Salmeterol for the treatment of asthma.
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Administration, Inhalation↗
Biomedical subjects
M Weinberger
Publications and source records attributed to M Weinberger.
Surprising activity of flutamide withdrawal, when combined with aminoglutethimide, in treatment of "hormone-refractory" prostate cancer.
BACKGROUND: The best treatment for patients with "hormone-refractory" metastatic prostate cancer is unclear, particularly in patients for whom suramin and hydrocortisone have failed. PURPOSE: We investigated a combination of flutamide withdrawal and aminoglutethimide in suramin- and hydrocortisone-pretreated patients with "hormone-refractory" prostate cancer. METHODS: Twenty-nine patients with metastatic prostate cancer were treated with simultaneous flutamide withdrawal and aminoglutethimide (250 mg given orally four times daily). All patients were taking flutamide at the time of entry, and previous treatments with medical or surgical castration, flutamide, suramin, and hydrocortisone had failed in all of these patients. Because of suramin-induced adrenal insufficiency, all patients had previously received, and continued to receive, physiological doses of hydrocortisone. Treatment of all non-surgically castrated patients had previously failed; however, these patients continued to receive depot leuprolide. RESULTS: In 14 (48%) of 29 patients, the prostate-specific antigen (PSA) decreased by more than 80% for 4 or more weeks. Improvements in anemia, thrombocytopenia, soft-tissue masses, bone scans, and symptoms were also noted. Factors associated with response included prolonged flutamide pretreatment, a markedly elevated pretreatment PSA, and the absence of soft-tissue disease. CONCLUSIONS: Flutamide withdrawal, when combined with the simultaneous administration of aminoglutethimide, is a therapeutically active approach in patients with "hormone-refractory" prostate cancer. IMPLICATIONS: On the basis of these and additional data, we hypothesize that prolonged exposure to flutamide results in the selective proliferation of cancer cells containing a mutant androgen receptor that aberrantly recognizes flutamide metabolites and nonandrogenic steroids as androgenic stimuli.
Aged↗
Lack of association between patients' measured burden of disease and risk for hospital readmission.
Identifying patients at increased risk for hospital readmission is important for clinicians, health policy-makers, hospital administrators, and researchers. We used a retrospective case-control design to compare the clinimetric properties of five validated indices that measure a patient's disease burden. The study was conducted on a random sample of patients discharged from the general medicine service at the Durham Department of Veterans Affairs Medical Center. Trained observers (two research assistants, one nurse, and two physicians) blinded to readmission status abstracted the required data elements from the medical record for three indices (Charlson, Kaplan-Feinstein, Index of Coexistent Disease). The hospital's computer provided data elements for two indices (Smith, adapted Charlson). Indices varied in the time required to complete, the ability to capture individual heterogeneity, and inter-observer variability. However, none of the indices discriminated among patients who did and those who did not have 6-month hospital readmissions. Factors other than summary scores derived from these indices should be used to identify patients at high risk for readmission.
Aged↗
A summated score for the medication appropriateness index: development and assessment of clinimetric properties including content validity.
Inappropriate medication prescribing is an important problem in the elderly, but is difficult to measure. As part of a randomized controlled trial to evaluate the effectiveness of a pharmacist intervention among elderly veterans using many medications, we developed the Medication Appropriateness Index (MAI), which uses implicit criteria to measure elements of appropriate prescribing. This paper describes the development and validation of a weighting scheme used to produce a single summated MAI score per medication. Using this weighting scheme, two clinical pharmacists rated 105 medications prescribed to 10 elderly veterans from a general medicine clinic. The summated score demonstrated acceptable reliability (intraclass correlation co-efficient = 0.74). In addition, the summated MAI adequately reflected the putative heterogeneity in prescribing appropriateness among 1644 medications prescribed to 208 elderly veterans in the same general medicine clinic. These data support the content validity of the summated MAI. The MAI appears to be a relatively reliable, valid measure of prescribing appropriateness and may be useful for research studies, quality improvement programs, and patient care.
Aged↗
Bacterial laryngotracheitis associated with toxic shock syndrome in an adult.
Nonmenstrual toxic shock syndrome (TSS) in adults has been associated with various staphylococcal respiratory tract infections, including pharyngitis, tonsillitis, pneumonia, and postinfluenza respiratory tract infections. In children, nonmenstrual TSS has also been described as a complication of bacterial tracheitis. We describe the case of a 40-year-old woman who presented with laryngotracheitis as well as clinical and laboratory evidence of TSS. Culture of her sputum samples yielded pure growth of Staphylococcus aureus, which was shown to produce TSS toxin 1 (TSST-1). The patient responded promptly to therapy with iv clindamycin. We discuss the association of TSS with staphylococcal laryngotracheitis and the role of clindamycin in the treatment of TSS. To our knowledge, there are no previous reports of TSS complicating laryngotracheitis in adults.
Adult↗
The relationship between glycemic control and health-related quality of life in patients with non-insulin-dependent diabetes mellitus.
The relationship between glycemic control and health-related quality of life was examined in patients with non-insulin-dependent diabetes mellitus (NIDDM). Within the context of a randomized controlled trial, 275 patients with NIDDM receiving primary care from a Veteran's Administration general medical clinic were enrolled and monitored for 1 year. Glycemic control (glycosylated hemoglobin levels) and health-related quality of life (Medical Outcomes Study Short-Form 36-item Health Survey [SF-36]) were assessed at baseline and at 1 year. Multivariate regression modeling using baseline and change scores during a 1-year period did not find a linear or curvilinear relationship between glycosylated hemoglobin and SF-36 scores (P = .15); this was true even after controlling for five covariates identified a priori (insulin use, number of diabetic complications, duration of diabetes, education, number of hyper-, or hypoglycemic episodes during the preceding month). Health services researchers and clinicians alike need to be aware that these two important outcomes may not be directly related. This lack of association could contribute to the high noncompliance rates observed among patients prescribed complex diabetic regimens. Unless patients perceive a benefit from following such regimens, good glycemic control may continue to be an elusive therapeutic goal, especially in patients with long-standing disease.
Blood Glucose↗
Appropriateness of medication prescribing in ambulatory elderly patients.
OBJECTIVE: To assess the quality of medication prescribing in ambulatory elderly patients on multiple medications using the Medication Appropriateness Index (MAI). DESIGN: Cross-sectional study. SETTING: General Medical Clinic of the Durham VA Medical Center. PATIENTS: 208 elderly outpatients on five or more regularly scheduled medications. MEASUREMENTS: Medication prescribing appropriateness was measured with the MAI, a reliable method that employs 10 implicit criteria. A weighted MAI score (range 0-18 per drug) served as a summary measure of appropriateness. RESULTS: There were 1644 medications evaluated; 26% received no inappropriate ratings, 37% had one, 19% had two, and 18% had three or more. Of 16,440 ratings, 2295 (14%) were evaluated as inappropriate. The percentage of inappropriate ratings varied across prescribing dimensions: drug-drug interactions, 0%; drug-disease interactions, 1.4%; medication effectiveness, 4.7%; therapeutic duplication, 5.7%; indication, 11.5%; duration of treatment, 16.5%; dosage, 17.3%; practical directions, 20.3%; cost, 29.7%; and correct directions, 32.4%. The mean MAI score for all medications was 2.2 +/- 2.1 (range 0-10) and varied by therapeutic class. MAI scores were significantly lower for medications with a high potential for adverse effects compared with those with a low potential (MAI score of 1.8 vs 2.9, P < 0.001). Regression analysis revealed that no patient characteristics were associated with a higher likelihood of inappropriate prescribing. CONCLUSIONS: Medication prescribing for elderly outpatients taking multiple medications was substantially appropriate. Prescribing dimensions with the most room for improvement were more exact directions, less expensive drugs, and practical directions. Drugs at high risk for adverse effects were prescribed more appropriately than those at low risk.
Age Factors↗
Assessing health-related quality of life in elderly outpatients: telephone versus face-to-face administration.
OBJECTIVE: While health-related quality of life (HRQOL) is increasingly being used as an outcome in clinical trials, it is unknown whether HRQOL assessments are influenced by the method of administration. Within the context of a randomized, controlled trial evaluating a pharmacist intervention for elderly outpatients prescribed at least five medications, we compared telephone and face-to-face administration of the SF-36, a widely used HRQOL measure. DESIGN: Survey. SETTING: General Medicine Clinic, Veterans Affairs Medical Center. PATIENTS: At entry, participants in the randomized trial received continuous care from a general medicine clinic physician, were > or = 65 years of age, and were prescribed > or = 5 regularly scheduled medications. Patients were excluded if they were cognitively impaired and had no caregiver available to participate in the study as a proxy or if they resided in a nursing home. MEASUREMENTS: Subjects completed the SF-36 by telephone at closeout and face-to-face at clinic visits within 1 month (mean = 16.7 days). MAIN RESULTS: Telephone administration required significantly less time than face-to-face interviews (10.2 vs 14.0 minutes, P < 0.001). Although systematic differences between modes of administration were generally small, there were substantial nonsystematic discrepancies for all eight SF-36 scales (mean absolute difference scores ranged from 10.8 to 30.1). Discrepancies were greatest for emotional role functioning, physical role functioning, social functioning, and bodily pain; these four scales also demonstrated low to moderate correlations (.33 to .58). CONCLUSIONS: The two modes of administration may not produce interchangeable results. Researchers should be cautious when mixing modes of administration to elderly patients.
Activities of Daily Living↗
Antibiotic induced meningitis.
Three patients with antibiotic induced meningitis, one following penicillin with seven episodes, are reported on--the first well documented description of penicillin induced meningitis. In this patient episodes of headache and nuchal rigidity appeared with and without CSF pleocytosis. Two patients had a total of five episodes of antibiotic induced meningitis after trimethoprim-sulphamethoxazole (co-trimoxazole) administration. The features common to all three patients were myalgia, confusion and low CSF glucose. CSF analysis was not a reliable method to differentiate antibiotic induced meningitis from partially treated bacterial meningitis.
Adolescent↗
A telephone-delivered intervention for patients with NIDDM. Effect on coronary risk factors.
OBJECTIVE: To examine whether a telephone-delivered intervention (TDI), designed to improve glycemic control in patients with non-insulin-dependent diabetes mellitus (NIDDM), improved coronary risk factors in high-risk patients. RESEARCH DESIGN AND METHODS: This randomized controlled trial involved 275 veterans with NIDDM followed in a general medical clinic. Intervention (TDI) patients were telephoned at least monthly by a nurse. Calls emphasized compliance with the medical regimen (diet, medications, and exercise), encouraged behavioral changes, and facilitated referrals to a dietitian or smoking cessation clinic. Control patients received no such calls. Baseline and 12-month follow-up measurements included fasting lipid profiles, weight, smoking status (self-reported; cessation verified by measurement of exhaled CO), adherence to diet and exercise (self-reported), appointments, and medications (hospital computerized data base). RESULTS: After 12 months, equal numbers of obese patients in the two groups reported adhering to a diabetic diet and exercising, although more obese TDI patients had seen a dietitian (30 vs. 7%, P = 0.003). Weight loss was not seen in either group (-0.9 +/- 5.3 vs. -0.1 +/- 3.6 kg, P = 0.202). Hyperlipidemic TDI patients were more likely to see a dietitian (31 vs. 6%, P = 0.003) and receive lipid-lowering medications (22 vs. 9%, P = 0.096), but serum cholesterol reduction was similar between groups (-11.7 +/- 33.4 vs. -4.3 +/- 32.7 mg/dl, P = 0.270); comparable results were seen for high-density lipoprotein, low-density lipoprotein, and triglyceride levels. More TDI group smokers reported quitting (26 vs. 0%, P = 0.033), but the difference was not significant for CO-verified abstention (10 vs. 0%, P = 0.231). CONCLUSIONS: The TDI improved self-reported adherence to regimens that might reduce coronary risk, but had little effect on objective measures of risk.
Blood Glucose↗
Successful surgical management of neutropenic enterocolitis in two patients with severe aplastic anemia. Case reports and review of the literature.
We describe two patients with severe aplastic anemia in whom neutropenic enterocolitis developed while they were undergoing treatment at the National Institutes of Health. Both patients had progressive symptoms while receiving optimal medical management and both underwent and survived surgical intervention despite continued prolonged neutropenia in the perioperative period. This experience contrasts with six cases reported in the literature and suggests that surgery can be employed even in patients with profound neutropenia. Thus, in patients who remain persistently septic or who develop clinical deterioration despite medical management or who have other indications for surgical intervention, neutropenia should not be a contraindication to the appropriate or necessary procedure.
Adolescent↗
Cost-effectiveness of increased telephone contact for patients with osteoarthritis. A randomized, controlled trial.
OBJECTIVE: To evaluate the cost-effectiveness of telephone intervention for patients with osteoarthritis. METHODS: Randomized, controlled trial. RESULTS: The intervention did not significantly increase health care costs. The annual costs for a 1-unit improvement in physical functioning and in pain, as measured by the Arthritis Impact Measurement Scales, were $70.86 and $31.00, respectively. CONCLUSION: Telephone contact is a potentially cost-effective intervention in osteoarthritis.
Aged↗
Theophylline: when should it be used?
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Adrenal Cortex Hormones↗
Health care research in rheumatology.
In the first three sections of this review, studies of disability among patients with musculoskeletal conditions are discussed. Evidence continues to demonstrate that arthritis has a substantial impact on disability. Correlates of disability for patients with general musculoskeletal conditions, rheumatoid arthritis, and osteoarthritis are reviewed, as are strategies to ameliorate arthritis-related disability. The fourth section of this review highlights the importance of pain-coping strategies for arthritis patients. The concluding section reviews educational strategies in the rheumatic diseases.
Adult↗
Social service interventions for caregivers of patients with dementia: impact on health care utilization and expenditures.
OBJECTIVES: An intervention, which had as its primary goal the enhancement of compliance to social work recommendations, was shown to produce extremely high rates of compliance. This report addresses the secondary objective of the study: to evaluate the impact of the intervention on short-term (ie, 6-month) health services utilization and expenditures. DESIGN: Randomized controlled trial. SETTING: University-based memory disorders clinic. PARTICIPANTS: Caregivers of patients with progressive memory disorders. MAIN OUTCOME MEASURES: Service utilization and expenditures. RESULTS: The intervention did not have a statistically significant impact on utilization of either health care or community resources. The intervention group had $903 less expenditures during the study period, a difference that did not achieve statistical significance. The results were consistent when controlling for caregiver characteristics that differed at baseline. CONCLUSIONS: Although the intervention was successful in enhancing compliance with recommendations, more intensive interventions may be required to increase subsequent service utilization. Future investigations may wish to target the appropriateness of services used over a period longer than 6 months.
Aged↗
Prophylactic nitroglycerin infusion during noncardiac surgery does not reduce perioperative ischemia.
We evaluated the impact of prophylactic nitroglycerin on the incidence of perioperative myocardial ischemia in patients with known or suspected coronary artery disease who undergo noncardiac surgery. Our goals were to better define the role of nitroglycerin in the management of high-risk patients and to explore the mechanisms of perioperative myocardial ischemia. Patients were assigned randomly to either a control group (n = 23) or to receive 0.9 micrograms.kg-1.min-1 of intravenous nitroglycerin (n = 22). The diagnosis of myocardial ischemia was based on a review of Holter electrocardiogram (ECG) recordings. There was no difference in the incidence of ischemia between groups. Seven control patients (30%) and seven nitroglycerin patients (32%) exhibited ECG evidence of ischemia. The preponderance of myocardial ischemia occurred during emergence from anesthesia (of the 14 patients exhibiting ischemia, 12 did so at emergence). There was an acute increase in heart rate at the onset of ischemia in all patients exhibiting ischemia with 14 of 18 episodes associated with an increase of 20% or greater. The heart rate associated with the onset of ischemia was greater in the nitroglycerin-treated patients than in the control group. We also found that the occurrence of myocardial ischemia on a preoperative Holter recording was strongly predictive of the subsequent occurrence of perioperative ischemia. In conclusion, the addition of nitroglycerin to standard anesthetic management of these high-risk patients does not measurably reduce perioperative ischemia.
Aged↗
Expenditures in caring for patients with dementia who live at home.
OBJECTIVES: Given the national interest in progressive dementia, we estimated expenditures incurred in caring for dementia patients who live at home. METHODS: Primary caregivers of 264 patients from a university-based memory disorders clinic were interviewed at baseline and asked to keep service use diaries for 6 months; 141 caregivers who returned the diaries are the focus of this report. We examined both formal and informal services (distinguished by whether money was exchanged) and associated expenditures. RESULTS: Neither caregivers returning diaries nor their patients differed at baseline from those not returning diaries and their patients. Expenditures incurred over 6 months were extensive for both formal ($6986) and informal ($786) services. Out-of-pocket expenditures were high (e.g., in-home companion or sitter, adult day care, visiting nurse). Multivariable analyses indicated that patients with more severe symptoms of dementia and families with higher incomes reported significantly higher expenditures. CONCLUSIONS: The expense of caring for patients with progressive dementia living at home may be higher than previously estimated and frequently involves expenses paid directly by patients and their families.
Aged↗
Sexual behavior of homosexual and bisexual men attending an HIV testing clinic in Jerusalem 1986/7-1990.
We investigated whether the sexual practices of homosexual and bisexual men attending the Jerusalem AIDS Clinic had changed between 1986/7 and 1990. The responses of a group of 79 homosexual and bisexual men to a questionnaire in 1986/7 were compared to the responses of a group of 37 homosexuals/bisexuals in 1990. Consistent yet statistically insignificant differences in sexual behavior between the 1990 and 1986/7 groups were observed: More individuals were using condoms (53% vs 36% respectively), and at an earlier age. The practice of anal sex was less common (48% vs 67% respectively) and that of oral sex more common (46% vs 27% respectively). These differences were not confounded by the level of education between the two groups. Analyzed separately for homosexuals and bisexuals, the increase in condom use was more noticeable among homosexuals compared with bisexuals, while the decrease in anal sex was greater in bisexuals compared with homosexuals. These results may indicate a trend towards safer sexual behavior in this at risk population, but further studies are needed to support or refute these observations.
AIDS Serodiagnosis↗