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At least 127 records · Page 7Linked to original sources

PubMed1992

Isradipine--another calcium-channel blocker for the treatment of hypertension and angina.

OBJECTIVE: To review the pharmacology, pharmacokinetic disposition, dose recommendations, adverse effects, drug interactions, and efficacy of isradipine in patients with hypertension or ischemic heart disease. DATA SOURCES: Data from scientific literature were extracted, evaluated, and summarized for presentation. A MEDLINE search was conducted using the following indexing terms: isradipine, calcium-channel blockers, hypertension, and angina pectoris. Experiences from studies evaluating isradipine reported in the form of articles, abstracts, or proceedings involving patients or healthy subjects were considered for inclusion. STUDY SELECTION: Special consideration was given to clinical studies that had been designed in a blind, randomized fashion. Studies that compared the effectiveness and safety of isradipine with another antihypertensive or antianginal agent or placebo were included. DATA EXTRACTION: Data from human studies published in the English language were evaluated. Trials were evaluated according to sample size, design, and adequacy of description of therapeutic response. DATA SYNTHESIS: Isradipine is a new dihydropyridine calcium-channel blocker that appears to exert less negative inotropic activity than nifedipine and to selectively inhibit sinoatrial conduction. Pharmacokinetic parameters are quite variable and considerably more work is needed to better describe the kinetic disposition of isradipine. Antihypertensive efficacy has been demonstrated extensively in a number of short-term trials. Antianginal efficacy also has been observed in a few short-term trials and is comparable to that of isosorbide dinitrate and nifedipine. Extensive experience with isradipine is minimal and no clear-cut advantages over existing compounds have been noted thus far. CONCLUSIONS: The place of isradipine in the therapy of hypertension and myocardial ischemia is unclear and its routine use cannot yet be recommended based solely on clinical grounds.

Angina Pectoris↗

PubMed1993

Nabumetone: a "nonacidic" nonsteroidal antiinflammatory drug.

OBJECTIVE: To review the pharmacology, pharmacokinetic disposition, dosage recommendations, adverse effects, drug interactions, and efficacy of nabumetone in patients with selected rheumatic disorders and soft-tissue injuries. DATA SOURCES: Data from scientific literature were extracted, evaluated, and summarized for presentation. A MEDLINE search was conducted using the following indexing terms: antiinflammatory agents, nonsteroidal, nabumetone, rheumatoid arthritis (RA), and osteoarthritis (OA). Studies evaluating nabumetone reported in articles, abstracts, or proceedings involving human subjects were considered for inclusion. STUDY SELECTION: Special consideration was given to clinical studies using double-blind, randomized, parallel, controlled designs. Studies comparing the effectiveness and safety of nabumetone with placebo and other nonsteroidal antiinflammatory drugs (NSAIDs) were included. DATA EXTRACTION: Data from human studies published in the English language were evaluated. Trials were assessed according to study design, sample size, and description of outcomes. DATA SYNTHESIS: Nabumetone is a nonacidic prodrug that is metabolized to an active nonsteroidal antiinflammatory moiety, 6-methoxy-2-naphthylacetic acid (6-MNA). 6-MNA is a structural analog of naproxen. Like naproxen and other NSAIDs, 6-MNA possesses analgesic, antipyretic, and antiinflammatory activity, 6-MNA has a prolonged elimination half-life, ranging from 17 to 74 hours, which allows for once-daily dosing. The efficacy of nabumetone for treating symptoms of RA and OA has been established in controlled clinical trials. Nabumetone also has been studied in ankylosing spondylitis and soft-tissue injuries. Adverse effects associated with nabumetone are similar to those associated with other NSAIDs. Gastrointestinal reactions occur most frequently in the form of abdominal pain or indigestion, nausea, or vomiting. Central nervous system adverse effects occur less frequently, and are followed in order of occurrence by rashes. CONCLUSIONS: Nabumetone is a prodrug metabolized to an active metabolite structurally related to naproxen. Studies have demonstrated the efficacy of nabumetone, but no advantages over the many other NSAIDs now available.

Anti-Inflammatory Agents, Non-Steroidal↗

PubMed1993

Meaningful interpretation of risk reduction from clinical drug trials.

OBJECTIVE: To illustrate the concepts of relative and absolute risk reduction, and by example, present and discuss the results of prevention trials that have evaluated the impact of drug therapy on cardiovascular disease. Additional approaches to evaluating the results of prevention trials are also presented. DATA SOURCES: Data were gathered from eight frequently quoted major cardiovascular intervention trials. CONCLUSIONS: Reference to large reductions in relative risk in review papers, newspapers, and at professional meetings can lead to false expectations among clinicians and patients regarding the potential impact of the treatment in individual patients. When making decisions about preventive drug therapy, clinicians are encouraged to examine measures other than relative risk reduction and to include the patient in the decision process. Educators should emphasize these other measures of outcome and not rely solely on relative risk reduction in discussing particular areas of therapeutics.

Canada↗

PubMed1994

Tacrolimus, a new immunosuppressant--a review of the literature.

OBJECTIVE: To review the clinical pharmacology, pharmacokinetics, adverse effects, therapeutic uses, and current status of tacrolimus. DATA SOURCES: Data from scientific literature were identified by a MEDLINE search. The data were extracted, evaluated, and summarized for presentation. Experiences from studies evaluating tacrolimus in the form of articles, abstracts, letters to the editor, or proceedings were considered for inclusion. STUDY SELECTION: Open and controlled clinical and animal trials were reviewed in evaluating the pharmacology, pharmacokinetics, and adverse effects of tacrolimus. DATA EXTRACTION: Data from animal and human studies published in the English literature were evaluated. DATA SYNTHESIS: Tacrolimus is an 822-kDa macrolide antibiotic that has potent immunosuppressive properties. The mechanism of action is similar to that of cyclosporine in that it ultimately blocks the production of interleukin 2, thereby inhibiting further T-lymphocyte proliferation. Tacrolimus is metabolized solely in the liver and the metabolites are primarily excreted in the bile. The elimination half-life of tacrolimus is approximately 8.5 h, and is prolonged in hepatic dysfunction. Tacrolimus has shown efficacy in the prophylaxis of allograft rejection in both animals and human clinical trials, and has been used effectively to rescue patients who have exhibited refractory rejection failing cyclosporine prophylaxis. Adverse effects requiring tacrolimus dosage adjustment include nephrotoxicity, neurotoxicity, alterations in glucose metabolism, and infection or susceptibility to malignancy. CONCLUSIONS: To date, trials comparing tacrolimus with cyclosporine are not available in the literature; however, tacrolimus appears to be useful in rescuing grafts, particularly liver grafts that fail cyclosporine-based immunosuppression. Direct comparisons with cyclosporine are needed to define the role of tacrolimus as primary transplant therapy.

Absorption↗

PubMed1994

Tacrine: first drug approved for Alzheimer's disease.

OBJECTIVE: To review the pharmacology, biopharmaceutics/pharmacokinetics, clinical efficacy, adverse effects, and therapeutic considerations regarding the use of tacrine in patients with Alzheimer's disease. DATA SOURCES: Data from the scientific and professional literature were analyzed, interpreted, and summarized. Citations were obtained by performing a MEDLINE search using the following indexing terms: tacrine, tetrahydroaminoacridine, and Alzheimer's drug therapy. Data also were obtained from a summary of the New Drug Application (Summary Basis of Approval of Cognex) and from the approved product labeling. STUDY SELECTION: Studies in Alzheimer's disease have been plagued by methodologic inconsistencies and deficiencies. Only efficacy studies subsequent to the Food and Drug Administration's (FDA) issuance of recommendations for studies in Alzheimer's disease (1991) were used. Therefore, only double-blind, placebo-controlled, parallel design studies of at least three-month's duration using the Alzheimer's Disease Assessment Scale-Cognitive Subscale and the Clinical Interview-Based Impression of Change as efficacy parameters were included. DATA EXTRACTION: Trials were assessed according to the criteria listed above. Results were evaluated on the basis of both completed patients and last observation carried forward models. DATA SYNTHESIS: Tacrine is a cholinesterase inhibitor that increases the availability of acetylcholine in muscarinic neurons. It has a mean bioavailability after oral administration of about 17 percent and an elimination half-life of approximately three hours. Although drug interactions are poorly studied, tacrine is metabolized by isoenzyme P-450IA2 and may interact with other drugs metabolized by this isoenzyme. Tacrine has been shown to have efficacy in mildly to moderately impaired Alzheimer's patients on both psychometric testing and a clinician's structured interview. Although efficacious, its effects are not dramatic, and it does not affect the ultimate course of the disease. Adverse effects are frequent, and significantly elevated hepatic transaminase concentrations may occur in approximately 25 percent of patients. CONCLUSIONS: Tacrine is the first drug approved by the FDA for treatment of Alzheimer's disease. Although it may improve psychometric test scores in mild to moderately impaired patients, it is not a panacea and does not affect the course of the disease. Patients must be monitored closely for elevated transaminase, cholinergic adverse effects, and interactions with drugs metabolized through P-450IA2.

Alanine Transaminase↗

PubMed1995

Cigarette smoking and clinically significant drug interactions.

OBJECTIVE: To review clinically significant drug interactions associated with cigarette smoking. DATA SOURCES: Data from scientific literature were identified by using a MEDLINE search. Data were extracted, evaluated, and summarized for this review. STUDY SELECTION: Findings and experiences were selected from clinical, epidemiologic, and pharmacokinetic studies; review articles; case studies; abstracts; letters to the editor, and proceedings. DATA EXTRACTION: Data from human studies published in English were evaluated. Only interactions deemed clinically significant are included in this review. Conclusions derived from review articles on the subject of smoking and drug interactions also were used. DATA SYNTHESIS: Cigarette smoking can affect drug therapy via pharmacokinetic and pharmacodynamic mechanisms. Pharmacokinetic drug interactions are presented for theophylline, tacrine, insulin, flecainide, propoxyphene, propranolol, diazepam, and chlordiazepoxide. Pharmacodynamic interactions are described for antihypertensive and antianginal agents, antilipidemics, oral contraceptives, and histamine2-receptor antagonists. CONCLUSIONS: Cigarette smoking can reduce the efficacy of certain drugs or make drug therapy more unpredictable. Pharmacokinetic interactions may cause smokers to require a larger dosage of certain drugs through an increase in plasma clearance, a decrease in absorption, an induction of cytochrome P450 enzymes, or a combination of these factors. Pharmacodynamic interactions may increase the risk of adverse events in smokers with cardiovascular or peptic ulcer disease, and in women who smoke and use oral contraceptives. Healthcare professionals should pay special attention to patients with these profiles and should try to prevent cigarette smoking or encourage patients to discontinue this addictive habit.

Clinical Trials as Topic↗

PubMed1996

Pharmacotherapy of aggressive behavior.

OBJECTIVE: To review the definition, clinical characteristics, prevalence, etiology, neurochemistry, and pharmacologic treatment of aggressive behavior, and provide recommendations regarding the use of specific pharmacologic agents for treating aggressive behavior. DATA SOURCES: Data from the scientific literature were analyzed, interpreted, and summarized. An English-language MEDLINE search yielded clinical trials, case reports, letters, and review articles addressing the etiology and pharmacotherapy of aggression. STUDY SELECTION: Because few well-controlled studies are available in aggression research, all literature addressing the pharmacologic treatment of aggressive behavior, as well as the neurochemistry and psychobiology of aggressive behavior, was reviewed. DATA EXTRACTION: The literature was reviewed on the basis of the particular pharmacotherapy and the specific population used. A separate review of the treatment of aggressive behavior in the elderly was included. DATA SYNTHESIS: The literature was assessed for applicability to clinical practice and usefulness to the general clinician. Recommendations were made from the primary literature in conjunction with trends in clinical practice. Pharmacotherapy is a primary mainstay of treatment for aggressive patients. In individuals for whom behavioral intervention alone is unsuccessful, drug therapy should be initiated along with continued nonpharmacologic intervention. Short-acting benzodiazepines and high-potency antipsychotic agents are effective in treating acute aggression on a short-term or as needed basis. Agents such as lithium, beta adrenergic blockers, carbamazepine, valproic acid, buspirone, trazodone, serotonin reuptake inhibitors, and clozapine may be useful in the chronic management of aggressive behavior. Every attempt should be made to streamline drug therapy in patients with chronic aggression and comorbid psychiatric disorders. CONCLUSIONS: On the basis of available research and extensive clinical experience, lithium or propranolol should be considered as first-line antiaggressive agents in patients without comorbid psychiatric disorders. A minimum trial period for assessing drug efficacy should last at least 6-8 weeks at maximum tolerated dosages. Patients responding to pharmacotherapy should be reevaluated every 3-6 months, and periodic medication tapers and/or drug-free periods should be attempted.

Aggression↗

PubMed1992

Cervical cancer--what role for human papillomavirus?

OBJECTIVE: To review the role of human papillomavirus (HPV) as a causative agent of cancer of the cervix. DATA SOURCES, data synthesis, study selection: Medical journals, recently published text books related to cancer of the cervix and HPV and Papillomavirus Reports were examined to review the pathology of cervical cancer and its precursor lesions, its epidemiology in Australia and overseas, methods of detection of HPV (in particular molecular biology techniques used to diagnose HPV) and evidence linking HPV with genital neoplasia. CONCLUSION: While there is compelling evidence strongly linking certain HPV types with genital cancer, a causative role is yet to be proven and the aetiology is most likely multifactorial. Detection and typing of high risk genotypes of HPV in the genital tract as a diagnostic exercise to identify those women most at risk of developing genital neoplasia is not currently recommended.

Female↗

PubMedDate not supplied

Electrocution in Western Australia, 1976-1990.

OBJECTIVE: To describe the epidemiology of electrical fatalities in Western Australia between 1976 and 1990. DATA SOURCES: Data for the study were gathered from hospital records, autopsy reports and findings from State Energy Commission and coronal investigations. DATA EXTRACTION: Information that was abstracted included age, sex, occupation, voltage, history of incident and autopsy findings. DATA SYNTHESIS: There were 104 victims. Death occurred most frequently in young men exposed to low voltage current during summer, and nearly half the fatalities occurred in the workplace. Water was present in up to 52% of fatalities. Without exception, all victims developed a lethal arrhythmia at the time of exposure to the electric shock, which usually resulted in death at the scene. CONCLUSION: When a victim is exposed to a fatal electric shock, the lethal arrhythmia occurs at the time of electrocution and is just as likely to occur at home as in the workplace. Electrical fatalities can be prevented largely by the use of residual current devices.

Accidents, Home↗

PubMed1993

Genital Chlamydia trachomatis infection in Australia.

OBJECTIVE: To review available data on genital chlamydial infections in Australia, to determine trends and to make recommendations for improving future data collection. DATA SOURCES: Data are presented from representative laboratories around Australia for the 11-year period 1980-1990. Studies of the prevalence of chlamydial infection in Australia and overseas for the same period were selected for review where relevant epidemiological information (such as patient population, reason for test, demographic data) was available. RESULTS: Overall rates of chlamydial infection from the surveyed laboratories ranged from 3.2%-14.6% for the period 1980-1982 and 2.7%-5.5% for 1990. Rates of diagnosis of Chlamydia appeared to decline in some centres while remaining relatively stable at others. Between 2800 and 4000 cases per year have been reported to the CDI (Communicable Diseases Intelligence) scheme since 1985. Substantial increases in the number of tests performed were seen in nearly all laboratories, reflecting a shift towards screening asymptomatic lower-risk women, however detailed data on the populations tested were unavailable. Studies of prevalence of genital chlamydial infection in Australia revealed highest infection rates among sexually transmitted disease clinic clients (2.5%-14%) and a prevalence of more than 5% in women attending family planning clinics. Studies from overseas showed wide variations in prevalence of infection, from 6% to 28% depending on the populations studied. CONCLUSION: Improved data collection is imperative for assessing the impact of intervention programs for chlamydial infection, which has potentially serious but largely preventable sequelae in women. Although diagnosis of genital chlamydial infection appears to be declining or at least stable in Australia, possibly due to intervention programs, it remains a relatively common sexually transmitted infection. Comparison of rates and interpretation of the figures is made difficult by changes in screening practices, lack of standard case definitions, denominator information and probable under-reporting. Recommendations proposed for improving data collection for Chlamydia include establishing sentinel sites, standardising the collection of data, and ensuring standard case definitions between sites.

Adolescent↗

PubMed1993

Drug-induced disorders of glucose tolerance.

PURPOSE: To review the medications that influence glucose metabolism and to examine the mechanisms of these medications on glucose metabolism. DATA SOURCES: Data were obtained from a MEDLINE search back to 1966 and included animal and human studies published in the English language. STUDY SELECTION: Approximately 80% of original publications were included after review by the authors. Case reports were included if they provided additional information. DATE EXTRACTION: The original data from the literature were included on the basis of independent extraction by the authors. DATA SYNTHESIS: Many common therapeutic agents influence glucose metabolism. Multiple mechanisms of action on glucose metabolism exist through pancreatic, hepatic, and peripheral effects. Based on circumstances at the time of use, a drug may cause both hyper- and hypoglycemia in a patient. The patient's previous pancreatic reserve, nutritional state, use of other medication, or exposure to alcohol may influence the direction of the plasma glucose alterations. CONCLUSION: Hyperinsulinemia and insulin resistance form an intrinsic component of diabetes, hyperlipidemia, and atherosclerotic vascular disease (syndrome X). The induction of hyperinsulinemia and insulin resistance by medication may therefore counteract intended benefits. An extensive review of recent medication in patients with disorders of glucose tolerance and the avoidance of polypharmacy are recommended. It is prudent to monitor plasma glucose values when it is not possible to avoid prescription of medication with known effects on carbohydrate metabolism.

Animals↗

PubMed1992

The clinical application of the interferons: a review. NSW Therapeutic Assessment Group.

OBJECTIVES: To review the clinical information on the use of alpha, beta and gamma interferons and to classify the use of alpha interferons in Australia according to approved indications, indications for which there is good supporting evidence and indications where therapy is under investigation; and to estimate the cost of therapy with alpha interferons in New South Wales in 1991. DATA SOURCES: Data were obtained from computerised literature searches. DATA EXTRACTION: A position paper was drafted on behalf of the NSW Therapeutic Assessment Group (NSWTAG). This was circulated to clinicians identified as having a particular interest in the use of the interferons in major NSW teaching hospitals, for comment and amendment where necessary. CONCLUSIONS: Two forms of alpha interferon, interferon alfa-2b and interferon alfa-2a have been approved for use in Australia, interferon alfa-2b for use in the management of hairy cell leukaemia and condylomata acuminata and interferon alfa-2a for use in the management of hairy cell leukaemia and human immunodeficiency virus (HIV) related Kaposi's sarcoma. Applications have been lodged for the use of interferon alfa-2b in HIV related Kaposi's sarcoma, cutaneous basal cell carcinoma and hepatitis B and C and for the use of interferon alfa-2a in the management of hepatitis B, cutaneous T-cell lymphoma and metastatic renal cancer. Interferon alfa-n1 is not available in Australia except for use in a clinical trial in patients who are HIV seropositive. The use of the alpha interferons is currently under investigation in a wide variety of other diseases, with the likelihood that other indications will soon be established. However, the alpha interferons are generally not regarded as first line agents. Beta and gamma interferons have been studied less intensively than the alpha interferons, but it is likely that selected applications for their use will also be defined with the passage of time.

Australia↗

PubMed1992

Thrombolytic therapy of acute myocardial infarction. Keeping the unfulfilled promises.

OBJECTIVE: To assess the use of thrombolytic therapy for acute myocardial infarction, evaluating whether inclusion and exclusion criteria should be altered as well as the public health implications of any such alterations. DATA SOURCES: Data obtained were from English-language articles on the use of thrombolytic therapy in acute myocardial infarction. Articles that reported on inclusion and exclusion criteria as well as specific complications of this therapy were specifically sought. The review included articles under the terms thrombolytic therapy and acute myocardial infarction in the National Library of Medicine's MEDLINE database. STUDY SELECTION: Studies selected for detailed review were those reporting specifics about inclusion and exclusion criteria and efficacy. Data extraction guidelines for assessing data quality included study size, patient population, detail of patient information acquired, and consecutive patient enrollment. DATA SYNTHESIS: Thrombolytic therapy can provide substantial decrements of morbidity and mortality of acute myocardial infarction in the subset of patients who receive this therapy, but is underused in the United States. Advanced age per se should not be an exclusion criterion. Improvements can be made in electrocardiographic diagnosis of acute myocardial infarction. Many of the clinical conditions initially excluded from thrombolytic consideration, such as hypertension or having received cardiopulmonary resuscitation, are only relative contraindications. The benefit/risk ratio in treatment of these patients is often acceptable. Several well-documented points of delay from onset of symptoms to treatment can be minimized, and accelerated therapy can result in a reduction in mortality rates. CONCLUSION: Significant public health benefits will result from greater use of thrombolytic therapy in acute myocardial infarction.

Contraindications↗

PubMed1992

Can we alter survival in patients with congestive heart failure?

OBJECTIVE: To assess the efficacy of pharmacologic therapy in improving survival in patients with congestive heart failure (CHF) in the context of recent investigational studies having mortality as an end point. DATA SOURCES: Data were obtained from English-language articles that reported both randomized and retrospective studies assessing the efficacy of pharmacologic therapy in the treatment of patients with CHF. The review included articles indexed under the terms congestive heart failure and drug therapy in the National Library of Medicine's MEDLINE database. STUDY SELECTION: Studies selected for detailed review were those having mortality as a primary or secondary end point. DATA EXTRACTION: Guidelines for assessing data quality and validity included study size, double-blind and randomized design, the number of end points, the sensitivity and specificity of objective measurements, and the validity of the statistical analysis. DATA SYNTHESIS: Review of the existing literature demonstrates that pharmacologic agents that improve resting hemodynamics or exercise duration in patients with CHF may not necessarily prolong survival. However, recent studies demonstrate that angiotensin-converting enzyme inhibitors prolong survival in patients with symptomatic CHF, while at the same time improving exercise capacity and left ventricular performance. Although less well tolerated, the combination of hydralazine hydrochloride and isosorbide dinitrate therapy also improves survival, but to a lesser degree. New agents show promise, but definitive assessment requires the results of large, randomized and double-blind studies having mortality as an end point. CONCLUSIONS: Mortality is an important end point in assessing the efficacy of drugs for the treatment of CHF.

Anti-Arrhythmia Agents↗

PubMed1992

The epidemiology of murder-suicide.

OBJECTIVE: To review the epidemiology, patterns, and major determinants of murder-suicide and to discuss the clinical and research strategies for identifying the individuals at greatest risk for this type of violence. DATA SOURCES: Data were obtained from English-language articles based on searches using MEDLINE (from 1966), PsychINFO (from 1967), and EMBASE (from 1974) programs. In addition, relevant articles, books, and monographs identified from the reference list of retrieved articles were reviewed. STUDY SELECTION: Case-control studies, descriptive epidemiologic surveys, and case series were chosen for review. DATA EXTRACTION: Because of the limited scope of the pertinent research literature, all data relevant to the incidence, demographics, circumstances, and precipitants of murder-suicide were summarized by the authors. DATA SYNTHESIS: Murder-suicide occurs with an annual incidence of 0.2 to 0.3 per 100,000 person-years and accounts for approximately 1000 to 1500 deaths yearly in the United States. The annual incidence of these events is relatively constant across industrialized nations and has not significantly changed over several decades. The principal perpetrators are young males with intense sexual jealousy, depressed mothers, or despairing elderly men with ailing spouses. The principal victims are female sexual partners or consanguineous relatives, usually young children. Clinical depression, specific motivations such as male sexual proprietariness or maternal salvation fantasies, and a history of previous suicide attempts are important in explaining underlying psychopathological mechanisms. CONCLUSIONS: Murder-suicide occupies a distinct epidemiological domain that overlaps with suicide, domestic homicide, and mass murder. These events may be categorized into one of only several phenomenologic typologies that share similar demographics, motivations, and circumstances. Despite the disruption of families and communities caused by murder-suicide, there are no standardized operational definitions, validated taxonomic systems, or national surveillance networks for these events, all of which are needed to develop prevention strategies.

Case-Control Studies↗

PubMed1991

[Factual databanks of the International Register of Potentially Toxic Chemicals].

The computerized IRPTC data bank will cover the needs for factual information of the Toxicological Information System established in the Institute of Occupational Medicine. The conception and principles of the International Register of Potentially Toxic Chemicals (IRPTC) have been discussed. The main aim of the data bank is providing its users with information necessary to assess the potential threat posed by chemicals to man and his environment. The structure of the data bank, the rules for selection, extraction and presentation of data have been discussed as well as data sources, data management and dissemination of information.

Databases, Factual↗

PubMed1991

The safety and cost-effectiveness of low osmolar contrast media. Can economic analysis determine the real worth of a new technology?

OBJECTIVES: To estimate the reduction in mortality associated with a reduced adverse reaction rate following the substitution of older high osmolar radiocontrast media (HOCM) by the newer and more expensive low osmolar contrast media (LOCM), and to assess the cost-effectiveness of switching from HOCM to LOCM in patients with and without underlying risk factors for adverse reactions from radiocontrast agents. DATA SOURCES: Data from large prospective studies of adverse reactions to HOCM and LOCM were used to estimate the expected number of deaths and severe non-fatal reactions in a hypothetical population receiving one million intravenous radiocontrast injections with HOCM, and the expected reduction in the frequency of these outcomes after substitution by LOCM in high-risk and low-risk groups respectively. Life-years lost with each radiocontrast-related death were estimated from an audit of fatal adverse reaction reports submitted to the Adverse Drug Reactions Advisory Committee. The direct costs considered in the study were the increased costs of LOCM and the hospital costs of treating radiocontrast reactions which were estimated from an audit of cases admitted to public hospitals in Newcastle. STUDY SELECTION: The literature search included Medline (1966-1989) and bibliographies of original and review articles. We included only studies which were prospective, monitored patients in a formal way, described a mechanism for the recording of adverse events and were of sufficient size to have been capable of detecting severe reactions to radiocontrast agents. DATA EXTRACTION: Data were extracted independently by two investigators, unblinded, with disagreements resolved by consensus. DATA SYNTHESIS: Mortality data from individual reports were pooled and exact confidence intervals were calculated on the assumption of a Poisson distribution. In the case of comparative studies the relative risks of severe reactions in low-risk versus high-risk patients and with LOCM compared with HOCM were treated for homogeneity, and pooled odds ratios and 95% confidence intervals (CI) were calculated by combining the logarithms of the odds ratios weighted by their variances. RESULTS: The mortality after intravenous administration of HOCM was estimated from all studies to be 23.3 (95% CI, 2.4-33.1) per million injections. However, the mortality was 11.7 per million (95% CI, 2.4-34.1) in studies published since 1986. The mortality after the use of LOCM was estimated as 3.9 per million (95% CI, 0.1-21.7).(ABSTRACT TRUNCATED AT 400 WORDS)

Australia↗

PubMed1995

Which physicians limit their Medicaid participation, and why.

OBJECTIVE: This study identifies factors differentiating Medicaid participating physicians who accept all Medicaid patients from those limiting their Medicaid participation. DATA SOURCES: Data come from periodic telephone surveys of random samples of physicians conducted by the American Medical Association (AMA). STUDY DESIGN: Surveys conducted in 1990-1993 were pooled to form a sample of 4,188 Medicaid-participating office-based physicians. Respondents were classified as accepting all Medicaid patients or as limiting their Medicaid participation. Descriptive statistics are used to examine differences between these groups with respect to selected personal, practice, community, and reimbursement variables. Logistic regression analysis is used to identify factors associated with physicians accepting all Medicaid patients or limiting their Medicaid participation in some way. DATA COLLECTION METHODS: Survey data were supplemented with 1990 census data, 1990 AMA Physician Masterfile data, and 1989 data on physician payment levels. PRINCIPAL FINDINGS: Less than half of Medicaid-participating physicians and only about one-third of participating primary care physicians accept all Medicaid patients. Higher Medicaid fees are associated with physicians participating fully, but the marginal effects of changes in fees on the probability of physicians participating fully is small. CONCLUSIONS: Increases in Medicaid reimbursement aimed at primary care physicians or those in underserved areas may convert limited participants into full participants and, in so doing, improve the access of Medicaid eligibles to care. The increases in payment level needed to increase the proportion of physicians participating fully would be substantial, however, and may not be politically feasible.

Data Collection↗