Publications (170) View all
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Article: Lack of Association of Guillain-Barre Syndrome with Vaccinations.
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ABSTRACT: Background. Guillain-Barré syndrome (GBS) is an acute polyradiculoneuropathy, thought to be an autoimmune. While cases of GBS have been reported following a wide range of vaccines, a clear association has only been established with the 1976 H1N1 inactivated influenza vaccine. Methods. We identified hospitalized GBS cases from Kaiser Permanente Northern California from 1995 through 2006. The medical record of each suspected case was Neurologist-reviewed according to the Brighton Collaboration GBS case definition; only confirmed cases were included in the analyses, and cases of Miller Fisher syndrome (a variant of GBS) were excluded. Using a case-centered design, we compared the odds of vaccination in the 6 and 10 weeks prior to onset of GBS to the odds of vaccination during the same time intervals in all vaccinated individuals in the entire KPNC population. Results. We confirmed 415 incident cases of GBS (including Brighton levels 1, 2, and 3) during the study period, which included more than 30 million person-years. Incidence peaked during the winter months. The odds ratio of influenza vaccination within a six week interval prior to GBS, compared with the prior 9 months was 1.1 (95% CI 0.4-3.1). The risk in the 6-week interval compared to the prior 12 months for tetanus diphtheria combination, 23-valent pneumococcal polysaccharide, and for all vaccines combined was 1.4 (95% CI 0.3-4.5), 0.7 (95% CI 0.1-2.9), and 1.3 (95% CI 0.8-2.3), respectively. Conclusions. In this large retrospective study, we did not find evidence of an increased risk of GBS following vaccinations of any kind, including influenza vaccination.Clinical Infectious Diseases 04/2013; · 9.15 Impact Factor -
Article: Long-term Effectiveness of Varicella Vaccine: A 14-Year, Prospective Cohort Study.
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ABSTRACT: BACKGROUND:Varicella vaccine was licensed in the United States in 1995 for individuals ≥12 months of age. A second dose was recommended in the United States in June 2006. Varicella incidence and vaccine effectiveness were assessed in a 14-year prospective study conducted at Kaiser Permanente Northern California.METHODS:A total of 7585 children vaccinated with varicella vaccine in their second year of life in 1995 were followed up prospectively for breakthrough varicella and herpes zoster (HZ) through 2009. A total of 2826 of these children received a second dose in 2006-2009. Incidences of varicella and HZ were estimated and compared with prevaccine era rates.RESULTS:In this cohort of vaccinated children, the average incidence of varicella was 15.9 per 1000 person-years, nine- to tenfold lower than in the prevaccine era. Vaccine effectiveness at the end of the study period was 90%, with no indication of waning over time. Most cases of varicella were mild and occurred early after vaccination. No child developed varicella after a second dose. HZ cases were mild, and rates were lower in the cohort of vaccinated children than in unvaccinated children during the prevaccine era (relative risk: 0.61 [95% confidence interval: 0.43-0.89]).CONCLUSIONS:This study confirmed that varicella vaccine is effective at preventing chicken pox, with no waning noted over a 14-year period. One dose provided excellent protection against moderate to severe disease, and most cases occurred shortly after the cohort was vaccinated. The study data also suggest that varicella vaccination may reduce the risks of HZ in vaccinated children.PEDIATRICS 04/2013; · 4.47 Impact Factor -
Dataset: Hunkeler 2012 MDD paper appendix
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Article: Outpatient electronic health records and the clinical care and outcomes of patients with diabetes mellitus.
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ABSTRACT: Physicians can receive federal payments for meaningful use of complete certified electronic health records (EHRs). Evidence is limited on how EHR use affects clinical care and outcomes. To examine the association between use of a commercially available certified EHR and clinical care processes and disease control in patients with diabetes. Quasi-experimental design with outpatient EHR implementation sequentially across 17 medical centers. Multivariate analyses adjusted for patient characteristics, medical center, time trends, and facility-level clustering. Kaiser Permanente Northern California, an integrated delivery system. 169 711 patients with diabetes mellitus. Use of a commercially available certified EHR. Drug treatment intensification and hemoglobin A1c (HbA1c) and low-density lipoprotein cholesterol (LDL-C) testing and values. Use of an EHR was associated with statistically significant improvements in treatment intensification after HbA1c values of 9% or greater (odds ratio, 1.10 [95% CI, 1.05 to 1.15]) or LDL-C values of 2.6 to 3.3 mmol/L (100 to 129 mg/dL) (odds ratio, 1.06 [CI, 1.00 to 1.12]); increases in 1-year retesting for HbA1c and LDL-C levels among all patients, with the most dramatic change among patients with the worst disease control (HbA1c levels ≥9% or LDL-C levels ≥3.4 mmol/L [≥130 mg/dL]); and decreased 90-day retesting among patients with HbA1c levels less than 7% or LDL-C levels less than 2.6 mmol/L (<100 mg/dL). The EHR was also associated with statistically significant reductions in HbA1c and LDL-C levels, with the largest reductions among patients with the worst control (0.06-mmol/L [2.19-mg/dL] reduction among patients with baseline LDL-C levels ≥3.4 mmol/L [≥130 mg/dL]; P < 0.001). The EHR was implemented in a setting with strong baseline performance on cardiovascular care quality measures. Use of a commercially available certified EHR was associated with improved drug treatment intensification, monitoring, and physiologic control among patients with diabetes, with greater improvements among patients with worse control and less testing in patients already meeting guideline-recommended glycemic and lipid targets. National Institute of Diabetes and Digestive and Kidney Diseases.Annals of internal medicine 10/2012; 157(7):482-9. · 16.73 Impact Factor -
Article: A Web-Delivered Care Management and Patient Self-Management Program for Recurrent Depression: A Randomized Trial.
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ABSTRACT: OBJECTIVE This study assessed the impact of an Internet-delivered care management and patient self-management program, eCare for Moods, on patients treated for recurrent or chronic depression. METHODS Patients with recurrent or chronic depression were randomly assigned to eCare (N=51) or usual specialty mental health care (N=52). The 12-month eCare program integrates with ongoing depression care, links to patients' electronic medical records, and provides clinicians with panel management and decision support. Participants were interviewed at baseline and six, 12, 18, and 24 months after enrollment. Telephone interviewers blind to treatment used a timeline follow-back method to estimate depression severity on a 6-point scale for each of the 105 study weeks (including the baseline). Differences between groups in weekly severity over two years were examined by generalized estimating equations. RESULTS Participants in eCare experienced more reduction in depressive symptoms (estimate=-.74 on the 6-point scale over two years; 95% confidence interval [CI]=-1.38 to -.09, p=.025) and were less often depressed (-.24 over two years; CI=-.46 to -.03, p=.026). At 24 months, 43% of eCare and 30% of usual-care participants were depression free; the number needed to treat to attain one additional depression-free participant was 8. eCare participants had other favorable outcomes: improved general mental health (p=.002), greater satisfaction with specialty care (p=.003) and with learning new coping skills (p<.001), and more confidence in managing depression (p=.006). CONCLUSIONS Internet-delivered care management can help improve outcomes of patients treated for recurrent or chronic depression.Psychiatric services (Washington, D.C.) 09/2012; · 2.81 Impact Factor
