The treatment of migraines and tension-type headaches with intravenous and oral niacin (nicotinic acid): systematic review of the literature

BACKGROUND: Migraine and tension-type headaches impose a tremendous economic drain upon the healthcare system. Intravenous and oral niacin has been employed in the treatment of acute and chronic migraine and tension-type headaches, but its use has not become part of contemporary medicine, nor have there been randomized controlled trials further assessing this novel treatment. We aimed to systematically review the evidence of using intravenous and/or oral niacin as a treatment for migraine headaches, tension-type headaches, and for headaches of other etiologic types. METHODS: We searched English and non-English language articles in the following databases: MEDLINE (1966–February 2004), AMED (1995–February 2004) and Alt HealthWatch (1990–February 2004). RESULTS: Nine articles were found to meet the inclusion criteria and were included in this systematic review. Hypothetical reasons for niacin's effectiveness include its vasodilatory properties, and its ability to improve mitochondrial energy metabolism. Important side effects of niacin include flushing, nausea and fainting. CONCLUSION: Although niacin's mechanisms of action have not been substantiated from controlled clinical trials, this agent may have beneficial effects upon migraine and tension-type headaches. Adequately designed randomized trials are required to determine its clinical implications

Maternal care and birth outcomes among ethnic minority women in Finland

<p>Abstract</p> <p>Background</p> <p>Care during pregnancy and labour is of great importance in every culture. Studies show that people of migrant origin have barriers to obtaining accessible and good quality care compared to people in the host society. The aim of this study is to compare the access to and use of maternity services, and their outcomes among ethnic minority women having a singleton birth in Finland.</p> <p>Methods</p> <p>The study is based on data from the Finnish Medical Birth Register in 1999–2001 linked with the information of Statistics Finland on woman's country of birth, citizenship and mother tongue. Our study data included 6,532 women of foreign origin (3.9% of all singletons) giving singleton birth in Finland during 1999–2001 (compared to 158,469 Finnish origin singletons).</p> <p>Results</p> <p>Most women have migrated during the last fifteen years, mainly from Russia, Baltic countries, Somalia and East Europe. Migrant origin women participated substantially in prenatal care. Interventions performed or needed during pregnancy and childbirth varied between ethnic groups. Women of African and Somali origin had most health problems resulted in the highest perinatal mortality rates. Women from East Europe, the Middle East, North Africa and Somalia had a significant risk of low birth weight and small for gestational age newborns. Most premature newborns were found among women from the Middle East, North Africa and South Asia. Primiparous women from Africa, Somalia and Latin America and Caribbean had most caesarean sections while newborns of Latin American origin had more interventions after birth.</p> <p>Conclusion</p> <p>Despite good general coverage of maternal care among migrant origin women, there were clear variations in the type of treatment given to them or needed by them. African origin women had the most health problems during pregnancy and childbirth and the worst perinatal outcomes indicating the urgent need of targeted preventive and special care. These study results do not confirm either healthy migrant effect or epidemiological paradox according to which migrant origin women have considerable good birth outcomes.</p

Effect of panel composition on physician ratings of appropriateness of abdominal aortic aneurysm surgery: elucidating differences between multispecialty panel results and specialty society recommendations.

OBJECTIVE: To investigate how the composition of multispecialty physician panels is associated with both the summary ratings assigned by such panels and the agreement of such panels with the recommendations of specialty societies. DATA SOURCES/STUDY SETTING: We examined the final ratings assigned by a nine-member multispecialty RAND Corporation physician panel regarding indications for abdominal aortic aneurysm surgery and the recommendations of a specialty society representing vascular surgeons who perform the same surgery. STUDY DESIGN: The panel was retrospectively divided into two sub-panels, one composed of the three vascular surgeons on the panel and the other composed of the six remaining physicians. We analyzed the two sub-panels\u27 rating patterns with respect to each other and with respect to concurrent guidelines generated by the Joint Council of the Society of Vascular Surgery and the North American Chapter of the International Society for Cardiovascular Surgery. PRINCIPAL FINDINGS: Of the 782 indications considered by the panel for appropriateness, the vascular surgeons had an average of mean ratings for appropriateness of 5.1, significantly higher than the 4.5 average of the other physicians. Across the 221 indications considered by the panel for necessity, the vascular surgeons had an average of mean necessity ratings of 6.8, significantly higher than the 5.8 average of the other physicians. The vascular surgeons\u27 rankings of agreement with the guidelines of the Joint Council were significantly higher than those of the physician panelists from other specialties. CONCLUSIONS: statements of clinical appropriateness and necessity produced by summarizing ratings assigned to indications by expert panel members may disguise marked underlying disagreements among well-defined groups of practitioners within these panels. In the case of abdominal aortic aneurysm management, these disagreements within the RAND panel explain the marked discrepancy between the RAND multidisciplinary panel ratings and the recommendations issued by vascular surgeon professional societies

Management strategies for Helicobacter pylori-seropositive patients with dyspepsia: clinical and economic consequences.

BACKGROUND: Noninvasive testing for Helicobacter pylori is widely available and has been considered as an initial management strategy for uninvestigated dyspepsia. However, data to guide clinicians in the management of patients with dyspepsia who are seropositive for H. pylori are lacking. OBJECTIVE: To examine the economic, clinical, and policy implications of alternative initial management strategies for patients with uninvestigated dyspepsia who are seropositive for H. pylori. DESIGN: Decision analysis comparing the costs and outcomes of initial anti-H. pylori therapy and initial endoscopy. PATIENTS: Helicobacter pylori-seropositive patients with dyspepsia. MEASUREMENTS: Cost estimates were obtained from the Medicare reimbursement schedule and a health maintenance organization pharmacy. Probability estimates were derived from the medical literature. RESULTS: Initial endoscopy costs an average of $1276 per patient, whereas initial anti-H, pylori therapy costs$820 per patient; the average saving is $456 per patient treated. The financial effect of a 252% increase in the use of antibiotics for initial H. pylori therapy is more than offset by reducing the endoscopy workload by 53%. Endoscopy-related costs must be reduced by 96% before the two strategies become equally cost-effective. In patients with nonulcer dyspepsia, the financial benefits of initial anti-H. pylori therapy are not substantially affected by varying the rates of H. pylori eradication, the complications of antibiotics, or the response of symptoms to cure of H. pylori infection. CONCLUSIONS: In H. pylori-seropositive patients with dyspepsia, initial anti-H. pylori therapy is the most cost, effective management strategy. Randomized studies of these strategies that evaluate outcomes and patient preferences are needed to optimize management decisions. In the meantime, unless physicians are concerned about resistance to antimicrobial agents or the lack of proven benefit of anti-H. pylori therapy in nonucler dyspepsia, the strategy outlined in this analysis can be used as a basis for management and policy decisions about H. pylori-seropositive patients with dyspepsia

Effect of panel composition on physician ratings of appropriateness of abdominal aortic aneurysm surgery: elucidating differences between multispecialty panel results and specialty society recommendations.

OBJECTIVE: To investigate how the composition of multispecialty physician panels is associated with both the summary ratings assigned by such panels and the agreement of such panels with the recommendations of specialty societies. DATA SOURCES/STUDY SETTING: We examined the final ratings assigned by a nine-member multispecialty RAND Corporation physician panel regarding indications for abdominal aortic aneurysm surgery and the recommendations of a specialty society representing vascular surgeons who perform the same surgery. STUDY DESIGN: The panel was retrospectively divided into two sub-panels, one composed of the three vascular surgeons on the panel and the other composed of the six remaining physicians. We analyzed the two sub-panels\u27 rating patterns with respect to each other and with respect to concurrent guidelines generated by the Joint Council of the Society of Vascular Surgery and the North American Chapter of the International Society for Cardiovascular Surgery. PRINCIPAL FINDINGS: Of the 782 indications considered by the panel for appropriateness, the vascular surgeons had an average of mean ratings for appropriateness of 5.1, significantly higher than the 4.5 average of the other physicians. Across the 221 indications considered by the panel for necessity, the vascular surgeons had an average of mean necessity ratings of 6.8, significantly higher than the 5.8 average of the other physicians. The vascular surgeons\u27 rankings of agreement with the guidelines of the Joint Council were significantly higher than those of the physician panelists from other specialties. CONCLUSIONS: statements of clinical appropriateness and necessity produced by summarizing ratings assigned to indications by expert panel members may disguise marked underlying disagreements among well-defined groups of practitioners within these panels. In the case of abdominal aortic aneurysm management, these disagreements within the RAND panel explain the marked discrepancy between the RAND multidisciplinary panel ratings and the recommendations issued by vascular surgeon professional societies

Management strategies for Helicobacter pylori-seropositive patients with dyspepsia: clinical and economic consequences.

BACKGROUND: Noninvasive testing for Helicobacter pylori is widely available and has been considered as an initial management strategy for uninvestigated dyspepsia. However, data to guide clinicians in the management of patients with dyspepsia who are seropositive for H. pylori are lacking. OBJECTIVE: To examine the economic, clinical, and policy implications of alternative initial management strategies for patients with uninvestigated dyspepsia who are seropositive for H. pylori. DESIGN: Decision analysis comparing the costs and outcomes of initial anti-H. pylori therapy and initial endoscopy. PATIENTS: Helicobacter pylori-seropositive patients with dyspepsia. MEASUREMENTS: Cost estimates were obtained from the Medicare reimbursement schedule and a health maintenance organization pharmacy. Probability estimates were derived from the medical literature. RESULTS: Initial endoscopy costs an average of $1276 per patient, whereas initial anti-H, pylori therapy costs$820 per patient; the average saving is $456 per patient treated. The financial effect of a 252% increase in the use of antibiotics for initial H. pylori therapy is more than offset by reducing the endoscopy workload by 53%. Endoscopy-related costs must be reduced by 96% before the two strategies become equally cost-effective. In patients with nonulcer dyspepsia, the financial benefits of initial anti-H. pylori therapy are not substantially affected by varying the rates of H. pylori eradication, the complications of antibiotics, or the response of symptoms to cure of H. pylori infection. CONCLUSIONS: In H. pylori-seropositive patients with dyspepsia, initial anti-H. pylori therapy is the most cost, effective management strategy. Randomized studies of these strategies that evaluate outcomes and patient preferences are needed to optimize management decisions. In the meantime, unless physicians are concerned about resistance to antimicrobial agents or the lack of proven benefit of anti-H. pylori therapy in nonucler dyspepsia, the strategy outlined in this analysis can be used as a basis for management and policy decisions about H. pylori-seropositive patients with dyspepsia

Niacin-induced hepatitis: a potential side effect with low-dose time-release niacin.

Hepatitis developed in five patients who were taking low dosages (3 g/day or less) of time-release niacin. In four of the five patients, clinical symptoms of hepatitis developed after the medication had been taken for a relatively short time (2 days to 7 weeks). This manifestation of hepatotoxicity seems to differ from that previously reported in association with use of crystalline niacin, which occurred with high dosage and prolonged usage of the medication. In view of the recent increased frequency of prescribing niacin for the treatment of hyperlipidemia, physicians should be aware of the potential for hepatotoxicity with even low-dose and short-term use of time-release niacin

Niacin-induced hepatitis: a potential side effect with low-dose time-release niacin.

Hepatitis developed in five patients who were taking low dosages (3 g/day or less) of time-release niacin. In four of the five patients, clinical symptoms of hepatitis developed after the medication had been taken for a relatively short time (2 days to 7 weeks). This manifestation of hepatotoxicity seems to differ from that previously reported in association with use of crystalline niacin, which occurred with high dosage and prolonged usage of the medication. In view of the recent increased frequency of prescribing niacin for the treatment of hyperlipidemia, physicians should be aware of the potential for hepatotoxicity with even low-dose and short-term use of time-release niacin

The quality of care for Medicare patients with peptic ulcer disease.

OBJECTIVE: The aim of this study was to examine quality of care for hospitalized Medicare beneficiaries with peptic ulcer disease. METHODS: Collaborating with five Peer Review Organizations, we used 1995 Medicare claim files to select samples of inpatients with a principal diagnosis of peptic ulcer disease. Quality of care indicators developed by content experts included percentages for ulcer patients tested for Helicobacter pylori (H. pylori); biopsied patients who received tissue tests; H. pylori-positive patients who received appropriate therapy; and ulcer patients screened for preadmission nonsteroidal anti-inflammatory drug (NSAID) use and counseled about risks. RESULTS: Of 2,644 patients eligible for medical record review, 56% were tested for H. pylori, and 73% of those testing positive were treated appropriately; 84% of patients with endoscopic biopsies received a tissue test for H. pylori; 74% of patients were screened for preadmission NSAID use, 24% had documented counseling of NSAID use, and only 2% had documented counseling on the ulcer risk of NSAID use. Statistically significant regional variation occurred in four of six quality indicators. Outpatient records were reviewed for 529 patients to document prior outpatient H. pylori in this population; only 2% (n = 12) were tested for H. pylori in the year before admission. CONCLUSIONS: Opportunities exist to improve quality of care by testing for and treating H. pylori in hospitalized Medicare beneficiaries with peptic ulcer disease and to improve screening for NSAIDs and counseling on ulcer risks