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Publications (7)27.37 Total impact

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    ABSTRACT: The object of the study was to evaluate outcomes of a randomized clinical trial (RCT) of a pharmacist intervention for depressed patients in primary care (PC). We report antidepressant (AD) use and depression severity outcomes at 6-months. The RCT was conducted between 1998 and 2000 in 9 eastern Massachusetts PC practices. We studied 533 patients with major depression and/or dysthymia as determined by a screening test done at the time of a routine PC office visit. The majority of participants had recurrent depressive episodes (63.5% with >/=4 lifetime episodes), and 49.5% were taking AD medications at enrollment. Consultation in person and by telephone was performed by a clinical pharmacist who assisted the primary care practitioner (PCP) and patient in medication choice, dose, and regimen, in accordance with AHCPR depression guidelines. Six-month AD use rates for intervention patients exceeded controls (57.5% vs. 46.2%, P =.03). Furthermore, the intervention was effective in improving AD use rates for patients not on ADs at enrollment (32.3% vs. 10.9%, P =.001). The pharmacist intervention proved equally effective in subgroups traditionally considered difficult to treat: those with chronic depression and dysthymia. Patients taking ADs had better modified Beck Depression Inventory (mBDI) outcomes than patients not taking ADs, (-6.3 points change, vs. -2.8, P =.01) but the outcome differences between intervention and control patients were not statistically significant (17.7 BDI points vs. 19.4 BDI points, P =.16). Pharmacists significantly improved rates of AD use in PC patients, especially for those not on ADs at enrollment, but outcome differences were too small to be statistically significant. Difficult-to-treat subgroups may benefit from pharmacists' care.
    General Hospital Psychiatry 01/2004; 26(3):199-209. · 2.98 Impact Factor
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    ABSTRACT: The objective of this article is to provide a detailed description of interactions between patients with depression and pharmacists. Analysis was conducted on patients from the intervention arm (n=268) of an randomized controlled trial that evaluated the impact of a clinical pharmacist on the outcomes for depressed primary care patients from nine metropolitan Boston practices. The main outcome measure was the amount of intervention time spent with patients, physicians, and other activities. Details of the behavioral intervention and a categorization of the activities are offered. Pharmacists reported 978 encounters with 268 patients in 6 months. Eighty percent of patient encounters occurred by telephone. Initial encounters took 45 min if in person and 13.3 min if by telephone. Subsequent encounters followed a similar pattern. Follow-up visits occurred 2.3 times per patient. Physician contact took considerably less time. In total, the pharmacist intervention took 70.3 min per patient over 6 months; 42.2% of encounters involved an activity related to non-antidepressant medication and 85% of encounters involved general support. Other activities (education, advocating antidepressants, and motivating adherence) occurred in at least 50% of encounters. Pharmacists repeated intervention activities in the same category approximately two to three times. Interventions to improve the care of depression in primary care patients must anticipate encountering intense needs for information, personal support, and help negotiating the healthcare system. Research that identifies relationships between the components (active ingredients) of an intervention and the outcomes of care will benefit future intervention strategies and contribute to improved and efficient care.
    General Hospital Psychiatry 01/2004; 26(3):210-8. · 2.98 Impact Factor
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    ABSTRACT: Skin cancer is a well-recognized long-term complication of transplantation and immunosuppression. Although risk factors for the development of skin cancer in the general population are well defined, risk factors for the development of these lesions have not been identified clearly in the liver transplant population. We surveyed 151 liver transplant (LTx) recipients for risk factors associated with cutaneous malignancies in the general population. Variables included were: demographics, primary liver disease, severity of disease at LTx, immunosuppression history, complexion, hair color, eye color, tanning profile, number of moles, occupational history, sun exposure history, sunburn history, family history of skin cancer, and any history of removed skin lesions. All skin cancers were confirmed histologically. There were 86 documented skin cancers in 34 patients: 56 squamous cell, 23 basal cell and 7 melanomas. Median follow-up was 1490 days. In a univariate analysis, age, male gender, red hair, brown eyes, primary sclerosing cholangitis (PSC), primary biliary cirrhosis (protective), cyclosporine, number of second degree sunburns, and frequent lifetime sun exposure were associated with the development of new skin cancers. In a multivariate model, age, male gender, red hair, brown eyes, PSC, and cyclosporine remain the strongest predictors. The incidence of skin cancer after liver transplantation is underestimated. In particular, there is a higher incidence of squamous cell carcinoma compared with the general population. Recipients with identified risk factors may be candidates for prophylactic treatment and should be followed more intensively after liver transplantation.
    Liver Transplantation 11/2002; 8(10):939-44. · 3.94 Impact Factor
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    ABSTRACT: To determine the sensitivity, specificity, and predictive values of cultures done with blood drawn through a central venous or arterial catheter compared with peripheral venipuncture. Retrospective cohort study of critically ill surgical patients in whom samples for paired cultures were drawn through a central venous or arterial catheter and peripheral venipuncture. Tertiary-care, university-affiliated medical center. Two hundred seventy-one patients hospitalized on a surgical and a cardiothoracic intensive care unit between November 1994 and August 1997. None. Blinded assessments of culture results done by two physicians were used as the gold standard. Sensitivity, specificity, and positive and negative predictive values were compared for culture of blood from catheters and culture of blood from peripheral venipuncture. Of 499 observations, 426 were catheter-negative/venipuncture-negative, 19 were catheter-positive/venipuncture-positive, 18 were catheter-negative/venipuncture-positive, and 36 were catheter-positive/venipuncture-negative pairs. For catheter draws compared with peripheral venipuncture, sensitivity was 78% (confidence interval [CI], 65% to 90%) and 65% (CI, 50% to 79%) (p = .2), specificity was 95% (CI, 94% to 97%) and 98% (CI, 97% to 99%) (p = .002), positive predictive value was 63% (CI, 51% to 76%) and 78% (CI, 64% to 91%) (p = .1) and negative predictive value was 98% (CI, 96% to 99%) and 97% (CI, 95% to 98%) (p = .3). When central venous specimens as differentiated from arterial catheter specimens were compared with peripheral venipuncture, the difference between positive predictive values reached statistical significance (61% and 82%; p = .04). In critically ill surgical patients, cultures of blood drawn through a catheter are less specific than those obtained from a peripheral venipuncture. Both types of cultures have an excellent negative predictive value. Positive predictive value of cultures of blood drawn through a catheter is low and, when obtained from a central line, statistically less than from a peripheral venipuncture. Additional cultures seem to be necessary for the proper interpretation of a positive culture drawn through a catheter in critical care patients.
    Critical Care Medicine 02/2002; 30(1):7-13. · 6.12 Impact Factor
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    Transplantation 01/2000; 70(9):880-884. · 3.78 Impact Factor
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    ABSTRACT: Background. Transplantation of organs from donors who are bacteremic is controversial. We examined the outcome of recipients of solid organs from donors with bacteremia and/or fungemia at the time of organ recovery. Methods. All organ donors from a single organ procurement organization between January 1990 and December 1996 were retrospectively analyzed. We calculated rates of transmission from bacteremic or fungemic donors to their recipients and compared the graft and patient survival rates for recipients of these organs with those for recipients of organs from nonbacteremic donors. Results. There were 95 (5.1%) bacteremic donors from a total of 1775, from whom 212 recipients received organs. Forty-six (48%) of the bacteremic donors had pathogens in their blood. Among the 101 recipients of organs from these, no evidence of transmission could be documented. (0% transmission rate, 95% CI 0-3). The remaining 49 donors had either Staphylococcus epidermidis or other unlikely pathogens recovered from the blood. Examination of the 111 recipients of organs from these donors also found no evidence for transmission (0% transmission rate, 95% CI 0-3). Of the 212 recipients, 193 (91%) received a mean of 3.8±2.5 days of antibiotics postoperatively. The 30-day graft and patient survival for recipients of organs from bacteremic donors was not significantly different from recipients of organs from nonbacteremic donors (P=0.695 for patient survival, and P=0.310 for graft survival). Conclusions. Organs transplanted from bacteremic donors do not transmit bacterial infection or result in poorer outcomes. Use of organs from these donors could help increase organ availability.
    Transplantation 10/1999; 68(8):1107-1111. · 3.78 Impact Factor
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    ABSTRACT: Tumor necrosis factor-α (TNF-α) is a pro-inflammatory mediator of the immune response to allogenic and infectious stimuli. Non-immunosuppressed individuals possessing a NcoI restriction enzyme site in the TNF gene locus produce less TNF-α in vitro and in vivo compared with individuals lacking this restriction site. We performed polymerase chain reaction amplification and restriction enzyme fragment length analysis of the TNF locus from 86 liver transplant recipients to determine if presence of the NcoI site is associated with the frequency of rejection or infection, time to rejection or infection, and patient and graft survival. We controlled for recipient primary diagnosis, age, sex, United Network for Organ Sharing status, year of transplant, type of immunosuppression, use of anti-lymphocyte agents, and graft ischemia time. Fifty-six recipients possessed the NcoI+/low TNF-α genotype and 30 were NcoI-/high TNF-α genotype. In the first year after transplant, there were no significant differences in the frequency, or time to first rejections or the overall number of rejection episodes between the two genotypes. NcoI+/low TNF-α genotype recipients had significantly more infections (1.52 vs. 0.87, P=0.014). In a linear regression, multivariate model controlling for all marginally significant variables, the NcoI+/low TNF-α genotype was still associated with significantly more infections (P=0.0031). Patient and graft survival were equal for the two groups. One implication of this study, in individuals genetically predetermined to be low TNF-α producers, is that additional inhibition of TNF-α production by routine immunosuppression may be excessive, rendering these individuals less able to respond to infectious stimuli. These patients may benefit from lower doses or with-drawal of corticosteroids.
    Transplantation 04/1999; 67(7):1005-1010. · 3.78 Impact Factor