The effect of the nitric oxide synthase inhibitor, L-NMMA, on sodium metabisulphite-induced bronchoconstriction and refractoriness in asthma.
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Refractoriness to indirect bronchoconstrictor stimuli, is a feature of asthma but the mechanism is poorly understood. This study tested the hypothesis that endogenous nitric oxide (NO) produced during a first bronchoconstrictor challenge protects against subsequent challenge and therefore has a role in the refractory process. The effect of an NO synthase inhibitor, N(G)-mono-methyl-L-arginine (L-NMMA), on refractoriness to sodium metabisulphite (MBS) was investigated in 20 subjects with mild asthma. On visit one, the dose of MBS which caused a 20% fall in forced expiratory volume in one second (FEV1) (PD20) was determined. On visit two, the refractory index (RI) to MBS was determined by challenging the subjects twice with their PD20 of MBS, the second challenge proceeding after recovery from the first. Those showing a refractory index of approximately 30% (10 subjects) inhaled either L-NMMA or placebo followed 5 min later by two challenges with their PD20 of MBS in a double-blind cross over study at two further visits. The dose of L-NMMA used was shown to reduce exhaled NO for a duration sufficient to cover the second MBS challenge However, no significant difference was found between L-NMMA and placebo in maximum fall in FEV1% and area under the curve (AUC) during first or second MBS challenges or in RI on the two study days. It is concluded that subjects with mild asthma show refractoriness to sodium metabisulphite, but that endogenous nitric oxide is unlikely to be involved either in the refractory process or in the response to sodium metabisulphite per se. (+info)
Rates of U.S. physicians counseling adolescents about smoking.
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BACKGROUND: The health care system provides an important opportunity for addressing tobacco use among youths, but there is little information about how frequently physicians discuss smoking with their adolescent patients. We analyzed data from the National Ambulatory Medical Care Surveys to assess the prevalence and the predictors of physicians' identification of smoking status and counseling about smoking at office visits by adolescents. METHODS: From 1991 through 1996, 5087 physicians recorded data on 16 648 visits by adolescents aged 11-21 years. We determined the proportion of office visits at which physicians identified an adolescent's smoking status and counseled about smoking and then identified predictors of these outcomes with logistic regression. Statistical tests were two-sided. RESULTS: In 1991, physicians identified an adolescent's smoking status at 72.4% of visits but provided smoking counseling at only 1.6% of all adolescent visits and 16.9% of visits by adolescents identified as smokers. These proportions did not increase from 1991 through 1996. Compared with specialists, primary care physicians were more likely to identify smoking status (odds ratio [OR] = 1.70; 95% confidence interval [CI] = 1.53-1.89) and to counsel about smoking (OR = 3.43; 95% CI = 2.18-5.38). Patients with diagnoses of conditions potentially complicated by smoking were more likely to have their smoking status identified and to be counseled about smoking. Younger and nonwhite adolescents were less likely to be counseled about smoking than older and white teens. CONCLUSIONS: We found that physicians frequently identified adolescents' smoking status but rarely counseled them about smoking. Physicians' practices did not improve in the first half of the 1990s, despite a clear consensus about the importance of this activity and the publication of physician guidelines targeting this population. Physicians treating adolescents are missing opportunities to discourage tobacco use among teens. (+info)
A short-term cost-of-treatment model for type 2 diabetes: comparison of glipizide gastrointestinal therapeutic system, metformin, and acarbose.
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OBJECTIVE: To compare, from a managed care perspective, the 3-year costs of 3 first-line monotherapy strategies in type 2 diabetes patients: glipizide gastrointestinal therapeutic system (GITS), metformin, and acarbose. STUDY DESIGN: A Markov model, with a Monte Carlo simulation, was developed to compare the costs to achieve full glycemic control (hemoglobin A1c of < or = 7%) with each first-line strategy. PATIENTS AND METHODS: The patient population for the model was assumed to be all newly diagnosed type 2 diabetes patients eligible for monotherapy with an oral agent. Each monotherapy could be succeeded by add-on treatments. The model included the costs of routine medical care and supplies, medication, adverse events, and treatment failures. RESULTS: Using a Monte Carlo simulation, the mean 3-year cumulative costs per patient were $4971, $5273, and $5311 for glipizide GITS, metformin, and acarbose first-line strategies, respectively. The main cost drivers were drug prices. Mean 3-year cost savings for first-line glipizide GITS were $301 over metformin and $340 over acarbose. Between 83% and 85% of all simulations showed cost savings with glipizide GITS compared with the other agents. CONCLUSIONS: The model suggests first-line monotherapy with glipizide GITS should result in desirable short-term economic benefits for managed care. Because the model incorporates recommended glycemic goals and performed well in sensitivity analyses, it should be applicable to a variety of clinical practices and useful for economic assessments of new therapies. Results of this model should be verified prospectively in typical care settings. (+info)
National Ambulatory Medical Care Survey: 1995-96 summary.
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OBJECTIVE: This report describes ambulatory medical care visits to nonfederally employed, office-based physicians in the United States during 1995 and 1996. Statistics are presented on selected physician, patient, and visit characteristics. METHODS: The data in this report were collected in the 1995 and 1996 National Ambulatory Medical Care Surveys (NAMCS). The NAMCS is part of the ambulatory care component of the National Health Care Survey (NHCS), which measures health care utilization across a variety of providers. The NAMCS is a national probability sample survey of visits to nonfederally employed, office-based physicians in the United States. Sample data were weighted to produce annual estimates. Estimates are presented in this report as annual averages unless otherwise noted. RESULTS: During 1995-96, an estimated 1.4 billion visits were made to physician offices in the United States, an annual average of 715.8 million visits. The visit rate was 2.7 visits per person per year. This rate did not differ significantly from visit rates observed in any previous survey year. Females made 59.4 percent of the visits, or 3.2 visits per person annually. This was higher than the visit rate for males. White persons had a higher visit rate than black persons. Six of every 10 visits were to primary care providers. Injury-related visits accounted for 11.8 percent of all office visits, or 84.6 million per year. The annual rate of injury-related office visits was 32.2 visits per 100 persons. The most frequent reason for visiting the physician was for a general medical examination (6.8 percent). Cough was the most frequent symptomatic reason. Acute respiratory infections and essential hypertension were the diagnoses reported most frequently. (+info)
Ambulatory care visits to physician offices, hospital outpatient departments, and emergency departments: United States, 1997.
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OBJECTIVE: This report describes ambulatory care visits in the United States across three ambulatory care settings--physician offices, hospital outpatient departments, and hospital emergency departments. Statistics are presented on selected patient and visit characteristics for all ambulatory care visits and separately for each setting. METHODS: The data presented in this report are from the 1997 National Ambulatory Medical Care Survey (NAMCS) and the 1997 National Hospital Ambulatory Medical Care Survey (NHAMCS). These surveys are part of the ambulatory care component of the National Health Care Survey that measures health care utilization across a variety of health care providers. NAMCS and NHAMCS are national probability sample surveys of visits to office-based physicians (NAMCS) and visits to the outpatient departments and emergency departments of non-Federal, short-stay and general hospitals (NHAMCS) in the United States. Sample data are weighted to produce annual estimates. RESULTS: During 1997, an estimated 959.3 million visits were made to physician offices, hospital outpatient departments, and hospital emergency departments in the United States, an overall rate of 3.6 visits per person. Visits to office-based physicians accounted for 82.1 percent of ambulatory care utilization, followed by visits to emergency departments (9.9 percent) and outpatient departments (8.0 percent). Utilization varied by patient age, sex, and race. Persons 75 years and over had the highest rate of ambulatory care visits. Females had significantly higher rates of visits to physician offices and hospital outpatient departments than males did. White persons utilized physician offices at a higher rate compared with black persons. There were an estimated 123.8 million injury-related ambulatory care visits during 1997, or 46.4 visits per 100 persons. (+info)
The cost of Medicaid-covered services provided to disabled adults with neurologic disorders: implications for managed care.
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OBJECTIVES: To estimate the mean annual per capita cost of care provided to disabled adult Medicaid recipients with neurologic conditions and to compare mean annual costs for disabled adult Medicaid recipients with those of nondisabled adult Medicaid recipients. STUDY DESIGN: Medicaid eligibility and claims files for all of calendar year 1993 were obtained from the state of Pennsylvania. Mean annual per capita costs are mean Medicaid expenditures on claims filed for Medicaid-covered services and pharmaceuticals provided in 1993 to full-year eligible Medicaid recipients. PATIENTS AND METHODS: Disabled adults aged 18 to 64 years with one or more of several neurologic conditions were identified from medical diagnoses (International Classification of Diseases, 9th Revision codes) reported on claims. A comparison group of nondisabled adults was chosen from the Medicaid Eligibility File. Annual costs were estimated for a wide range of specific services as well as for 3 broad service categories. RESULTS: There were large differences between disabled and nondisabled adults in mean annual per capita costs of acute care and other medical services ($4142 vs $1451), rehabilitation and support services ($3835 vs $235), and pharmaceuticals ($1116 vs $382). Mean costs also differed significantly among persons with different neurologic conditions. The mean annual per capita cost for all services was $5368 for adults with epilepsy and $19,356 for those with a spinal cord injury. All differences are statistically significant (P < .001). CONCLUSIONS: States may want to separately capitate rehabilitation and support services given the large differences in the magnitude and relative distribution of costs for disabled and nondisabled Medicaid recipients. (+info)
Attenuation of the "white-coat effect" by antihypertensive treatment and regression of target organ damage.
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This study assessed whether 2 common surrogate measures of the "white-coat effect," namely the clinic-daytime and the clinic-home differences in blood pressure (BP), were attenuated by long-term antihypertensive treatment and whether this attenuation is relevant to the treatment-induced regression of left ventricular hypertrophy, thus having clinical significance. We considered data from 206 patients with essential hypertension (aged 20 to 65 years) who had a diastolic BP between 95 and 115 mm Hg and echocardiographic evidence of left ventricular hypertrophy. In each patient, clinic BP, 24-hour ambulatory BP, and left ventricular mass index were assessed at baseline, after 3 and 12 months of treatment with an angiotensin-converting enzyme inhibitor, and after a final 4-week placebo run-off period. At baseline, the clinic-daytime differences in systolic and diastolic BP were 12.1+/-15.4 and 6.8+/-10.1 mm Hg, respectively; the corresponding values for the clinic-home differences were 5.7+/-10.6 and 2.9+/-6.1 mm Hg, respectively. These differences were reduced by 57.6% and 77.1% (P<0.01) and by 65.7% and 64.3% (P<0.01), respectively, after 12 months of treatment, with a partial return toward the pretreatment differences after the final placebo period. The observed treatment-induced reductions in left ventricular mass index and those in the clinic-daytime or clinic-home differences for systolic and diastolic BP showed no significant relationship when tested by multiple regression analysis. This provides the first longitudinal evidence that clinic-daytime and clinic-home differences in BP have no substantial value in predicting the regression of target organ damage, such as left ventricular hypertrophy, that has prognostic relevance. (+info)
Minimal smoking cessation interventions in prenatal, family planning, and well-child public health clinics.
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OBJECTIVES: This study assessed the prevalence and effectiveness of smoking cessation interventions for women of childbearing age in public health clinics. METHODS: Smokers in prenatal, family planning, and well-child services in 10 public health clinics (n = 1021) were interviewed 5 to 8 weeks after a medical visit to assess their exposure to smoking cessation interventions and smoking cessation outcomes. RESULTS: Depending on clinic service and intervention component (poster, video segment, provider advice, booklet), 16% to 63% of women reported exposure to an intervention component during their visit. Women in prenatal services received more interventions and had better outcomes than those in the other services. CONCLUSIONS: Exposure to more interventions increased readiness and motivation to quit and the number of actions taken toward quitting. (+info)