Refill patterns of atypical and conventional antipsychotic medications at a national retail pharmacy chain.

This study examined whether patients who received prescriptions for conventional and atypical antipsychotics in routine outpatient care continued medication therapy. Prescription refill records of more than 25,000 patients from a national retail pharmacy chain were surveyed during a full eight-month period. At the start of the ninth month, 48 percent of the patients taking conventional agents were continuing therapy. The overall rate for those taking atypical agents was 44 percent; however, the rate for those taking clozapine was 71 percent. Atypical agents, despite their improved side effect profile, were not associated with higher rates of continued treatment. A highly supervised medication administration process, frequent patient-provider contact, and favorable patient selection may help explain the higher rate among patients taking clozapine.

Vascular imaging by ultrasound: 3D reconstruction of flow velocity fields for endothelial shear stress calculation.

A new method for quantitative reconstruction of a three dimensional (3D) velocity field from ultrasound color doppler mapping (USCDM) images is used here to calculate the shear stress distribution on the endothelial layer of an artery. Measurements of a few spatially unrestricted USCDM transverse cross sectional images of the artery, and of several echo-ultrasound B-mode images of the same area, are required for reconstructing the geometry of the vessel's endothelial surface. The calculation is based on assuming a physical model of flow, and solving the Continuity and the Navier-Stokes equations numerically for a steady flow of an incompressible Newtonian fluid at constant temperature within a non-flexible tube. The correct choice of the penalty parameter in the finite element method (FEM) algorithm provides proper convergence of the reconstruction. The endothelial shear stress is calculated from the gradient of the velocity field at each point of the vessel's inner surface.

High long-standing fertilizing capacity of human sperm isolated for male sex preselection.

A method of separating a Y-enriched human sperm population for male sex preselection with a single-column, four-step, four-layer albumin gradient technique is presented. This technique provides an efficient separation of spermatozoa, good Y-enriched sperm motility, and high fertilization capacity of this fraction as tested by the zona-free hamster ova sperm penetration assay.

Relative incomes and rates of return for U.S. physicians.

Since 1967 the supply of physicians in the U.S. has been growing by more than 3 percent per annum. This, coupled with public insurer fee discounts, might have been expected to depress both the relative and absolute incomes of physicians in spite of growing insurance coverage and new technologies. Real incomes of physicians did decline at a 0.2 percent annual rate between 1967 and 1980, but this was apparently due to economy-wide events since the income trends for lawyers, dentists, and college graduates were virtually identical. Internal rates of return to undergraduate medical training remained high--between 14 and 17 percent in 1980. Specialty training became more profitable for internists, general surgeons, and obstetricians/gynecologists (all with 10-15 percent rates of return), while pediatricians continued to suffer a financial loss. While Medicare and Medicaid fee discounts have been criticized as inequitable, the programs are also shown to provide a 'hidden subsidy' to physicians during residency training, materially adding to rates of returns.

Nonimmunologic hydrops fetalis: a review of 11 cases.

Eleven cases of nonimmunologic hydrops fetalis occurring during a six year period were reviewed. The etiology of hydrops fetalis was established only in four cases. It included one case of endocardial fibrosis, two cases of non-immunologic hemolysis and one case of tachycardia. The pregnancies were complicated by polyhydramnios in 9 cases, preterm delivery in 10 cases, twins in 3 cases and pre-eclampsia in one case. Four of 11 fetuses died in utero, on one of them, intrauterine blood transfusion and administration of digoxin and furosemide was carried out. Five fetuses died neonatally and two survived. In one of the later cases, intravenous administration of digoxin with quinidine to the mother was without effect, nor did such treatment cause any effect on the neonate after delivery. Electric cardioversion supplemented with digoxin slowed the neonatal cardiac rhythm to normal range with later successful outcome. Earlier diagnosis by ultrasonography especially in cases of hydramnios and appropriate treatment are likely to improve this outcome.

Physician losses from Medicare and Medicaid discounts: how real are they?

Physicians' claims that extensive Medicare and Medicaid fee discounting imposes an inequitable burden on them are examined using survey data from the Health Care Financing Administration on 5,000 primary care physicians. A definite fee hierarchy is documented, with the physician's usual charge at the top and Medicare and Medicaid allowables at the bottom. Under usual, customary, and reasonable methods, physicians can use fees to maximize payment, and insurer attempts to control fees result in both sides participating in a revenue maximization-expenditure control game. Raising Medicare and Medicaid allowables to the physician's usual fee is shown to result in large windfall gains that are unnecessary and unjustified in terms of work effort, human capital investment, or eliciting an adequate supply of practitioners.

Male pseudohermaphroditism due to 17 alpha-hydroxylase deficiency: diagnosis by gas chromatography--mass spectrometry.

A case of male pseudohermaphroditism associated with 17 alpha-hydroxylase deficiency is reported in which the diagnosis was firmly established by gas chromatography-mass spectrometry. The patient was a 20-year-old genotypic male, phenotypic female who presented with primary amenorrhea, absence of body hair, and no breast development. She was hypertensive. Corticosterone and progesterone levels were very high and sex steroids were virtually absent. Gonadotropins were in the menopausal range. The results of radioimmunoassay were not diagnostic. Analysis of urine using gas chromatography-mass spectrometry revealed a striking absence of steroids with 17-oxygen function-nor were there any 18 or 19 carbon steroids. These results clearly establish a total deficiency of 17 alpha-hydroxylase activity.

Receptor and postreceptor defects contribute to the insulin resistance in noninsulin-dependent diabetes mellitus.

We have assessed the mechanisms involved in the pathogenesis of the insulin resistance associated with impaired glucose tolerance and Type II diabetes mellitus by exploring, by means of the euglycemic glucose-clamp technique, the in vivo dose-response relationship between serum insulin and the overall rate of glucose disposal in 14 control subjects; 8 subjects with impaired glucose tolerance, and 23 subjects with Type II diabetes. Each subject had at least three studies performed on separate days at insulin infusion rates of 40, 120, 240, 1,200, or 1,800 mU/M2 per min. In the subjects with impaired glucose tolerance, the dose-response curve was shifted to the right (half-maximally effective insulin level 240 vs. 135 microunits/ml for controls), but the maximal rate of glucose disposal remained normal. In patients with Type II diabetes mellitus, the dose-response curve was also shifted to the right, but in addition, there was a posal. This pattern was seen both in the 13 nonobese and the 10 obese diabetic subjects. Among these patients, an inverse linear relationship exists (r = -0.72) so that the higher the fasting glucose level, the lower the maximal glucose disposal rate. Basal rates of hepatic glucose output were 74 +/- 4, 82 +/- 7, 139 +/- 24, and 125 +/- 16 mg/M2 per min for the control subjects, subjects with impaired glucose tolerance, nonobese Type II diabetic subjects, and obese Type II diabetic subjects, respectively. Higher serum insulin levels were required to suppress hepatic glucose output in the subjects with impaired glucose tolerance and Type II diabetics, compared with controls, but hepatic glucose output could be totally suppressed in each study group. We conclude that the mechanisms of insulin resistance in patients with impaired glucose tolerance and in patients with Type II noninsulin-dependent diabetes are complex, and result from heterogeneous causes. (a) In the patients with the mildest disorders of carbohydrate homeostasis (patients with impaired glucose tolerance) the insulin resistance can be accounted for solely on the basis of decreased insulin receptors. (b) In patients with fasting hyperglycemia, insulin resistance is due to both decreased insulin receptors and postreceptor defect in the glucose mechanisms. (c) As the hyperglycemia worsens, the postreceptor defect in peripheral glucose disposal emerges and progressively increases. And (d) no postreceptor defect was detected in any of the patient groups when insulin's ability to suppress hepatic glucose output was measured.

Serum thyroglobulin levels predict total body iodine scan findings in patients with treated well-differentiated thyroid carcinoma.

Forty-eight consecutive patients with treated thyroid carcinoma were studied with 131-I total body scans and serum thyroglobulin (hTg) levels. Serum hTg levels during thyroxine treatment accurately predicted scan results (chi square = 18.6, p < 0.001). All patients with negative scans (24 patients) had serum hTg levels (< 7 ng/ml whereas in patients with metastatic thyroid cancer (eight patients) they ranged from 11 to 690 ng/ml. In patients with iodine uptake confined to the thyroid bed (16 patients) serum hTg values ranged from 2 to 17 ng/ml. Serum hTg levels rose in patients with negative scans during hypothyroidism or after exogenous TSH suggesting that hTg levels are more sensitive than iodine scans in detecting residual thyroid tissue. Serum hTg levels could replace total body iodine scans in many patients with treated thyroid carcinoma.