An Inner-City Asthma Disease Management Initiative

Objectives: The purpose of this study was to evaluate the effects of a recently implemented disease management programme [Asthma Control and Education Program (ACE)] on patient outcomes (clinical and functional) and on resource utilisation in socio-economically disadvantaged (and largely Hispanic) individuals with asthma treated at Hartford Hospital. Design and Setting: Using standardised measures (i.e. the Health Status Questionnaire [HSQ] and the Center for Epidemiologic Studies Depression Scale) and conducting serial assessments the investigators determined: (i) functional status at intake and follow-up; (ii) change in the level of illness severity over time; (iii) patientss’ acquisition of self-management skills; and (iv) the type and frequency of acute care services utilised pre- and post-enrolment in ACE. Patient Population:The study participants consisted of consenting individuals, aged 18 years or older, enrolled in ACE from 1 January 1997 to 30 September 1998. Each individual had a comprehensive intake interview (data collected included clinical and financial status) followed by 3 educational sessions. Results: While only 34.7% (n = 282) of the 813 patients referred from Hartford Hospital to physicians or emergency department services elected to participate in the programme, 60% of participants completed the educational sessions. 73% of these enrollees returned for the 3-month follow-up.On the HSQ, the mean Physical Composite Summary (PCS) scores increased from 33.3 ± 10.01 at baseline to 41.6 ± 11.48 at the 3-month follow up and 45.3 ± 10.30 at the 6-month follow-up. In an analysis using only those patients (n = 50) with HSQ scores at baseline and 3- and 6-month follow-ups, there were statistically significant increases in both the PCS and the Mental Composite Summary scores (p < 0.001).For the 68 patients with severity data at baseline, 3 months and 6 months there was a statistically significant improvement over time (p < 0.001). For example, 4.4% had severe disease at 6 months versus 69.1% at baseline. A subset of 73 patients for whom pre-ACE data were available realised a 37% reduction in emergency department use and a 52% reduction in in-patient visits. Conclusions: The evaluation of disease management programmes requires outcomes data. The results of this study of an asthma disease management programme indicate there was an improvement in overall functioning, illness severity, self-management, and utilisation of inpatient and emergency department services. Although a cause and effect relationship could not be assumed, the results suggest that the disease management model is an effective one for the studied population of inner-city patients, socioeconomically disadvantaged individuals previously identified as high utilisers of healthcare services and as having significant environmental exposures problematic for patients with asthma. As currently designed, however, this programme does not address the healthcare needs of the large number of referred patients who choose not to enrol or the enrollees (40%) who do not complete the education and follow-up sessions.     

Challenges of and strategies for changing prescribing practices of health care providers

Problems related to inappropriate prescribing practices of physicians in general are well recognized. Dietary fluoride supplements have been implicated as one of the contributing factors in an increase in dental fluorosis. Inappropriate prescribing practices of providers have been cited as a major factor in this implication. Numerous studies of physicians and dentists have documented a lack of knowledge and inappropriate prescribing practices regarding fluoride supplements. The purpose of this paper is to identify barriers to changing fluoride-prescribing practices of health care providers and to suggest strategies for implementing change. To increase optimal and appropriate use of fluoride supplements, educational interventions are necessary for all user groups--detail men and women, physicians, dentists, pharmacists, nurse practitioners, dental hygienists, and the public. In addition, environmental supports for the educational activities in the form of policy, regulation, standards of care, and guidelines are recommended for consideration.     

Intravitreal gas injection diminishes hyaluronic acid

OBJECTIVES: To determine if compression of the vitreous by an intraocular gas bubble diminishes the concentration of hyaluronic acid (NaHA). MATERIALS AND METHODS: Eighteen albino rabbits had air, xenon or perfluoroethane (C2F6) injected into the vitreous to displace 12.5% to 90% of the vitreous volume. After the gas was absorbed, the vitreous was analyzed for NaHA by the Carbazole method (1, 13). RESULTS: A 90% displacement diminished the NaHA concentration by 18.6%. Lesser displacements caused a lesser loss, but the differences are not significant. CONCLUSION: Intraocular gas injections, both large and small, reduce the concentration of NaHA and destabilize the vitreous structure.     

Tolerance induction by transdermal glyceryl trinitrate in rats.

Mechanisms of mild glyceryl trinitrate tolerance in rats (transdermal application; 15 mg/day/2 days) were examined in isolated aortic rings contracted with phenylephrine. Tolerance to glyceryl trinitrate was comparable in both endothelium-intact and -denuded vessels; the maximum relaxation decreased to 70-80% and the EC50 increased 3-4-fold. There was minimal cross-tolerance to acetylcholine (1.7-fold increase in EC50) and none to sodium nitroprusside. The results suggest that mild tolerance to glyceryl trinitrate in rats is mediated by mechanisms which are predominantly endothelium-independent and which produce little activation of the cellular mechanism responsible for cross-tolerance.     

New flavonoid-glycosides from Crataegus monogyna and Crataegus pentagyna

From the leaves and flowers of Crataegus monogyna and C. Pentagyna six new flavonoid-C- and O-glycosides respectively have been isolated and identified as 2'-O-rhamnosyl-orientin, 2'-O-rhamnosyl-isoorientin, 2'-O-rhamnosyl-isovitexin, rutin, spiraeosid, 8-methoxy-k?mpferol and 8-methoxy-k?mpferol-3-O-glucoside. The structure of O-rhamnosyl-vitexin and O-acetyl-O-rhamnosyl-vitexin isolated previously, have been elucidated unambigiously mainly by NMR- and MS-spectroscopy.     

Comparative trial of mexiletine and lignocaine in the treatment of early ventricular tachyarrhythmias after acute myocardial infarction

The antiarrhythmic effects of intravenously administered lignocaine and mexiletine were compared over a period of 48 hr in a randomized trial on 24 patients who developed ventricular tachyarrhythmias within 48 hr of the onset of acute myocardial infarction. Mexiletine was given as an initial bolus of 200 mg, followed by an infusion of 1 mg/min reduced to 0.5 mg/min after 1 hr. Lignocaine was given as a bolus of 100 mg, followed by an infusion of 3 mg/min reduced to 2 mg/min after 1 hr. Plasma levels of mexiletine, lignocaine, and monoethylglycinexylidide were monitored. The frequency of "complex" ventricular tachyarrhythmias was significantly lower in the mexiletine-treated group. This group of patients also had significantly fewer ventricular extrasystoles than those receiving lignocaine, the difference being most marked during the second 24 hr of treatment. Too few episodes of ventricular fibrillation occurred for statistical comment. The greater efficacy of mexiletine was not associated with increased drug toxicity.     

The incidence of known diabetics among U.S. Army active duty dental patients

Diabetes affects an estimated 16 million Americans. The purpose of this study was to determine the incidence of known diabetes among active duty soldiers by reviewing medications dispensed for diabetes at a large military installation. This study was conducted from July 31, 1997, through August 1, 1998. Fifty-eight (0.18%) members of the total active duty male population of 32,593 had been dispensed diabetes medications, whereas 43 (0.48%) members of the total female active duty population of 8,898 had been dispensed medications for diabetes. Gestational diabetes was the cause for 88.37% of the total active duty females dispensed diabetic medication at Fort Hood, Texas. The female-to-male ratio for diabetes was 2.7:1. Diabetics made up 0.27% of the total population.     

Delayed transient neurologic toxicity due to tacrolimus: CT and MRI

We report a case of transient neurologic toxicity secondary to tacrolimus. The clinical and imaging findings are reported and their subsequent regression after interruption of therapy in the patient following a bone-marrow transplant is also described. The etiology of the neurotoxicity and its analogy with other immunosuppressant agents are discussed. Received: 18 June 1999/Accepted: 14 December 1999     

In vivo fate of folate-targeted polyethylene-glycol liposomes in tumor-bearing mice.

PURPOSE: To compare the in vivo tissue distribution of folate-targeted liposomes (FTLs) injected i.v. in mice bearing folate receptor (FR)-overexpressing tumors (mouse M109 and human KB carcinomas, and mouse J6456 lymphoma) to that of nontargeted liposomes (NTLs) of similar composition. EXPERIMENTAL DESIGN: A small fraction of a folate-polyethylene-glycol (PEG)-distearoyl-phosphatidylethanolamine conjugate was incorporated in FTLs. Both FTLs and NTLs were PEGylated with a PEG-distearoyl-phosphatidylethanolamine conjugate to prolong circulation time. Liposomes were labeled with [(3)H]cholesterol hexadecyl ether with or without doxorubicin loading. Liposome levels in plasma, tissues, or ascites were assessed by the number of [(3)H] counts. For doxorubicin-loaded formulations, we also determined the tissue doxorubicin levels by fluorimetry. To estimate the amount of liposomes directly associated with tumor cells in vivo, we determined the [(3)H]radiolabel counts in washed pellets of ascitic tumor cells using the ascitic J6456 lymphoma RESULTS: FTLs retained the folate ligand in vivo, as demonstrated by their ability to bind ex vivo to FR-expressing cells after prolonged circulation and extravasation into malignant ascitic fluid. In comparison with NTLs, FTLs were cleared faster from circulation as a result of greater liver uptake. Despite the lower plasma levels, tumor levels of FTL-injected mice were not significantly different from those of NTL-injected mice. When NTLs and FTLs were loaded with doxorubicin, liver uptake decreased because of liver blockade, and uptake by spleen and tumor increased. When tumor-to-tissue liposome uptake ratios were analyzed, the targeting profile of FTLs was characterized by higher tumor:skin, and tumor:kidney ratios but lower tumor:liver ratio than NTLs. After a concomitant dose of free folic acid, FTLs (but not NTLs) plasma clearance and liver uptake were inhibited, indicating that accelerated clearance was mediated by the folate ligand. Surprisingly tumor uptake was not significantly affected by a codose of folic acid. In the J6456 ascitic tumor model, tumor cell-associated liposome levels were significantly greater for FTL-injected mice than for NTL-injected mice, despite slightly higher levels of the latter in whole ascites. CONCLUSIONS: Whereas folate targeting does not enhance overall liposome deposition in tumors, the targeting profile of tumor versus other tissues is substantially different and intratumor liposome distribution in ascitic tumors is affected favorably with a selective shift toward liposome association with FR-expressing cells.     

Vitamin D status: effects on parathyroid hormone and 1, 25-dihydroxyvitamin D in postmenopausal women

BACKGROUND: Low serum 25-hydroxyvitamin D ?25(OH)D concentrations are commonly found in the elderly and are associated with hip fracture. Treatment with vitamin D and calcium can reduce the risk of fracture. The relation between the rise in parathyroid hormone (PTH) with age and the decrease in 25(OH)D is not clear. Neither is there any consensus on the serum concentration of 25(OH)D required for bone health. OBJECTIVE: Our objective was to study the relations between serum PTH, serum vitamin D metabolites, and other calcium-related variables in postmenopausal women. DESIGN: This was a cross-sectional study of 496 postmenopausal women without vertebral fractures attending our menopausal osteoporosis clinics. RESULTS: PTH was significantly positively related to age and serum 1, 25-dihydroxyvitamin D ?1,25(OH)(2)D and inversely related to 25(OH)D and plasma ionized calcium. There was a step-like increase in PTH as serum 25(OH)D fell below 40 nmol/L. In women with 25(OH)D concentrations >40 nmol/L, 1,25(OH)(2)D was positively related to 25(OH)D; in women with 25(OH)D concentrations 40 nmol/L, 1,25(OH)(2)D was most closely (inversely) related to plasma creatinine. Therefore, with serum 25(OH)D concentrations increasingly <40 nmol/L, serum 1,25(OH)(2)D becomes critically dependent on rising concentrations of PTH. CONCLUSION: The data suggest that aging women should maintain 25(OH)D concentrations >40 nmol/L (which is the lower limit of our normal range for healthy young subjects) for optimal bone health.