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Streptokinase

Streptokinase is an extracellular metallo-enzyme produced by beta-haemolytic streptococcus and is used as an effective and cheap clot-dissolving medication in some cases of myocardial infarction (heart attack) and pulmonary embolism. more...

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It belongs to a group of medicines known as fibrinolytics, and works by cleaving plasminogen and producing plasmin.

Plasmin is produced in the blood to break down the major constituent of blood clots fibrin, therefore dissolving clots once they have fulfilled their purpose in stopping bleeding. Extra production of plasmin caused by streptokinase breaks down unwanted blood clots, for example, in the lungs (pulmonary embolism).

It is given intravenously as soon as possible after the onset of a heart attack (acute phase - myocardial infarction) to dissolve clots in the arteries of the heart wall. This reduces the amount of damage to the heart muscle. Streptokinase is a bacterial product so the body will build up an immunity to it. It is recommended that this medicine should not be used again after four days from the first administration, as it may not be as effective and can also cause an allergic reaction. For this reason, it is usually given only for a person's first heart attack.

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Evaluation of intrapleural streptokinase failure criteria used in MIST1 for the treatment of complicated pleural effusions
From CHEST, 10/1/05 by Kelvin K. Shiu

PURPOSE: Recently reported results in the New England Journal of Medicine from the Multicenter Intrapleural Sepsis Trial (MIST1) showed that intrapleural administration of streptokinase does not improve mortality, rate of surgery, or length of stay among patients with pleural infection. Referral to surgical drainage was one of the primary studied outcomes. The decision to refer was made by managing physicians locally at the 52 centers. Our study investigated the potential effects and contributions from procedure and practice variance on the surgical drainage referral decision.

METHODS: Criteria for surgery referral from MIST1 were based on persistent fever and/or raised blood inflammatory markers, and residual pleural fluid. Probabilistic risk assessment (PRA) was used to model and quantify the surgical drainage decision making process. Event tree analysis was employed to simulate different decision branch points based on the referral criteria. Each of these branch points were evaluated by fault tree analysis. The MIST1 result was adopted as the baseline reference case in our study.

RESULTS: Results from PRA analysis show that the decision to refer to surgical drainage is complex and depends on the managing physician's perceived importance of several parameters including the severity and duration of fever, the extent of elevated blood inflammatory markers, and the degree of residual effusion. The non ambiguous decisions of referral or no referral constitute between 60 to 80 percent of the total. The balance is more arbitrary. This introduced a substantial variability and uncertainty into the final results. Our study further shows that by refining the definitions of fever, residual effusion, and inflammatory markers, the relative contributions to the streptokinase and placebo groups could vary up to 40 percent.

CONCLUSION: This study suggests that the primary outcome selected in MIST1 to compare streptokinase with placebo may be sensitive to how the surgical drainage referral criteria are defined.

CLINICAL IMPLICATIONS: Modified definitions of residual effusion, fever, and elevated inflammatory markers could potentially alter the conclusion on the efficacy of streptokinase as a fibrinolytic agent for complicated pleural effusions.

DISCLOSURE: Kelvin Shiu, None.

Kelvin K. Shiu DO * Paul H. Mayo MD Mark J. Rosen MD Beth Israel Medical Center, New York, NY

COPYRIGHT 2005 American College of Chest Physicians
COPYRIGHT 2005 Gale Group

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