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This study compares the effects of atypical and conventional antipsychotic medications on treatment continuation and outcomes in a first admission sample of patients with schizophrenia treated in usual practice settings. In a sample of 189 participants with a research diagnosis of DSM-IV schizophrenia drawn from the Suffolk County Mental Health Project, we compared the effects of atypical and conventional agents on change of medication, medication gaps, and rehospitalization. For these analyses we used the method of survival analysis for recurrent events, in which the episodes of treatment rather than individual subjects are the units of analysis. In addition, we compared improvement in positive and negative symptoms from intake to 24- or 48-month followups for subjects who stayed on one type of medication or changed to atypicals from conventional antipsychotics. Atypical agents were associated with lower risk of medication change, medication gaps, and rehospitalization. Both conventional and atypical agents were associated with improvement of positive symptoms at followup, but only subjects on atypical agents at followup experienced a significant improvement in negative symptoms. We conclude that in usual practice settings, as in randomized clinical trials, atypical agents are associated with improved treatment continuation and outcomes.

The authors examined gaps in the use of antipsychotic medications during the one-year period after discharge in an epidemiological sample of 189 first-admission patients with schizophrenia between July 1989 and January 1996. Sixty-three percent of the patients had one or more such gaps, and 51 percent had gaps of 30 days or longer, with an average total time off medication of about seven months. Most gaps occurred soon after discharge, and 73 percent were initiated by the patient. These data, which were obtained before the widespread use of atypical antipsychotic agents, provide a benchmark against which to examine the impact of the newer medications on adherence and continuity of treatment in the critical early stages of schizophrenia.

This article presents an analytic tool populated with data from published studies to illustrate the likely impacts of a switch from typical to atypical antipsychotic drugs over a 3-year period on individual, family, and societal outcomes for a U.S. schizophrenia population. Data taken from clinical trials and observational data studies are used. Changes in annual health care costs, schizophrenia symptom days, extrapyramidal symptom (EPS) days, suicide rates, and employment days are estimated. For each 1,000 people treated with typical drugs, the base case scenario gives estimates of annual medical care costs of dollar 28.9 million with 80,253 moderate/severe schizophrenia symptom days and 92,006 EPS days. In the base case scenario, after switching to atypical drugs, schizophrenia symptom days are estimated to decrease up to 33 percent, EPS days up to 50 percent, and total medical care costs up to 19 percent over the 3-year period. Suicide rates fall and employment rates increase. The direction of the impacts remain the same for a wide range of input parameter values used in sensitivity analyses. Thus, switching to atypical drugs will likely reduce total medical care costs and decrease other disease burdens for people with schizophrenia, their families, and society.

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.

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.

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.

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.

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.

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.

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.

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.

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.