Ethnicity and prescription patterns for haloperidol, risperidone, and olanzapine.

OBJECTIVE: Patients with schizophrenia may respond better to second-generation antipsychotics than to older antipsychotics because of their superior efficacy and safety profiles. However, the reduced likelihood among ethnic minority groups of receiving newer antipsychotics may be associated with reduced medication adherence and health service use, potentially contributing to poor response rates. This study examined whether ethnicity helped predict whether patients with schizophrenia were given a first- or a second-generation antipsychotic, haloperidol versus risperidone or olanzapine, and what type of second-generation antipsychotic was prescribed, risperidone or olanzapine, when other factors were controlled for. METHODS: Texas Medicaid claims were analyzed for persons aged 21 to 65 years with a diagnosis of schizophrenia or schizoaffective disorder who started treatment with olanzapine (N=1875), risperidone (N=982), or haloperidol (N= 726) between January 1, 1997 and August 31, 1998. The association between antipsychotic prescribing patterns among African Americans, Mexican Americans, and whites was assessed by using logistic regression analysis. Covariates included other patient demographic characteristics, region, comorbid mental health conditions, and medication and health care resource use in the 12 months before antipsychotic initiation. RESULTS: The results of the first- versus second-generation antipsychotic analysis indicated that African Americans were significantly less likely than whites to receive risperidone or olanzapine. Although not statistically significant, the odds ratio indicated that Mexican Americans were also less likely to receive risperidone or olanzapine. Ethnicity was not associated with significant differences in the prescribing patterns of risperidone versus olanzapine. CONCLUSIONS: When other factors were controlled for, African Americans were significantly less likely to receive the newer antipsychotics. Among those who received the newer antipsychotics, ethnicity did not affect medication choice.

Long-term olanzapine therapy in the treatment of bipolar I disorder: an open-label continuation phase study.

BACKGROUND: Olanzapine has demonstrated efficacy in the treatment of acute mania in 2 double-blind, placebo-controlled trials. We describe the results of the open-label extension from one of these trials. METHOD: In a 3-week, double-blind study of patients with DSM-IV bipolar I disorder, olanzapine was superior to placebo for the treatment of acute manic symptoms. Of the 139 patients who entered the double-blind phase of the 3-week study, 113 patients continued into the 49-week open-label extension. Efficacy measurements including the Young Mania Rating Scale (YMRS), the 21-item Hamilton Rating Scale for Depression (HAM-D-21), the Clinical Global Impressions scale-Bipolar Version, and the Positive and Negative Syndrome Scale and safety measurements including the Simpson-Angus scale, the Barnes Akathisia Scale, and the Abnormal Involuntary Movement Scale were completed throughout. The analysis considered all treatment results, starting with the first olanzapine dose. Adjunctive lithium and fluoxetine were allowed during the open-label extension. RESULTS: The mean length of olanzapine treatment was 6.6 months, with a mean modal dose of 13.9 mg/day. A significant mean improvement in the YMRS total score, baseline to endpoint (-18.01, p < .001), was observed. During treatment, 88.3% of patients experienced a remission of manic symptoms (YMRS total score < or =12), and only 25.5% subsequently relapsed (YMRS total score > or = 15). Significant improvement in HAM-D-21 scores was observed (p < .001). Forty-one percent of patients were maintained on olanzapine monotherapy. The most common treatment-emergent adverse events reported were somnolence (46.0%), depression (38.9%), and weight gain (36.3%). CONCLUSION: During up to 1 year of olanzapine therapy, either as monotherapy or in combination with lithium and/or fluoxetine, patients with bipolar disorder demonstrated significant improvement in mania and depression symptoms with a favorable safety profile. Further double-blind, controlled studies are needed to confirm these results.

Annual health outcomes and treatment costs for schizophrenia populations.

This article describes a model that estimates annual patient health and cost outcomes for schizophrenia under alternative treatment scenarios. We estimate these outcomes for typical antipsychotics and show how treatment with atypical antipsychotics could have an impact on these outcomes. Patients are divided into 5 subcategories--newly diagnosed, no episode, acute episode(s), extended care, and institutionalized--and patient health and cost outcomes are estimated for each category. The proportion of people in each category is estimated for U.S. general, state mental hospital, and community mental health populations. Outcomes include extrapyramidal and moderate/severe schizophrenia symptom days, employed days, suicides, hospital days, and health costs. For patients treated with typical antipsychotics, annual per-patient symptom days ranged from 55 to 365 and costs ranged from $16,000 to $57,000, depending on disease severity. Atypical antipsychotics may reduce symptoms and costs through better efficacy for negative symptoms and better compliance.

Changes in perceived health and functioning as a cost-effectiveness measure for olanzapine versus haloperidol treatment of schizophrenia.

We utilize data from a large, double-blind, randomized clinical trial of treatment for schizophrenia to compare the effect of therapy with the second generation antipsychotic olanzapine versus therapy with the conventional agent haloperidol on the perceived functioning and well-being of patients over 1 year as measured by the Medical Outcome Study Short Form (SF-36). We also compare the total cost of care between the treatment groups over 1 year and combine cost and functional outcomes information to estimate the incremental cost-effectiveness of both therapies in this sample. Over 1 year of therapy, patients receiving olanzapine experienced a mean of 5.75 units greater improvement than did haloperidol-treated patients on the physical health and functioning factor of the SF-36 and 1.66 units greater improvement on the mental health and functioning factor. The mean annual total cost of care, including the cost of medication therapies, was $9386.87 less for olanzapine-treated patients than for haloperidol-treated patients. The incremental cost-effectiveness ratio for olanzapine versus haloperidol treatment indicated a savings of $1632.50 per unit of improvement in the SF-36 physical health and functioning score and a savings of $5654.74 per unit of improvement in the mental health and functioning composite. Improvements in perceived health and functioning were also associated with reduction in hospital costs in the full sample. These findings suggest that patient-centered measures of functioning such as the SF-36 are an important component of the evaluation of the cost-effectiveness of novel treatments for schizophrenia.

Increasing response rates for mailed surveys of Medicaid clients and other low-income populations.

Mailing surveys to low-income populations is often avoided because of concern about low response rates. In this study, the authors used a mailed survey of a low-income population to test whether $1.00 or $2.00 cash-response incentives were worth the expense and whether 2-day priority mail ($2.90 postage) would yield a sufficiently higher response rate than certified mail ($1.52 postage) to justify its cost. In 1994, 2,243 randomly selected families in subsidized health care programs in Pierce County, Washington, were randomly sent no incentive, $1.00, or $2.00 in the first of three mailings. For the third mailing, nonrespondents were randomly assigned to receive either certified or 2-day priority mail. After 4 weeks, the response rates were 36.7%, 48.1%, and 50.3% for the no-incentive, $1.00, and $2.00 groups, respectively. After three mailings, the cost per response was the lowest for the group that received $1.00. The response rate for the certified mailing (28.1%) was significantly higher than the rate for the more expensive priority mailing (21.7%). No incentive-related bias was detected. The authors concluded that the most efficient protocol for this low-income population was to use a $1.00 incentive in the first mailing and a certified third mailing.

Assessment of maternal anxiety following neonatal screening and investigation for occult spinal dysraphism.

The objective was to determine maternal anxiety and attitudes associated with a programme of neonatal screening and investigation for occult spinal dysraphism. Questionnaires were completed after diagnostic investigation (time 1) and 6 months later (time 2) by 83 mothers of babies with possible markers of occult spinal dysraphism who were normal on spinal ultrasound. Outcome measures were: attitudes to the programme; maternal adjustment and attitudes to the baby; the State-Trait Anxiety Inventory. Fifty-four other postnatal mothers formed the comparison group for maternal adjustment. No significant differences were found between investigation group (time 1) and comparisons on measures of maternal adjustment. Anxious mothers gave more negative responses to some maternal adjustment items but not to attitudes to the programme. Mean state anxiety at time 1 (33.66) and time 2 (33.69) and mean trait anxiety (36.23) were not higher than in mothers of normal babies. It can be concluded that a programme of investigation for neonatal abnormalities that pays attention to detail need not cause excessive maternal anxiety. However, some mothers remain anxious even after receiving normal results. Anxiety can be assessed during appraisal of a new investigation programme, but refinements are needed.

A population-based case-control study of risk factors for breech presentation.

OBJECTIVE: We evaluated relationships between breech presentation and infant, maternal, and pregnancy characteristics of singleton births. STUDY DESIGN: A population-based case-control study (3588 breech cases, 8183 controls) was conducted with data from the 1987 to 1988 Washington State birth certificate. RESULTS: Low birth weight, short gestational age, primiparity, and older maternal age were associated with increased risk of breech birth, and after we controlled for these factors, the following were also associated with breech birth: hydrocephalus, established maternal diabetes, congenital malformation of the infant, smoking during pregnancy, and late or no prenatal care. In addition, black and Filipino women had decreased risk of breech presentation compared with white women. CONCLUSION: Several different maternal and infant characteristics appear to increase risk of breech birth, suggesting that there may be several different biologic mechanisms leading to breech presentation.

Ultrasound determination of the normal location of the conus medullaris in neonates.

PURPOSE: To establish the normal range of the position of the conus medullaris in neonates and determine whether it differs from that in adults. METHODS: One hundred five healthy neonates born over an 18-day period in a single obstetric unit had ultrasound examinations of their lower spines to relate the conus medullaris to the nearest intervertebral disk or midvertebral level. RESULTS: The mean position of the conus was midway between the L1-2 disk and mid-L-2 body, ranging from T-12/L-1 to L-3, with the modal position being L1-2 (47.6%). A small but significant rise in position from 33 to 42 weeks postconceptual age was identified. Comparison with data previously reported from adults showed a small but highly significant difference in conus position of approximately 0.25 vertebral levels. DISCUSSION: Our data confirm studies suggesting that ascent of the cord after birth is minor.

Does subclinical pancreatic inflammation occur after parathyroidectomy?

Pancreatitis is accepted as an uncommon complication of parathyroid surgery, but it has been suggested that up to 35% of patients may experience hyperamylasaemia after parathyroidectomy indicating subclinical inflammation of the pancreas. A series of 26 patients undergoing parathyroidectomy were studied by preoperative biochemical analyses repeated 24 and 48 h postoperatively allowing changes in calcium metabolism and serum and urinary amylase levels to be documented. Of the patients, 21 also underwent a CT scan of the pancreas between 24 and 48 h after operation. Despite highly significant changes in serum parathormone, calcium and phosphate levels postoperatively, there was no evidence in any patient of acute pancreatic inflammation or hyperamylasaemia. Twenty-one patients underwent unilateral neck exploration, and we suggest that the absence of any detectable amylase elevation supports the suggestion that such elevation may reflect an increase in salivary isoamylase as a result of extensive neck dissection, rather than reflecting a subclinical pancreatitis. The development of postparathyroidectomy pancreatitis appears to be an all or nothing phenomenon of unknown aetiology.

Lumbosacral skin markers and identification of occult spinal dysraphism in neonates.

Some skin lesions over the spine are known to be associated with occult spinal dysraphism, but the significance of common skin lesions, such as sacral pits and dimples, is uncertain. In this prospective study, 95 neonates (1.9% of 4989 live births) were referred with possible markers of occult spinal dysraphism. Seven of 94 babies examined had abnormalities demonstrated by spinal ultrasound, compared with 5 of 105 controls. In 2 of 94 and 3 of 105 of these, the conus medullaris was located at L3 but no other abnormalities were found. Of the 75 babies with a sacral dimple or pit alone, none had an abnormality, suggesting that these skin lesions do not indicate a high risk of occult spinal dysraphism.

Bacterial tracheitis in Down's syndrome.

Four children with Down's syndrome and bacterial tracheitis are described. In three the infection was due to Haemophilus influenza. In patients with Down's syndrome presenting with stridor tracheitis should be considered and appropriate treatment started.

Ethanol poisoning.

A 3-year-old boy with severe ethanol poisoning metabolised ethanol more rapidly than expected (0.33 g/l/hour or 7.16 mmol/l/hour) and recovered fully with conservative management. It is concluded that active elimination techniques are unnecessary for most children with acute ethanol poisoning.