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Biomedical subjects

W A Ray

Publications and source records attributed to W A Ray.

At least 91 records · Page 5Linked to original sources
PubMed1989

Use of Medicaid data for pharmacoepidemiology.

Because of the high prevalence of prescription drug use and the incomplete understanding of drug effects at the time of licensing, ongoing epidemiologic monitoring is required to provide information for clinical and regulatory decisions. Data produced through the administration of Medicaid programs have been considered for this purpose because the computerized files include prescription and diagnostic information for large, defined populations. However, the limited amount of data available in the computerized files and the atypical demographic characteristics of Medicaid populations create formidable difficulties in the use of these data for pharmacoepidemiology. This paper reviews these methodological problems and describes pragmatic solutions that have been developed through the ongoing use of these data bases for epidemiologic studies.

Adolescent↗
PubMed1989

Experience of a Medicaid nursing home entry cohort.

Long-term care cost-containment policies have focused on reducing the numbers of persons entering nursing homes. To provide insight and background for such efforts, the authors studied the experience of Medicaid nursing home entry cohorts in three individual States. They found substantial interstate variation in rates of nursing home entry and subsequent patterns of discharge, suggesting the operation of fundamentally different policies for provision of Medicaid nursing home services. Analysis of the cost effectiveness and quality of care implications of these policies may provide guidance for future cost-containment efforts.

Aged↗
PubMed1988

Risk of sudden infant death syndrome after immunization with the diphtheria-tetanus-pertussis vaccine.

To evaluate recent immunization against diphtheria, tetanus, and pertussis (DTP) as a possible risk factor for sudden infant death syndrome (SIDS), we studied the rates of SIDS after the administration of DTP vaccine in a cohort of 129,834 children who were born in four urban Tennessee counties during the period from 1974 through 1984. All the children received at least one DTP immunization in the first year of life at county health-department clinics or from Medicaid providers. Computerized immunization records from these sources were linked with Tennessee birth and death certificates to establish the cohort, ascertain the timing of immunization, and identify cases of SIDS. These children represented 42 percent of the births in the four counties. Among these children, 204 deaths occurred at the ages of 29 to 365 days; 109 deaths were classified as due to SIDS. We estimated the risk of SIDS according to the length of time, up to 30 days, since DTP immunization and compared it with the risk 31 days or more after immunization to calculate the relative risk. With control for age, the relative risk from 0 to 3 days after DTP immunization was 0.18 (95 percent confidence interval, 0.04 to 0.8); from 4 to 7 days, 0.17 (95 percent confidence interval, 0.04 to 0.7); from 8 to 14 days, 0.75 (95 percent confidence interval, 0.4 to 1.5); and from 15 to 30 days, 1.0 (95 percent confidence interval, 0.6 to 1.6). A multivariate analysis in which we controlled for age, sex, race, year, birth weight, and Medicaid enrollment, produced similar results. We conclude that in this large population of children there was no increase in the risk of SIDS after immunization with the DTP vaccine.

Analysis of Variance↗
PubMed1988

Nonsteroidal anti-inflammatory drug use and death from peptic ulcer in elderly persons.

STUDY OBJECTIVE: To determine the association between current non-aspirin nonsteroidal anti-inflammatory drug (NSAID) use and fatal peptic ulcers or upper gastrointestinal hemorrhage. DESIGN: Nested case control study using a linked Medicaid-death certificate database. SETTING: Tennessee Medicaid enrollees aged 60 and greater from 1976 to 1984. PATIENTS: One hundred twenty-two patients, "the cases," had a terminal hospitalization and a peptic ulcer or upper gastrointestinal hemorrhage confirmed by hospital chart review. Population controls (n = 3897) were matched to potential cases by age, sex, race, calendar year, and nursing home status. MEASUREMENTS AND MAIN RESULTS: "Cases" more frequently filled a prescription for an NSAID within 30 days before onset of illness than controls (34% compared with 11%; adjusted odds ratio, 4.7; 95% CI, 3.1 to 7.2). This association between fatal ulcer disease and current NSAID use was consistent in three age groups, women and men, whites and nonwhites, and community and nursing home dwellers. There was no significant association between case status and previous NSAID use (adjusted odds ratio, 1.9; 95% CI, 0.7 to 4.7). CONCLUSIONS: The findings of this study add to the growing evidence that NSAIDs can increase the risk for clinically serious peptic ulcer disease in the elderly.

Aged↗
PubMed1987

Genetic predisposition to bladder cancer: ability to hydroxylate debrisoquine and mephenytoin as risk factors.

The hypothesis that the frequency distribution of indices of oxidative drug-metabolizing activity is different between patients with bladder cancer (n = 98) and age, sex-matched control subjects (n = 110) has been investigated. Urinary recovery ratios of debrisoquine and R/S ratios of mephenytoin have been measured in an 8-h urine sample after simultaneous administration of debrisoquine (10 mg) and racemic mephenytoin (100 mg). In addition, alcohol consumption, smoking habit, and acetylation phenotype (using 100 mg dapsone as a substrate) have been measured. Patients with bladder cancer were classified on histological criteria as having aggressive (Stage III) (34%) or nonaggressive (Stages I and II) (66%) disease. The median of the frequency distribution of the debrisoquine urinary recovery ratio in patients with aggressive bladder cancer was greater than in control subjects, and only four patients had recovery ratios lower than the mean of the control group. Using logistic regression analysis, efficient debrisoquine metabolism and a synergistic interaction between smoking and ethanol consumption were significant, independent risk factors, while S-mephenytoin hydroxylation and acetylation phenotype were not significant risk factors. In contrast, patients with non-aggressive bladder cancer had a significant, but weaker, association with rapid hydroxylation of S-mephenytoin, which was independent of a significant synergistic interaction between smoking and alcohol consumption. Acetylation phenotype and debrisoquine urinary recovery ratio were not associated with increased risk of nonaggressive cancer. These results are consistent with the concept that oxidative isozymes might be responsible for conversion of environmental agents to proximate bladder carcinogens in nonindustrial-related bladder cancer. They also suggest that different etiological factors are involved in the pathogenesis of aggressive and nonaggressive bladder cancer.

Acetylation↗
PubMed1987

Amphotericin-B nephrotoxicity in humans decreased by sodium supplements with coadministration of ticarcillin or intravenous saline.

Previous observations suggest that salt loading can help reverse amphotericin-B induced nephrotoxicity. Evidence is presented indicating that sodium supplements provide prophylaxis against the development of amphotericin-B nephrotoxicity. In a retrospective study at Vanderbilt University, 14/21 patients receiving amphotericin B (target dose, 25 mg/day) without salt supplements developed impaired renal function; in 10 instances amphotericin B was temporarily withdrawn. In contrast, only 2/17 patients who received amphotericin B with ticarcillin (with its obligatory sodium supplement) developed nephrotoxicity (P less than 0.01). All four patients, who were receiving the combination of amphotericin B and ticarcillin and who had their ticarcillin therapy stopped, developed nephrotoxicity in the subsequent week. In a prospective observational study at Essen, 20 patients had 24 courses of amphotericin B (target dose, 40 mg/day) with routine supplementation of 1 liter of 0.9% sodium chloride daily. Only two patients showed evidence of nephrotoxicity and no dosage modification of amphotericin B was required in any patient. Four patients with initial evidence of mildly impaired renal function received full supplements without adverse effects or the development of nephrotoxicity. These observations suggest that routine parenteral administration of sodium supplements can help minimize the nephrotoxic potential of amphotericin B.

Amphotericin B↗
PubMed1987

Psychotropic drug use and the risk of hip fracture.

To assess the risk of hip fracture associated with the use of four classes of psychotropic drugs, we performed a case-control study of 1021 patients with hip fractures and 5606 controls among elderly Medicaid enrollees. Persons treated with hypnotics-anxiolytics having short (less than or equal to 24 hours) elimination half-lives had no increased risk of hip fracture. By contrast, a significantly increased risk was associated with current use of hypnotics-anxiolytics having long (greater than 24 hours) elimination half-lives (odds ratio, 1.8; 95 percent confidence interval, 1.3 to 2.4), tricyclic antidepressants (odds ratio, 1.9; 95 percent confidence interval, 1.3 to 2.8), and antipsychotics (odds ratio, 2.0; 95 percent confidence interval, 1.6 to 2.6). The risk increased in relation to the doses of drugs in these three classes. An analysis for possible confounding by dementia did not alter the results. Previous but noncurrent use of drugs in these classes conferred no increase in risk. Although a cause-and-effect relation was not proved, these data support the hypothesis that the sedative and autonomic effects of psychotropic drugs increase the risk of falling and fractures in elderly persons. The results suggest the need for studies of this association in other populations and for evaluation of newer psychotropic drugs with fewer undesirable sedative and autonomic effects.

Accidental Falls↗
PubMed1987

Interstate variation in elderly Medicaid nursing home populations. Comparisons of resident characteristics and medical care utilization.

Nursing home care in the United States is financed primarily through the federal-state Medicaid program. Because Medicaid nursing home programs are administered within the individual states, there may be interstate differences in the characteristics of Medicaid nursing home residents and their utilization of medical care. We used Medicaid claims and enrollment data for calendar 1981 from three large states--Michigan, California, and New York--to study this question. We found that the populations of elderly Medicaid nursing home residents in each of the three states had similar characteristics. In contrast to the homogeneity of resident characteristics, there were pronounced interstate differences in the use of medical care, particularly for the relation between nursing homes and hospitals. California was characterized by frequent turnover among elderly Medicaid nursing home residents and a high rate of transfers to and from hospitals. One third of residents entered the nursing home in the study year, 43% of enterers came from the hospital, and 51% of enterers were discharged within 180 days of admission, usually to the community. In New York, both turnover among elderly Medicaid nursing home residents and interinstitutional transfers were less frequent. However, those residents entering from the hospital had an average pre-entry hospital stay of 60 days, three to five times that of the other two states. Medicaid payments per day of nursing home care totaled +60 per day, twice those in the other two states. Michigan was characterized by patterns of medical care utilization intermediate between these two extremes. These findings suggest caution in the interpretation of single-state studies of nursing home residents, particularly for those of the dynamic relation between nursing homes and hospitals. They also suggest that further study of the experience of the individual states could provide valuable insights into the effects of different levels of nursing home reimbursement and different policies for transfers between nursing homes and hospitals.

Aged↗
PubMed1987

Reducing antipsychotic drug prescribing for nursing home patients: a controlled trial of the effect of an educational visit.

We conducted a statewide, controlled trial of the efficacy of an educational visit in reducing antipsychotic drug prescribing for nursing home patients. Frequent antipsychotic drug prescribers were visited by a trained physician counselor who stressed known drug risks for elderly patients and suggested techniques for reducing antipsychotic drug use. Although well-received, the visit did not reduce antipsychotic drug prescribing. This negative finding suggests that future interventions address factors within the nursing home which encourage antipsychotic drug use.

Aged↗
PubMed1987

Impact of growing numbers of the very old on Medicaid expenditures for nursing homes: a multi-state, population-based analysis.

We utilized Medicaid data from five states which account for 39 per cent of Medicaid expenditures to study the impact of the near-trebling of persons age 85 and older (the very old) projected to occur by the year 2012 upon Medicaid nursing home expenditures. We found a one-year prevalence of Medicaid-covered nursing home residence of 20 per 100 among the very old. If this rate continues, with no changes in current levels of Medicaid nursing home payments, and if population forecasts are accurate, increasing numbers of the very old will generate an additional +6.3 billion (1982 dollars) annually of Medicaid nursing home payments by 2012: an increase of 280 per cent from 1982 levels. The stress this trend will place upon societal ability to check growth in public expenditures for medical care while maintaining basic services for other low income populations will be an important force shaping public health policy in the next 25 years.

Aged↗
PubMed1987

The influence of yeast growth phase in vivo on the efficacy of topical polyenes.

We compared the efficacy of two polyenes, amphotericin B and natamycin, in two models of yeast infection. In one, treatment was begun immediately after inoculation, in the other it was delayed 24 hours. In each model infection with Candida albicans was established in the corneal stroma of dutch-belted rabbits and treated topically with 5% natamycin or amphotericin B 0.15% and 0.075%. Quantitative isolate recovery techniques were used to assess response after 5 days of treatment. A significant therapeutic effect was present for amphotericin B in both models. However, delayed treatment with natamycin was ineffective using treatment schedules efficacious when begun 1 hour after inoculation. A therapeutic effect was present only with administration of the drug every 1/2 hr. This altered response may reflect a difference in susceptibility between different growth phases in yeasts.

Administration, Topical↗
PubMed1987

Correlation of in vitro and in vivo susceptibility of Candida albicans to amphotericin B and natamycin.

The efficacy of topical 0.15% amphotericin B and 5% natamycin was examined in a model of Candida keratitis in rabbits and correlated with three tests of in vitro susceptibility: tube dilution minimal inhibitory concentration (MIC), minimal fungicidal concentration (MFC) and agar diffusion zones of inhibition. For a panel of 17 strains, the MIC classified precisely the same strains as resistant or susceptible to amphotericin B as did the in vivo response. Several strains were misclassified using the MFC and the zone of inhibition. For natamycin the MIC misclassified two strains but it was still superior to the other two tests. For all strains, amphotericin B was equal or superior in efficacy to natamycin in vivo. The tube dilution MIC for amphotericin B was a reliable indicator for natamycin efficacy in vivo.

Amphotericin B↗
PubMed1987

In vitro and in vivo susceptibility of Candida keratitis to topical polyenes.

The susceptibility of Candida albicans to topical amphotericin B and natamycin was evaluated in a model of stromal keratitis in Dutch-belted rabbits and compared with minimal inhibitory concentrations in vitro. Treatment was delayed 24 hr to allow invasive disease to occur and was then continued for 5 days. Ten strains of Candida albicans comprised the test panel. For amphotericin B, the minimal inhibitory concentration (MIC) by tube dilution classified the same strains as resistant or susceptible as did the in vivo response. A dose-response was observed with different concentrations of the drug. For natamycin, the MIC misclassified two strains. The rate of administration of natamycin required in this model was much higher than for amphotericin B, a therapeutic effect being observed with natamycin only when the drug was administered every 30 min during the in vivo efficacy and in vitro susceptibility with these strains is in agreement with that observed in the authors' previous studies using a model of immediate treatment.

Administration, Topical↗
PubMed1987

High-dose cytosine arabinoside and daunorubicin as consolidation therapy for acute nonlymphocytic leukemia in first remission: an update.

High-dose (HD) cytosine arabinoside (ara-C) is more effective treatment than conventional-dose ara-C regimens for patients with relapsed acute nonlymphocytic leukemia (ANLL). Previously, we have reported that HD-ara-C administered during the first remission of ANLL has resulted in long remission durations and a high proportion of patients with long-term disease-free survival. In this update, those patients have been observed further and additional patients have been treated, affirming the initial conclusions. Since August 1979, 55 adult patients with ANLL in first remission received one to three courses of HD-ara-C (3 g/m2 by one-hour infusion every 12 hours for 12 doses on days 1 to 6) alone or with daunorubicin (30 mg/m2 for two or three doses on days 7 to 9). Three patients died of sepsis or hemorrhage during consolidation and 19 patients have relapsed from 5 to 48 months after diagnosis. The remaining 33 patients remain in continued complete remission (CCR) from 5 to 75 months. Denoting all deaths in remission as relapse, the actuarial probability of CCR is 51% at 75 months with an apparent plateau in the survival curve. Of the first 22 patients is 27 months. Using univariate and multivariate analysis, age is the only statistically significant prognostic parameter with the actuarial CCR of ages less than 25, 25 to 44, and greater than 44 being 100%, 48%, and 23%, respectively. Due to its heightened antileukemic activity, HD-ara-C allows brief but effective consolidation of ANLL in first remission with long-term disease-free survival comparable with other approaches including bone-marrow transplantation.

Acute Disease↗
PubMed1986

Therapeutic choice in the treatment of hypertension. Initial treatment of newly diagnosed hypertension and secular trends in the prescribing of antihypertensive medications for Medicaid patients.

A "stepped-care" approach has been widely recommended for more than 10 years as an empiric method for the treatment of hypertension. This approach encourages the use of diuretics or beta blockers as initial monotherapy for hypertension. Although these and other antihypertensive regimens tested in clinical trials have substantially reduced morbidity and mortality from cerebrovascular disease, their relative effectiveness in reducing the sequelae of coronary artery disease is not as well established. These findings, coupled with the development of new drug regimens, have led to a re-examination of the stepped-care guidelines. This re-examination will stimulate increased interest in the therapeutic choices made by practicing physicians, particularly because the newer drugs are more costly than the traditional treatments. To address this question, we performed two specific studies, using data bases from Michigan and Tennessee Medicaid programs. The first study analyzed prescriptions for newly diagnosed cases of essential hypertension. The second study analyzed secular trends in the prescribing of antihypertensive regimens since that time. The data suggest that in 1982 and 1983 (the time period under consideration in the first part of the study), physicians treating hypertension for Medicaid enrollees followed the stepped-care recommendations, the majority using diuretics as step-one monotherapy. The secular trend data in the second study showed a moderate decrease in the use of diuretics since 1983. There were marked increases in the use of newer antihypertensive medications such as calcium channel blockers and the angiotensin converting enzyme inhibitor captopril. Because the costs of the newer drugs are substantially higher, a shift to these drugs would significantly increase the cost of treating hypertension in this country. Prospective, controlled trials are necessary to ascertain if the increased costs of the newly developed drugs are justified by potential benefits.

Adrenergic beta-Antagonists↗
PubMed1986

Reducing long-term diazepam prescribing in office practice. A controlled trial of educational visits.

We conducted a controlled, statewide trial of the efficacy of an educational visit by a physician counselor in the reduction of diazepam prescribing in outpatient practice. A novel aspect of this trial was the provision of a schedule for gradual withdrawal of long-term diazepam users from drug therapy; 51% of visited doctors attempted to withdraw patients from diazepam therapy and 26% utilized the withdrawal schedule. The entire group of 43 visited doctors reduced the rate of long-term diazepam users in their practice by 18% relative to the control group; the subgroup of doctors who utilized the withdrawal schedule had and even greater reduction of 33%. These results suggest that practicing doctors are concerned with long-term use of diazepam and that the educational visit by another physician is one method for reducing such use.

Anti-Anxiety Agents↗
PubMed1986

Differences between female and male children in the receipt of prescribed psychotropic and controlled-analgesic drugs. A five-year epidemiologic study.

This study describes the differences between male and female children in the receipt of prescriptions for psychotropic and controlled-analgesic drugs in office practice. The study encompassed 341,422 children of ages 0 through 17 years enrolled in the Tennessee Medicaid program during the 5 years 1977-1981. These children made 1,342,573 office visits and received 1,636,127 prescriptions during the study. There were 18,023 (5.3%) children who received prescriptions for psychotropic drugs and 18,744 (5.5%) who received prescriptions for combination products containing psychotropic drugs. There were 26,071 (7.6%) children who were prescribed controlled analgesics and 50,240 (14.7%) who received prescriptions for these substances as fixed combination medications. In this population, proportions of male and female children who received prescriptions for psychotropic and controlled-analgesic drugs were similar through age 11. After age 11, females were increasingly more likely to receive prescriptions for drugs from both categories than were males of the same age. By age 17, the rate of psychotropic drug prescription receipt for female children (6.3%) was nearly twice that for males (3.3%), a ratio consistent with numerous studies in adults. These differences were consistent over diagnostic categories and were only partially explained by differences in office-visit rates. These findings suggest that the known greater rates of psychotropic drug use among adult females are the result of factors whose influence begins at puberty, not before.

Adolescent↗