Publications (17)137.83 Total impact
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Article: Catatonia associated with pegylated interferon-α 2b and ribavirin for hepatitis C.
Psychosomatics 07/2012; 53(4):400-1. · 2.12 Impact Factor -
Article: Building capacity to reduce disparities in diabetes: training community health workers using an integrated distance learning model.
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ABSTRACT: The purpose of this study is to determine whether an innovative interactive distance training program is an effective modality to train community health workers (CHWs) to become members of the diabetes health care team. The University of New Mexico Health Sciences Center has developed a rigorous diabetes training program for CHWs involving both distance and hands-on learning as part of Project ECHO™ (Extension for Community Healthcare Outcomes). Twenty-three diverse CHW participants from across New Mexico were enrolled in the first training session. Participants completed surveys at baseline and at the end of the program. They attended a 3-day hands-on training session, followed by weekly participation in tele/video conferences for 6 months. Wilcoxon signed-rank statistics were used to compare pre- and posttest results. Participants demonstrated significant improvements in diabetes knowledge (P = .002), diabetes attitudes (P = .04) and confidence in both clinical and nonclinical skills (P < .001 and P = .04, respectively). Additionally, during focus group discussions, participants reported numerous benefits from participation in the program. Community health worker participation in the Project ECHO diabetes training program resulted in significant increases in knowledge, confidence, and attitudes in providing care to patients with diabetes. Studies are ongoing to determine whether the training has a positive impact on patient outcomes.The Diabetes Educator 04/2012; 38(3):386-96. · 1.96 Impact Factor -
Chapter: Knowledge Networks for Treating Complex Diseases in Remote, Rural, and Underserved Communities
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ABSTRACT: Project ECHO (Extension for Community Healthcare Outcomes) is an innovative healthcare program developed to address the treatment of patients with chronic and complex diseases in rural and underserved areas of New Mexico. Through the use of technology and iterative, case-based discussion with ongoing support, the model used in Project ECHO bridges the gap between academic healthcare specialists and providers in rural and underserved settings. Its prime foci are the provision of workplace learning, evidence-based practices, and the delivery of best quality care to patients with chronic diseases. Collaboration between academic specialists and community-based providers enables patients to receive state-of-the-art healthcare from the professionals they know and trust in their own communities. For local providers, co-management of the often lengthy and involved treatments gives them additional expertise in competencies associated with chronic disease and involves them in continuing communication and patient management. As they learn more about specific chronic diseases, the community-based providers become engaged with expanded networks of providers and organizations, become more satisfied in their work, and experience less professional isolation. With continued involvement, community-based providers become highly skilled in the treatment of these chronic and complex diseases, thus creating centers of excellence in their own communities. This chapter describes the activities and outcomes associated with the collaborative, iterative, and workplace-focused care of patients with Hepatitis C, the first chronic disease to be addressed, and how new modes of collaboration were forged between specialists in academic settings and community-based primary care providers in rural and underserved communities. Work on other chronic diseases is now being organized using a similar approach to developing expanded expertise in rural and underserved areas of the state.09/2011: pages 47-70; -
Article: Viral clearance is associated with improved insulin resistance in genotype 1 chronic hepatitis C but not genotype 2/3.
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ABSTRACT: Genotype-specific associations between hepatitis C virus (HCV) and insulin resistance (IR) have been described, but a causal relationship remains unclear. This study investigated the association between a sustained virological response (SVR) and IR after chronic HCV therapy. 2255 treatment-naive patients with chronic HCV genotype 1 or 2/3 were enrolled in two phase 3 trials of albinterferon alpha-2b versus pegylated interferon alpha-2a for 48 or 24 weeks, respectively. IR was measured before treatment and 12 weeks after treatment using homeostasis model assessment (HOMA)-IR. Paired HOMA-IR measurements were available in 1038 non-diabetic patients (497 with genotype 1; 541 with genotype 2/3). At baseline the prevalence of HOMA-IR >3 was greater in patients with genotype 1 than 2/3 (33% vs 27%; p=0.048). There was a significant reduction in the prevalence of IR in patients with genotype 1 achieving SVR (δ 10%; p<0.001), but not in genotype 1 non-responders or those with genotype 2/3. Multivariate analysis indicated that SVR was associated with a significant reduction in mean HOMA-IR in patients with genotype 1 (p=0.004), but not in those with genotype 2/3, which was independent of body mass index, alanine transaminase, γ-glutamyl transpeptidase and lipid level changes. SVR is associated with a reduction in HOMA-IR in patients with HCV genotype 1 but not in those with genotype 2/3. Genotype 1 may have a direct effect on the development of IR, independent of host metabolic factors, and may be partially reversed by viral eradication.Gut 08/2011; 61(1):128-34. · 10.11 Impact Factor -
Article: Taribavirin in the treatment of hepatitis C.
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ABSTRACT: INTRODUCTION: Treatment of chronic hepatitis C virus (HCV) is limited by substantial side effects including ribavirin-induced hemolytic anemia. Taribavirin, a ribavirin prodrug, was designed to concentrate within the liver to target HCV-infected hepatocytes while minimizing distribution within red blood cells (RBCs) and the subsequent development of hemolytic anemia. AREAS COVERED: The objective of the review is to evaluate the efficacy and safety of taribavirin as compared with ribavirin in the treatment of chronic HCV infections. A PubMed search was performed using the following key words: viramidine, taribavirin and ribavirin analog. Additional sources included press releases on preliminary results of clinical trials of taribavirin and abstracts presented at international meetings. The literature suggests that weight-based dosing of taribavirin at 25 mg/kg demonstrates lower rates of hemolytic anemia with comparable rates of sustained virologic response (SVR) and is the optimum dose for further studies comparing the efficacy of taribavirin with weight-based dosing of ribavirin. EXPERT OPINION: Failure to eradicate HCV may be associated with extrahepatic viral replication. The dosing strategy of taribavirin favors concentration within the liver to reduce treatment-limiting rates of anemia but may be insufficient to prevent virologic relapse.Expert Opinion on Investigational Drugs 08/2011; 20(10):1435-43. · 5.27 Impact Factor -
Article: Outcomes of treatment for hepatitis C virus infection by primary care providers.
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ABSTRACT: The Extension for Community Healthcare Outcomes (ECHO) model was developed to improve access to care for underserved populations with complex health problems such as hepatitis C virus (HCV) infection. With the use of video-conferencing technology, the ECHO program trains primary care providers to treat complex diseases. We conducted a prospective cohort study comparing treatment for HCV infection at the University of New Mexico (UNM) HCV clinic with treatment by primary care clinicians at 21 ECHO sites in rural areas and prisons in New Mexico. A total of 407 patients with chronic HCV infection who had received no previous treatment for the infection were enrolled. The primary end point was a sustained virologic response. A total of 57.5% of the patients treated at the UNM HCV clinic (84 of 146 patients) and 58.2% of those treated at ECHO sites (152 of 261 patients) had a sustained viral response (difference in rates between sites, 0.7 percentage points; 95% confidence interval, -9.2 to 10.7; P=0.89). Among patients with HCV genotype 1 infection, the rate of sustained viral response was 45.8% (38 of 83 patients) at the UNM HCV clinic and 49.7% (73 of 147 patients) at ECHO sites (P=0.57). Serious adverse events occurred in 13.7% of the patients at the UNM HCV clinic and in 6.9% of the patients at ECHO sites. The results of this study show that the ECHO model is an effective way to treat HCV infection in underserved communities. Implementation of this model would allow other states and nations to treat a greater number of patients infected with HCV than they are currently able to treat. (Funded by the Agency for Healthcare Research and Quality and others.).New England Journal of Medicine 06/2011; 364(23):2199-207. · 53.30 Impact Factor -
Article: Partnering urban academic medical centers and rural primary care clinicians to provide complex chronic disease care.
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ABSTRACT: Many of the estimated thirty-two million Americans expected to gain coverage under the Affordable Care Act are likely to have high levels of unmet need because of various chronic illnesses and to live in areas that are already underserved. In New Mexico an innovative new model of health care education and delivery known as Project ECHO (Extension for Community Healthcare Outcomes) provides high-quality primary and specialty care to a comparable population. Using state-of-the-art telehealth technology and case-based learning, Project ECHO enables specialists at the University of New Mexico Health Sciences Center to partner with primary care clinicians in underserved areas to deliver complex specialty care to patients with hepatitis C, asthma, diabetes, HIV/AIDS, pediatric obesity, chronic pain, substance use disorders, rheumatoid arthritis, cardiovascular conditions, and mental illness. As of March 2011, 298 Project ECHO teams across New Mexico have collaborated on more than 10,000 specialty care consultations for hepatitis C and other chronic diseases.Health Affairs 06/2011; 30(6):1176-84. · 4.31 Impact Factor -
Article: Expanding access to hepatitis C virus treatment--Extension for Community Healthcare Outcomes (ECHO) project: disruptive innovation in specialty care.
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ABSTRACT: The Extension for Community Healthcare Outcomes (ECHO) Model was developed by the University of New Mexico Health Sciences Center as a platform to deliver complex specialty medical care to underserved populations through an innovative educational model of team-based interdisciplinary development. Using state-of-the-art telehealth technology, best practice protocols, and case-based learning, ECHO trains and supports primary care providers to develop knowledge and self-efficacy on a variety of diseases. As a result, they can deliver best practice care for complex health conditions in communities where specialty care is unavailable. ECHO was first developed for the management of hepatitis C virus (HCV), optimal management of which requires consultation with multidisciplinary experts in medical specialties, mental health, and substance abuse. Few practitioners, particularly in rural and underserved areas, have the knowledge to manage its emerging treatment options, side effects, drug toxicities, and treatment-induced depression. In addition, data were obtained from observation of ECHO weekly clinics and database of ECHO clinic participation and patient presentations by clinical provider. Evaluation of the ECHO program incorporates an annual survey integrated into the ECHO annual meeting and routine surveys of community providers about workplace learning, personal and professional experiences, systems and environmental factors associated with professional practice, self-efficacy, facilitators, and barriers to ECHO. The initial survey data show a significant improvement in provider knowledge, self-efficacy, and professional satisfaction through participation in ECHO HCV clinics. Clinicians reported a moderate to major benefit from participation. We conclude that ECHO expands access to best practice care for underserved populations, builds communities of practice to enhance professional development and satisfaction of primary care clinicians, and expands sustainable capacity for care by building local centers of excellence.Hepatology 09/2010; 52(3):1124-33. · 11.66 Impact Factor -
Article: Response to therapy with pegylated interferon and ribavirin for chronic hepatitis C in hispanics compared to non-Hispanic whites.
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ABSTRACT: Ethnicity has been shown to play an important role in hepatitis C virus (HCV) treatment response. However, few studies have examined the treatment response of Hispanics to combination therapy with pegylated interferon and ribavirin. The aim of this study was to compare the treatment responses of Hispanics and non-Hispanic whites (NHW) treated with pegylated interferon and ribavirin for chronic HCV. A retrospective review was conducted of all treatment-naive Hispanics and NHW with HCV who were treated at the University of New Mexico Hospital or Albuquerque VA Medical Center between October 2001 and January 2007. Genotype 1 patients received 48 weeks of therapy with pegylated interferon and ribavirin; genotype 2 and 3 patients received 24 weeks of treatment. A total of 396 patients were included in the analysis, consisting of 179 Hispanics and 217 NHW. Overall, fewer Hispanics completed therapy compared with NHW (64.8% vs. 80.2%, P<0.001). In genotype 1 patients, early virologic response (EVR), end-of-treatment response (ETR), and sustained virologic response (SVR) did not differ significantly between the two ethnic groups. In genotype 2 and 3 patients, Hispanics had similar EVR compared with NHW (81.3% vs. 88.2%, P=0.25), but lower ETR (64.1% vs. 83.1%, P=0.01) and SVR (45.3% vs. 75.3%, P<0.001). After correcting for patients who prematurely discontinued therapy, genotype 2 and 3 Hispanics continued to have a reduced SVR compared with NHW (65.9% vs. 87.3%, P=0.014). The attenuated SVR in Hispanics was because of a higher relapse rate after achieving ETR compared with NHW (25% vs. 7.5%, P=0.02). Hispanics with genotype 2 and 3 HCV infection treated with pegylated interferon and ribavirin are less likely to achieve SVR compared with NHW. The lower rate of SVR in Hispanic patients is, in part, because of an increased rate of relapse after ETR.The American Journal of Gastroenterology 05/2009; 104(7):1686-92. · 7.28 Impact Factor -
Article: Chronic hepatitis C in pregnancy.
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ABSTRACT: To estimate outcomes, to determine whether appropriate follow-up was performed for pregnant patients with hepatitis C virus (HCV), and to show that maternal and neonatal complications would be higher in the HCV-positive group. We compared pregnant women from a drug dependence and treatment program who were HCV antibody-positive with those who were HCV antibody-negative using the University of New Mexico Perinatal Database. Maternal and neonatal outcomes were evaluated, including cholestasis of pregnancy, preterm birth, low birth weight, neonatal intensive care unit admissions, and neonatal methadone withdrawal. Variables were compared using Student t, Fisher exact, and chi(2) tests. Among 351 pregnancies between January 2000 and 2006, 159 (53%) were HCV antibody reactive, 141 (47%) tested nonreactive, and 51 (15%) were not screened. Hepatitis C reactivity was more common among Hispanics. Cholestasis of pregnancy was increased in HCV antibody reactive (Ab+) pregnancies (10 of 159, 6.3% compared with 0 of 141, P=.002). Among women taking methadone, there was a significantly higher incidence of neonatal withdrawal (P=.001). This was significant in mothers on low (0-30 mg) and moderate (31-90 mg) methadone doses. Despite the high cure rate with intensive therapy, only 5.7% of HCV Ab+ mothers and 1.9% of their neonates received gastroenterology referrals. In pregnant women involved in this drug treatment program, HCV reactivity was associated with Hispanic ethnicity, cholestasis of pregnancy, and increased neonatal methadone withdrawal regardless of maternal methadone dose. Gastroenterology consultation was inadequate.Obstetrics and Gynecology 09/2008; 112(2 Pt 1):304-10. · 4.73 Impact Factor -
Article: Widening the door: the evolution of hepatitis C treatment in patients with psychiatric disorders.
Hepatology 11/2007; 46(4):957-9. · 11.66 Impact Factor -
Article: Virological response and safety outcomes in therapy-nai ve patients treated for chronic hepatitis C with taribavirin or ribavirin in combination with pegylated interferon alfa-2a: a randomized, phase 2 study.
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ABSTRACT: Pegylated interferon plus ribavirin can cause dose-limiting anemia. Taribavirin, a ribavirin prodrug, has shown a lower incidence of anemia. We sought to determine the efficacy and safety of taribavirin vs. ribavirin combined with pegylated interferon in patients with chronic hepatitis C (CHC). This phase 2 open-label study randomized 180 patients with CHC to receive pegylated interferon alfa-2a 180 microg/week plus taribavirin 800, 1200 or 1600 mg QD or ribavirin 1000 or 1200 mg QD. Efficacy variables included proportions of patients with undetectable serum HCV RNA levels at end of treatment and after a 24-week follow-up. The proportions of patients with undetectable HCV RNA at 12 weeks did not differ significantly between taribavirin (38%, 42%, and 49% for the 800, 1200, and 1600 mg groups) and ribavirin (49%). The highest proportion of patients with undetectable HCV RNA at end of treatment and at follow-up occurred in both the taribavirin 1200mg QD (63% and 37%) and ribavirin groups (62% and 44%). SVR rates were 23%, 37% and 29% for taribavirin and 44% for ribavirin. Fewer patients on any dose of taribavirin had severe anemia (hemoglobin <10 g/dL) than on ribavirin (6/135 [4%] vs. 12/45 [27%]). Given with interferon, taribavirin produced SVR rates comparable to those of ribavirin, with a lower occurrence of anemia.Journal of Hepatology 08/2007; 47(1):51-9. · 9.26 Impact Factor -
Article: Academic health center management of chronic diseases through knowledge networks: Project ECHO.
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ABSTRACT: The authors describe an innovative academic health center (AHC)-led program of health care delivery and clinical education for the management of complex, common, and chronic diseases in underserved areas, using hepatitis C virus (HCV) as a model. The program, based at the University of New Mexico School of Medicine, represents a paradigm shift in thinking and funding for the threefold mission of AHCs, moving from traditional fee-for-service models to public health funding of knowledge networks. This program, Project Extension for Community Health care Outcomes (ECHO), involves a partnership of academic medicine, public health offices, corrections departments, and rural community clinics dedicated to providing best practices and protocol-driven health care in rural areas. Telemedicine and Internet connections enable specialists in the program to comanage patients with complex diseases, using case-based knowledge networks and learning loops. Project ECHO partners (nurse practitioners, primary care physicians, physician assistants, and pharmacists) present HCV-positive patients during weekly two-hour telemedicine clinics using a standardized, case-based format that includes discussion of history, physical examination, test results, treatment complications, and psychiatric, medical, and substance abuse issues. In these case-based learning clinics, partners rapidly gain deep domain expertise in HCV as they collaborate with university specialists in hepatology, infectious disease, psychiatry, and substance abuse in comanaging their patients. Systematic monitoring of treatment outcomes is an integral aspect of the project. The authors believe this methodology will be generalizable to other complex and chronic conditions in a wide variety of underserved areas to improve disease outcomes, and it offers an opportunity for AHCs to enhance and expand their traditional mission of teaching, patient care, and research.Academic Medicine 03/2007; 82(2):154-60. · 3.52 Impact Factor -
Article: Project ECHO: linking university specialists with rural and prison-based clinicians to improve care for people with chronic hepatitis C in New Mexico.
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ABSTRACT: Project Extension for Community Healthcare Outcomes (Project ECHO) is a telemedicine and distance-learning program designed to improve access to quality health care for New Mexicans with hepatitis C. Project ECHO links health-care providers from rural clinics, the Indian Health Service, and prisons with specialists at the University of New Mexico. At weekly clinics, partners present and discuss patients with hepatitis C with specialists. Partners can receive continuing education credits for participating. Since June 2003, 173 hepatitis C clinics have been conducted with 1,843 case presentations. Partners have received 390 hours of training and 2,997 hours of continuing education credits. And in 2006, the State Legislature approved $1.5 million in annual funding for the project. Project ECHO has increased access to state-of-the art hepatitis C virus care for patients living in rural areas or prisons. Because of its success with hepatitis C, this project is being expanded to other chronic medical conditions.Public Health Reports 02/2007; 122 Suppl 2:74-7. · 1.27 Impact Factor -
Article: Treatment of chronic hepatitis C patients with persistently normal alanine aminotransferase levels with the combination of peginterferon alpha-2a (40 kDa) plus ribavirin: impact on health-related quality of life.
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ABSTRACT: Peginterferon alpha-2a (40 kDa) plus ribavirin is equally effective in chronic hepatitis C patients with normal or elevated alanine aminotransferase (ALT) values. This analysis, in patients with normal ALT levels, compared health-related quality of life (HRQoL) measurements between untreated control patients and treated patients grouped by virological response. HRQoL in the present population was also compared with HRQoL in patients with elevated ALT levels, observed in a previous study. A total of 491 patients with persistently normal ALT levels were randomized to peginterferon alpha-2a (40 kDa)/ribavirin for 24 (group A) or 48 weeks (group B) or no treatment for 72 weeks (group C). Quality of life was assessed with valid instruments (self-administered Short Form (SF)-36 Health Survey and Fatigue Severity Scale). In groups A and B, patients with sustained virological responses after combination therapy had significantly better quality of life and less fatigue than patients without sustained responses. Differences were significant for five SF-36 domains, the SF-36 Physical Component score and both Fatigue Severity Scale scores. Viral clearance was not observed in any untreated patients (group C). Comparison with data from elevated ALT patients revealed little difference in baseline quality of life, although normal ALT patients had significantly higher scores related to mental health than elevated ALT patients. Eradication of HCV with peginterferon alpha-2a (40 kDa) plus ribavirin is associated with better quality of life and less fatigue in normal ALT patients. These patient benefits, coupled with the high probability of eradicating HCV, should be considered in making decisions about treating this population.Journal of Gastroenterology and Hepatology 03/2006; 21(2):406-12. · 2.87 Impact Factor -
Article: Ethical issues in the treatment of hepatitis C.
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ABSTRACT: Four million Americans are infected with hepatitis C virus (HCV), making it the most common blood-borne infection in the United States. Members of disadvantaged groups such as prisoners and those with psychiatric disorders have a higher prevalence of HCV infection than the general population. Ethical, clinical, economic, and social barriers often prevent these patients from receiving the effective antiviral treatments now available. These barriers to care have received little attention in the literature, and yet, knowledge of the ethical and social justice aspects of HCV treatment can enhance the quality of gastroenterologists' patient care. This article analyzes 5 clinical-ethical arguments frequently presented for limiting patient access to HCV treatment: risk/benefit balance, justice, compliance, cost-effectiveness, and discrimination. Appropriate psychiatric and substance use intervention can result in a favorable cost-effectiveness and risk/benefit balance for treating members of disadvantaged groups. Although members of disadvantaged populations might exhibit higher rates of psychiatric side effects and poorer compliance with antiviral regimens, collaborative care can improve adherence and reduce adverse effects. The principle of justice might warrant treatment of these populations if the rate of adherence and risk/benefit balance is not significantly different than in other populations. Discrimination against persons with hepatitis C often reduces access to care among prisoners and other stigmatized groups. This analysis suggests that if gastroenterologists and mental health and substance abuse professionals actively collaborate, access to antiviral therapy for HCV can, in many cases, be safely and effectively expanded to disadvantaged populations.Clinical Gastroenterology and Hepatology 11/2005; 3(10):937-44. · 5.63 Impact Factor -
Article: Bouveret syndrome.
Radiographics 24(4):1171-5. · 2.85 Impact Factor
Top co-authors
Top Journals
Institutions
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2005–2012
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University of New Mexico
- • Department of Internal Medicine
- • School of Medicine
- • Department of Psychiatry
Albuquerque, NM, USA
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2007–2011
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University of New Mexico Hospitals
Albuquerque, NM, USA
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