. R-huEPO treatment saved transfusion in both groups. Again, less patients required transfusion among those treated with cisplatin. There was a marked improvement in the quality of life which was more pronounced in patients who responded to r-huEPO treatment and in those receiving non cisplatin chemotherapy. No serious adverse experiences occurred. In conclusion, two third of patients with anemia secondary to cancer and cyclic chemotherapy can be effectively treated with r-huEPO. R-huEPO treatment invariably saves transfusion and is highly effective in improving quality of life. Adverse reaction is exceptional.

Septal myectomy for left ventricular outflow tract obstruction after mitral valve repair.

We describe a patient with a left ventricular outflow tract obstruction after mitral valve repair. Intraoperative transesophageal echocardiography permitted us to recognize the role of a bulging septum in the development of a systolic motion of the mitral valve. A left ventricular septal myectomy and myotomy was able to relieve the left ventricular outflow tract obstruction and the systolic anterior motion of the mitral valve.

Management of orthostatic hypotension.

The pathogenesis, clinical manifestations, and management of orthostatic hypotension (OH) are reviewed. OH is a decline in blood pressure that occurs when one moves from a lying to a standing position that results in symptoms of cerebral hypoperfusion, most commonly lightheadedness and syncope. The disorder may result from primary autonomic disorders, such as Shy-Drager syndrome; reversible nonautonomic causes, such as reduced blood volume; underlying diseases, such as diabetes mellitus; and drugs. Elderly people are predisposed to OH. The diagnosis of OH is based on the documentation of postural hypotension accompanied by symptoms of cerebral ischemia. The goal of therapy is to relieve symptoms. Nonpharmacologic approaches are preferred and include increasing sodium intake, avoiding rapid postural changes, and wearing elastic garments. OH is difficult to treat pharmacologically because of varying responses and adverse effects. The drug of choice for all types of OH is fludrocortisone acetate, although caution must be used in patients with congestive heart failure. Prostaglandin synthetase inhibitors can also be used for all types of OH but have had more limited success. Sympathomimetics with or without monoamine oxidase inhibitors, beta-adrenergic antagonists, and ergot alkaloids should be administered only to patients with certain types of OH, and patients must be monitored closely. Clonidine, midodrine, yohimbine, octreotide, dopamine antagonists, desmopressin, and epoetin alfa have not been well studied and should be limited to patients with severe, refractory disease. Although no uniformly effective treatment regimen exists, OH can often be adequately managed with a combination of nondrug and drug therapies.

The use of norfloxacin in a university hospital.

Because of increasing norfloxacin use and the development of resistant organisms, an evaluation was undertaken in a University Hospital to assess the appropriateness of norfloxacin for the treatment of urinary tract infections and to calculate the potential cost savings associated with more cost-effective antibiotic therapy. Medical records of 64 patients receiving norfloxacin for a 31-day period were concurrently reviewed. Of these, 58 patients were treated for urinary tract infections and four patients received urinary tract infection prophylaxis. Fourteen patients were prescribed solely empiric therapy whereas an additional 44 patients received definitive treatment confirmed by culture results. Based on the predetermined criteria, norfloxacin use for the definitive treatment of urinary tract infections was deemed to be appropriate in 34 of the 44 patients. Three additional courses of therapy were also judged to be appropriate due to documented signs and symptoms associated with urinary tract infections, despite cultures with less than 10(5) colony forming units per mL urine. Reasons for inappropriate use in the remaining seven patients included isolation of fewer bacteria than required by the criteria in asymptomatic patients (3 cases), isolation of organisms not sensitive to norfloxacin (1 case) and lack of dosage adjustment for renal insufficiency (3 cases). Nineteen of 32 evaluable inpatients (59%) received norfloxacin when a less expensive, equally effective agent was available. Although savings from more cost-effective therapy of urinary tract infections are minimal, due to the potential emergence of resistant organisms, norfloxacin should be reserved for infections not amenable to treatment with other oral antibiotics.