A double blind randomized cross over trial comparing rate of decortication and efficacy of intrapleural instillation of alteplase vs placebo in patients with empyemas and complicated parapneumonic effusions.

AIM: A double blind randomized cross over trial to compare the rate of decortication, safety and efficacy of intrapleural instillation of Alteplase vs. Placebo in empyema and complicated parapneumonic effusions (CPE). METHODS: Patients diagnosed with empyema or CPE and considered for surgery were given the option to enter into this trial. Intrapleural instillation of the 'Drug' was given daily for three days. Patient that failed the first arm of the trial were offered surgery or to cross over to the second arm. Failure was documented if pleural effusions did not improve by 50% on CT scans after three doses of the 'Drug' or if these effusions recurred within six weeks. RESULTS: One hundred and eight patients were evaluated and one hundred enrolled in the trial. 32 patients were excluded, 29 for noninfectious loculated effusions, two for protocol violation and one for bleeding at chest tube site. There were 17 patients with empyema and 51 patients with CPE. 58 of the 61 patients (26 crossed over) with empyema/CPE resolved with Alteplase therapy compared to 4 of the 32 patients (one crossed over) treated with Placebo (p value <0.001). None of the patients went to surgery. Adverse events with Alteplase therapy compared to Placebo were not statistically significant, with chest pain and bleeding complications being the most common. CONCLUSION: Intrapleural instillation of Alteplase is significantly more effective than Placebo in patients with empyema and PPE (95% vs.12%). This study demonstrates it is safe and efficacious with minimal adverse reactions.

Porphyria cutanea tarda associated with an acute gastrointestinal bleed: the roles of supplemental iron and blood transfusion.

We describe a case of porphyria cutanea tarda (PCT) induced by blood transfusion and oral iron supplementation in an 80-year-old white woman. The patient experienced acute blood loss from 2 duodenal ulcers 2 months prior to presentation. During her hospitalization for the gastrointestinal bleed, her anemia was treated with blood transfusion, iron supplementation, and erythropoietin. Multiple blistering lesions developed on her skin 2 months after hospital discharge. Clinical and laboratory findings were consistent with a diagnosis of porphyria cutanea tarda. Treatment included discontinuation of iron therapy, local skin care, and phlebotomy, which prevented the development of more lesions. The roles of iron overload and chronic renal disease in the pathogenesis of the porphyria are discussed.

Setting the baseline parameters for clinical assessment of foot to ground contact using the Musgrave pressure plate system.

The Musgrave Pressure Plate System for the measurement of foot contact patterns comprises two fixed pressure plates constructed from arrays of load cells, interfaced to a BBC computer. Its main advantage is the ability to measure and analyse spatial distributions of contact pressures and their time dynamics, and to do this relatively inexpensively in a clinical setting. Its main potential disadvantage is that it can disrupt the natural gait pattern by the discipline in enforces on the foot placement. The eventual aim of the project of which this study forms the pilot phase, is to develop formal decision rules based on the analysis of a large number of normal subjects for the diagnosis of abnormal foot pathology and the evaluation of therapy, using data collected by a Musgrave system. The objective of this study is to set baseline norms, and to evaluate the system. The analysis is based on 100 normal subjects using selected parameters on foot contact pressure, contact area and time, available from the system. Several stages of the foot contact process are described in terms of the selected parameters. The results show clearly that even with a relatively small subset of the available recorded data on each foot plant, a wide range of descriptive information can be accumulated. Statistically significant differences were found between the right and left feet on most of the parameters considered. However, these differences were based on a large sample and are not large in absolute terms in many instances. Therefore the observed differences may be small compared to differences between normal and abnormal cases.(ABSTRACT TRUNCATED AT 250 WORDS)