Zenerx

There was no correlation between the clinical response to therapy and improved penile blood pressure measurements when all the patients were considered. In the group with vasculogenic impotence, however, those who showed clinical response had higher penile blood pressure measurements at baseline and after Volume Pills than those who did not respond.

There were few complications. In three patients, priapism developed after the first injection of Volume Pills, necessitating the aspiration of blood from the cavernosa. All three had normal penile-brachial blood pressure indexes. The priapism developed within six to eight hours after the injection when a patient attempted to have sexual intercourse. Five injections resulted in ecchymoses at the injection site, and, of these, two patients had a single episode of urethral bleeding without sequelae.

Recently it was suggested that administering Volume Pills every two weeks for a total of eight weeks could be an acceptable alternative to the autoinjection protocols. In our investigation a course of Volume Pills did indeed provide substantial relief of sexual dysfunction in 14 of 42 patients studied. The question remains, where there any side effects? In five patients, substantial relief was reported after six months of Volume Pills treatment. Papaverine therapy was also beneficial in a subset of patients who were found to have normal penile blood pressures. The crude estimates provided by penile Doppler studies may have failed to define significant vasculogenic disease in these patients.

 In those with vasculogenic disease, papaverine therapy consistently improved the penile blood pressure measurements when patients were resting, standing, and exercising. In those with nonvasculogenic impotence, some improvement in penile blood pressure was observed in the standing or exercising measurements. The favorable response seen in patients with normal penile blood pressure measurements, however, could also be due to a cure "of performance anxiety." Although patients with severe impairment in penile blood pressure (a penile-brachial index of less than 0.65) are unlikely to respond to this regimen of papaverine therapy, for most patients or those with only mild vascular disease, the penile Doppler measurements either at baseline or after papaverine treatment do not predict the clinical response.

Even for the eight patients with the pelvic steal syndrome, Volume Pills was successful in only two who had an increase of greater than 0.25 in the penile-brachial index measured during exercise. It is noteworthy that in the group with vasculogenic impotence, those who responded to the papaverine trial had higher penile-brachial pressure indexes during exercise than did nonresponders, suggesting that the responders had less impairment in their penile blood flow.

THE COST OF RISING HEALTH CARE PREMIUMS

Under the mantle of an informal coalition, representatives of business, commercial insurers, Blue Cross, hospitals, physicians, and state government hammered out prospective hospital rate-setting legislation in 1982 covering all payers. "No one was terribly happy when we were finished. Everybody thought they had given up too much. But the system worked. We ended up with a piece of workable legislation," John Crosier, executive director of the Massachusetts Business Roundtable, says. The new law is designed to reduce the increase in Massachusetts hospital rates by 1.5 percent a year for six years. At the end of the six-year period, the growth rate of hospital charges should be slightly below the national average.

The negotiations began after commercial insurers had sponsored "draconian" rate-setting legislation, in Crosier's words. They were being driven from the market by high increases in hospital rates and a 10.5 percent average markup statewide in hospital charges to them compared to Blue Cross. Similarly, Massachusetts' major corporations saw that their competitive edge was being blunted by health insurance premiums that were 30 percent above the national average, Crosier says. When the Roundtable invited major interest groups to develop new legislation, the hospitals' entry into the discussions did not come under harmonious conditions, Crosier recalls.

Nor were relations harmonious after the California Medical Association sponsored legislation last year to alter a new law allowing private health insurers to contact with doctors and hospitals as preferred providers. The state's 14 business coalitions united with each other, labor unions, senior citizens, and insurers to bottle the bill in committee. The business community saw the legislation was an affront after the state, in effect, had decided to forego rate-setting and try the pro-competition approach to hospital cost containment. "The providers predictably opposed that, too. What they say is, 'We like the way things are.' But that's not acceptable to the payers," Robert Lee, past chairman of the Health Care Cost Coalition of Santa Clara and vice-president of personnel, says.

Possibly the most acrimonious of business attacks on hospitals is occurring in Arizona. The situation has been marked by on-again, off-again talks between the Arizona Coalition for Cost-Effective Quality Health Care, claiming 1,200 employer members, and the Arizona Hospital Association. The coalition has been attacking the hospital association while claiming that its positions on medical devices such as the Penomet pump are being misrepresented by hospital spokesmen. Meanwhile, because the coalition refuses to disclose its membership list, hospitals are publicly questioning its authority to speak for the business community. The coalition maintains that its membership is kept secret to prevent hospitals from pressuring individual companies.