The effects of cocaine on mood and sleep in cocaine-dependent males

The effects of cocaine use and withdrawal on mood and sleep were examined. Three cocaine-dependent men lived in an inpatient facility for approximately 4 weeks, which included an initial abstinence phase (8-10 days), a cocaine administration phase (5 days), and a 2nd abstinence phase (14-16 days). During the 2nd phase, cocaine was administered intranasally a few hours before bedtime. During the day, mood and daytime sleepiness were measured, and sleep was monitored each night. Cocaine produced typical changes in mood and blood pressure, and sleep was severely disrupted. Following Phase 2, there were no changes in mood that was indicative of an abstinence syndrome, although, initially, daytime sleepiness increased. After 2 weeks, sleep architecture remained different from age-matched controls. This study is the first to measure changes in sleep architecture polysomnographically following a period of controlled cocaine use.

The effects of cocaine on mood and sleep in cocaine-dependent males

The effects of cocaine use and withdrawal on mood and sleep were examined. Three cocaine-dependent men lived in an inpatient facility for approximately 4 weeks, which included an initial abstinence phase (8-10 days), a cocaine administration phase (5 days), and a 2nd abstinence phase (14-16 days). During the 2nd phase, cocaine was administered intranasally a few hours before bedtime. During the day, mood and daytime sleepiness were measured, and sleep was monitored each night. Cocaine produced typical changes in mood and blood pressure, and sleep was severely disrupted. Following Phase 2, there were no changes in mood that was indicative of an abstinence syndrome, although, initially, daytime sleepiness increased. After 2 weeks, sleep architecture remained different from age-matched controls. This study is the first to measure changes in sleep architecture polysomnographically following a period of controlled cocaine use.

Evaluation of the dyspeptic patient: a cost-utility study

BACKGROUND

Traditionally, patients presenting with uncomplicated dyspepsia have been managed using empiric antisecretory therapy, followed by endoscopy in the event of persistent symptoms or complication. Since Helicobacter pylori is now accepted as an important and potentially reversible cause of ulcer disease, it is important to reevaluate the management of dyspepsia. The goal of this study is to evaluate seven outpatient strategies for the management of dyspeptic patients using a cost-utility analysis.

METHODS

The study design was that of a cost-utility analysis. The model assumes that an adult patient with signs of dyspepsia but no signs of complication presents to the outpatient office of a primary care physician. Seven strategies are modeled: empiric antisecretory therapy; empiric H pylori eradication using oral omeprazole (20 mg [corrected] twice daily), clarithromycin (500 mg twice daily), and amoxicillin (1000 mg twice daily); use of either upper endoscopy, an upper gastrointestinal barium study (an upper GI), or the serum titer for H pylori as a diagnostic test to identify patients for H pylori eradication; or use of an initial diagnostic test followed by the serum titer for H pylori. The primary outcome was the cost per quality-adjusted life year (QALY) for each strategy for a 1-year period from presentation; secondary outcomes included the probability of symptomatic ulcer recurrence, cost per ulcer cure, and mortality.

RESULTS

Three strategies were similarly cost-effective: empiric H pylori eradication ($1198 per QALY), use of a serum H pylori titer as an initial diagnostic test ($1214 per QALY), and empiric antisecretory therapy ($1288 per QALY). Empiric antisecretory therapy, however, was associated with significantly more symptomatic ulcer recurrences and deaths than any other strategy.

CONCLUSIONS

This cost-utility analysis suggests that two strategies are reasonable for patients presenting with dyspepsia: (1) empiric H pylori eradication and (2) use of a serum H pylori titer to identify patients who might benefit from H pylori eradication. The latter strategy may be preferable because it is less likely to lead to antibiotic resistance. Strategies utilizing an upper GI or upper endoscopy (either with or without serum H pylori titer) or empiric antisecretory therapy do not improve outcomes and are associated with greater cost, morbidity, and/or mortality.

The inability of physicians to predict the outcome of in-hospital resuscitation

OBJECTIVE

To measure the accuracy, reliability, and discrimination of physicians' predictions of the outcome of in-hospital cardiopulmonary resuscitation (CPR), using a large series of detailed clinical vignettes of patients with known outcomes.

DESIGN

Faculty and resident physicians at three university-affiliated generalist training programs were given one-page summaries of admission data for patients who later underwent in-hospital CPR. These summaries included all pre-arrest variables known to be related to the outcome of CPR. Physicians were asked to estimate the probability that patients would survive the resuscitation long enough to be stabilized, and the probability of survival to discharge.

SETTING

Patient cases were derived from a consecutive series of patients undergoing CPR at two urban teaching hospitals in Detroit, Michigan.

PARTICIPANTS

Faculty members and residents at a university-based department of internal medicine and two university-based departments of family medicine were surveyed.

INTERVENTIONS

Accuracy of the physician predictions was assessed by comparing the mean predicted probability of survival with the percentage of patients who actually survived. The reliability of probability estimates of survival was evaluated by assessing the numerical proximity of the estimates to the actual outcome of the resuscitative effort. The ability to discriminate between survivors and nonsurvivors was measured by comparing the mean predicted probability of survival for those patients who survived CPR with that for those who did not, and by stratifying physician predictions and measuring the area under a receiver operating characteristic (ROC) curve. MEASUREMENTS AND MAIN RESULTS. Physicians (n = 51) made a total of 713 estimates, and showed poor accuracy, reliability, and discrimination in predicting the outcome of in-hospital CPR. The mean predicted probability of survival to discharge did not differ between patients who actually survived to discharge and those who did not (29.5% vs 26.4%, z = 0.35, p = .73). Similarly, the mean predicted probabilities of surviving resuscitation were the same for patients who actually survived long enough to be stabilized and those who did not (37.8% vs 39.9%, z = 0.55, p = .58). Accounting for type of physician and institution by analysis of variance did not change this finding. The area under the ROC curve for the prediction of arrest survival was 0.476, which is not significantly different from 0.5, and is consistent with an ability to discriminate between survivors and nonsurvivors that is no better than random choice.

CONCLUSIONS

Physicians were no better at identifying patients who would survive resuscitation than would be expected by chance alone. Further work is needed to establish which variables are used by physicians in the decision-making process, and to design educational interventions that will make physicians more accurate prognosticators.

Promoting screening mammography in inner-city settings: a randomized controlled trial of computerized reminders as a component of a program to facilitate mammography

In a one-year randomized controlled trial, we assessed the effectiveness of a computerized mammography reminder system as a component of a program to increase the use of screening mammography in three health care organizations serving inner-city women in Detroit, Michigan (two sites of a health department, one HMO site, and two sites of a private hospital). Four thousand four hundred and one women older than 40 who had visited a study site in the preceding year were randomly assigned to one of two treatment groups. Limited intervention (LI) included physician and staff breast cancer control education, facilitated mammography appointment scheduling procedures, and elimination of out-of-pocket patient cost for mammography (at three of five sites). Full intervention (FI) included all components of limited intervention plus an additional series of "cues-to-action." These included a mammography reminder form inserted in the medical record of women who were due to have mammography, intended to increase physician referral for mammography appointments, and patient reminders intended to increase completion of mammography among referred women. During the one-year intervention period 2,725 randomized women visited a study site. The 6-month mammography appointment rates among FI women vary from 38% to 65% and the FI rate exceeds the LI rate at each site with differences from 13% (95% CI, 6 to 20) to 29% (21 to 38). The annual completed mammography rate among FI women extends from 43% to 64% and exceeds the LI rate at each site by 12% (5 to 19) to 25% (16 to 34). After age-adjustment, the mammography intervention effect sizes among the five sites were not significantly different. The average increase in FI compared to LI was 18%. The computerized reminder system is effective in increasing the use of mammography in each of the study institutions and the major effect is on physician referral for mammography.

Patterns of use of mammography among inner-city Detroit women: contrasts between a health department, HMO, and private hospital

This study assessed the pattern of utilization of mammography among 2,880 inner-city minority women 40 years of age or older who received ongoing primary care services during 1988 or 1989 at four practice sites operated by a health department (two sites), Health Maintenance Organization (HMO), and private hospital. Mammography referral could be documented for 23% to 32% of age eligible women and completed mammograms for 15% to 26%. Among women without a mammogram, 85% had never been referred while 15% were referred but unable to complete the procedure. In multiple logistic regression analysis, factors associated with mammography include age less than 70 years, presence of a breast cancer risk factor and more frequent clinic visits. Mammography was somewhat more frequent at the HMO and hospital clinic than at the health department, but this relationship varied with the women's previous visit and mammography experience. At sites serving uninsured women, mammography use was not associated with the presence or absence of health insurance. It is concluded that the underutilization of mammography is a substantial barrier to the early detection of breast cancer in each of the three different health care organizations studied, and that interventions to improve breast cancer control should focus upon facilitating physician referral practices.

Detroit's avoidable mortality project: breast cancer control for inner-city women

Mammography remains substantially under-used in low-income minority populations despite its well-established efficacy as a means of breast cancer control. The Metropolitan Detroit Avoidable Mortality Project is a 2-year controlled clinical trial of coordinated interventions which seek to improve the use of early breast cancer detection services at five clinical sites providing primary health care services to inner-city women. Baseline assessment for two of the five participating clinic populations demonstrated that only one-quarter of women who visited these clinics were referred for mammography in 1988, and only half of those who were referred were able to complete the procedure. Patient characteristics including age, marital status, ethnicity, and insurance status were not associated with use of mammography during the baseline period. Each of the project's intervention components is a cue to action: a physician prompt for mammography referral within the medical record of procedure-due women, a reminder postcard for scheduled appointments, and a telephone call to encourage rescheduling of missed appointments. The interventions are initiated by a computerized information management system in the existing network of health care services. The patient's out-of-pocket mammography expense has been eliminated in three of the five sites. Although their efficacy as individual interventions has been well established, a controlled trial of computer prompts to physicians, reduced expense for patients, and patient appointment reminders as an integrated system in inner-city medical care settings has not been previously described. We have implemented the prompting, facilitated rescheduling procedures, and eliminated patient expense for mammography at three of five eventual clinical sites. This report provides an overview of the study's design, data management system, and methodology for evaluation.