Using multiple pharmacoeconomic methods to conduct a cost-effectiveness analysis of histamine H2-receptor antagonists

A formulary decision at a health care institution was studied by using two pharmacoeconomic methods. A pharmacoeconomic study was undertaken to assess the impact of a 1995 formulary decision to designate cimetidine as the primary histamine H2-receptor antagonist (H2RA) and to restrict the use of famotidine. Consecutive patients receiving either i.v. cimetidine or famotidine for stress ulcer prophylaxis were reviewed during a two-month period in 1997, and information on demographics, dosage and duration of H2RA therapy, admission date, laboratory test values, and adverse drug reactions was collected. Data for 62 patients (43 cimetidine recipients and 19 famotidine recipients) were evaluated. Therapy was categorized as successful or failed, and the data were then evaluated by decision analysis to evaluate the cost-effectiveness of the agents and by multiattribute utility theory (MAUT) to incorporate a humanistic evaluation of the treatments, namely, the number of doses administered and the number of times dosages were changed. The decision tree revealed that the average cost of receiving cimetidine was $82.01 and the average cost of famotidine therapy was $92.45. The MAUT analysis showed that cimetidine was the preferred agent as long as cost was valued at greater than 60% of the decision-making process and efficacy remained equal between the two agents. Two pharmacoeconomic methods lent support to a formulary decision at a health care institution.

Perspectives on the nursing management of osteoarthritis

Osteoarthritis is a daily presence in the lives of almost 16 million older people. Without expert nursing care, functional health status and the ability to manage independently may be dramatically altered. Nursing parameters include pain control, medication assessment, use of exercise, diet, joint protection, and attention to the psychosocial factors that affect both pain and disability. Patient education with regular, periodic follow-up is a vital part of successful long-term management.

An evaluation of the copper-bromide laser for treating telangiectasia

BACKGROUND

Copper bromide lasers, producing pulsed yellow and green light, have been developed for treating cutaneous lesions.

OBJECTIVE

A clinical trial was conducted to evaluate the role of this laser, using its yellow wavelength, to treat benign vascular ectasia and establish some clinical guidelines for therapy.

METHODS

Twenty-three informed consenting adults with facial telangiectasia, spider angiomas, or vascular nevi on the head, neck, or upper chest were treated with the laser. Assessment of results was performed by: blinded clinical evaluation, blinded comparison of "before" and "after" photographs, and patients' own reports of satisfaction levels.

RESULTS

Good to excellent results were obtained in most patients, except for a few suffering minor skin atrophy where very large vessels were treated.

CONCLUSIONS

The copper bromide laser was an effective tool in the treatment of certain cutaneous vascular lesions.

More uniform diurnal blood glucose control and a reduction in daily insulin dosage on addition of glibenclamide to insulin in type 1 diabetes mellitus: role of enhanced insulin sensitivity

Combination therapy with insulin and sulphonylurea has gained acceptance in management of subjects with Type 2 (non-insulin-dependent) diabetes mellitus. However, its role in management of Type 1 (insulin-dependent) diabetes mellitus remains controversial. In this study, the effect of combination therapy with insulin and glibenclamide on metabolic control, daily insulin dosage, and insulin sensitivity was assessed in subjects with Type 1 diabetes mellitus. Ten men with Type 1 diabetes mellitus participated in a randomized, double-blind, crossover, clinical trial with three treatment regimens, namely (1) insulin alone, (2) insulin and placebo, (3) insulin and glibenclamide, each lasting 3 months. Combination therapy induced: (1) reduction in daily insulin dosage; (2) more uniform blood glucose control as reflected by a lower average 24 h blood glucose level, a smaller difference between mean preprandial and 2 h postprandial blood glucose concentrations, decreased 24 h urine glucose excretion, and a decline in number of hypoglycaemic events; (3) improved insulin sensitivity as expressed by more rapid plasma glucose disappearance rate, without a significant alteration in fasting plasma glucagon and 1h postprandial serum C-peptide levels; when compared with treatment with either insulin alone or with insulin and placebo. Therefore, it is apparent that the addition of glibenclamide to insulin reduces daily insulin dosage and renders a greater uniformity to diurnal blood glucose control, most probably secondary to enhancement of insulin sensitivity.

Nonspecific laryngeal granuloma: a case study of a professional singer

A professional singer with laryngeal granuloma underwent surgery following failed response to conservative treatments. Two primary findings emerged. First, although a sizable lesion was present initially, presurgical voice measures were largely normal or superior. The exception was elevated phonatory effort during singing. Second, postsurgical voice functions were entirely normal or superior (including phonatory effort), despite demanding singing performances a few weeks following surgery. The results add to the limited corpus of quantitative, normative-referenced data on voice in patients with granulomas and are inconsistent with previous reports of voice abnormalities in such patients and poor functional response to surgery.

Perfluorocarbons as blood substitutes: the early years. Experience with Fluosol DA-20% in the 1980s

Clinical testing of perfluorocarbons (PFC) as blood substitutes began in the early 1980's in the form of Fluosol DA-20% (FDA), a mixture of perfluorodecalin and perfluorotripropylamine emulsified with Pluronic F68. We have treated 55 patients (Treatment (T) = 40; Control (C) = 15) with intravenous infusions of 30 cc/kg of FDA as part of either a randomized, clinical trial or a humanitarian protocol. All patients were Jehovah's Witnesses who refused blood transfusion and were severely anemic (mean hemoglobin = 4.6 g/d). FDA successfully increased dissolved or plasma oxygen content (P1O2 in ml/dl), but not overall oxygen content (T group: P1O2 baseline = 1.01 +/- .27, P1O2 12hrs = 1.58 +/- .47 [p = < .0001, t-test]; P1O2 12 hrs: T = 1.58 +/- .47, C = 1.00 +/- .31, p = < .0002, t-test). This effect persisted for only 12 hours post infusion, and had no apparent effect on survival. FDA is an ineffective blood substitute because of low concentration and short half-life. Improved emulsion design may resolve these problems, thereby producing a more effective agent. Our discussion will include a review of our data plus a summary of other reports of FDA efficacy as a blood substitute.

Effects of behavioral stimuli on plasma interleukin-1 activity in humans at rest

Interleukin-1 (IL-1) bioassays were done on 208 serum samples drawn from 7 volunteers, over several hours at 5-minute intervals, before, during, and after a relaxation-related behavioral stimulus. Individuals showed up to a 267% increase (t[29] = 7.750, p = 1 x 10(-7).) in IL-1, and for the group, a mean 48.1% elevation (t[5] = 4.128, p = .003) occurred, during the stimulus interval relative to baseline. When baselines were repeated, IL-1 activity rapidly returned toward baseline values. Suggestions to picture one's immune cells fighting illness appeared to have no uniform effect for all subjects. Such rapid changes in plasma IL-1, concomitant with stimuli, indicate a new way to alter immune function and further understand disease susceptibility.

Linking the elderly to community services

Sometimes, the only contact elderly patients have with outside medical services is through the EMS network. Find out how one city uses prehospital providers to link these patients with community services tailored to their needs.

Altered regulation of atrial natriuretic peptide in essential hypernatremia

Hypothalamic osmoreceptor dysfunction resulting in hypodipsia and altered regulation of vasopressin secretion is well established as the pathogenetic mechanism in the syndrome of 'essential hypernatremia'. However, little is known about the secretory pattern of atrial natriuretic peptide (ANP) in this syndrome. Therefore, we assessed ANP regulation by determining ANP concentrations in a patient manifesting this syndrome of essential hypernatremia during several well-established experimental protocols. The serum ANP level was within normal limits despite severe euvolemic hypernatremia (serum Na+ 163 mEq/l) during one of the many admissions and remained unchanged following normalization of serum Na+. Furthermore, a decline in serum ANP instead of an appropriate rise was noted when hypernatremia (serum Na+ 152 mEq/l) was induced by either hypertonic (3%) saline infusion or following a high-Na+ (300 mEq/day) diet for several days (serum Na+ 161 mEq/l). Similarly, exogenous pitressin administration failed to cause a rise in ANP, although an appropriate fall in ANP concentration occurred following fluid deprivation. Therefore, it is apparent that ANP regulation may be significantly altered in essential hypernatremia. However, further studies are required to define whether it plays a role in the pathogenesis of hypernatremia in this syndrome.

Fluosol DA-20 in the treatment of severe anemia: randomized, controlled study of 46 patients

We evaluated the safety and efficacy of Fluosol DA-20% (FDA) as a blood substitute in the treatment of severe anemia. Thirty-six patients received either FDA (n = 21) or crystalloid/hydroxyethyl starch (CHS) (n = 15) as part of a randomized, controlled trial. Ten patients received FDA as part of a humanitarian protocol. All were Jehovah's Witnesses who refused transfusion, had bled recently, and had average Hgb levels of 4.3 g/dl. After pulmonary artery catheter insertion, each patient was infused with CHS to attain a pulmonary artery wedge pressure (WP) of 10 to 18 mm Hg. FDA was given as a one-time dose of 30 ml/kg. Data were collected at baseline, 12, 24, and 48 h. None of the patients with negative reactions to a 0.5-ml test dose of FDA had adverse reactions to the subsequent infusion. The plasma or dissolved component of oxygen content was significantly higher in the FDA group at 12 h (FDA group 1.58 +/- 0.47 ml/dl, control group 1.01 +/- 0.31 ml/dl, p less than .02, t-test). Nineteen patients died: 12 (37.5%) FDA, seven (46.6%) control. The difference was not significant. We conclude the following: a) FDA can be given safely to severely anemic patients in doses of 30 ml/kg; b) FDA significantly increased the dissolved component of oxygen content after 12 h but the effect did not persist; c) severely anemic patients can survive without transfusion although mortality is high. In this study, inability of FDA to sustain increased oxygen content was due in part to the rapid elimination of FDA and also to the limited amount given.(ABSTRACT TRUNCATED AT 250 WORDS)

Elective surgery without transfusion: influence of preoperative hemoglobin level and blood loss on mortality

To clarify the widespread practice of preoperative transfusion to attain a 10 g/dL level of hemoglobin, the relationship between preoperative hemoglobin level, operative blood loss, and mortality was studied by analyzing the results of 113 operations in 107 consecutive Jehovah's Witness patients who underwent major elective surgery. Ninety-three patients had preoperative hemoglobin values greater than 10 g/dL; 20 had preoperative hemoglobin levels between 6 to 10 g/dL. Mortality for preoperative hemoglobin levels greater than 10 g/dL was 3 of 93 (3.2%); for preoperative hemoglobin levels between 6 to 10 g/dL, mortality was 1 of 20 (5%). Mortality was significantly increased with an estimated blood loss of greater than 500 mL, regardless of the preoperative hemoglobin level (p less than 0.025). More importantly, there was no mortality if estimated blood loss was less than 500 mL, regardless of the preoperative hemoglobin level. From these data, we conclude that: (1) Mortality in elective surgery appears to depend more on estimated blood loss than on preoperative hemoglobin levels; and (2) Elective surgery can be done safely in patients with a preoperative hemoglobin level as low as 6 g/dL if estimated blood loss is kept below 500 mL.

Sera from HTLV-III/LAV antibody-positive individuals mediate antibody-dependent cellular cytotoxicity against HTLV-III/LAV-infected T cells

The causative agent of the acquired immunodeficiency syndrome (AIDS) has been shown to be a human retrovirus called human T lymphotropic virus (HTLV)-III or lymphadenopathy-associated virus (LAV). The nature of the protective immune response against this virus is currently unknown. We report here results using an antibody-dependent cellular cytotoxicity (ADCC) assay which has been developed for measuring a specific immune response against HTLV-III/LAV. Forty-four sera were examined for their ability to mediate ADCC against HTLV-III/LAV-infected T cells. Sera from healthy HTLV-III/LAV seropositive individuals in the presence of mononuclear cells from healthy HTLV-III/LAV seronegative donors exhibited significantly higher levels of ADCC activity compared to sera from patients with AIDS. Western blot analysis of serum samples indicated that antibody reactivity with the p24 protein of HTLV-III/LAV correlated with higher levels of ADCC activity than did reactivity with Gp120/160. The observation that sera from healthy HTLV-III/LAV seropositive individuals mediated higher levels of ADCC activity than did sera obtained from subjects with AIDS suggests that ADCC may represent a protective immune response to infection with HTLV-III/LAV.

Sera from HTLV-III/LAV antibody-positive individuals mediate antibody-dependent cellular cytotoxicity against HTLV-III/LAV-infected T cells

The causative agent of the acquired immunodeficiency syndrome (AIDS) has been shown to be a human retrovirus called human T lymphotropic virus (HTLV)-III or lymphadenopathy-associated virus (LAV). The nature of the protective immune response against this virus is currently unknown. We report here results using an antibody-dependent cellular cytotoxicity (ADCC) assay which has been developed for measuring a specific immune response against HTLV-III/LAV. Forty-four sera were examined for their ability to mediate ADCC against HTLV-III/LAV-infected T cells. Sera from healthy HTLV-III/LAV seropositive individuals in the presence of mononuclear cells from healthy HTLV-III/LAV seronegative donors exhibited significantly higher levels of ADCC activity compared to sera from patients with AIDS. Western blot analysis of serum samples indicated that antibody reactivity with the p24 protein of HTLV-III/LAV correlated with higher levels of ADCC activity than did reactivity with Gp120/160. The observation that sera from healthy HTLV-III/LAV seropositive individuals mediated higher levels of ADCC activity than did sera obtained from subjects with AIDS suggests that ADCC may represent a protective immune response to infection with HTLV-III/LAV.

Insulin effectiveness in hypovolemic dogs

The question addressed in this study was whether exogenous insulin can enhance the rate of assimilation of blood glucose after prolonged hypovolemia when homeostasis is waning. Twenty-three well-fed mongrel dogs were maintained at a mean arterial blood pressure of 50 mm Hg by bleeding. Periodic analyses were made of arterial and venous plasma concentration of glucose, femoral blood flow, arterial plasma concentration of insulin, and hematocrit. At the onset of physiologic deterioration signaled by the need to reinfuse 50 ml of shed blood to maintain 50 mm Hg blood pressure, dogs received either 10 ml saline (control; n=15) or 10 ml saline containing 2 units insulin (treated; n=8). Administration of 2 units of insulin to eight of the dogs caused a significantly faster decline of blood glucose than that observed in saline-treated animals. Despite the more rapid decline in plasma concentration of glucose in animals that received insulin, there was no significant difference in glucose uptake between the two groups of animals. The hemoconcentration reflected by a rising hematocrit that develops when hypovolemia persists was accentuated by the administration of insulin without supplementary fluids. The absence of any effect of insulin on glucose uptake in the hindlimb in the late phase of hypovolemic shock suggests that the accelerated decline in arterial glucose levels may be due to inhibitory effects of insulin on hepatic glucose release. These results are not consistent with the resistance of plasma glucose to insulin in the late phases of hypovolemic shock.

Aneurysm of the inferior mesenteric artery

Current diagnostic techniques make it possible to diagnose unsuspected aneurysms. Two unsuspected cases of aneurysms of the inferior mesenteric artery are reported. One was iatrogenic and represented a false aneurysm of the proximal end of the inferior mesenteric artery following resection of an abdominal aortic aneurysm. The second was an aneurysm of the proximal protion of the inferior mesenteric artery in a patient with occlusion of the celiac axis, superior mesenteric artery and left ileofemoral system. The authors believe this to be the first published aneurysm of the inferior mesenteric artery.

Determinants of blood amino acid concentration after hemorrhage

Many mechanisms, including alterations in muscle metabolism, cellular damage, decreased blood volume, and hepatic disfunction, are influential in producing the observed progressive rise in the concentration of amino acids in arterial and venous blood during persisting hypovolemic shock. The rapid rise of venous and arterial concentrations of amino acids and the increase in venoarterial concentration difference suggest that hypovolemia causes a net release from muscle of a potential substrate for energy metabolism. The blood flow through peripheral tissues, however, is reduced to such an extent during hypovolemic shock that the net rate of release of amino acids is not greater than preshock release and may be less. Therefore, the homeostatic advantages served by the alteration in protein metabolism during the more chronic stresses of starvation or after injury may not obtain during acute hypovolemia.