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ABSTRACT: To define current clinical practice for evaluating distal symmetric polyneuropathy.
Using a modified Dillman method, we sent surveys to 600 internists, 600 neurologists, and 45 neuromuscular specialists selected from the American Medical Association Physician Masterfile. Survey questions pertained to which tests providers would order in the following 3 scenarios: (1) the initial evaluation of distal symmetric polyneuropathy, (2) the use of additional tests if the initial evaluation was unrevealing, and (3) patients with diabetes. The t test was used to compare the number of tests ordered by physician type, and the χ(2) test was used to compare proportions of tests ordered.
National survey of physicians.
Internists, neurologists, and neuromuscular specialists.
The response rate was 35%. Overall, many tests were ordered for the full evaluation of distal symmetric polyneuropathy (mean [SD], 16.5 [7.2] tests), and there was substantial variation within and between provider types. Internists ordered fewer tests (mean [SD], 14.5 [6.1] tests) than did neurologists (mean [SD], 17.5 [7.9] tests) (P < .001). Regarding the glucose tolerance test, substantial differences were found between physician types, with neurologists and neuromuscular specialists ordering this test more frequently (28.6% and 72.3%, respectively) and internists ordering it less frequently (4.1%). A brain and/or spine magnetic resonance imaging scan was ordered by 19.8% of internists and 12.9% of neurologists.
From the supporting evidence, current practice intent on evaluating distal symmetric polyneuropathy is highly variable and differs widely. For this disorder of the peripheral nerves, a high-yield test such as the glucose tolerance test is rarely used, whereas magnetic resonance imaging is likely overused. Research that defines the optimal evaluation of distal symmetric polyneuropathy has the potential to result in more efficient care.
Archives of neurology 11/2011; 69(3):339-45. · 6.31 Impact Factor
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ABSTRACT: We conducted a needs assessment to ascertain patients' interests and preferences for using email reminders ('E-minders') to assist in the self-management of their depression. The E-minders would help patients achieve remission by reminding them of their personal strategies for self-management and their personalized sources of support. Once patients had achieved remission, E-minders would be used to remind them of their original symptoms of depression so that they could monitor for recurrence. Results from a focus group with eight patients suggested that patients would be interested in using E-minders. However, they should not be used to replace aspects of treatment but rather to supplement existing depression treatment regimens.
Journal of telemedicine and telecare 09/2011; 17(7):378-81. · 0.92 Impact Factor
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ABSTRACT: Studies have demonstrated an influence of dosage release formulations on drug interactions and enantiomeric plasma concentrations. Metoprolol is a commonly used beta-adrenergic antagonist metabolized by CYP2D6. The CYP2D6 inhibitor paroxetine has previously been shown to interact with metoprolol tartrate. This open-label, randomized, 4-phase crossover study assessed the potential differential effects of paroxetine on stereoselective pharmacokinetics of immediate-release (IR) tartrate and extended-release (ER) succinate metoprolol formulations. Ten healthy participants received metoprolol IR (50 mg) and ER (100 mg) with and without paroxetine coadministration. Blood samples were collected over 24 hours for determination of metoprolol plasma enantiomer concentrations. Paroxetine coadministration significantly increased S and R metoprolol area under the plasma concentration-time curve from time 0 to the 24-hour blood draw (AUC(0-24h)) by 4- and 5-fold, respectively for IR, and 3- and 4-fold, respectively, for ER. S/R AUC ratios significantly decreased. These results demonstrate a pharmacokinetic interaction between paroxetine and both formulations of metoprolol. The interaction is greater with R metoprolol, and stereoselective metabolism is lost. This could theoretically result in greater beta-blockade and lost cardioselectivity. The magnitude of the interaction was similar between metoprolol formulations, which may be attributable to low doses/drug input rates employed.
The Journal of Clinical Pharmacology 03/2011; 51(3):389-96. · 2.91 Impact Factor
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ABSTRACT: To determine the association between triglyceride levels and lower-extremity amputation (LEA) risk in a large diabetic cohort.
This is a 10-year survey follow-up study (from 1995-2006) of 28,701 diabetic patients with a baseline triglyceride measure. All patients were fully insured members of the Kaiser Permanente Medical Care Program and responded to a survey at baseline that included information on ethnicity, socioeconomic status, education, behavioral factors, and information required to determine type of diabetes. The relationship between triglycerides and time to incident nontraumatic LEA, defined by primary hospitalization discharge or procedures, was evaluated using Cox proportional hazards models.
Triglyceride level was an independent, stepwise risk factor for nontraumatic LEAs within this large diabetic cohort: triglycerides 150-199 mg/dL, hazard ratio (HR) 1.10 (95% CI 0.92-1.32); 200-499 mg/dL, 1.27 (1.10-1.47); >500 mg/dL, 1.65 (1.30-2.10) (reference <150 mg/dL).
Hypertriglyceridemia is a significant risk factor for LEA in diabetic patients even after controlling for known socioeconomic, health behavioral, and clinical factors. This previously unrecognized clinical risk needs to be further investigated to determine if treatment of triglycerides can reduce amputation risk.
Diabetes care 02/2011; 34(3):635-40. · 8.09 Impact Factor
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ABSTRACT: to assess the impact of paroxetine coadministration on the stereoselective pharmacokinetic (PK) properties of carvedilol.
prospective, randomized, 2-phase crossover.
the University of Michigan General Clinical Research Unit and Michigan Clinical Research Unit.
twelve healthy volunteers aged 18 to 45 years, male and female, receiving no treatment with prescription or nonprescription medications.
participants received single dose oral carvedilol (12.5 mg) with and without coadministration of immediate-release paroxetine (10 mg orally twice daily), in random order. Blood samples were collected at 0, 0.25, 0.5, 0.75, 1, 1.5, 2, 4, 6, 8, 10, 12, and 24 hours post-carvedilol dose for determination of R and S carvedilol plasma enantiomer concentrations by high pressure liquid chromatography.
pharmacokinetic (PK) parameters were calculated for each enantiomer by noncompartmental methods and compared between study phases by analysis of variance (ANOVA) controlling for study phase order and subject, with Tukey's studentized range test post hoc. Area under the concentration-time curve (AUC) increased significantly with paroxetine coadministration, approximately 2.5-fold and 1.9-fold for the R and S enantiomers, respectively. R/S AUC ratio increased significantly, from approximately 2.3 to 3.0. Individual increases in enantiomeric AUCs with paroxetine coadministration ranged from 0% to 571% and changes in R/S ratio ranged from -8% to 108%. Heart rate, P-R interval, and blood pressure were monitored and no clinically significant changes in carvedilol effects were noted.
this study demonstrated a PK drug-drug interaction between paroxetine and carvedilol, with considerable interparticipant variability in carvedilol PK parameters and magnitude of drug interaction. Stereoselectivity of carvedilol metabolism is preserved with paroxetine coadministration, and R/S AUC ratio generally widens. Although this drug interaction could potentially increase adrenergic antagonism and have significant clinical effects in patients, these effects were not seen in our healthy volunteer participants.
Journal of Cardiovascular Pharmacology and Therapeutics 12/2010; 15(4):373-9. · 1.75 Impact Factor
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ABSTRACT: We examined whether there were differences in depression and work function outcomes among primary care and specialty mental health patients treated by the Michigan Depression Outreach and Collaborative Care (M-DOCC), a depression care management program, developed by the University of Michigan Depression Center. In addition, we examined the relationship between depressive symptoms and workplace functioning among M-DOCC enrollees over time.
We used mixed model and logistic regression analyses.
Despite baseline differences in patient characteristics between primary care and specialty care patients, the location of treatment setting was not a significant predictor of depression or work function outcomes over time among patients enrolled in a depression care management program. Patients in both treatment settings showed significant decreases in depressive and functional impairment over time, with improvements in these symptoms occurring concurrently. Patients with greater case severity were less likely to demonstrate depression and work function improvements over time, and more severe side effects were associated with fewer depression symptom improvements over time.
Both depression and work function outcomes improved over time among patients enrolled in a depression care management program, and this improvement did not differ based on whether a patient was treated in a primary or specialty care setting.
The International Journal of Psychiatry in Medicine 02/2009; 39(1):1-13. · 1.03 Impact Factor
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Scott A Langenecker,
Angela F Caveney,
Bruno Giordani,
Elizabeth A Young,
Kristy A Nielson,
Lisa J Rapport,
Linas A Bieliauskas,
Matthew J Mordhorst,
Sheila Marcus,
Naomi Yodkovik, Kevin Kerber,
Stanley Berent,
Jon-Kar Zubieta
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ABSTRACT: At present, there is poor accuracy in assessing cognitive and vegetative symptoms in depression using clinician or self-rated measures, suggesting the need for development of standardized tasks to assess these functions. The current study assessed the psychometric properties and diagnostic specificity of a brief neuropsychological screening battery designed to assess core signs of depression; psychomotor retardation, attention and executive functioning difficulties, and impaired emotion perception within an outpatient psychiatry setting. Three hundred eighty-four patients with mood disorders and 77 healthy volunteers participated. A large percentage of patients met diagnostic criteria for Major Depressive Disorder alone (49%) or with another comorbid psychiatric disorder (24%). A brief, 25-min battery of computer-based tests was administered to control participants and patients measuring the constructs of inhibitory control, attention, visual perception, and both executive and visual processing speed. The patient groups performed significantly worse than the control group regardless of diagnosis on visual perception and attention accuracy and processing speed factors. Surprisingly, the anxiety disorder group performed better than several other psychiatric disorder groups in inhibitory control accuracy. Developing valid and reliable measures of cognitive signs in mood disorders creates excellent opportunities for tracking cognitive status prior to initiation of treatment, and allows for reliable retest following treatment.
Psychiatry Research 09/2007; 152(2-3):143-54. · 2.52 Impact Factor
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ABSTRACT: Clinical care management promises to help diminish the major health problem of depression. To realize this promise, front line clinicians must know which care management interventions are best for which patients and act accordingly. Unfortunately, the detailed intervention data required for such differentiated assessments are missing in most clinical information systems (CIS). To determine frontline clinicians' needs for these data and to identify the data that CIS should keep, we conducted an 18 month ethnographic study and discourse analysis of telehealth depression care management. Results show care managers need data-based evidence to choose best options, and discourse analysis suggests some personalized interventions that CIS should and can feasibly capture for evidence.
AMIA ... Annual Symposium proceedings / AMIA Symposium. AMIA Symposium 02/2006;
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ABSTRACT: Empirical evidence shows that care management is an effective tool for improving depression treatment in primary care patients. However, several conceptual and practical issues have not been sufficiently addressed. This article explores questions concerning the scope of care management services within the chronic illness care model; optimal ways to identify depressed patients in the primary care setting; responsibilities and desirable qualifications of depression care managers; the location and manner in which care managers interact with patients; costs of services provided by care managers; and the level of supervision by mental health specialists that is necessary to ensure quality care.
Administration and Policy in Mental Health 02/2006; 33(1):65-75. · 2.09 Impact Factor
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ABSTRACT: This study assessed concerns about and perceptions of electronic psychiatric records in a university psychiatric adult outpatient clinic. Forty-one patients who refused to have their psychiatric records transferred to the electronic record system were compared with 39 patients who agreed to an electronic record. Regardless of whether or not they refused to have their information transferred to an electronic record, a majority of patients reported numerous concerns about electronic records, such as concerns about unauthorized access to their records by parties within the university health care system. Patients' concerns may affect patient disclosure and other help-seeking behavior and therefore must be addressed by clinicians and health care systems.
Psychiatric Services 12/2003; 54(11):1539-41. · 2.38 Impact Factor
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ABSTRACT: Recent studies examining depression disease management report improvements in short-term outcomes, but less is known about whether improvements are sustainable over time. This study evaluated the sustained clinical effectiveness of low-intensity depression disease management in chronically depressed patients.
The Depression in Primary Care (DPC) intervention was introduced in 5 primary care practices in the University of Michigan Health System, with 5 matched practices selected as control sites. Clinicians were free to refer none, some, or all of their depressed patients at their discretion. Core clinical outcomes of remission and serial change in Patient Health Questionnaire (PHQ-8) scores for 728 DPC enrollees observed for up to 18 months after enrollment were compared with those for 78 patients receiving usual care who completed mailed questionnaires at baseline, 6, 12, and 18 months.
DPC enrollees had sustained improvement in remission rates and reduced-function days over the full 18 months. Mean change in the PHQ-8 score over each 6-month interval was more favorable for DPC enrollees than for usual care patients, and the proportion of DPC enrollees in remission was higher at 6 months (43.4% vs 33.3%; P = .11), 12 months (52.0% vs 33.9%; P = .012), and 18 months (49.2% vs 27.3%; P = .004). Multivariate analysis controlling for age, sex, ethnicity, baseline severity, and comorbid medical illness confirmed that DPC enrollees had significantly more reduction in depressive symptom burden over 18 months.
The DPC intervention produced sustained improvement in clinical outcomes over 18 months in a cohort of chronically depressed patients with persistent symptoms despite active treatment.
The Annals of Family Medicine 8(5):387-96. · 5.36 Impact Factor
