Tripler's Emergency Medical Response Team.
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Emergency Medical Services↗
Biomedical subjects
R E Johnson
Publications and source records attributed to R E Johnson.
The functional status of inner-city primary care patients. Diminished function in a family practice population and its potential determinants.
BACKGROUND: Research on health care quality and effectiveness often relies on global health status measures, such as functional status, but little is known about the functional status of patients in the primary care setting (without limitation to specific diseases) and even less about the function of the poor or ethnic minorities. In preparation for a planned practice-based research network, we administered a functional-status survey to patients visiting an inner-city family practice center. METHODS: Over 9 weeks, 555 established patients older than 18 years, as well as adolescents accompanied by a parent or guardian, completed a survey that included the SF-36 Health Survey and questions about demographic variables and cigarette use. The survey was self-administered in the waiting area and examination room, and patients received no assistance from staff. RESULTS: Functional-status scores reported by this primary care cohort were significantly lower than those of the general population (P < .001) and comparable with those reported nationally for patients with chronic diseases (e.g., congestive heart failure, diabetes). Functional-status scores were associated with age, sex, and, most strikingly, socioeconomic status. For example, patients with a yearly income of less than $15,000 had lower mean physical function scores than those reported nationally for patients with hypertension, diabetes, depression, recent myocardial infarction, or hypertension (P < .05). Patients who currently smoked reported lower physical function (P = .004) and strikingly lower mental function (P < .001) than nonsmokers. CONCLUSIONS: Although patients completing the survey included healthy persons seeking preventive care and sick patients with acute and chronic illnesses, their overall functional status resembled that reported nationally for patients with chronic disease, perhaps reflecting the influence of poverty. Few studies have reported the association we observed between smoking and lower functional status. Further longitudinal studies in the primary care setting are necessary to fully interpret these associations and to evaluate the true impact of interventions on outcomes.
Adolescent↗
Herpes simplex virus type 2 in the United States, 1976 to 1994.
BACKGROUND: Herpes simplex virus type 2 (HSV-2) infection is usually transmitted sexually and can cause recurrent, painful genital ulcers. In neonates the infection is potentially lethal. We investigated the seroprevalence and correlates of HSV-2 infection in the United States and identified changes in HSV-2 seroprevalence since the late 1970s. METHODS: Serum samples and questionnaire data were collected during the National Health and Nutrition Examination Surveys (NHANES) II (1976 to 1980) and III (1988 to 1994). HSV-2 antibody was assessed with an immunodot assay specific for glycoprotein gG-2 of HSV-2. RESULTS: From 1988 to 1994, the seroprevalence of HSV-2 in persons 12 years of age or older in the United States was 21.9 percent (95 percent confidence interval, 20.2 to 23.6 percent), corresponding to 45 million infected people in the noninstitutionalized civilian population. The seroprevalence was higher among women (25.6 percent) than men (17.8 percent) and higher among blacks (45.9 percent) than whites (17.6 percent). Less than 10 percent of all those who were seropositive reported a history of genital herpes infection. In a multivariate model, the independent predictors of HSV-2 seropositivity were female sex, black race or Mexican-American ethnic background, older age, less education, poverty, cocaine use, and a greater lifetime number of sexual partners. As compared with the period from 1976 to 1980, the age-adjusted seroprevalence of HSV-2 rose 30 percent (95 percent confidence interval, 15.8 to 45.8 percent). The seroprevalence quintupled among white teenagers and doubled among whites in their twenties. Among blacks and older whites, the increases were smaller. CONCLUSIONS: Since the late 1970s, the prevalence of HSV-2 infection has increased by 30 percent, and HSV-2 is now detectable in roughly one of five persons 12 years of age or older nationwide. Improvements in the prevention of HSV-2 infection are needed, particularly since genital ulcers may facilitate the transmission of the human immunodeficiency virus.
Adolescent↗
Detection of ozone on Saturn's satellites Rhea and Dione.
The satellites Rhea and Dione orbit within the magnetosphere of Saturn, where they are exposed to particle irradiation from trapped ions. A similar situation applies to the galilean moons Europa, Ganymede and Callisto, which reside within Jupiter's radiation belts. All of these satellites have surfaces rich in water ice. Laboratory studies of the interaction of charged-particle radiation with water ice predicted the tenuous oxygen atmospheres recently found on Europa and Ganymede. However, theoretical investigations did not anticipate the trapping of significantly larger quantities of O2 within the surface ice. The accumulation of detectable abundances of O3, produced by the action of ultraviolet or charged-particle radiation on O2, was also not predicted before being observed on Ganymede. Here we report the identification of O3 in spectra of the saturnian satellites Rhea and Dione. The presence of trapped O3 is thus no longer unique to Ganymede, suggesting that special circumstances may not be required for its production.
Extraterrestrial Environment↗
Dose-related efficacy of levomethadyl acetate for treatment of opioid dependence. A randomized clinical trial.
OBJECTIVE: To compare the clinical efficacy of different doses of levomethadyl acetate hydrochloride (known as LAAM) in the treatment of opioid dependence. DESIGN: A randomized controlled, double-blind, parallel group, 17-week study. SETTING: Outpatient facilities at Johns Hopkins University Bayview Medical Center, Baltimore, Md. PATIENTS: Opioid-dependent volunteers (N=180) applying to a treatment-research clinic. INTERVENTION: Thrice-weekly (Monday/Wednesday/Friday) oral LAAM dose conditions of 25/25/35 mg, 50/50/70 mg, and 100/100/140 mg and nonmandatory counseling. MAIN OUTCOME MEASURES: Retention in treatment, self-reported heroin use, and opioid-positive urine specimens. RESULTS: Retention was independent of subjects' sex and dose. Self-reported heroin use decreased in a dose-related manner. At final assessment, patients in the high-dose condition reported using heroin 2.5 of 30 days as compared with 4.1 or 6.3 days for patients in the medium-dose and low-dose conditions, respectively (high dose vs low dose, P<.05); urinalysis results were similarly dose related. Overall, 20 (34%) of 59 patients in the high-dose condition remained opioid-abstinent for 4 consecutive weeks, as compared with 8 (14%) of 59 in the medium-dose and 7 (11%) of 62 in the low-dose conditions (P<.01). Self-report and urinalysis data are consistent with a greater than 90% reduction in illicit opioid use by the high-dose group relative to pretreatment levels. CONCLUSION: Opioid substitution treatment with LAAM substantially reduces illicit opioid use. The clinical efficacy of LAAM is positively related to dose.
Adult↗
Controlled opioid withdrawal evaluation during 72 h dose omission in buprenorphine-maintained patients.
Buprenorphine's clinical utility as an opioid dependence pharmacotherapy may be enhanced with less-than-daily dosing. This study assessed opioid withdrawal after an acute 72 h dose omission in buprenorphine-maintained patients (8 mg/day s.l.). Eight outpatients required to remain free of opioids, cocaine and benzodiazepines completed four double-blind, double-dummy, Latin-square ordered conditions. Test conditions of 8 or 16 mg s.l. buprenorphine were followed by 2 days of placebo dosing. Control conditions were buprenorphine maintenance (8 mg/day), to provide a reference for evaluation of placebo test days and naloxone administration (10 mg 70 kg i.m.) during 8 mg buprenorphine maintenance to assess withdrawal measure sensitivity. Subjective measures and pupil diameter were significantly influenced only by naloxone. The lack of subjective symptoms and physiological signs of opioid withdrawal during 72 h of acute dose omission supports the feasibility of less-than-daily dosing at buprenorphine doses of 8 mg/day in patients who have demonstrated an ability to remain drug-free for an extended period.
Adult↗
Quantification of surgical margin shrinkage in the oral cavity.
BACKGROUND: Obtaining adequate surgical margins, free of tumor, is crucial for success in oncologic surgery. The head and neck surgeon often finds that the tumor-free margin reported from histopathologic measurement is significantly smaller than the margin measured in-situ. It was the purpose of this study to quantify the change in size of mucosal and muscle surgical margins following excision, formalin fixation, and slide preparation of tongue and labiobuccal tissue in a canine model. METHODS: Ten mongrel dogs under general anesthesia for a concurrent project were used in this study. Changes in mucosal and muscle dimensions around custom-made brass disks, one with a needle depth gauge, were measured immediately following excision after formalin fixation and after slide preparation. RESULTS: The mean shrinkage from initial resection to final microscopic assessment of the lingual surface mucosal margins was 30.7% (p < 0.0001). The deep tongue margin shrank 34.5% (p < 0.0001). The mean shrinkage of the labiobuccal mucosal margin was 47.3% (p < 0.0001). In all cases, the greatest proportion of shrinkage occurred immediately upon resection. CONCLUSIONS: From the in-situ measurement by the surgeon to final pathologic evaluation on the microscope slide, the measured dimensions of oral cavity mucosal and tongue muscle margins shrink significantly. To obtain 5 mm of pathologically clear margin an in-situ margin of resection of at least 8 to 10 mm needs to be taken. Studies reporting clinical correlation of recurrence and survival information with surgical margin status should include a detailed description of the technique used to determine the reported surgical margin status.
Animals↗
Utilization and safety of oral acyclovir over an 8-year period.
The primary purpose of this project was to develop and implement surveillance systems to monitor the short- and long-term safety of acyclovir in oral dosage forms in a general population, the Kaiser Permanente Northwest (KPNW) region membership. KPNW is a group model HMO providing comprehensive care to over 390,000 members located primarily in the Portland, Oregon-Vancouver, Washington metropolitan area. Data were collected from the automated outpatient prescription, hospital discharge, tumor registry, KPNW membership information, and from medical record reviews, over an 8-year period. The findings showed oral acyclovir use increased substantially, and females were twice as likely to receive oral acyclovir as males. Most use was short-term. When the hospitalizations of oral acyclovir users with select serious morbidities conditions were examined following the receipt of acyclovir, no temporal association was observed between exposure to oral acyclovir and the hospitalizations. Similarly, where oral acyclovir was being used within a time frame possibly associated with serious life-threatening conditions, other morbidities rather than acyclovir were the likely cause of the condition, and no mention was made in the medical record that acyclovir might have been involved in the condition. In summary, oral acyclovir was a safe drug within the use patterns of the HMO population over an 8-year period.
Journal Article↗
Evaluation of a self-report screening instrument to predict frailty outcomes in aging populations.
The purpose of this study is to investigate the utility of a self-report screening instrument, the Health Status Form (HSF), to predict elderly members at risk of frailty in the subsequent year. The predictive ability of self-report HSF data was also compared to the predictive ability of inpatient discharges and pharmacy dispensings from administrative utilization databases. Four HSF variables best predicted elderly members at risk of frailty: (a) age, (b) indicating that health conditions interfered with daily activities, (c) needing or receiving assistance from another person for bathing, and (d) needing or receiving assistance from another person for taking medications. The predictive model yielded sensitivity 50.7%, specificity 97.8%, and correctly classified 90.9% of the population. Self-report population-based screening is a reliable method for predicting elderly members at risk of frailty in the coming year. Further studies should test a new brief instrument composed of portions of validated measures as a stand alone screener to select frail members for care management purposes.
Aged↗
Whither triazolam?
OBJECTIVES: The authors compare the extent and nature of triazolam use before and after its deletion from a health maintenance organization's (HMO) open and advisory-type drug formulary. METHODS: Benzodiazepine dispensings of HMO members were collected for the 3 years before (1989-1991) and for the 2 years after (1992-1993) the deletion of triazolam from the HMO's drug formulary. The number of triazolam users, their sex and ages, total annual exposure, estimated daily doses, and total days of annual exposure were calculated and compared before and after its deletion from the formulary. RESULTS: From being the most frequently dispensed short-acting benzodiazepine in the HMO in 1989, the prescribing and use of triazolam decreased tenfold by the end of 1993. The effect on who was using the drug and how it was being used was less dramatic. The elderly were frequent long-term users and had the longest exposure to the drug. CONCLUSIONS: An open and advisory-type formulary can affect providers' drug selection behavior.
Adult↗
The effect of increased prescription drug cost-sharing on medical care utilization and expenses of elderly health maintenance organization members.
OBJECTIVES: The nature and extent of prescription drug benefits for the elderly are a continuing concern for health-care managers and policy makers. This study examined the impact of increased prescription drug cost-sharing on the drug and medical care utilization and expenses of the elderly. METHODS: Two groups of well-insured Medicare risk-based members of a large health maintenance organization (HMO) had their copayments increased in different years during a 3-year period. Four 2-year analysis periods were established for comparing these elderly groups. During one analysis period, copayments did not change in either group. RESULTS: Moderate increases of from $1 to $3, from $3 to $5 per copayment, and from 50% per dispensing to 70% per dispensing with a maximum payment per dispensing resulted in lower annual per capita prescription drug use and expenses. No consistent annual changes were observed in either medical care utilization (office visits, emergency room visits, home health-care visits, hospitalizations) or total medical care expenses across analysis periods. CONCLUSIONS: No consistent relationships were observed between increased copayments per dispensing and medical care utilization and expense. Future research needs to address the impact on the classes of medications received and related health status, and the impact of larger increases in copayments per dispensing on medical care and health-related factors.
Aged↗
Changing patterns of antidepressant use and costs in a health maintenance organisation.
This study examined changes in the utilisation and costs of different antidepressants, particularly the selective serotonin reuptake inhibitors (SSRIs), and changes in the use of mental health services in a US health maintenance organisation (HMO) over the 8-year period following the introduction of SSRIs. It was hypothesised that SSRIs would be used increasingly in this setting, and that SSRI users would show a pattern of mental health service utilisation that was indicative of more severe psychiatric illnesses or prior treatment failures. Both hypotheses were accepted. The use of antidepressants nearly tripled over the 8-year period, with SSRIs showing the largest increase; per capita antidepressant costs increased more than 10-fold, largely because of the high cost per unit of SSRIs. Estimated daily doses of SSRIs were largely within the recommended ranges, although the duration of use was short if their primary purpose was the treatment of depression. Incident (first-time) users of SSRIs, and patients who switched to SSRIs from other antidepressants, used more inpatient and outpatient mental health services than users of other antidepressants. Use of the psychiatric hospital among antidepressant users increased, then decreased back to its first year level, psychiatric hospital days appeared to decrease over time, and outpatient mental health visits increased. The inverse relationship between use of SSRIs and use of inpatient mental health services suggests the need for a cost-effectiveness analysis in this setting.
Antidepressive Agents↗
Analysis of the costs of NSAID-associated gastropathy. Experience in a US health maintenance organisation.
Clinicians recognise nonsteroidal anti-inflammatory drugs (NSAIDs) as valuable first-line agents in the treatment of rheumatic disorders and as dangerous irritants to the gastrointestinal tract. This has led to questions about the economic impact of NSAID-induced gastropathy in populations. This study estimated the 1992 costs of NSAID-associated gastropathy episodes, and calculated an iatrogenic cost factor for NSAID-associated gastropathy among elderly members of a health maintenance organisation (HMO), the Northwest Region of Kaiser Permanente. Using data retrieved from automated databases and from medical records, NSAID and antiulcer drug costs were calculated, and estimates were made of the incidence rates of inpatient and outpatient NSAID-associated gastropathies, the services provided to treat them, and the cost of those services. Kaiser Permanente Northwest spent $US0.35 for each $US1.00 spent on NSAID therapy for the elderly, an iatrogenic cost factor of 1.35. The estimated average treatment per NSAID-associated gastropathy episode was $US2172. The average outpatient pharmacy cost per elderly NSAID user was $US80 and estimated average NSAID-associated treatment cost per elderly NSAID user was $US43. Although the findings were specific to the HMO because of the databases used, the methodology employed and the drug formulary influence on NSAID selection, they show that a substantial amount of resources were used to treat NSAID-induced gastropathies in the elderly, underscoring the risk of prescribing NSAIDs and reinforcing the need for their prudent use in elderly patients.
Adolescent↗
The impact of increasing patient prescription drug cost sharing on therapeutic classes of drugs received and on the health status of elderly HMO members.
OBJECTIVE: To assess the impact of increased prescription drug copayments on the therapeutic classes of drugs received and health status of the elderly. HYPOTHESES TESTED: Increased prescription drug copayments will reduce the relative exposure to, annual days use of, and prescription drug costs for drugs used in self-limiting conditions, but will not affect drugs used in progressive chronic conditions and will not reduce health status. STUDY DESIGN: Each year over a three-year period, one or the other of two well-insured Medicare risk groups in an HMO setting had their copayments per dispensing increased. Sample sizes ranged from 6,704 to 7,962. DATA SOURCES/DATA COLLECTION: Automated administrative data systems of the HMO were used to determine HMO eligibility, prescription drug utilization, and health status. ANALYSIS DESIGN: Analysis of variance or covariance was employed to measure change in dependent variables. FINDINGS: Relative exposure, annual days of use, and prescription drug costs for drugs used in self-limiting conditions and in progressive chronic conditions were not affected in a consistent manner across years by increases in prescription drug copayment. Health status may have been adversely affected. Larger increases in copayments appeared to generate more changes. CONCLUSIONS: Small changes in copayments did not appear to substantially affect outcomes. Large changes in copayments need further examination.
Aged↗
The loss of atmosphere from Mars.
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Atmosphere↗
Evidence for involvement of yeast proliferating cell nuclear antigen in DNA mismatch repair.
DNA mismatch repair plays a key role in the maintenance of genetic fidelity. Mutations in the human mismatch repair genes hMSH2, hMLH1, hPMS1, and hPMS2 are associated with hereditary nonpolyposis colorectal cancer. The proliferating cell nuclear antigen (PCNA) is essential for DNA replication, where it acts as a processivity factor. Here, we identify a point mutation, pol30-104, in the Saccharomyces cerevisiae POL30 gene encoding PCNA that increases the rate of instability of simple repetitive DNA sequences and raises the rate of spontaneous forward mutation. Epistasis analyses with mutations in mismatch repair genes MSH2, MLH1, and PMS1 suggest that the pol30-104 mutation impairs MSH2/MLH1/PMS1-dependent mismatch repair, consistent with the hypothesis that PCNA functions in mismatch repair. MSH2 functions in mismatch repair with either MSH3 or MSH6, and the MSH2-MSH3 and MSH2-MSH6 heterodimers have a role in the recognition of DNA mismatches. Consistent with the genetic data, we find specific interaction of PCNA with the MSH2-MSH3 heterodimer.
Adaptor Proteins, Signal Transducing↗
Detection of ozone on Ganymede.
An absorption band at 260 nanometers on the trailing hemisphere of Ganymede, identified as the Hartley band of Ozone (O3), was measured with the Hubble Space Telescope. The column abundance of ozone, 4.5 x 10(16) per square centimeter, can be produced by ion impacts or by photochemical equilibrium with previously detected molecular oxygen (O2). An estimated number density ratio of [O3]/[O2] = 10(-4) to 10(-3) requires an atmospheric density orders of magnitude higher than upper limits from spacecraft occultation experiments. Apparently, this O2-O3 "atmosphere" is trapped in Ganymede's surface ice, an inference consistent with the shift and broadening of the band compared with the gas-phase O3 band.
Extraterrestrial Environment↗
Requirement of the yeast MSH3 and MSH6 genes for MSH2-dependent genomic stability.
Defects in DNA mismatch repair result in instability of simple repetitive DNA sequences and elevated levels of spontaneous mutability. The human G/T mismatch binding protein, GTBP/p160, has been suggested to have a role in the repair of base-base and single nucleotide insertion-deletion mismatches. Here we examine the role of the yeast GTBP homolog, MSH6, in mismatch repair. We show that both MSH6 and MSH3 genes are essential for normal genomic stability. Interestingly, although mutations in either MSH3 or MSH6 do not cause the extreme microsatellite instability and spontaneous mutability observed in the msh2 mutant, yeast cells harboring null mutations in both the MSH3 and MSH6 genes exhibit microsatellite instability and mutability similar to that in the msh2 mutant. Results from epistasis analyses indicate that MSH2 functions in mismatch repair in conjunction with MSH3 or MSH6 and that MSH3 and MSH6 constitute alternate pathways of MSH2-dependent mismatch repair.
Amino Acid Sequence↗