Prescription drug utilization following patient co-payment changes in Australia

In November 1990 major patient co-payment changes were introduced into the Pharmaceutical Benefits Scheme (PBS), which accounts for around 90% of all community prescriptions in Australia. Interrupted time series analyses were performed to assess the impact of these co-payment changes on the prescription levels of defined groups of 'discretionary' and 'essential' drugs for both the general community and for a subgroup comprising elderly returned servicemen and women. While the co-payment changes themselves had a significant immediate effect on lowering the use of both categories of drugs, the effects were substantially larger for the 'discretionary' groups in both cases. Notably there was a clear post-intervention trend for increased prescriptions of 'essential' drugs after the initial decline, which was not evident for the 'discretionary' drugs. The introduction of programmes to compensate high risk groups in Australia may have enabled the co-payment to become a more selective policy instrument than has been shown in other settings.

Autologous transfusion techniques: a systematic review of their efficacy

Shortages of donor blood and fears of transmitted infections have prompted the use of a range of blood-sparing techniques in the peri-operative period. We conducted a systematic review of three techniques that involve the re-infusion of a patient's blood--pre-operative autologous blood deposit (PAD), acute normovolaemic haemodilution (ANH), and cell salvage (CS). We examined the effects of these interventions on the need for peri-operative allogeneic red blood cell transfusion and on clinical outcomes. Controlled clinical studies were identified by computer searches of comprehensive electronic databases and bibliographic searches of published articles. The literature search retrieved a total of 68 randomized trials (RCTs) and 81 controlled observational studies that included data from over 34 000 individuals. In summary, the RCTs found that autologous transfusion techniques consistently reduced the frequency of allogeneic transfusions, with intervention effect sizes ranging from a relative 63% reduction (95% CI 46-74%) with PAD, to 42% (27-53%) with CS and to 31% (16-44%) with ANH. Non-randomized studies reported larger effect sizes than RCTs. PAD increased overall transfusion rates by 30% (95% CI 12-48%) and reduced pre-operative haemoglobin levels by an average of 1.23 g dL(-1). Intervention effects were substantially reduced when these techniques were performed under transfusion protocols. Interpretation of the studies was hampered by serious methodological weaknesses, particularly inadequate randomization techniques, unblinded measurements and the subjective nature of the outcome variables. The studies reported few clinical outcome and adverse event data. Previous claims regarding reduced rates of mortality and infection with autologous transfusions were not confirmed.

Glyburide/metformin combination product is safe and efficacious in patients with type 2 diabetes failing sulphonylurea therapy

AIM

To compare the efficacy, safety and tolerability of a fixed combination glyburide/metformin preparation with those of glyburide or metformin alone in patients with type 2 diabetes inadequately controlled by sulphonylurea, diet and exercise.

METHODS

In this 16-week, randomized, double-blind, parallel group study, 639 patients with inadequate glycaemic control on at least half-maximal dose of sulphonylurea were randomly assigned to: glyburide 10 mg b.i.d. (n = 164); metformin 500 mg (n = 153); glyburide/metformin 2.5 mg/500 mg (n = 160); or glyburide/metformin 5 mg/500 mg (n = 162). Titration was allowed to maximum doses of 2000 mg for metformin or 10 mg/2000 mg and 20 mg/2000 mg for glyburide/metformin 2.5 mg/500 mg and 5 mg/500 mg respectively. The primary outcome measure was HbA1c level after 16 weeks; secondary end-points included fasting and 2-h post-prandial plasma glucose. Adverse events (AEs) were recorded and summarized by treatment group.

RESULTS

Both strengths of glyburide/metformin equally reduced mean HbA1c by 1.7% more than did glyburide alone (p < 0.001), and by 1.9% more than did metformin alone (p < 0.001). Final mean fasting plasma glucose concentrations were also lower in both glyburide/metformin groups than in the glyburide (-2.8 mmol/l, -51.3 mg/dl; p < 0.001) and metformin groups (-3.6 mmol/l, -64.2 mg/dl; p < 0.001). Safety and tolerability were similar across all treatment groups, except for a higher incidence of gastrointestinal AEs in the metformin monotherapy group, and more patients reporting mild or moderate symptoms of hypoglycaemia while taking glyburide/metformin.

CONCLUSIONS

Both glyburide/metformin tablet strengths produced, with equal efficacy, significantly better glycaemic control than monotherapy with either agent. These data also confirm that glycaemic efficacy does not require maximal sulphonylurea doses in combination with metformin.

Attitudes of Japanese students toward people with intellectual disability

BACKGROUND

The purpose of the present study was to gain insight into the structure and organization of the attitudes of Japanese students toward people with intellectual disability (ID). The study also examined how these attitudes are related to individual characteristics, such as experience with people with ID, major field of study and career interests.

METHODS

The participants completed a series of measures developed in the USA: three measures of attitudes toward people with ID, a demographic questionnaire and a social desirability scale. Students completed the measures anonymously.

RESULTS

The factor structures of all three attitude scales replicated the structures found in the USA. Attitudes toward the community inclusion of people with ID were negatively correlated with an endorsement of eugenics. Students in social work and psychology had more positive attitudes than other students. Participants who expressed an interest in a career working with people with ID had more positive attitudes than students with no interest in such a career.

CONCLUSIONS

Attitude measures developed in the USA can be used in Japan, and can provide useful information as well as an opportunity for cross-cultural comparisons. For a more complete understanding of the attitudes of Japanese people toward people with ID, these attitudes should also be studied using measures based in Japanese culture which have specifically developed to measure attitudes in Japan.

Simultaneous glyburide/metformin therapy is superior to component monotherapy as an initial pharmacological treatment for type 2 diabetes

OBJECTIVE

To evaluate whether simultaneous initial treatment of both insulin resistance and impaired beta-cell insulin secretion with glyburide/metformin tablets is superior to monotherapy with each component agent.

RESEARCH DESIGN AND METHODS

In this randomized, parallel-group, placebo-controlled, multicentre study, 806 patients with type 2 diabetes (mean duration, 3 years) who had failed diet and exercise were randomly assigned to 4 weeks of therapy with placebo, glyburide 2.5 mg, metformin 500 mg, glyburide/metformin 1.25/250 mg, or glyburide/metformin 2.5/500 mg once daily. Doses were then titrated over 8 weeks based on glycaemic response. The primary outcome measure was change from baseline in mean HbA1c after 20 weeks. Changes in fasting plasma glucose, lipids and body weight were also assessed along with 2-h postprandial glucose and insulin values after a standardized meal.

RESULTS

At week 20, patients taking glyburide/metformin 1.25/250 mg or 2.5/500 mg tablets had greater reductions in HbA1c levels (-1.48% and -1.53% respectively) compared with placebo (-0.21%; both p < 0.001), glyburide (-1.24%; p = 0.016 and p = 0.004 respectively) or metformin (-1.03%; both p < 0.001). Fasting plasma glucose concentrations were reduced more in both glyburide/metformin groups compared with placebo and metformin (p < 0.001); patients in both combination therapy groups also had significantly lower postprandial glucose concentrations compared with placebo, glyburide and metformin.

CONCLUSIONS

Initial combination treatment with glyburide/metformin tablets produces greater improvements in glycaemic control than either glyburide or metformin monotherapy. The superiority of initial therapy with glyburide/metformin tablets may arise from simultaneous treatment of both pathophysiological defects of type 2 diabetes.

Tricyclic drugs for depression in children and adolescents

BACKGROUND

There is a need to identify effective and safe treatments for depression in children and adolescents. While tricyclic drugs are effective in treating depression in adults, individual studies involving children and adolescents have been equivocal.

OBJECTIVES

To assess the effects of oral tricyclic antidepressants compared to placebo in the treatment of child and adolescent depression.

SEARCH STRATEGY

We searched MEDLINE (1966-1997), EMBASE, Excerpta Medica (June 1974-1997), the Cochrane Collaboration Depression, Anxiety and Neurosis Group trials register (most recent search 25/1/2000) and bibliographies of previously published reviews and papers describing original research were cross-checked. Current Contents was screened for recent publications. We contacted authors of relevant abstracts in conference proceedings of the American Academy of Child and Adolescent Psychiatry, and we hand searched the Journal of the American Academy of Child and Adolescent Psychiatry (1978-1999).

SELECTION CRITERIA

Randomised controlled trials comparing the efficacy of orally administered tricyclic medication with placebo in depressed people aged 6-18 years.

DATA COLLECTION AND ANALYSIS

Most studies reported multiple outcome measures including depression scales and clinical global impression scales. For each study the best available depression measure was taken as the index measure of depression outcome. Predetermined criteria were established to assist in the ranking of measures. Where authors reported categorical outcomes we calculated individual and pooled odds ratios for the odds of improvement in treated compared with control subjects. For continuous outcomes pooled effect sizes were calculated as the number of standard deviations by which the change in depression scores for the treatment group exceeded those for the control groups.

MAIN RESULTS

Thirteen trials (involving 506 participants) were included. No overall improvement with treatment compared to placebo was seen for children or adolescents (odds ratio = 0.84, 95% confidence interval 0.56 to 1.25). A statistically significant but small benefit of treatment over placebo was seen in reducing symptoms (effect size (standardised mean difference) = -0.31, 95% confidence interval -0.62 to -0.01). Subgroup analyses suggest a larger benefit among adolescents (effect size = -0.47, 95% confidence interval -0.92 to -0.02), and no benefit among children (effect size = 0.15, 95% confidence interval -0.34 to 0.64). Treatment with a tricyclic antidepressant caused more vertigo (odds ratio = 4.38, 95% confidence interval 2.33 to 8.25), orthostatic hypotension (odds ratio = 6.78, 95% confidence interval 2.06 to 22.26), tremor (odds ratio 6.29, 95% confidence interval 1.78 to 22.17) and dry mouth (odds ratio = 5.17, 95% confidence interval 2.68 to 29.99) than did placebo, but no statistically significant difference was found for other possible adverse effects.

REVIEWER'S CONCLUSIONS

Data suggest tricyclic antidepressants are not useful in treating depression in pre pubertal children. There is marginal evidence to support the use of tricyclic antidepressants in the treatment of depression in adolescents, although the magnitude of effect is likely to be moderate at best.

Office-based arthroscopic synovectomy of the wrist in rheumatoid arthritis

We present an office-based technique for performing arthroscopic synovectomy of the wrist in patients with rheumatoid arthritis. Intra-articular anesthesia as well as subcutaneous portal anesthesia are used. Standard portals are used in the radial carpal and midcarpal joints. Standard instrumentation is used and the synovectomy is accomplished using a motorized shaver. We performed 30 procedures in 21 patients: 15 complete synovectomies, 3 radioulnar carpal synovectomies because of only limited disease, and 12 limited synovectomies because these patients were participants in a clinical trial and required only limited synovectomy for investigational purposes. There were no complications. Office-based arthroscopic synovectomy of the wrist in patients with refractory rheumatoid arthritis can be performed safety and effectively. This technique is useful in both a clinical as well as a research setting.

The effects of increased rehabilitation therapy after brain injury: results of a prospective controlled trial

OBJECTIVE

The objective was to investigate the effect of increased intensity of rehabilitation therapy provided to brain-injured subjects on the rate at which independence was regained and the duration of hospital admission.

DESIGN

A two-centre, prospective, controlled study with random allocation to groups.

SETTING

Two district general hospitals on the south coast of England.

SUBJECTS

Fifty-six people with moderate and severe head injury consecutively admitted to Southampton and Poole hospitals between June 1995 and September 1997.

INTERVENTIONS

Increased intensity of rehabilitation therapy input without change in content.

RESULTS

Subjects receiving more intensive therapy made more rapid progress and were discharged home sooner. The different intensities of therapy employed in this study showed no evidence of a 'ceiling' effect and the 'intervention group' made significantly more rapid progress on tests of dependency during the period of admission. A clear response to increased therapy input was seen in one of the centres with more rapid functional improvement and a shorter length of hospital stay. This centre already had more therapy and better community facilities. No such benefits were seen at the other centre where the intervention group had a longer hospital stay than the routine group.

CONCLUSION

Increasing the hours per week of therapy given to adults recovering from brain injury in hospital can accelerate the rate of recovery of personal independence and result in their being discharged from hospital sooner. Increased rehabilitation therapy after brain injury is associated with enhanced functional recovery and shorter hospital stay if provided in the context of an integrated service that can provide ongoing community support. There is no evidence of any ceiling effect of therapeutic intensity beyond which no further response is observed.

C-peptide prevents and improves chronic Type I diabetic polyneuropathy in the BB/Wor rat

AIMS/HYPOTHESIS

Insulin and C-peptide exert neuroprotective effects and are deficient in Type I (insulin-dependent) diabetes mellitus but not in Type II (non-insulin-dependent) diabetes mellitus. These studies were designed to test the preventive and interventional effects of C-peptide replacement on diabetic polyneuropathy in the Type I diabetic BB/Wor rat.

METHODS

Diabetic BB/Wor rats were replaced with rat C-peptide from onset of diabetes and between 5 and 8 months of diabetes. They were examined at 2 and 8 months and compared to non-C-peptide replaced BB/Wor rats, Type II diabetic (non-C-peptide deficient) BB/Z rats and non-diabetic control rats. Animals were monitored as to hyperglycaemia and nerve conduction velocity (NCV). Acute changes such as neural Na+/K+-ATPase and paranodal swelling were examined at 2 months, morphometric and teased fiber analyses were done at 8 months.

RESULTS

C-peptide replacement for 2 months in Type I diabetic rats prevented the acute NCV defect by 59% (p < 0.005), the neural Na+/K+-ATPase defect by 55% (p < 0.001) and acute paranodal swelling by 61% (p < 0.001). Eight months of C-peptide replacement prevented the chronic nerve conduction defect by 71% (p < 0.001) and totally prevented axoglial dysjunction (p < 0.001) and paranodal demyelination (p < 0.001). C-peptide treatment from 5 to 8 months showed a 13% (p < 0.05) improvement in NCV, a 33% (p < 0.05) improvement in axoglial dysjunction, normalization (p < 0.001) of paranodal demyelination, repair of axonal degeneration (p < 0.01), and a fourfold (p < 0.001) increase in nerve fibre regeneration.

CONCLUSION/INTERPRETATION

C-peptide replacement of Type I BB/Wor-rats partially prevents acute and chronic metabolic, functional and structural changes that separate Type I diabetic polyneuropathy from its Type II counterpart suggesting that C-peptide deficiency plays a pathogenetic role in Type I diabetic polyneuropathy.

Voltage-dependent sodium channels are expressed in nonspiking retinal bipolar neurons

Retinal bipolar neurons transmit visual information by means of graded synaptic potentials that spread to the synaptic terminal without sodium-dependent action potentials. Although action potentials are not involved, voltage-dependent sodium channels may enhance subthreshold depolarizing potentials in the dendrites and soma of bipolar cells, as they do in other CNS neurons. We report here that voltage-dependent sodium currents are observed in a subset of bipolar neurons from goldfish retina. Single-cell reverse transcriptase-PCR identified four different sodium channel alpha subunits in goldfish bipolar cells, putatively corresponding to the mammalian voltage-gated sodium channels Na(v)1.1, Na(v)1.2, Na(v)1.3, and Na(v)1.6. The amount of sodium current was largest in cells with smaller synaptic terminals, which probably represent cone bipolar cells. Localization of sodium channel immunoreactivity in goldfish retina confirmed the expression of voltage-gated sodium channels in cone bipolar cells of both ON and OFF types. Both immunocytochemical and physiological evidence suggests that the sodium channels are localized to the soma and dendrites where they may play a role in transmission of synaptic signals, particularly in the long, thin dendrites of cone bipolar cells.

Burkholderia ambifaria sp. nov., a novel member of the Burkholderia cepacia complex including biocontrol and cystic fibrosis-related isolates

A polyphasic taxonomic study, including amplified fragment length polymorphism (AFLP) fingerprinting, DNA-DNA hybridizations, DNA base-ratio determinations, phylogenetic analysis, whole-cell fatty acid analyses and an extensive biochemical characterization, was performed on 19 Burkholderia cepacia-like isolates from the environment and cystic fibrosis (CF) patients. Several of the environmental isolates have attracted considerable interest due to their biocontrol properties. The polyphasic taxonomic data showed that the strains represent a new member of the B. cepacia complex, for which the name Burkholderia ambifaria sp. nov. is proposed. The type strain is strain LMG 19182T. B. ambifaria can be differentiated from the other members of the B. cepacia complex by means of AFLP fingerprinting, whole-cell fatty acid analysis, biochemical tests (including ornithine and lysine decarboxylase activity, acidification of sucrose and beta-haemolysis) and a newly developed recA gene-based PCR assay. 16S rDNA-based RFLP analysis and PCR tests allowed differentiation of B. ambifaria from Burkholderia multivorans, Burkholderia vietnamiensis and B. cepacia genomovar VI, but not from B. cepacia genomovars I and III and Burkholderia stabilis. The finding that this new taxon includes both strains isolated from CF patients and potentially useful biocontrol strains supports the general consensus that the large-scale use of biocontrol strains belonging to the B. cepacia complex would be ill-advised until more is known about their potential pathogenic mechanisms.

Antisense GLUT-1 protects mesangial cells from glucose induction of GLUT-1 and fibronectin expression

A stable clone of rat mesangial cells expressing antisense GLUT-1 (i.e., MCGT1AS cells) was developed to protect them from high glucose exposure. GLUT-1 protein was reduced 50%, and the 2-deoxy-[(3)H]glucose uptake rate was reduced 33% in MCGT1AS. MCLacZ control cells and MCGT1 GLUT-1-overexpressing cells were used for comparisons. In MCLacZ, 20 mM D-glucose increased GLUT-1 transcription 90% vs. no increase in MCGT1AS. Glucose (8 mM) and 12 mM xylitol [a hexose monophosphate (HMP) shunt substrate] did not stimulate GLUT-1 transcription. An 87% replacement of the standard 8 mM D-glucose with 3-O-methylglucose reduced GLUT-1 transcription 80%. D-Glucose (20 mM) increased fibronectin mRNA and protein by 47 and 100%, respectively, in MCLacZ vs. no increases in MCGT1AS. Fibronectin synthesis was elevated 48% in MCGT1 and reduced 44% in MCGT1AS. We conclude that 1) transcription of GLUT-1 in response to D-glucose depends on glucose metabolism, although not through the HMP shunt, and 2) antisense GLUT-1 treatment of mesangial cells blocks D-glucose-induced GLUT-1 and fibronectin expression, thereby demonstrating a protective effect that could be beneficial in the setting of diabetes.

Burkholderia cepacia genomovar VI, a new member of the Burkholderia cepacia complex isolated from cystic fibrosis patients

A polyphasic taxonomic study was performed on 23 strains isolated from cystic fibrosis (CF) patients in the USA. These strains were tentatively identified as Burkholderia cepacia, Burkholderia vietnamiensis and Burkholderia or Ralstonia sp. using biochemical tests and 16S rDNA-based PCR assays. Visual comparison of protein profiles indicated that they belonged to a single new group ('group 13'). The polyphasic taxonomic data showed that 18 of these strains represent a new member of the B. cepacia complex, referred to in this report as B. cepacia genomovar VI, whereas the other five strains belonged to Burkholderia multivorans. By means of biochemical tests, B. cepacia genomovar VI strains can be separated from B. cepacia genomovars I and III, Burkholderia stabilis, B. vietnamiensis and Burkholderia gladioli, but not from B. multivorans. Separation of B. cepacia genomovar VI and B. multivorans is possible using AFLP (amplified fragment length polymorphism) fingerprinting and DNA-DNA hybridizations. Retrospective analysis of epidemiological and genotypic data suggests that strains of B. cepacia genomovar VI have been involved in chronic colonization of CF patients and have been spread from person to person.

[The use of erythropoietin alpha in programs of high-dose chemotherapy]

Epoetin (Epo) is physiologically present in the human body, stimulating erythropoiesis from bone marrow. Anemia is observed in cancer patients submitted to high-dose chemotherapy (HDCT), mainly caused by myelosuppression. Epoetin alfa has been widely used to treat the anemia that develops in the HDCT setting. Controlled studies in patients with hematologic malignancies or solid tumors who received Epo following HDCT have shown a decreased red blood cell transfusion requirement at least in patients receiving allogeneic bone marrow transplantation (BMT), while results in patients receiving autologous BMT have been disappointing. The administration of Epo before HDCT, in a period when bone marrow is still responsive to growth factors, may represent a new strategy aimed at decreasing the degree of anemia in these patients. A combination of granulocyte-colony stimulating factor and Epo has proved to be effective in mobilizing stem cell and committed myeloid/erythroid precursors.

Current problems with non-specific COX inhibitors

Non-steroidal anti-inflammatory drugs (NSAIDs) are widely used and effective treatments for pain and inflammation. They have a substantial toxicity profile with side effects mainly affecting the gastrointestinal tract, heart and kidneys. Although they comprise a chemically diverse group of drugs, NSAIDs are unified by a common mode of action the ability to inhibit the enzyme cyclo-oxygenase (COX). This also accounts for much of their toxicity. The enzyme exists in at least 2 isoforms. COX-1 generates prostaglandins with physiological functions, COX-2 is induced by inflammation and its physiologic functions are unclear at present. Conventional NSAIDs, like diclofenac, ibuprofen, and naproxen, are non-selective COX inhibitors, blocking the production of both physiologic and inflammatory prostaglandins. In this chapter, we describe the main predictable gastrointestinal, cardiac and renal toxicities that can be explained by such blockade and review the supporting clinical and epidemiological evidence. In the gastrointestinal tract, the side effects associated with conventional NSAIDs are both local and systemic, and include ulceration, bleeding, perforation, and obstruction. The upper gastrointestinal tract is more commonly affected than the lower. The cardiac and renal side effects are most likely to occur in patients with existing heart or kidney disease, where prostaglandins play an essential role in maintaining the vasoconstrictor/dilator balance necessary for homeostasis. The patients at highest risk of toxicity are the elderly, those with a prior history of ulceration or bleeding, and those with a history of cardiac disease. Among such patients, the decision to prescribe NSAIDs requires careful consideration of the potential benefits and harms.

Cloning and characterization of a Na+-driven anion exchanger (NDAE1). A new bicarbonate transporter

Regulation of intra- and extracellular ion activities (e.g. H(+), Cl(-), Na(+)) is key to normal function of the central nervous system, digestive tract, respiratory tract, and urinary system. With our cloning of an electrogenic Na(+)/HCO(3)(-) cotransporter (NBC), we found that NBC and the anion exchangers form a bicarbonate transporter superfamily. Functionally three other HCO(3)(-) transporters are known: a neutral Na(+)/ HCO(3)(-) cotransporter, a K(+)/ HCO(3)(-) cotransporter, and a Na(+)-dependent Cl(-)-HCO(3)(-) exchanger. We report the cloning and characterization of a Na(+)-coupled Cl(-)-HCO(3)(-) exchanger and a physiologically unique bicarbonate transporter superfamily member. This Drosophila cDNA encodes a 1030-amino acid membrane protein with both sequence homology and predicted topology similar to the anion exchangers and NBCs. The mRNA is expressed throughout Drosophila development and is prominent in the central nervous system. When expressed in Xenopus oocytes, this membrane protein mediates the transport of Cl(-), Na(+), H(+), and HCO(3)(-) but does not require HCO(3)(-). Transport is blocked by the stilbene 4,4'-diisothiocyanodihydrostilbene- 2, 2'-disulfonates and may not be strictly electroneutral. Our functional data suggest this Na(+) driven anion exchanger (NDAE1) is responsible for the Na(+)-dependent Cl(-)-HCO(3)(-) exchange activity characterized in neurons, kidney, and fibroblasts. NDAE1 may be generally important for fly development, because disruption of this gene is apparently lethal to the Drosophila larva.

Specialist or generalist care? A study of the impact of a selective admitting policy for patients with cardiac failure

CONTEXT

The debate on the respective roles of medical specialists and generalists has tended to portray them as alternatives, rather than seeking ways to build on the complementary skills of these professional groups.

OBJECTIVE

We wished to evaluate the impact of a selective admitting policy that attempts to exploit the complementary strengths of specialists and generalists.

DESIGN

Prospective cohort study of patients admitted to hospital with congestive heart failure.

SETTING

Public hospital in New South Wales, Australia.

PATIENTS

Subjects aged 60 years or more with congestive heart failure defined by the Framingham criteria (see Appendix).

INTERVENTION

A selective admission policy which referred patients with identifiable single system disorders to the relevant subspecialist, while patients with multiple medical problems were admitted under a general physician.

MAIN OUTCOME MEASURES

Length of hospital stay, survival, quality of life and satisfaction with care.

RESULTS

Two-hundred and seventy-five patients with congestive heart failure were followed up from admission to 1 year after discharge from hospital. Of these, 102 were cared for by cardiologists and 154 by generalists. The patients under the generalists were older, had greater co-morbidity, but appeared to have less severe cardiac disease than those cared for by cardiologists. The use of cardiac drugs and investigations was similar in the two groups. The generalists' patients had a longer length of hospital stay, but the cardiologists' patients had a higher mortality during the early follow-up period. There were no differences in levels of satisfaction with care or in health-related quality of life between the two groups of patients. Multivariate analysis suggested that any differences in outcomes between the two groups of patients were due to the severity of underlying disease, and co-morbidity, rather than the quality of care that was provided by the physicians.

CONCLUSIONS

It is possible to implement a hospital admission policy that selectively refers patients with congestive heart failure to specialists or generalists, according to the presence of co-morbid conditions, without adversely affecting the outcomes of care. Such a policy should represent optimum use of the complementary skills of these professional groups.

Effectiveness of sumatriptan in reducing productivity loss due to migraine: results of a randomized, double-blind, placebo-controlled clinical trial

OBJECTIVE

To determine the effect of sumatriptan on migraine-related workplace productivity loss.

PATIENTS AND METHODS

In this randomized, double-blind, placebo-controlled, parallel-group trial, adult migraineurs self-injected 6 mg of sumatriptan or matching placebo to treat a moderate or severe migraine within the first 4 hours of a minimum of an 8-hour work shift. Outcome measures included productivity loss and number of patients returning to normal work performance 2 hours after injection and across the work shift, time to return to normal work performance, and time to headache relief.

RESULTS

A total of 206 patients underwent screening, 140 (safety population) of whom returned for clinic treatment. Of these 140 patients, 119 received migraine treatment in the workplace (intent-to-treat population), 116 of whom comprised the study population. Of these 116 patients, 76 self-administered sumatriptan, and 40 self-administered placebo. Sumatriptan treatment tended to reduce median productivity loss 2 hours after injection compared with placebo (25.2 vs 29.9 minutes, respectively; P = .14). Significant reductions in productivity loss were obtained across the work shift after sumatriptan treatment compared with placebo (36.8 vs 72.6 minutes, respectively; P = .001). Significantly more sumatriptan-treated patients vs placebo-treated patients experienced shorter return to normal work performance at 2 hours (53/76 [70%] vs 12/40 [30%], respectively) and across the work shift (64/76 [84%] vs 23/40 [58%], respectively; P < .001). Significantly more sumatriptan-treated patients experienced headache relief 1 hour after injection compared with placebo-treated patients (48/76 [63%] vs 13/40 [33%], respectively; P = .004).

CONCLUSION

Across an 8-hour work shift, sumatriptan was superior to placebo in reducing productivity loss due to migraine.

Coverage by the news media of the benefits and risks of medications

BACKGROUND

The news media are an important source of information about new medical treatments, but there is concern that some coverage may be inaccurate and overly enthusiastic.

METHODS

We studied coverage by U.S. news media of the benefits and risks of three medications that are used to prevent major diseases. The medications were pravastatin, a cholesterol-lowering drug for the prevention of cardiovascular disease; alendronate, a bisphosphonate for the treatment and prevention of osteoporosis; and aspirin, which is used for the prevention of cardiovascular disease. We analyzed a systematic probability sample of 180 newspaper articles (60 for each drug) and 27 television reports that appeared between 1994 and 1998.

RESULTS

Of the 207 stories, 83 (40 percent) did not report benefits quantitatively. Of the 124 that did, 103 (83 percent) reported relative benefits only, 3 (2 percent) absolute benefits only, and 18 (15 percent) both absolute and relative benefits. Of the 207 stories, 98 (47 percent) mentioned potential harm to patients, and only 63 (30 percent) mentioned costs. Of the 170 stories citing an expert or a scientific study, 85 (50 percent) cited at least one expert or study with a financial tie to a manufacturer of the drug that had been disclosed in the scientific literature. These ties were disclosed in only 33 (39 percent) of the 85 stories.

CONCLUSIONS

News-media stories about medications may include inadequate or incomplete information about the benefits, risks, and costs of the drugs as well as the financial ties between study groups or experts and pharmaceutical manufacturers.

Precipitation of Wax From Crude Oil Under the Influence of a Magnetic Field

Abstract

The use of magnetic fluid conditioning (MFC) technology to treat downhole wax deposition in the production of waxy crude oil has sparked considerable controversy. A variety of claims have been made about the success rate of the technology in field applications. The interpretation of results from MFC field treatments is extremely difficult, since field conditions involve a number of uncontrolled parameters, including oil composition and gas content, downhole temperature and pressure, and flow rate. In an effort to examine the influence of a magnetic field on wax precipitation from crude oil, a set of laboratory experiments was performed under controlled conditions. The experiments demonstrated that the application of a magnetic field can have a measurable effect on waxy crude oil. Properties of waxy crude oil samples, such as viscosity and wax out temperature, were measured before and after magnetic treatment. No changes in the wax out temperature were detected. Increases in the viscosity of oil samples following treatment were observed, but only when the temperature at which an experiment was performed was close to the wax out temperature of the sample. However, not all of the experiments performed near the wax out temperature of the oil resulted in measurable magnetic effects. The variability in the experimental results suggests that all of the key factors affecting the magnetic treatment process were not identified or adequately addressed. The results indicate, though, that one key factor is the state of wax saturation in the oil as it is undergoing magnetic treatment. A mechanism that may account for the magnetic effects observed in the experiments is proposed. Some implications of this mechanism on field applications of magnetic technology are presented.

Introduction

One of the major problems faced in the production of waxy crude oil is wax deposition in producing wells and associated piping and production facilities. A technology that has been proposed for handling wax deposition is magnetic fluid conditioning (MFC). To date, this technology has achieved varying degrees of success in field applications. Attempts to improve the effectiveness of MFC technology have been hindered by a lack of understanding of the mechanisms that may be responsible for the influence of a magnetic field on wax deposition.

The scientific literature on magnetic fluid conditioning is contained almost exclusively in Russian and Chinese journals. For the most part, these papers mention some experimental evidence of magnetic treatment effects on waxy crude oils, but provide little supporting details about the experiments. Moreover, the observations are not consistent from paper to paper, and no credible explanation of the mechanisms involved in magnetic treatment is advanced in any of the papers. The patent literature associated with magnetic fluid conditioning technologies is largely US based. Although a handful of patents have been granted in which the treatment of waxy crude oils is identified as an application, a large number (more than 100) of others have listed water treatment (prevention of scaling) as the intended application. The devices for the latter application are generally similar in design to those for the former.