New classification and update on the quinolone antibiotics.

The newer fluoroquinolones have broad-spectrum bactericidal activity, excellent oral bioavailability, good tissue penetration and favorable safety and tolerability profiles. A new four-generation classification of the quinolone drugs takes into account the expanded antimicrobial spectrum of the more recently introduced fluoroquinolones and their clinical indications. First-generation drugs (e.g., nalidixic acid) achieve minimal serum levels. Second-generation quinolones (e.g., ciprofloxacin) have increased gram-negative and systemic activity. Third-generation drugs (e.g., levofloxacin) have expanded activity against gram-positive bacteria and atypical pathogens. Fourth-generation quinolone drugs (currently only trovafloxacin) add significant activity against anaerobes. The quinolones can be differentiated within classes based on their pharmacokinetic properties. The new classification can help family physicians prescribe these drugs appropriately.

Changing practices in the use of pneumococcal vaccine.

BACKGROUND AND OBJECTIVES: An important issue facing primary care practices is how to best improve preventive services to patients. We sought to determine if an intervention designed by a continuous quality improvement (CQI) process (reminder sticker and patient education sign in each examining room) or a patient education intervention (sign only) could increase the rate of pneumococcal vaccination. METHODS: These two interventions were administered over a 6-month period in a controlled, prospective study design in a family practice residency program clinic. The study targeted patients ages 65 and older and patients ages 2-64 with diabetes mellitus who had never received the pneumococcal vaccine. The main outcome measure was the vaccination rate in the targeted population. RESULTS: A total of 1,647 patient encounters involving 778 patients were documented during the study period. Overall, the reminder and sign module had higher percentages of pneumococcal vaccination in this target population (20% versus 11% for sign only, versus 7% control). Chi-square analysis revealed a statistically significant difference for this group, compared with placebo, but not for the sign-only group. CONCLUSIONS: An intervention designed from a CQI process to impact the office patterns of primary care physicians can produce measurable changes in pneumococcal vaccination rates.

Management of hospitalized patients with type 2 diabetes mellitus.

Subopitmal glycemic control in hospitalized patients with type 2 (non-insulin-dependent) diabetes mellitus can have adverse consequences, including increased neurologic ischemia, delayed wound healing and an increased infection rate. Poor glycemic control can also affect the outcome of the primary illness. If possible, hospitalized diabetic patients should continue their previous antihyperglycemic treatment regimen. Decreased physical activity and the stress of illness often lead to hyperglycemia in hospitalized patients with type 2 diabetes. When indicated, insulin is given either as a supplement to usual therapy or as a temporary substitute. The overall benefit of the traditional sliding-scale insulin regimen has been questioned. Insulin supplementation given according to an algorithm may be a logical alternative. Any antihyperglycemic regimen should be administered and monitored in a manner coincident with the intake of food or other sources of calories. Factors that can alter glycemic control acutely, including specific medical conditions and medications, should be identified and anticipated.

Interdisciplinary rural health training for health professional students: strategies for curriculum design.

Interdisciplinary rural health program offer a promising solution to the challenge of preparing graduates for rural practice, with the ultimate goal of promoting better health care for rural populations. This article focuses on the three-year experience of a model interdisciplinary rural health curriculum implemented in eastern North Carolina. Ten strategies are presented as a framework for the design and implementation of an effective practice-based curriculum for interdisciplinary rural health training. Allied health educators should examine existing curriculum models to build upon their strengths and explore new models to meet evolving delivery system and consumer needs.

Lipid and lipoprotein responses to oral combined hormone replacement therapy in normolipemic obese women with controlled type 2 diabetes mellitus.

This study investigated the effects of oral combined hormone replacement therapy (OCHRT) on lipid concentrations and subpopulation distribution of lipoproteins in nine postmenopausal women with type 2 diabetes mellitus and moderate glycemic control. After 16 weeks of continuous daily therapy of conjugated estrogens 0.625 mg and medroxyprogesterone 2.5 mg, the mean concentration of high-density lipoprotein (HDL) cholesterol showed a statistically significant increase of 16.7%, predominantly in the HDL2 subfraction. No statistically significant changes in mean concentrations of total cholesterol, low-density lipoprotein (LDL) cholesterol, triglycerides, very low-density lipoprotein (VLDL) triglycerides, apolipoprotein A1, or apolipoprotein B were evident. Likewise, no changes were found in the average diameter of VLDL, LDL, or HDL particles; triglyceride concentrations of VLDL subfractions; cholesterol concentrations of LDL subfractions; or chemical composition of plasma LDL. These findings lend further support to the use of OCHRT in postmenopausal women with diabetes to decrease their risk for coronary artery disease.