Biomedical subjects
Publications and source records attributed to C Hogan.
The general practitioner must be prepared and equipped to cope with the unexpected. As we do not choose our patients--they choose us--we may be confronted with an urgent or potentially lethal problem at any time. It is vital to remain alert to the possibilities, keep equipment stocked and ready, and maintain the basic skills of ABC: airway, breathing, circulation.
The travel patterns of individuals living in rural areas of New York State who were discharged from short-term general hospitals in New York State in 1983 are examined. Counties are used as the geographical unit, and rural individuals who cross geographic boundaries to obtain inpatient hospital care are compared with those who receive such care in their own geographic area. Hospital serving the rural population of New York are classified into three types: urban, consisting of all hospitals located in MSAs; rural referral centers; and other rural hospitals. Next, the rural patients who are admitted to each of these three types of hospitals are characterized in terms of distance traveled, case mix, length of stay, and age. Individuals who travel beyond the counties adjacent to their county of residence had a higher case mix index but were less likely to be more than 75 years old. Distance traveled and the expected cost of care were strongly positively related for patients admitted to urban and rural referral center hospitals, but were only weakly related for other rural hospitals. Finally, comparisons of rural patients in these three types of hospitals were performed adjusting for DRG mix, a comparison which is relevant to hospital reimbursements under the Medicare Prospective Payment System. Using several measures of illness severity, rural patients in urban hospitals and rural referral center hospitals were more severely ill than rural patients in other rural hospitals after adjusting for DRG mix. We conclude that somewhat higher payments to urban hospitals and rural referral center hospitals in New York are justified based on the more severely ill patients which they treat
Painful transcutaneous electrical nerve stimulation (TENS) of the foot dorsum evoked axon reflex vasodilatation, measured by laser Doppler flowmetry. In addition, acetylcholine (ACh) and sodium nitrite (NaNO2) were iontophoresed to cause vasodilatation by endothelium dependent and independent mechanisms, respectively. Compared with healthy volunteers, diabetic patients with clinically diagnosed neuropathy showed reduced electrical axon reflex flare and ACh responses, but not NaNO2 responses. Such reduced cutaneous nocifensor functions may contribute to some symptoms and complications of diabetes mellitus.
This paper describes the value of non-invasive neurovascular function tests in the clinical setting. Painful transcutaneous electrical nerve stimulation (TENS) of the dorsum of the foot evoked axon reflex vasodilatation, measured by laser Doppler flowmetry. In addition, acetylcholine and sodium nitrite (NaNO2) were iontophoresed to cause vasodilatation by endothelium-dependent and -independent mechanisms, respectively. Compared with healthy volunteers, diabetic patients with clinically diagnosed neuropathy showed reduced electrical axon reflex flare responses. These responses in one additional subject were absent in a region of denervated skin. Acetylcholine responses, but not NaNO2 responses, were also depressed in patients with diabetic neuropathy. Such reduced cutaneous nocifensor functions may contribute to some symptoms and complications of diabetes mellitus.
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Bacteriophage immunoassays, radioimmunoassays, and biological assays have been used to measure levels of NGF in media conditioned by rat C-6 glioma cells in culture. By all three criteria, these cells secrete a macromolecule which is indistinguishable from mouse submandibular gland NGF.
In most clinical trials of antiretroviral therapy for patients infected with HIV, the major outcome variable has been the combined clinical endpoint of any new or recurrent AIDS defining event. We review features of combined endpoints and use data from the Terry Beirn Community Programs for Clinical Research on AIDS (CPCRA) to evaluate this outcome measure in terms of relevance, diagnostic certainty and sensitivity. We conclude that this endpoint is not relevant because: (i) the 19 different events constituting the combined endpoint are equally weighted in analyses even though they vary considerably in terms of risk of death; and (ii) events after the first are ignored, thus the event profile of patients is not taken into account in making treatment comparisons. We also conclude that power may be low with use of this endpoint if treatments under study do not have an immediate impact on disease progression, if some events which occur soon after randomization represent a disease process that has already begun to incubate, or if treatment differences for the various events constituting the combined endpoint are differentially effected by treatment. Since the ease and certainty of diagnosis of each of the 19 events also vary, we recommend that survival be the primary endpoint of antiretroviral trials, and that all opportunistic events experienced by patients, not just the first, be collected and summarized. Trial reports should include comparisons of incidence of each event by treatment group so that readers can rank events as they please. A single summary measure which considers severity and the entire event profile, as described here, would also be useful for assessing the impact of treatments on quality of life. Further research on approaches for weighting and combining multiple outcome measures is needed.
About 13 percent of Medicare beneficiaries receive some assistance from Medicaid. States "buy in" Medicare coverage for these low-income beneficiaries. For those eligible, states also provide benefits beyond those covered by Medicare. Buy-in beneficiaries are different from other Medicare beneficiaries in many ways. They have lower incomes, which is consistent with the policy intent. They use more health services in general but do not appear to receive timely, appropriate care relative to several disease-specific standards. As policymakers consider restructuring Medicare and Medicaid, careful attention needs to be paid to the effects of changes on these beneficiaries.
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This paper profiles Medicare beneficiaries' costs for care in the last year of life. About one-quarter of Medicare outlays are for the last year of life, unchanged from twenty years ago. Costs reflect care for multiple severe illnesses typically present near death. Thirty-eight percent of beneficiaries have some nursing home stay in the year of their death; hospice is now used by half of Medicare cancer decedents and 19 percent of Medicare decedents overall. African Americans have much higher end-of-life costs than others have, an unexpected finding in light of their generally lower health care spending.
Medicare has more than five million beneficiaries with disabilities who are under age sixty-five, and enrollment is rising rapidly. This paper presents a profile of nonelderly beneficiaries in fee-for-service Medicare by major disability category, excluding those with end-stage renal disease. The profile is based on Medicare Current Beneficiary Survey (MCBS) Cost and Use data for 1994-1996. We estimate Medicare costs by service type and health care costs by payer type, and we discuss implications for Medicare reform and related federal disability policy issues.
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