Relationship among cattle breed and anabolic implant protocol relative to feedlot performance: Growth, temperament, feeding behavior, carcass traits, and economic return.

Recent research has suggested that different cattle breed types may respond differently to anabolic implant protocols of varying intensity. Therefore, the purpose of this research was to compare anabolic implant protocols in feedlot steers of 2 different breed types. Sixty steers were stratified by weight and breed in a 2 × 3 factorial design examining 2 different breeds: Angus (AN; n=38) or Santa Gertrudis influenced (SG; n=22), and 3 implant strategies: no implant (CON; n=20), a moderate intensity implant protocol (d0 implant: Revalor-G, d56 implant: Revalor-IS, d112 implant: Revalor-S; MI; n=20), or a high intensity implant protocol (d0 implant: Revalor-IS, d56 implant: Revalor-S, d112 implant: Revalor-200; HI; n=20). Steers were randomly placed into pens equipped with GrowSafe bunks to collect dry matter intake and feeding behavior. All animals were fed the same diet. Weight, chute score, exit velocity, serum, rectal temperature, hip height and 12th rib fat thickness were collected approximately every 28 d over a 196 d period. Serum urea nitrogen (SUN) was evaluated as well. Total average daily gain was increased (P < 0.0001) in both the HI and MI steers compared to the CON steers by 29.4% and 26%, respectively. A treatment × breed interaction was observed (P < 0.0001) for hip height, with AN-CON steers being shorter (P < 0.0007) than AN-HI, SG-CON, SG-MI, and SG-HI steers. A breed × treatment interaction was observed (P < 0.004) for chute score and rectal temperature, with SG-HI and SG-MI steers having increased chute scores (P < 0.001) when compared to AN-HI, AN-MI, AN-CON, and SG-CON throughout the course of the trial. Additionally, SG-HI and SG-MI steers had an increased rectal temperature (P < 0.004) compared to AN-HI, AN-MI, AN-CON, and SG-CON steers. A breed effect was observed (P = 0.002) for SUN with AN steers having increased (P = 0.002) SUN concentration compared to SG sired steers, in addition to a treatment effect (P < 0.0001), with CON steers having a higher (P < 0.0001) SUN concentration than MI and HI steers, regardless of breed. The MI implant protocol increased net return per head, on average, by $97.28, regardless of breed, while the HI implant protocol increased net return by only $80.84. Taken together, despite the cattle breed types responding differently to the different anabolic implant protocols at times, a moderate intensity anabolic implant protocol was optimal in this experiment for steers raised in a temperate climate.

The face of postural tachycardia syndrome - insights from a large cross-sectional online community-based survey.

BACKGROUND: Patients with postural tachycardia syndrome (POTS) experience chronic symptoms of orthostatic intolerance. There are minimal data detailing the demographics, clinical features and clinical course of this condition. This online, community-based survey highlights patients' experience with POTS. It consists of the largest sample of POTS patients reported to date. OBJECTIVES: To describe the demographics, past medical history, medications, treatments and diagnostic journey for patients living with POTS. METHODS: Postural tachycardia syndrome patients completed an online, community-based, cross-sectional survey. Participants were excluded if they had not received a diagnosis of POTS from a physician. The questions focused on the patient experience and journey, rather than physiological responses. RESULTS: The final analysis included 4835 participants. POTS predominantly affects white (93%) females (94%) of childbearing age, with approximately half developing symptoms in adolescence (mode 14 years). POTS is a chronic multisystem disorder involving a broad array of symptoms, with many patients diagnosed with comorbidities in addition to POTS. POTS patients often experience lengthy delays [median (interquartile range) 24 (6-72) months] and misdiagnosis, but the diagnostic delay is improving. POTS patients can present with a myriad of symptoms most commonly including lightheadedness (99%), tachycardia (97%), presyncope (94%), headache (94%) and difficulty concentrating (94%). CONCLUSIONS: These data provide important insights into the background, clinical features and diagnostic journey of patients suffering from POTS. These data should serve as an essential step for moving forward with future studies aimed at early and accurate diagnoses of these patients leading to appropriate treatments for their symptoms.

Health care utilization and costs by metabolic syndrome risk factors.

BACKGROUND: This study compared prevalent health utilization and costs for persons with and without metabolic syndrome and investigated the independent associations of the various factors that make up metabolic syndrome. METHODS: Subjects were enrollees of three health plans who had all clinical measurements (blood pressure, fasting plasma glucose, body mass index, triglycerides, and high-density lipoprotein cholesterol) necessary to determine metabolic syndrome risk factors over the 2-year study period (n = 170,648). We used clinical values, International Classification of Diseases, Ninth Revision (ICD-9) diagnoses, and medication dispensings to identify risk factors. We report unadjusted mean annual utilization and modeled mean annual costs adjusting for age, sex, and co-morbidity. RESULTS: Subjects with metabolic syndrome (n = 98,091) had higher utilization and costs compared to subjects with no metabolic syndrome (n = 72,557) overall, and when stratified by diabetes (P < 0.001). Average annual total costs between subjects with metabolic syndrome versus no metabolic syndrome differed by a magnitude of 1.6 overall ($5,732 vs. $3,581), and a magnitude of 1.3 when stratified by diabetes (diabetes, $7,896 vs. $6,038; no diabetes, $4,476 vs. $3,422). Overall, total costs increased by an average of 24% per additional risk factor (P < 0.001). Costs and utilization differed by risk factor clusters, but the more prevalent clusters were not necessarily the most costly. Costs for subjects with diabetes plus weight risk, dyslipidemia, and hypertension were almost double the costs for subjects with prediabetes plus similar risk factors ($8,067 vs. $4,638). CONCLUSIONS: Metabolic syndrome, number of risk factors, and specific combinations of risk factors are markers for high utilization and costs among patients receiving medical care. Diabetes and certain risk clusters are major drivers of utilization and costs.

A descriptive analysis of the use and cost of new-generation antihistamines in the treatment of allergic rhinitis: a retrospective database analysis.

OBJECTIVE: This retrospective database analysis was conducted to evaluate the use and cost of new-generation antihistamines (i.e., those that are nonsedating) in the treatment of allergic rhinitis in a managed care population. STUDY DESIGN: The study is a retrospective database review of medical and pharmacy-related claims linked by episodes of care. METHODS: Patients who had been diagnosed as having allergic rhinitis and had at least 1 prescription claim were identified from a database containing patient-level medical and pharmacy-related claims. The treatment patterns of patients with allergic rhinitis who met the study criteria were documented for a 12-month period in which the use of nonsedating antihistamines was described and the associated costs of various medications were assessed. Subanalyses of patients categorized by comorbidity status were also performed. RESULTS: A total of 202,426 patients participated in the study. Nonsedating antihistamines were used by 71% of the patients; the most commonly prescribed drugs were loratadine and fexofenadine. The mean annual charges per patient for the treatment of allergic rhinitis in the study population were $465.21 (standard deviation [SD], 548). The greatest departmental cost was that of pharmacy-related charges (mean, $236.02; SD, 233); the next highest cost was that of outpatient charges (mean, $216.31; SD, 396). Comparisons of departmental charges indicated the use of loratadine was associated with significantly higher treatment costs than that of fexofenadine in a number of patient subgroups. CONCLUSION: In this analysis, loratadine was associated with significantly higher treatment charges than was fexofenadine. This result was observed consistently across different stratifications of patients, including the presence of comorbid respiratory infection, concomitant use of nasal steroids, and the presence of asthma and/or sinusitis. These results provided useful insights into the differential costs associated with the use of nonsedating antihistamines in the treatment of rhinitis.

Comorbid conditions in patients with erectile dysfunction in a community setting.

The objective of this study was to assess the prevalence of chronic comorbidities and the use of concomitant medications in men diagnosed with erectile dysfunction (ED) in a community setting, using a large integrated database. All patients who experienced an episode of ED during a two-month period were identified from the database. Comorbid conditions were determined through outpatient management claims and prescription claims for concomitant conditions were also assessed during the study period.

Cost of treating influenza in emergency department and hospital settings.

OBJECTIVES: To provide an estimate of the costs of treating influenza in emergency department and hospital settings. STUDY DESIGN: Retrospective, descriptive study using patient-level data from the Perspective Comparative Database. PATIENTS AND METHODS: We analyzed clinical and cost data obtained from 75 of the 169 hospitals in the database. These hospitals were located throughout the United States. Patients were included in the study if they visited the emergency department between January 1, 1997, and June 30, 1998, and had a primary diagnosis of influenza. RESULTS: A total of 1362 patients with influenza visited the emergency department during the study period. Of these, 333 (24.4%) required hospitalization. The mean cost of treatment for patients discharged directly from the emergency department was $141.89; the mean cost of treatment for hospitalized patients was $3251.04. The mean length of stay for hospitalized patients was 4.3 days. Compared with younger patients, elderly patients were more likely to be hospitalized and incur higher costs. Thirty-eight percent of hospitalized patients for whom drug data were available received either amantadine or rimantadine during their stay. CONCLUSIONS: Few data are available documenting resource utilization and associated costs for patients with influenza treated in the emergency department or hospital. Our results represent a significant addition to the identification of the costs associated with the treatment of influenza. This suggests early intervention care aimed at minimizing the impact of influenza, especially in the elderly, could result in decreased hospitalizations and substantial cost savings to managed care.

Rates of hospitalization for asthma by insurance status.

OBJECTIVE: To compare utilization of emergency department (ED) and inpatient resources for asthmatics across insurance types. METHODS: Retrospective cohort analysis consisting of patients over 18 years of age admitted to the ED of 27 hospitals located throughout the United States for asthma between October 1, 1996 and September 30, 1997. RESULTS: 2738 patients were identified who met all inclusion/exclusion criteria. Approximately 25% of the sample had traditional indemnity insurance, 22% were managed care enrollees, 35% were enrolled in Medicaid or Medicare, and 18% were self-pay. Cost of treatment varied by insurance type in the ED and for inpatient asthma care: Medicare patients tended to have higher ED costs than all other insurance types, while indemnity patients had higher costs than Medicaid and Medicare patients. No significant differences were observed between managed care or indemnity patients for ED or inpatient costs; however, indemnity patients were less likely to be hospitalized for asthma subsequent to visiting the ED than managed care patients (OR: 0.40, 95% CI: 0.31-0.52). CONCLUSION: Significant differences in types and costs of care were observed across differing insurance types, which may suggest an "insurance effect" on asthma-related treatment in the ED and/or hospital.

Cost associated with the treatment of influenza in a managed care setting.

OBJECTIVE: The purpose of this study was to assess the costs and treatments associated with influenza patients with and without secondary viral or bacterial infections in a managed care setting. METHODS: Patients with influenza diagnoses (ICD-9 = 487) were identified in the PharMetrics database between January 1, 1997 and June 30, 1998. Patients were placed into 3 cohorts: influenza only (INF), influenza plus a secondary bacterial respiratory infection (BRI), and influenza plus a secondary viral respiratory infection (VRI). The index date was defined as the date of the first occurrence of an influenza diagnosis during the study period. Medical claims were assessed from the index date to the end of the influenza episode, which was defined as the date of the last claim for influenza followed by a 90-day "clean period" during which no influenza-related charges occurred. RESULTS: A total of 18,000 patients met the inclusion criteria. The mean age was 29 years, and 54% were female. Approximately 93% of patients were placed in the INF cohort, and 3% each in the BRI and VRI groups. The BRI cohort had the highest mean total cost ($5593* SD = 10,939), compared with the VRI cohort ($847 SD = 1782) and INF cohort ($602 SD = 2813) (P less than.0001 vs INF; P less than.0001 vs VRI). This total cost disparity was primarily driven by differences in inpatient costs: BRI ($3509, SD = 9474); VRI ($208, SD = 1327); INF ($138, SD = 2145). Patients in the BRI cohort averaged 0.5 hospitalizations per patient vs 0.06 in the VRI cohort and 0.03 in the INF cohort. CONCLUSIONS: Subjects in the BRI cohort were significantly more costly and had an increased risk of hospitalization as compared with subjects in the VRI or INF cohorts. Early intervention with antiviral agents and/or antibiotics, where appropriate, could result in significant cost savings for managed care organizations.

The cost of asthma in the emergency department and hospital.

Treatment of asthma in the emergency department (ED) or hospital accounts for a significant portion of total treatment costs; however, little is known about the specific resources consumed. The purpose of this study was to estimate the type and amount of resources consumed for an asthma event requiring ED visit and/or hospitalization. Between October 1, 1996 and September 30, 1997, occurrences of asthma as a primary diagnosis were identified at 27 hospitals' emergency departments within Premier's Perspective Comparative Database. Patients visiting the ED could either be treated and released or admitted to the hospital. A total of 3,223 patients (age >/= 18 yr) were identified, with 1,074 (33.3%) requiring hospitalization. For the 2,149 patients who visited the ED only, the average visit cost was $234.48. For hospitalized patients, the average length of stay was 3.8 d, and the cost was $3,102.53. Nursing care was the source of the majority of hospital costs for asthma (43.6%), respiratory therapy (13.6%), and medications (10.4%). For adult asthma patients requiring hospitalization, the total cost is high and resources consumed are unavoidable. Thus, a continuum of care aimed at appropriate asthma management, especially in the elderly, could result in substantial cost savings over those aimed at reducing inpatient utilization of care.

The effect of fluticasone propionate on functional status and sleep in children with asthma and on the quality of life of their parents.

BACKGROUND: Although in the past drug interventions were measured primarily on the basis of their efficacy and safety, today we are increasingly interested in what impact treatments have on the patient's day-to-day activities and quality of life. OBJECTIVES: We sought to assess the effect of treatment with fluticasone propionate (FP) on functional status and sleep disturbances in children with asthma and to evaluate possible changes in the quality of life of the parents of these children after treatment. METHODS: As part of a randomized, double-blind, parallel-group, placebo-controlled, multicenter study on the effects of FP powder (50 or 100 microg twice daily) on growth in children aged 4 to 11 years with mild-to-moderate asthma (n = 325), parents/caregivers completed the following questionnaires at baseline and at weeks 24 and 52 of treatment: Functional Status IIR (FSII), Sleep Scale-Children (SLP-C), and Quality of Life of Parents of Asthmatic Children (QOL-PAC). Change from baseline to weeks 24 and 52 within each treatment group was analyzed by using paired t-tests, and differences between treatment groups were analyzed by using analysis of covariance. RESULTS: Mean FSII and SLP-C scores improved significantly over baseline values with either 50 or 100 microg FP at weeks 24 and 52 (p < 0.05) and were significantly better than scores in the placebo group (p < 0.05). In contrast, FSII scores at week 52 and SLP-C scores at weeks 24 and 52 decreased significantly in the placebo group (p < 0.05). QOL-PAC results revealed that scores on the Burden scale were significantly improved in both FP groups at weeks 24 and 52. Subjective Norms and Social scales improved significantly only in the 100 microg FP group at week 52. CONCLUSIONS: The results of this study show that FP (either 50 or 100 microg twice a day) was associated with significant improvements in functional status and decreased sleep disturbances in children with asthma. In addition, treatment of children with FP was associated with a decreased burden on the parents of these children with asthma.

A national estimate of the economic costs of asthma.

This cost of illness analysis examines national cost and resource utilization by persons with asthma using a single, comprehensive data source, the 1987 National Medical Expenditure Survey. Direct medical expenditures included payments for ambulatory care visits, hospital outpatient services, hospital inpatient stays, emergency department visits, physician and facility payments, and prescribed medicines. Indirect medical costs included costs resulting from missed work or school and days with restricted activity at work. Point estimates and 95% confidence intervals (CI) were calculated and inflated to 1994 dollars. The total estimated cost was $5.8 billion (95% CI, $3.6 to $8 billion). The estimated direct expenditures were $5.1 billion (95% CI, $3.3 to $7.0 billion), and indirect expenditures were valued at $673 million (95% CI, $271 to $1,076 million). Hospitalization accounted for more than half of all expenditures. More than 80% of resources were used by 20% of the population (defined as 'high-cost patients'). The estimated annual per patient cost for those high-cost patients was $2,584, in contrast with $140 for the rest of the sample. Findings from this study indicate that future asthma research and intervention efforts directed at hospitalizations and high-cost patients could help to decrease health care resource use and provide cost savings.

Impact of fluticasone propionate powder on health-related quality of life in patients with moderate asthma.

Because biological indicators alone do not adequately represent the comprehensive health status of a patient with asthma, we also assessed patients' health-related quality of life (HRQOL) in a randomized, double-blind, placebo-controlled study of the effects of the inhaled corticosteroid fluticasone propionate (FP). A total of 342 patients with moderate asthma were treated twice daily for 12 weeks with FP powder (50, 100, or 250 micrograms) or placebo. At regular intervals, patients completed the Medical Outcomes Study Short Form-36, acute version (SF-36A), a general health status questionnaire measuring eight dimensions of HRQOL; the 20-item Living with Asthma (LWA-20) questionnaire, a disease-specific instrument measuring HRQOL; and three additional questions related to sleep loss and number of nighttime awakenings. Each of the three FP groups compared with placebo had significantly higher scores at study endpoint on the Physical Functioning (p < 0.001) and Role-Physical (p < or = 0.0001) dimensions of the SF-36A; the FP 100- or 250-micrograms groups compared with placebo also had significantly higher scores on General Health Perceptions (p < 0.03), Vitality (p < 0.007), and Mental Health (p < 0.02). At endpoint, all three FP groups compared with placebo had significantly better scores on the LWA questionnaire (p < 0.05) and on the sleep-related items (p < 0.0001). These data, collected using both a general health status questionnaire and an asthma-specific questionnaire, demonstrate that fluticasone propionate powder can improve HRQOL in patients with mild-to-moderate asthma.

Importance of selected inhaler characteristics and acceptance of a new breath-actuated powder inhalation device.

The degree of patient comfort and satisfaction with an inhaler can have an important effect on compliance with asthma treatment and, hence, therapeutic success. The objective of this study was to assess, from the patient's perspective, the importance of various inhaler characteristics and then evaluate patient satisfaction with a new breath-actuated powder inhaler (Diskhaler) based on those characteristics. Self-administered patient satisfaction questionnaires were completed as part of a randomized, double-blind, placebo-controlled study of fluticasone propionate powder in the treatment of asthma. At baseline, patients rated the importance of five inhaler characteristics (convenient to carry, durability, easy to load, easy to hold and operate, and easy to clean). Following exposure to the Diskhaler over a period of 8 weeks, patients rated the inhaler on those same characteristics. They also rated their comfort using the inhaler and their overall satisfaction with the inhaler. Data were available from 274 patients, the majority of whom expressed a high or very high level of satisfaction with the Diskhaler on each of the five characteristics. These ratings were congruent with their ratings of the importance of those same characteristics; 80-90% rated "convenient to carry," "durability," "easy to load," and "easy to hold and operate" as important or very important characteristics for an inhaler, while "easy to clean" was considered somewhat less important, with 63% rating this characteristic as important or very important. Following the initial exposure to the Diskhaler, 67% of patients were comfortable or very comfortable with the inhaler; that percentage increased to 79% after 8 weeks of use. Following 2 and 8 weeks of use, 61 and 62%, respectively, were satisfied or very satisfied with the Diskhaler. In general, satisfaction ratings were not affected by treatment, indicating that patients were evaluating only the inhaler and not the efficacy of the study drug they received. This study helped to identify which selected inhaler characteristics are most important to patients with asthma. The Diskhaler inhaler performed well on those characteristics deemed important to the patients. From their first exposure to the Diskhaler, patients were comfortable using the device, and this overall acceptance of the inhaler was maintained throughout the study.

Patient satisfaction with the Diskhaler and the Diskus inhaler, a new multidose power delivery system for the treatment of asthma.

To evaluate patient satisfaction with two breath-actuated powder inhalers (Diskhaler and Diskus), investigators asked patients to complete questionnaires as part of a randomized, double-masked, double-dummy, placebo-controlled study of fluticasone propionate powder (500 mg twice daily) in the treatment of chronic persistent asthma. At baseline, patients rated the importance of various inhaler attributes (i.e., ease of use, ease of loading with medication, ease of holding and operating, ease of cleaning, and ease of telling how many doses of medication are left). After 2 weeks of placebo and 6 and 12 weeks of active therapy, patients rated the inhalers on these same attributes. They also rated their general satisfaction with the inhalers and how comfortable they were using them. After 12 weeks, patients also rated the durability and convenience of carrying each device and were asked to indicate which they preferred. Data were available from 213 patients. All seven inhaler attributes measured were considered important by the majority of patients (71% to 91%), contributing to the validity of the patient-rated performance assessments. After 12 weeks of use, 57% to 88% of patients expressed a high level of satisfaction with the performance of the Diskhaler on all attributes; a high level of overall satisfaction (72%) and comfort (79%) was reported with this inhaler. Patients rated the performance of the Diskus inhaler very favorably, with 76% to 96% expressing a high level of satisfaction on all attributes; a high level of overall satisfaction (87%) and comfort (85%) was reported with this inhaler. At end point, 61.4% preferred the Diskus inhaler, 25.4% preferred the Diskhaler inhaler, and 13.2% expressed no preference. These breath-actuated powder inhalers may be acceptable alternatives to traditional metered-dose inhalers for the treatment of patients with asthma.

Fluticasone propionate improves quality of life in patients with asthma requiring oral corticosteroids.

BACKGROUND: Fluticasone propionate is a potent inhaled corticosteroid that is effective in improving pulmonary function and symptoms in patients with asthma. OBJECTIVE: To evaluate the effects of fluticasone propionate on quality of life in patients with severe asthma requiring oral corticosteroids. METHODS: A total of 96 patients with severe asthma participated in a randomized, double-blind, placebo-controlled, parallel-group, oral steroid-sparing study. Patients received fluticasone propionate aerosol, 750 or 1000 micrograms bid, or placebo for 16 weeks; 91 of these patients continued in a 1-year open-label study, in which everyone initially received fluticasone propionate, 1000 micrograms bid. At regular intervals, patients completed the Medical Outcomes Study Short Form-36 (SF-36), a general health status questionnaire measuring eight dimensions of quality of life, plus one question on change in health from the previous year. RESULTS: Compared with the US population, patients scored significantly lower at baseline for five of eight SF-36 dimensions (P < .01). After 16 weeks, patients receiving fluticasone propionate, 1000 micrograms, improved significantly (P < or = .02) in physical functioning, role-physical, general health, and change in health, compared with the placebo group. After 1 year of open-label treatment with fluticasone propionate, these improvements were maintained. SF-36 scores in the placebo group during the double-blind period either worsened or remained unchanged; however, when these patients were switched to fluticasone propionate during the open-label period, their SF-36 scores also improved. Forced expiratory volume in 1 second (FEV1) at the end of the double-blind period was positively correlated with mean quality of life scores on physical functioning, role-physical, vitality, social functioning, and change-in-health status. CONCLUSION: Health-related quality of life improved in patients with severe asthma following 16 weeks of treatment with fluticasone propionate, 1000 micrograms bid. These improvements were maintained during subsequent fluticasone propionate treatment over a 1-year period.