Activated clotting time in inpatient diagnostic and interventional settings.

Monitoring for the anticoagulant effect of unfractionated (UFH) at the point of care using activated clotting time in real time is vital where risk of thrombosis is high. Although monitoring UFH effect is a routine and important task, changing from one ACT instrument type or technology to another must be preceded by a clinical and statistical evaluation to determine the suitability and repeatability and establish normal and treatable ranges of this newer instrument. In this multi-center prospective evaluation we tested 1236 paired ACT+ samples, and 463 paired ACT-LR samples (1699 total) from enrolled study subjects. Clinical settings included CVOR cardiopulmonary bypass, at the beside in extracorporeal life support (ELS), the Cardiac Catheterization Lab (CCL) during diagnostic studies and percutaneous coronary interventions (PCI), interventional radiology procedures and EP interventions. This study found more consistent clinical performance from the GEM Hemochron 100 as compared to the current clinical model, the Hemochron Signature Elite. The bias of GEM Hemochron 100 for ACT+ and ACT-LR was greatest in the setting of the CVOR where ACT levels were high. ACT-LR measurements by the GEM Hemochron 100 were comparable to the SE when performed in settings of CCL, ECM, EP and ICU. Results obtained for both ACT-LR and ACT+ in all clinical settings in this study using the GEM Hemochron 100 are as accurate and more repeatable as those with the current clinically available Signature Elite.

Tackling insomnia: diagnostic and treatment issues in primary care.

Primary care physicians are often the first healthcare providers to encounter insomnia in their patients. However, they face many obstacles to diagnosis and treatment of insomnia that stem from patient- and physician-related factors. During consultations, most patients do not mention their sleep difficulties because they believe that insomnia is a trivial concern that does not have serious health consequences. Physicians also face diagnostic obstacles related to conflicting or vague diagnostic definitions, office-based time constraints, and a lack of training in sleep medicine in medical school and residency programs. Once a diagnosis is made, initiating appropriate treatment is also complicated because of outdated treatment guidelines and US Food and Drug Administration prescribing constraints. These factors may have contributed to the perception that there are no good treatment options for insomnia and that all available medications have a poor risk-benefit ratio. For example, benzodiazepines are known to carry a risk of tolerance and abuse. Until recently, few long-term data were available on the safety and efficacy of current agents, which may have contributed to reticence to treat chronic insomnia. Furthermore, there is limited evidence that treating insomnia is associated with improved patient outcomes, and this may have discouraged active treatment programs for insomnia. Increased awareness that insomnia can precede and exacerbate coexisting illnesses, including depression and chronic pain syndromes, is needed. As data emerge from recent clinical trials with newer, promising nonbenzodiazepine medications, it should become easier for primary care physicians to take a proactive role in diagnosing and treating insomnia and thus improve patient functioning.

Safety of zaleplon in the treatment of insomnia.

OBJECTIVE: To evaluate the safety of zaleplon, a quick-acting, rapidly eliminated nonbenzodiazepine (non-BZD) hypnotic, as described in clinical investigations of adult and/or elderly subjects. DATA SOURCES: Published and presented studies evaluating zaleplon, a novel non-BZD, were identified via MEDLINE (1995-July 2001), Current Contents (ISI database), bibliographic reviews, and consultation with sleep specialists who also identified published abstracts containing data not yet published in peer-reviewed journals. DATA SYNTHESIS: Transient and chronic insomnia are common problems that should be clinically evaluated and appropriately treated. BZDs have been a primary pharmacotherapy for treating insomnia, despite their disadvantages. Newer hypnotics, characterized by increased receptor-binding specificity and favorable pharmacokinetics, provide potentially better alternatives to BZDs. Assessments included residual sedation, psychomotor impairment, or cognitive dysfunction during treatment, as well as the occurrence of rebound insomnia and withdrawal effects after discontinuation of therapy. CONCLUSIONS: Zolpidem, the first non-BZD hypnotic, appears to have short- and long-term safety profiles similar to those of the BZD triazolam. Zaleplon, a newer non-BZD sleep medication, has a quick onset of action and undergoes rapid elimination, which results in a better safety profile than previously available agents. Additionally, rebound insomnia and other withdrawal effects have not been demonstrated with zaleplon, and the drug is well tolerated in both young and elderly patients. These characteristics may be clinically advantageous for patients who should not receive BZDs.