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Biomedical subjects

W A Ray

Publications and source records attributed to W A Ray.

At least 73 records · Page 4Linked to original sources
PubMed1992

Medications and the safety of the older driver: is there a basis for concern?

Medications with central nervous system (CNS) effects, including benzodiazepines, cyclic antidepressants, antihistamines, narcotic analgesics, and hypoglycemics, have been thought to have the potential to impair driving. These drugs impair performance in younger drivers and some have been linked to an increased risk of motor vehicle crashes. Even though persons 65 years of age and older frequently take these drugs and are more susceptible to CNS effects, no direct data exist regarding whether or not medications adversely affect driving safety in this population. Thus there is an urgent need for further research in this area.

Accidents, Traffic↗
PubMed1992

Psychotropic drugs and injuries among the elderly: a review.

Injuries are a major public health problem among the elderly, and they have substantial medical, social, and economic consequences. There has been a longstanding concern that psychotropic drugs increase the risk of injury, particularly in the elderly, who frequently use psychotropic drugs and are more vulnerable to drug effects that may predispose to injuries. For benzodiazepines and antidepressants, the most commonly used psychotropic drugs outside of institutional settings, an extensive body of data demonstrating psychomotor function impairment establishes a firm basis for concern, which is reinforced by the more limited epidemiologic data. However, because of limitations in both types of data, this issue remains controversial. To resolve this controversy, we suggest three lines of further research: psychomotor function tests more directly relevant to the injury risk of the elderly medication user, epidemiologic studies designed to distinguish drug effects from those of underlying psychopathology, and clinical trials that include injuries as an outcome.

Aged↗
PubMed1992

Pregnancy outcome following exposure to angiotensin-converting enzyme inhibitors.

OBJECTIVE: Case reports of suspected adverse pregnancy outcomes associated with prenatal exposure to angiotensin-converting enzyme inhibitors, particularly oligohydramnios, prolonged neonatal anuria, and defects of ossification of the skull dome, prompted us to examine pregnancy outcome in a large cohort of pregnant women for whom complete drug exposure information was known. METHODS: We studied the prescribed drug exposure histories and pregnancy outcomes of all women aged 15-44 years enrolled in Tennessee Medicaid who delivered a live-born or stillborn infant between January 1, 1983 and December 31, 1988. RESULTS: Of the 106,813 women enrolled in Tennessee Medicaid who delivered either a live-born or stillborn infant during the study period, 19 were exposed to an angiotensin-converting enzyme inhibitor during pregnancy. All 19 women delivered live infants. Among the 19 newborns, one preterm infant had prolonged anuria necessitating dialysis and a second preterm infant had microcephaly and a large occipital encephalocele. CONCLUSIONS: These outcomes represent a systematic follow-up of all angiotensin-converting enzyme inhibitor-exposed pregnancies. Despite the small number of exposures, there were two outcomes previously linked to prenatal use of these drugs, suggesting that the absolute risk may be high. In light of these findings and the case reports of others, it is prudent to avoid the use of angiotensin-converting enzyme inhibitors in pregnancy.

Abnormalities, Drug-Induced↗
PubMed1992

No increased risk for invasive bacterial infection found following diphtheria-tetanus-pertussis immunization.

During the acellular pertussis vaccine trial in Sweden, 4 children who were randomly assigned to receive the vaccine died of suspected or confirmed bacterial infections compared to 1 expected. There were no deaths in the placebo arm. This raised concern about the role of pertussis immunization in the development of serious infections. Through linking computerized immunization records with an active surveillance system for serious bacterial infections in children, the authors studied a cohort of 64,591 children immunized through Tennessee county health clinics who had a total of 158 episodes of invasive bacterial infections after a diphtheria and tetanus toxoids and pertussis (DTP) immunization. There were 8 invasive bacterial infections that occurred within the first 7 days following DTP immunization, yielding an age-adjusted relative risk (95% confidence interval) of 1.0 (0.5 to 2.0), compared to the interval 29 or more days following immunization. There were 7 and 20 infections in the 8- through 14- and 15- through 28-day intervals following DTP immunization, giving relative risks of 0.8 (0.4 to 1.7) and 1.2 (0.7 to 1.9), respectively. These data provide reassurance that the use of DTP vaccine is not followed by a large increased risk of serious bacterial infections.

Bacterial Infections↗
PubMed1991

Corticosteroid use and peptic ulcer disease: role of nonsteroidal anti-inflammatory drugs.

OBJECTIVE: To estimate the relative risk for peptic ulcer disease that is associated with the use of oral corticosteroids. DESIGN: A nested case-control study. SETTING: Tennessee Medicaid program. PARTICIPANTS: The case patients (n = 1415) were hospitalized between 1984 and 1986 for gastric or duodenal ulcer or for upper gastrointestinal hemorrhage of unknown cause. The controls (n = 7063) were randomly selected from Medicaid enrollees not meeting the study criteria for inclusion as case patients. MEASUREMENTS AND MAIN RESULTS: The estimated relative risk for the development of peptic ulcer disease among current users of oral corticosteroids was 2.0 (95% CI, 1.3 to 3.0). However, the risk was increased only in those who concurrently received nonsteroidal anti-inflammatory drugs (NSAIDs); these persons had an estimated relative risk associated with current corticosteroid use of 4.4 (CI, 2.0 to 9.7). In contrast, the estimated relative risk for those corticosteroid users not receiving NSAIDs was 1.1 (CI, 0.5 to 2.1). Persons concurrently receiving corticosteroids and NSAIDs had a risk for peptic ulcer disease that was 15 times greater than that of nonusers of either drug. CONCLUSION: Discrepant findings among earlier studies regarding steroids and the risk for peptic ulcer disease could in part be due to differences in the use of NSAIDs among study participants. The high risk for peptic ulcer disease associated with combined use of NSAIDs and corticosteroids indicates the need to prescribe this drug combination cautiously.

Administration, Oral↗
PubMed1991

Nonsteroidal anti-inflammatory drug use and increased risk for peptic ulcer disease in elderly persons.

OBJECTIVE: To evaluate the relative risk for peptic ulcer disease that is associated with the use of nonaspirin nonsteroidal anti-inflammatory drugs. DESIGN: Nested case-control study. SETTING: Tennessee Medicaid program. PARTICIPANTS: Medicaid enrollees 65 years of age or older were included in the study. The 1415 case patients had been hospitalized for confirmed peptic ulcer disease at some point from 1984 through 1986. The 7063 control persons represented a stratified random sample of other Medicaid enrollees. MEASUREMENTS AND MAIN RESULTS: The estimated relative risk for the development of peptic ulcer disease among current users of nonaspirin nonsteroidal anti-inflammatory drugs, compared with that among nonusers, was 4.1 (95% CI, 3.5 to 4.7). For current users, the risk increased with increasing dose, from a relative risk of 2.8 (CI, 1.8 to 4.3) for the lowest to a relative risk of 8.0 (CI, 4.4 to 14.8) for the highest dose category. The risk was greatest in the first month of use (relative risk, 7.2; CI, 4.9 to 10.5). If the association is fully causal, 29% of peptic ulcers in the study sample resulted from the use of these drugs, and the excess risk associated with such use was 17.4 hospitalizations for ulcer disease per 1000 person-years of exposure. CONCLUSIONS: These data support other findings indicating that a clinically significant risk for serious ulcer disease is associated with the use of nonaspirin nonsteroidal anti-inflammatory drugs. The data show that this risk increases with dose and recency of use and that use of these drugs may be responsible for a large proportion of peptic ulcer disease among elderly persons.

Age Factors↗
PubMed1991

Influence of corticosteroid on experimentally induced keratomycosis.

To assess the effect of corticosteroid on the establishment of experimentally induced keratomycoses, rabbits were injected subconjunctivally with triamcinolone acetonide on two successive days before inoculation with Candida albicans, Aspergillus fumigatus, or Fusarium solanae. Whereas isolate recovery rates declined steadily in normal control corneas, they remained stable over 15 days in corticosteroid-treated corneas. Clinically, inflammation was equivalent (A fumigatus and F solanae) or significantly less (C albicans; P = .001) until the 10th day. At 15 days, inflammation in corticosteroid-treated corneas was significantly worse in animals infected with A fumigatus (P = .003) or F solanae (P = .02). Inflammatory signs correlated inconsistently with isolate recovery. Pathogenicity of the infecting organism appears to be important in determining the degree to which corticosteroid is able to mask clinical signs of infection while enhancing fungal replication.

Animals↗
PubMed1991

Risk of seizures after measles-mumps-rubella immunization.

To evaluate the risks of seizures and other neurologic events following measles-mumps-rubella (MMR) or measles-rubella (MR) immunization, a retrospective cohort study was conducted among 18,364 Tennessee children enrolled in Medicaid who received MMR or MR immunizations in their first 3 years of life. One hundred children had seizures at some time between immunization and 36 months; there were no encephalopathies during this period. Four children had febrile seizures in the 7 through 14 days following MMR or MR immunization compared with 72 in the interval 30 or more days following MMR or MR immunization yielding a relative risk (95% confidence interval) of 2.1 (0.7 to 6.4). Although not statistically significant, this increase in febrile seizures in the 7- through 14-day interval following MMR immunization is coincident with the occurrence of fever following MMR immunization and is consistent with reports of other investigators.

Brain Diseases↗
PubMed1991

Cyclic antidepressants and the risk of hip fracture.

To determine whether cyclic antidepressants increase the risk of hip fracture, we conducted a population-based case-control study in the Canadian province of Saskatchewan. We identified 4501 persons 65 years of age or older with a first hospitalization for hip fracture between 1977 and 1985 and 24,041 comparable controls. Current antidepressant users had a relative risk of hip fracture of 1.6 (95% confidence interval, 1.3 to 1.9). Medical record review for a sample of 164 cases suggested this finding was not due to confounding by body mass, impaired ambulation, functional status, or dementia.

Accidental Falls↗
PubMed1991

Differences in response in vivo to amphotericin B among Candida albicans strains.

A group of ten Candida albicans strains previously determined to be resistant or susceptible to topical amphotericin B in vivo and in vitro were exposed to treatment with different concentrations of the drug in a quantitative model of candidal keratitis in Dutch-belted rabbits. After 5 days of topical treatment with amphotericin B eye drops in concentrations of 0.3%, 0.03%, or 0.003%, quantitative isolate recovery in treated animals was compared with that of untreated controls. A dose response was observed for all five susceptible strains. The two strains that were most sensitive to amphotericin B in vitro also were the most susceptible in vivo. At each dose level there was a two- to eightfold reduction in isolate recovery among highly susceptible strains compared with less susceptible strains (P less than 0.05). The five resistant strains remained so even when the 0.3% concentration was used. Among strains of C. albicans susceptible to amphotericin B, there appeared to be a variation in degree of susceptibility in vivo that correlated with the minimum inhibitory concentration.

Administration, Topical↗
PubMed1990

Effects of Medicaid eligibility expansion on prenatal care and pregnancy outcome in Tennessee.

To investigate the effects of a 1985 Tennessee Medicaid regulatory change that expanded eligibility coverage specifically for married women during pregnancy, we studied vital statistics files linked to Medicaid enrollment files. The greatest Medicaid coverage increase in terms of an absolute difference in rates and the number of women covered occurred in white married women younger than 25 years with less than 12 years of education, where enrollment increased 18%. However, in that group of mothers, as well as for the total of all mothers studied, there were no concomitant improvements in use of early prenatal care, birth weight, or neonatal mortality. Analysis of the timing of enrollment relative to the beginning of pregnancy showed that more than two thirds of the women who enrolled did so after the first trimester.

Eligibility Determination↗
PubMed1990

Incidence of hip fracture in Saskatchewan, Canada, 1976-1985.

The authors ascertained the incidence of hip fracture in Saskatchewan, Canada, residents aged 65 years or older for the 10 years 1976-1985 from computerized hospital discharge records and compared it with rates for several other populations in Northern Europe and the United States. In Saskatchewan, the average annual incidence was 5.5 per 1,000 person-years. The incidence in women was twice that in men, the incidence in urban areas was 27% greater than that in nonurban areas, and there was no secular trend of increasing rates. The incidence of hip fracture in Saskatchewan was lower than that for populations in Scandinavia and the United States but was comparable to rates in English populations. Further study is needed to elucidate the genetic, environmental, and behavioral factors responsible for this variation.

Aged↗
PubMed1990

Methodological issues in evaluating expanded Medicaid coverage for pregnant women.

In a recent effort to lower the US infant mortality rate, Congress has expanded the Medicaid coverage options that states may offer pregnant women. Careful evaluation of changes in perinatal outcome associated with this expanded coverage is needed. The linkage of Medicaid enrollment files of mothers and infants to birth, death, and fetal death certificates is an initial step in assessing the effectiveness that Medicaid coverage expansions have had on pregnancy outcome. Creation of such a database for Tennessee for 1984-1987 revealed that complete information on mother, delivery, and child is available for only three quarters of Medicaid-reimbursed births. Furthermore, Medicaid-reimbursed births that had all three data components had different characteristics and lower mortality rates than did births with missing elements. Those persons seeking to evaluate expanded Medicaid coverage for pregnant women need to be aware that consideration of only those births for whom there is information on mother, delivery, and child may lead to serious underascertainment of fetal, perinatal, and neonatal mortality rates.

Adolescent↗
PubMed1990

Mortality following hip fracture before and after implementation of the prospective payment system.

Recent studies of patients with hip fractures from two hospitals have suggested that the marked reduction in length of stay that occurred following implementation of the Medicare prospective payment system (PPS) resulted in decreased quality of care for these patients. To assess whether this change influenced mortality, we studied patients with hip fractures aged 65 years or older from a 20% sample of Michigan Medicare enrollees. There were 2130 such patients in the 2 years preceding (October 1981 through September 1983) and 2238 in the 2 years following (October 1984 through September 1986) implementation of PPS. Although the demographic characteristics of patients with hip fractures did not change after PPS, the mean length of stay (95% confidence interval) decreased by 4.4 (4.1 to 4.7) days. However, mortality in the year following the fracture did not change: 23.2% before PPS, 23.7% after PPS; rate difference of 0.5% (-2.0 to 3.0). This finding was consistently present within subgroups defined by patient demographic characteristics. Furthermore, when the analysis was restricted to patients treated in those hospitals with the greatest reduction in average length of stay following PPS (7.5 days, or 35%), there was no significant change in 1-year mortality. For those patients who were enrolled in Medicaid and not in a nursing home at the time of the fracture, there was no increase in the rate of nursing home residence 1 year after the fracture. Thus, the findings of this population-based study suggest that the key outcomes of postfracture mortality and nursing home residence were not affected by the implementation of PPS.

Aged↗
PubMed1989

Benzodiazepines of long and short elimination half-life and the risk of hip fracture.

To determine if the risk of hip fracture difference between persons receiving benzodiazepines with long (greater than or equal to 24 hours) or short (less than 24 hours) elimination half-lives, we conducted a nested case-control study among residents of the Canadian province of Saskatchewan who were 65 years of age and older. We identified 4501 cases occurring between 1977 and 1985 from computerized hospital records and 24,041 population controls. Current benzodiazepine use, defined as having filled a prescription in the past 30 days, was ascertained from computerized pharmacy records. The relative risk of hip fracture was 1.7 (95% confidence interval, 1.5 to 2.0) for current users of long half-life benzodiazepines, in contrast to that of 1.1 (95% confidence interval, 0.9 to 1.3) for current users of short half-life drugs. This finding was not altered by sex, age, calendar year, nursing home residence, or history of hospitalization. Medical record review for a sample of 189 cases suggested that this finding was not due to confounding by dementia, ambulatory status, functional status, or body mass.

Aged↗
PubMed1989

Long-term use of thiazide diuretics and risk of hip fracture.

To assess whether long-term thiazide use is associated with a decreased risk of hip fracture, a nested case-control study was done in the Canadian province of Saskatchewan between 1984 and 1985 among residents who were 65 years of age or older and who were not receiving other drugs thought to affect bone mass. There were 905 hip fractures identified from hospital discharge records and 5137 population controls matched for age, sex, and calendar year. Drug use was ascertained from computerised pharmacy records. Risk of hip fracture decreased significantly with increasing duration of current thiazide use: relative risk (95% confidence interval) of 1.2 (0.9-1.5) for less than 2 years use, 0.8 (0.7-1.0) for use of 2-5 years, and 0.5 (0.3-0.7) for 6 or more years. In contrast, there was no such trend for use of other antihypertensive-diuretic drugs (relative risk 0.9 [0.6-1.3] for use of 6 or more years). This protective effect was not altered by age, sex, nursing home residence, previous hospital admission, or use of other antihypertensive-diuretic drugs or psychotropic drugs. Medical record review for a sample of 235 cases suggested this finding was not due to confounding by body mass, ambulatory status, functional status, or dementia. These results support the hypothesis that thiazides protect against osteoporosis in elderly people.

Aged↗