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Biomedical subjects

D R Rovner

Publications and source records attributed to D R Rovner.

At least 37 records · Page 2Linked to original sources
PubMed1987

Social policy and professional self-interest: physician responses to DRGs.

Prospective hospital reimbursement based on Diagnosis Related Groups (DRGs) began in 1983 for Medicare patients, and many states are adopting similar systems for Medicaid recipients in an attempt to curb rising health care costs. Because of their unprecedented intrusiveness compared to previous cost-containment measures and because they explicitly introduce financial incentives to reduce services, DRGs have great potential to affect health care delivery. To determine the effects of DRGs on hospitals and physicians, six months of ethnographic fieldwork was carried out on the medicine and pediatrics services of a university-affiliated hospital during the first year of DRG-based reimbursement. Observations and interviews were used to discern institutional responses to DRGs and physician knowledge of, experience with, and reactions to this cost-containment effort. Our findings indicate that the hospital instituted many changes to protect its interests. Data gathered from patients' abstracts suggest providers are successfully dealing with the new system; the average length of stay for Medicare patients was reduced by 38% in the first year of prospective reimbursement, compared with a 15% reduction for other patients (P less than 0.05). As a group, the physicians made no organized effort to educate themselves about the new cost-containment regulations. Their knowledge of DRGs was vague and included many misconceptions. Their response was not a coherent one taking broad social concerns into account. Cost-containment was viewed negatively, as a threat to the financial integrity of the hospital, patient care, and professional autonomy.(ABSTRACT TRUNCATED AT 250 WORDS)

Attitude of Health Personnel↗
PubMed1986

Comparison of physicians' decisions regarding estrogen replacement therapy for menopausal women and decisions derived from a decision analytic model.

Decisions regarding estrogen replacement therapy were obtained from 50 physicians for 12 cases representing menopausal women with systematically varying levels of cancer risk, fracture risk, and symptom severity. Their decisions were compared with a decision analytic model for which each physician provided needed quantities--subjective probabilities, utilities of various outcomes, and weightings of the importance of the outcome categories. The majority of observed decisions were not to treat. By contrast, the decision analysis based on physician-provided estimates indicated that the optimal strategy was either to treat or a toss-up. Sensitivity analysis showed that these conclusions would hold over all possible utilities, over all plausible probabilities of cancer, and so long as symptom relief and fracture prevention were also considered as treatment objectives. The increased probability of early detection of cancer by regular follow-up was systematically incorporated into the decision analysis but apparently neglected in unaided clinical judgment, which follows the principle of minimizing the most important risk, regardless of its probability.

Decision Theory↗
PubMed1986

Factitious hypoglycemia. Clues to identifying an elusive disorder.

Factitious hypoglycemia is similar in presentation to insulinoma and occurs most commonly in persons with ready access to insulin. Diagnosis previously was based on circumstantial evidence but now can be confirmed by demonstration of high insulin levels and low C-peptide levels in the presence of hypoglycemia. Treatment is primarily psychiatric, and success so far is limited.

Adult↗
PubMed1986

Human insulin. Its development and clinical use.

With the recent availability of human insulin, we have entered a new era in therapy for diabetes mellitus. Human insulin is not a cure for diabetes; however, no disadvantages are known to be associated with its use at present. Human insulin costs less than the other purified insulins, and because of its potential advantages, human insulin deserves consideration for use in all newly diagnosed insulin- dependent diabetics.

Amino Acid Sequence↗
PubMed1986

Hormonal effects of smoking--I: Effects on plasma renin activity.

It is generally recognized that smoking is associated with an increased risk for the development of coronary artery disease. Since it has been suggested that increased plasma renin activity (PRA) may be a risk factor for cardiovascular disease, PRA was measured in a group of smokers and nonsmokers. PRA was measured under basal conditions, following intravenous (IV) furosemide administration and after a short burst of smoking. In addition, the effect of nicotine on renin secretion was evaluated in vitro. Smoking was associated with a significant increase in pulse rate and systolic blood pressure, but no significant change in diastolic blood pressure in both groups. Basal PRA was similar among smokers and was not significantly influenced by smoking in either group. PRA increased significantly following IV administration of furosemide, but there was no significant difference between the two groups. Incubation of rat kidney slices with nicotine also did not result in increased renin secretion. These findings confirm that smoking affects the cardiovascular system, but no significant effect of smoking on PRA was observed both in vivo and in vitro experiments. These findings suggest that the increased risk for the development of coronary artery disease associated with smoking is not mediated by increased PRA.

Adult↗
PubMed1986

Hormonal effects of smoking--II: Effects on plasma cortisol, growth hormone, and prolactin.

Effect of smoking on the plasma levels of cortisol, growth hormone, and prolactin was evaluated in a group of smokers and nonsmokers. Plasma levels of these hormones were measured under basal conditions and following a short burst of smoking. In addition, to determine the mechanism of action of nicotine on the release of these hormones, rat renal cortical slices were incubated with nicotine and the generation of cyclic AMP was measured in vitro. Increasing concentrations of nicotine in the incubation medium resulted in increased generation of cyclic AMP. Basal levels of plasma cortisol were similar for both smokers and nonsmokers. After smoking, the cortisol levels increased significantly among smokers only and the levels achieved were significantly higher compared with nonsmokers. Mean prolactin curves were higher among nonsmokers compared with smokers, whereas growth hormone levels were similar in the two groups. These data suggest that the effects of smoking on pituitary/adrenal hormones differ among smokers and nonsmokers and that these effects may be mediated through increased generation of cyclic AMP induced by nicotine.

Adult↗
PubMed1985

Diabetic ketoacidosis: outcome in a community hospital.

The mortality among patients with diabetic ketoacidosis (DKA) has been reported to be as high as 5% to 15%. To determine the outcome of DKA, we reviewed the charts of all patients admitted to one of our community affiliated hospitals for the period of January 1979 to December 1981. We identified 66 episodes of DKA in 42 patients. All patients received intravenous fluids. Insulin was given by continuous infusion in six (9%), by bolus only in 14 (20%), and by a combination of the two in 46 (71%). The mean time for recovery from DKA was similar in all three subgroups. All patients recovered from DKA and were discharged from the hospital; no deaths occurred. We conclude that it is possible to treat DKA effectively in a community hospital, with mortality approaching zero.

Adolescent↗
PubMed1985

Rationale for physicians' decisions to refer obese patients.

Health care costs are an increasing burden upon American society. Referral of patients to a specialist generates additional cost. We studied the reasons behind decisions to refer patients with uncomplicated obesity to endocrinologists. Obesity may be viewed as a paradigm of diseases with relatively well-known etiology, low morbidity and mortality, chronicity, and poor outcome from standard therapy. In addition, it is a disease that is rarely curable by medical intervention, requiring behavioral change. Physicians have little direct experience in the differential diagnosis of endocrine disease, because of its low prevalence. We studied the referral decisions of 45 physicians in three medical specialties. Clinical decision making was studied using a standard set of 24 carefully structured case reports of obese women, all without obvious endocrine disease cues on history or physical. In these cases the patients' desire to be seen by endocrinologists was the major factor in the decision to refer. Referrals were not made primarily to rule out suspected endocrine disorder or because of concern for increased risk of morbidity.

Body Weight↗
PubMed1985

Systemic allergy to human (recombinant DNA) insulin.

Allergy to insulin is extremely rare and is, in part, due to the differences in amino acid sequence of animal and human insulin. We report here a 37-year-old, white, pregnant woman who was allergic to beef/pork, purified pork, as well as human insulin. She reacted with a wheal and flare reaction in response to intradermal human and purified porcine insulins. She was desensitized to human insulin in order to continue insulin therapy during pregnancy. The course of this patient emphasizes that some patients are allergic even to human insulin and may require desensitization prior to insulin therapy.

Adult↗
PubMed1984

Differences in medical referral decisions for obesity among family practitioners, general internists, and gynecologists.

This study explored variation in the decisions of primary care physicians to refer or not to refer obese patients to an endocrinologist and the principles underlying their decisions. Forty-five physicians--family practitioners, obstetricians, and general internists--made referral judgments on 24 cases and completed a questionnaire. Data indicated a difference among specialties in the number of cases referred (P less than or equal to 0.01) that was not accounted for by physician characteristics. The number of cases referred ranged from 0 to 19, with a mean of 8. The patient's desire for treatment by an endocrinologist was overwhelmingly the major factor in decisions to refer. Gynecologists differed from other physicians by referring for management and not expecting the patient to return to their care. Referrals were not made primarily to rule out suspected endocrine disease or out of concern for morbidity due to obesity. These referrals are thus not perceived as medically beneficial, but are responses to patient pressure or physicians' desire to transfer management.

Body Weight↗
PubMed1984

Primary hypothyroidism, pituitary insufficiency and pregnancy. A case report.

A 23-year-old woman presented with primary hypothyroidism and inability to lactate following uneventful childbirth. Endocrine evaluation revealed that she had autoimmune hypothyroidism and deficiencies of ACTH and prolactin. Despite partial hypopituitarism, she again conceived spontaneously, had an uneventful pregnancy and delivery but failed to lactate. Radiologic evaluation of the hypophysis, including CAT scan, was normal, and antibodies to anterior pituitary cells were not detected. The etiology of the pituitary insufficiency might have been autoimmune hypophysitis , a recently described entity in which anterior pituitary, along with the other endocrine glands, is destroyed by an autoimmune process. The clinical course suggested that women with pituitary insufficiency, although rare, are able to conceive and carry the pregnancy to term. Our patient illustrates that prolactin insufficiency does not preclude a successful outcome of pregnancy but can result in no lactation.

Adrenocorticotropic Hormone↗
PubMed1983

Effect of oral contraceptives on plasma glucose, insulin, and glucagon levels.

Effects of oral contraceptive agents (mestranol and norethindrone) on carbohydrate metabolism were evaluated in a group of 18 healthy young women. Plasma glucose, insulin, and glucagon responses were evaluated after a glucose load (oral and intravenous) and an amino acid challenge (oral and intravenous). The oral glucose tolerance was normal and was unaltered by the use of oral contraceptive agents. However, following intravenous administration of glucose, plasma glucose levels were slightly but significantly elevated when subjects were using oral contraceptives. Plasma insulin concentrations were slightly but significantly higher than control values in response to oral and intravenous administration of glucose while subjects were using oral contraceptives. Plasma glucagon concentrations in response to oral and intravenous glucose were similar whether the subjects were using oral contraceptive agents or not. No significant differences from control values were observed after oral and intravenous amino acid challenges when subjects were using oral contraceptive agents. Mild elevations of glucose and insulin without any significant change in glucagon concentrations suggest that glucagon levels do not play a major role in the development of insulin resistance seen in some patients using oral contraceptive agents.

Administration, Oral↗
PubMed1983

Recurrent transient hyperthyroidism and hypothyroidism associated with pregnancy.

We describe a female patient with insulin-dependent diabetes mellitus and autoimmune thyroiditis. Transient hyperthyroidism developed in the postpartum period in two successive pregnancies, followed by temporary hypothyroidism with eventual full recovery. The clinical course was consistent with "silent thyroiditis" and the circumstantial evidence suggested that alterations in the antibody titers due to pregnancy may have been responsible for these episodes. This case study serves to emphasize that hyperthyroidism and hypothyroidism in the postpartum period may be transient, and this fact should be considered in therapeutic management of such a patient.

Adult↗
PubMed1983

A chart audit study of the referral of obese patients to endocrinologists.

The aim of this study was to identify factors in primary care physicians' decisions to refer obese patients to an endocrine clinic. Charts of 83 referred obese patients were compared with randomly selected charts of 300 obese adults in the general ambulatory clinic files. The referral rate is estimated at 1% of obese patients in the clinical center and 0.25% of obese persons in the Lansing area. Referral of obese patients appears to depend primarily on degree of obesity and secondarily on suspicion of endocrine disease. Considerations limiting the usefulness of patient charts for studies of physicians' decision making are discussed.

Adolescent↗
PubMed1982

Pancreatic glucagon: possible implications of the hyperglycemic hormone in diabetes control.

Pancreatic glucagon, the hyperglycemic hormone secreted by the alpha cells of the islets of Langerhans, promotes glycogenolysis, neoglucogenesis, lipolysis, and ketogenesis. Several abnormalities of glucagon secretion have been described in diabetes mellitus. These include absolute or relative hyperglucagonemia, exaggerated response to a protein load, and insufficient response to hypoglycemia. Although glucagon's role in diabetes has been challenged, the bulk of the evidence suggests that while insufficiency of insulin is the major abnormality involved, inappropriately elevated glucagon levels contribute to worsening of hyperglycemia. It is suggested that lowering of glucagon levels will result in better control of diabetes. To some extent, this can be achieved by continuous infusion of insulin in insulin-dependent diabetics. In addition, development of analogs of somatostatin holds promise of therapeutic benefit in both insulin-dependent and non-insulin-dependent types of the disease.

Amino Acids↗