Objective : To assess the impact of geographic access to primary care providers (PCPs) on the rec... more Objective : To assess the impact of geographic access to primary care providers (PCPs) on the receipt of behavioral disorder screening among children and adolescents from different racial/ethnic groups. Data Sources/Study Setting: The primary data source was 2013-2016 administrative claims data from a large pediatric Medicaid Managed Care Plan linked to the US Census data and the National Provider Identi er (NPI) Registry. Study Design: The study was a retrospective cohort design which was conducted using data obtained from multiple sources. Data Collection/Extraction Methods : Geographic access was measured as one way travel distance to the nearest PCP estimated based on google map, and the PCP density per 10,000 population within a 10-mile travel radius from the population weighted centroid of each individual's zip code. Multivariate logistic regression was conducted to examine the association between the geographic access measures and the likelihood of receiving behavioral disorder screening within each racial/ethnic group. Principal Findings : Behavioral disorder screening rate was 12.6% among 457,870 children and adolescents who met the inclusion criteria. Multivariable analyses revealed that the travel distance to the nearest PCP was negatively associated with the screening uptake among Hispanics (10-20 vs. 0-10 miles: OR=0.78, 95%CI [0.71-0.86]; 20-30 vs. 0-10 miles: OR=0.35, 95%CI [0.23-0.54]). Similar effects associated with the travel distance were not observed in Blacks and Whites. Among those having access to ≥1 PCP within 10 miles of travel distance, the increase in PCP density had a greater positive impact on the receipt of behavioral disorder screening in minorities than that in Whites. Conclusion : Minorities, especially Hispanics, were more sensitive than Whites to the geographic access barriers to PCPs for pediatric behavioral disorder screening.
OBJECTIVE The objective of this study was to examine whether linkage with mental health treatment... more OBJECTIVE The objective of this study was to examine whether linkage with mental health treatment differed across three different Integrated Care Arrangements, following incident Attention Deficit Hyperactive Disorder (ADHD) and Major Depressive Disorder (MDD) diagnoses given by Primary Care Providers (PCPs) in the pediatric setting. METHODS Using claims linking with multiple public data sources, we examined the treatment initiation among children receiving an incident diagnosis of ADHD or MDD from PCPs working in practices with various Integrated Care Arrangements (ICA). ICA was categorized as PCP practiced alone (non-co-located), PCP practiced with specialist outside the practice but co-located at the practice site (co-located), and employed specialists who were co-located (co-located and co-affiliated). RESULTS A total of 4,203 incident ADHD and 298 incident MDD cases diagnosed by PCPs were identified, of which 3,123 (74%) with ADHD and 200 (67%) with MDD received treatment within 90 days since the diagnosis. Children diagnosed with ADHD by co-located and co-affiliated PCPs were twice as likely to receive treatment as those diagnosed by non-co-located PCPs (OR=1.93; 95%CI: 1.24-2.78). Of those treated, children diagnosed by co-located and co-affiliated PCPs were two times more likely to receive guideline recommended psychotherapy (OR=2.15; 95% CI: 1.35-3.44). These patients were also more likely to be treated at the diagnosing site versus elsewhere. Similar beneficial effects were not observed in those first diagnosed by co-located but non-affiliated PCPs. CONCLUSIONS Service co-location between co-affiliated PCPs and MH specialists was associated with significant higher ADHD treatment rate and the receipt of guideline-concordant psychotherapy.
Introduction: Despite high rates of unemployment and disability in adults with sickle cell diseas... more Introduction: Despite high rates of unemployment and disability in adults with sickle cell disease (SCD), these issues remain understudied. Since SCD mostly affect people of African descent, the potential risk factors for poor job performance and unemployment in adults with SCD are a complex combination of disease, demographic, and socio-economic variables. Recurrent acute vaso-occlusive crises and organ dysfunction related to SCD can limit employment options and interfere with job retention. Potential associates of unemployment and poor job performance in adults with SCD include health-related (pain frequency and intensity, health-care utilization) and psychosocial (support system, coping mechanism). The goal of this study is to compare patients’ rates of unemployment and disability with those of their unaffected siblings. We compare patients with siblings so as to adjust for some socioeconomic variables. Patients and Methods: Patients on chronic transfusion therapy and those with ...
Administration and Policy in Mental Health and Mental Health Services Research, 2019
Medicaid-enrolled adults with serious mental illness may be dually-enrolled in Medicare, and may ... more Medicaid-enrolled adults with serious mental illness may be dually-enrolled in Medicare, and may receive health care services from other state and local programs. To understand cross-program costs of care, we linked 2012 payment data across Medicaid, Medicare, state, and local programs. Average costs were calculated according to presence/absence of SMI, Medicare coverage, SSI coverage, medical comorbidities, and other characteristics. Costs for Medicaid adults with SMI were 57.4% greater than adults without SMI, but only 23.6% of costs were SMI-related. Greater costs were associated with Medicaid-Medicare dual-eligibility, multiple SMI diagnoses, and medical comorbidities. The results support cross-program efforts such as joint Medicaid-Medicare managed care and integrated care.
Background and Purpose— Bone marrow–derived mononuclear cells (BMMNCs) offer the promise of augme... more Background and Purpose— Bone marrow–derived mononuclear cells (BMMNCs) offer the promise of augmenting poststroke recovery. There is mounting evidence of safety and efficacy of BMMNCs from preclinical studies of ischemic stroke; however, their pooled effects have not been described. Methods— Using Preferred Reporting Items for Systematic Review and Meta-Analysis guidelines, we conducted a systematic review of preclinical literature for intravenous use of BMMNCs followed by meta-analyses of histological and behavioral outcomes. Studies were selected based on predefined criteria. Data were abstracted by 2 independent investigators. After quality assessment, the pooled effects were generated using mixed-effect models. Impact of possible biases on estimated effect size was evaluated. Results— Standardized mean difference and 95% confidence interval for reduction in lesion volume was significantly beneficial for BMMNC treatment (standardized mean difference: −3.3; 95% confidence interval...
sofosbuvir regimen and the ombitasvir/paritaprevir/ ritonavir and dasabuvir regimen, we may now b... more sofosbuvir regimen and the ombitasvir/paritaprevir/ ritonavir and dasabuvir regimen, we may now be in the era of all-pill regimens for HCV. Until this development, interferon-alpha along with Ribavirin has remained part of the standard of care for HCV patients. That regimen necessitates psychosocial assessment of factors affecting treatment eligibility, including interferon-alpharelated depressive symptoms, confounding psychiatric conditions, and social aspects such as homelessness affecting treatment eligibility. These factors have delayed as much as 70% of otherwise eligible candidates from interferon-based treatment, and have required treating physicians to monitor psychiatric as well as medical side effects throughout treatment. Allpill DAA regimens with the efficaciousness that would preclude reliance upon interferon-alpha or ribavirin have been anticipated for years. Efficacy studies for these recently approved DAA regimens provide evidence to assess the degree that psychosocial assessment and monitoring will be required. With shorter treatment timelines, greatly reduced side effect profiles, and easier regimens, psychosocial contraindications are greatly reduced. However, current or recent psychiatric comorbidity, and drug-drug interactions with psychiatric drugs, will require some level of clinical attention. Evidence from these efficacy studies tentatively demonstrate that the era of needing significant psychosocial assessment and monitoring may be at an end, as long as a manageable handful of clinical issues are managed.
Journal of Integrative Psychology and Therapeutics, 2014
Background: It is well-recognized that behavioral health problems are underdetected and undertrea... more Background: It is well-recognized that behavioral health problems are underdetected and undertreated in primary care. Medical settings have been identified as likely settings to detect and address these problems, but any such efforts would require a strategic approach based on needs in the treated population. Obstetric settings are being encouraged to detect and address behavioral health needs. Methods: An EMR-based approach for developing an initial estimate of the portion in need, and the range of conditions present, was developed for the obstetric setting. A list was developed of behavioral health diagnoses and prescriptions that could be queried using the electronic medical record (EMR). For diagnoses, the ICD-9 set of "mental disorder" diagnoses (codes 290-319) was used. For prescriptions, a list of behavioral health medications published by NIMH was used, augmented with the behavioral health medications noted in a recent "Top 200" prescription list published by Verispan, a commercial firm. Results: Of this cohort of 3,290 women beginning pregnancy care in a one-year time span, this EMR query indicated that 394 (12.0%) had a behavioral health need; 5.2% were prescribed a medication alone, 3.1% had a diagnosis alone, and 3.6% had both. This is likely an underestimate, but the efficient EMR method serves as a helpful starting place for determining behavioral health needs to be addressed. Conclusions: These data indicate that screening for these conditions will likely yield modest, but steady, numbers of patients with behavioral health needs that could be integrated with obstetric care. Readily available data regarding most common diagnoses and most frequently prescribed drugs can be used to develop an initial estimate of the burden of behavioral health need in obstetrics. Other primary care settings could readily replicate this approach as an initial step for addressing behavioral health burden in primary care.
have emerged. These significantly boost the likelihood of sustained viral response, including for... more have emerged. These significantly boost the likelihood of sustained viral response, including for genotype 1, and do not seem to have the side effects of interferonalpha or ribavirin. Relevant data are reviewed to assess the degree that these new treatments might reduce the portion not eligible for treatment due to psychiatric comorbidities, and might reduce the emergence of psychiatric symptoms during treatment. Several organizations have recently released evidence-based treatment recommendation guidelines. It is apparent that interferon-alpha continues to be a standard of care, with the new drugs added to this recognized regimen in order to shorten treatment and to boost efficacy. Clinical settings must continue to assess appropriateness for treatment, including current or recent psychiatric comorbidities, and must continue to closely monitor patients for the emergence of psychiatric side effects. The newly developed hepatitis C treatments may affect the metabolism of several categories of psychiatric drugs, and so drug-drug interactions must also be considered and monitored. With many promising drugs under development, an all-pill regimen, with no interferon-alpha and no ribavirin, may emerge in the near future. This will greatly change the challenge of treatment decision-making, and should expand the portion of patients able to successfully complete a treatment regimen.
Postpartum depression continues to be undertreated. This project identified state policies that h... more Postpartum depression continues to be undertreated. This project identified state policies that have been enacted regarding peripartum mental health and assessed how effective they might be. A systematic search strategy was used to detect state-level legislative initiatives. Legislative tracking resources were used to determine which were enacted. Policies were sorted into categories. Related evidence was reviewed to gauge the impact of each category. Thirteen states have enacted one or more state-level peripartum mental health policies. Categories include patient education mandates, depression screening mandates, mandated task force, and public awareness campaigns. Those mandating screening include Illinois, Massachusetts, New Jersey, and West Virginia. Related outcomes evidence suggests a very limited impact. Several states have enacted policies addressing peripartum mental health, but these are probably not influencing clinical outcomes. Home visits with a mental health component...
Study Purposes. This study examined whether melanonychia was more prevalent in 1) HIV positive in... more Study Purposes. This study examined whether melanonychia was more prevalent in 1) HIV positive individuals compared to HIV negative persons, 2) HIV positives exposed to zidovudine and/or stavudine and 3) those with darker skin pigmentation. Procedures. 267 HIV positive and 273 HIV negative patients were examined for presence or absence of melanonychia and level of skin pigmentation using the Fitzgerald scale. Pharmacy records were examined for determining exposure to zidovudine or stavudine. Chi square, odds ratios and logistic regression were used to examine the study questions Main Findings. Melanonychia appeared in 49.1% of 267 HIV positive and 21.8% of 273 HIV negative subjects. Adjusting for skin pigmentation, HIV positives were 4.1 times more likely to have melanonychia than HIV negatives. Melanonychia was present in 54% of those receiving zidovudine and in 42% of those receiving stavudine (OR = 2.73, p = 0.05). In a multivariate model in HIV positives which included skin type, prescription of zidovudine and/or Stavudine, only dark skin (OR = 14.62, p < 0.001) and zidovudine (OR = 2.65, p < 0.03) were significant. Principal Conclusions. HIV infected persons are prone to melanonychia. This is more frequent in darker skinned persons and is enhanced in those exposed to zidovudine.
We present an inventive method that generates intramolecular controls for SNP analysis, termed Mi... more We present an inventive method that generates intramolecular controls for SNP analysis, termed Mirror SNPs. Using the ovine diseases of callipyge and scrapie as examples, we describe the PCR-driven production of balanced heterozygote copies of the various SNPs implicated in these diseases. In the absence of a callipyge-positive control DNA, we generated a balanced heterozygote Mirror SNP that represents both the wild-type and mutant forms of the causal polymorphism. Simultaneous analysis of this artificial Mirror SNP and the Real (target) SNP was used to prove the absence of the mutant form of the nucleotide at the Real SNP position in tested samples. Scrapie susceptibility was assessed using a PCR-driven system which generated four separate Mirror SNPs, and these enabled the confirmation of an apparent departure from 'balanced' heterozygote appearance at Real SNPs tested. Mirror SNP technology is generic and will enable the accurate assessment of rare and medically important SNP variants, more accurate frequency determinations, and the potential assessment of SNPs in 'mixed template' samples common in forensic analyses.
This study was developed to evaluate the feasibility of implementing systematic depression screen... more This study was developed to evaluate the feasibility of implementing systematic depression screening in a large obstetric practice and to evaluate the degree that detection and referral led to linkage with behavioral healthcare. Depression screening was conducted using the Edinburgh Postnatal Depression Scale, administered at the initial pregnancy care appointment. Patients at or above a predetermined score of 14 were advised to seek further behavioral health assessment through the patient's behavioral healthcare coverage. Within 4 weeks of screening, those referred were contacted by telephone, by clinic staff, to determine whether they had pursued behavioral healthcare as recommended. Limited available data for newly established postdelivery screening were similarly evaluated. All 2,199 newly presenting pregnant women who were seen in our obstetric clinics from September 2008 to May 2009 were screened for depression, and 102 (4.6%) scored at or above an EPDS of 14. Follow-up calls revealed that none had pursued further behavioral health assessments. Of these 2,199, screening and follow-up data were available for 569 women at their 6-week postdelivery visit. Of these, 28 (4.9%) were above EPDS of 14, and 5 (17.9%) reported pursuit of further behavioral healthcare following screening and referral. Peripartum depression can be addressed with systematic screening, and the electronic medical record can readily be used to monitor results. Detection and referral at the beginning of pregnancy did not lead to intended linkage with behavioral healthcare, but detection and referral postdelivery had a modest influence. Barriers to pursuing behavioral healthcare need to be discovered and addressed.
Depression is often a side effect of interferon-alpha treatment for hepatitis C, and is recognize... more Depression is often a side effect of interferon-alpha treatment for hepatitis C, and is recognized as a cause for treatment discontinuation. When detected, antidepressant treatment begins promptly. In contrast to this rescue approach, prophylactic antidepressant treatment has been considered as a superior approach. While studies indicate that depression is lower with prophylaxis, no study has prospectively evaluated the degree that treatment completion might be boosted by the prophylactic strategy. A structured literature search was conducted to discover all trials of antidepressant prophylaxis for patients undergoing antiviral treatment for chronic hepatitis C. Selection criteria included: antidepressant prophylaxis study; report of depression treatment outcome; report of numbers discontinuing and reason for discontinuation (including any of the following: discontinuation data for medical side effects (i.e., thrombocytopenia); discontinuation due to lack of antiviral response; disc...
Objective: Postpartum depression continues to be under-treated. This project identified state pol... more Objective: Postpartum depression continues to be under-treated. This project identified state policies that have been enacted regarding peripartum mental health and assessed how effective they might be. Methods: A systematic search strategy was used to detect state-level legislative initiatives. Legislative tracking resources were used to determine which were enacted. Policies were sorted into categories. Related evidence was reviewed to gauge the impact of each category. Results: Thirteen states have enacted one or more state-level peripartum mental health policies. Categories include patient education mandates, depression screening mandates, mandated task force, and public awareness campaigns. Those mandating screening include Illinois, Massachusetts, New Jersey, and West Virginia. Related outcomes evidence suggests a very limited impact. Conclusions: Several states have enacted policies addressing peripartum mental health, but these are probably not influencing clinical outcomes. Home visits with a mental health component are effective for postpartum depression; state policies could support home visits.
Chronic hepatitis C virus (HCV) is a global concern. With the 2014 Food and Drug Administration a... more Chronic hepatitis C virus (HCV) is a global concern. With the 2014 Food and Drug Administration approvals of two direct-acting antiviral (DAA) regimens, ledipasvir/sofosbuvir regimen and the ombitasvir/paritaprevir/ritonavir and dasabuvir regimen, we may now be in the era of all-pill regimens for HCV.
Until this development, interferon-alpha along with Ribavirin has remained part of the standard of care for HCV patients. That regimen necessitates psychosocial assessment of factors affecting treatment eligibility, including interferon-alpharelated depressive symptoms, confounding psychiatric conditions, and social aspects such as homelessness affecting treatment eligibility. These factors have delayed as much as 70% of otherwise eligible candidates from interferon-based treatment, and have required treating physicians to monitor psychiatric as well as medical side effects throughout treatment.
All-pill DAA regimens with the efficaciousness that would preclude reliance upon interferon-alpha or ribavirin have been anticipated for years. Efficacy studies for these recently approved DAA regimens provide evidence to assess the degree that psychosocial assessment and monitoring will be required. With shorter treatment timelines, greatly reduced side effect profiles, and easier regimens, psychosocial contraindications are greatly reduced. However, current or recent psychiatric comorbidity, and drug-drug interactions with psychiatric drugs, will require some level of clinical attention.
Evidence from these efficacy studies tentatively demonstrate that the era of needing significant psychosocial assessment and monitoring may be at an end, as long as a manageable handful of clinical issues are managed.
There were significant reductions in risk in 12 of 17 studies of cardiovascular outcomes (risk re... more There were significant reductions in risk in 12 of 17 studies of cardiovascular outcomes (risk reductions ranging from 28% to 58%), in seven of eight studies of diabetes (14% to 46%), in seven of ten studies of breast cancer (11% to 67%), in two of two studies of endometrial cancer (68% to 90%), and in one of three studies of colorectal cancer (31% to 46%). There was mixed evidence for PA preventing gestational diabetes (three studies) and a range of other cancers (13 studies). Protective benefits for cardiovascular disease and diabetes were reported with as little as 60 minutes of moderate-intensity physical activity per week (240 Metabolic Equivalent (MET) minutes or 4 MET hours), with walking and moderate-intensity physical activity providing risk reductions comparable to those for the equivalent energy expenditure from more vigorous-intensity physical activity.
PURPOSE: Depression is a risk factor for incident coronary heart disease (CHD), and predicts poor... more PURPOSE: Depression is a risk factor for incident coronary heart disease (CHD), and predicts poor prognosis for patients post-myocardial infarction (MI). Few population-based, prospective studies have tested a gradient risk for depressive symptoms on CHD incidence. METHODS: The sample (n Z 1302) was derived from the Nova Scotia Health Survey-1995 (NSHS95), an age-and sex-stratified, random, population-based health survey. All subjects were 45 years or older, free of overt CHD at baseline, and completed the Center for Epidemiological Studies-Depression (CES-D) scale. Covariates included age, sex, body mass index, physical activity level, family history of premature CHD, diastolic blood pressure, lipids, smoking, alcohol use, diabetes, and education level. For the 4 years following NSHS95, MI-related hospitalizations (ICD-9-CM code 410) and CHD-related deaths (ICD-9-CM codes 410-414) were extracted from the provincial, universal healthcare registry. RESULTS: Fifty-two participants experienced a CHD event. A one standard-deviation increase in CES-D score was associated with a 1.32 hazard risk (confidence interval, 1.01-1.71) of CHD events, controlling for established CHD risk factors. CONCLUSIONS: An independent, gradient association between depression and incident CHD was detected in a population-based sample with complete 4-year CHD data. This evidence supports the value of investigating mechanisms linking depression and CHD. Ann Epidemiol 2005;15:316-320. Ó 2004 Elsevier Inc. All rights reserved.
Objective : To assess the impact of geographic access to primary care providers (PCPs) on the rec... more Objective : To assess the impact of geographic access to primary care providers (PCPs) on the receipt of behavioral disorder screening among children and adolescents from different racial/ethnic groups. Data Sources/Study Setting: The primary data source was 2013-2016 administrative claims data from a large pediatric Medicaid Managed Care Plan linked to the US Census data and the National Provider Identi er (NPI) Registry. Study Design: The study was a retrospective cohort design which was conducted using data obtained from multiple sources. Data Collection/Extraction Methods : Geographic access was measured as one way travel distance to the nearest PCP estimated based on google map, and the PCP density per 10,000 population within a 10-mile travel radius from the population weighted centroid of each individual's zip code. Multivariate logistic regression was conducted to examine the association between the geographic access measures and the likelihood of receiving behavioral disorder screening within each racial/ethnic group. Principal Findings : Behavioral disorder screening rate was 12.6% among 457,870 children and adolescents who met the inclusion criteria. Multivariable analyses revealed that the travel distance to the nearest PCP was negatively associated with the screening uptake among Hispanics (10-20 vs. 0-10 miles: OR=0.78, 95%CI [0.71-0.86]; 20-30 vs. 0-10 miles: OR=0.35, 95%CI [0.23-0.54]). Similar effects associated with the travel distance were not observed in Blacks and Whites. Among those having access to ≥1 PCP within 10 miles of travel distance, the increase in PCP density had a greater positive impact on the receipt of behavioral disorder screening in minorities than that in Whites. Conclusion : Minorities, especially Hispanics, were more sensitive than Whites to the geographic access barriers to PCPs for pediatric behavioral disorder screening.
OBJECTIVE The objective of this study was to examine whether linkage with mental health treatment... more OBJECTIVE The objective of this study was to examine whether linkage with mental health treatment differed across three different Integrated Care Arrangements, following incident Attention Deficit Hyperactive Disorder (ADHD) and Major Depressive Disorder (MDD) diagnoses given by Primary Care Providers (PCPs) in the pediatric setting. METHODS Using claims linking with multiple public data sources, we examined the treatment initiation among children receiving an incident diagnosis of ADHD or MDD from PCPs working in practices with various Integrated Care Arrangements (ICA). ICA was categorized as PCP practiced alone (non-co-located), PCP practiced with specialist outside the practice but co-located at the practice site (co-located), and employed specialists who were co-located (co-located and co-affiliated). RESULTS A total of 4,203 incident ADHD and 298 incident MDD cases diagnosed by PCPs were identified, of which 3,123 (74%) with ADHD and 200 (67%) with MDD received treatment within 90 days since the diagnosis. Children diagnosed with ADHD by co-located and co-affiliated PCPs were twice as likely to receive treatment as those diagnosed by non-co-located PCPs (OR=1.93; 95%CI: 1.24-2.78). Of those treated, children diagnosed by co-located and co-affiliated PCPs were two times more likely to receive guideline recommended psychotherapy (OR=2.15; 95% CI: 1.35-3.44). These patients were also more likely to be treated at the diagnosing site versus elsewhere. Similar beneficial effects were not observed in those first diagnosed by co-located but non-affiliated PCPs. CONCLUSIONS Service co-location between co-affiliated PCPs and MH specialists was associated with significant higher ADHD treatment rate and the receipt of guideline-concordant psychotherapy.
Introduction: Despite high rates of unemployment and disability in adults with sickle cell diseas... more Introduction: Despite high rates of unemployment and disability in adults with sickle cell disease (SCD), these issues remain understudied. Since SCD mostly affect people of African descent, the potential risk factors for poor job performance and unemployment in adults with SCD are a complex combination of disease, demographic, and socio-economic variables. Recurrent acute vaso-occlusive crises and organ dysfunction related to SCD can limit employment options and interfere with job retention. Potential associates of unemployment and poor job performance in adults with SCD include health-related (pain frequency and intensity, health-care utilization) and psychosocial (support system, coping mechanism). The goal of this study is to compare patients’ rates of unemployment and disability with those of their unaffected siblings. We compare patients with siblings so as to adjust for some socioeconomic variables. Patients and Methods: Patients on chronic transfusion therapy and those with ...
Administration and Policy in Mental Health and Mental Health Services Research, 2019
Medicaid-enrolled adults with serious mental illness may be dually-enrolled in Medicare, and may ... more Medicaid-enrolled adults with serious mental illness may be dually-enrolled in Medicare, and may receive health care services from other state and local programs. To understand cross-program costs of care, we linked 2012 payment data across Medicaid, Medicare, state, and local programs. Average costs were calculated according to presence/absence of SMI, Medicare coverage, SSI coverage, medical comorbidities, and other characteristics. Costs for Medicaid adults with SMI were 57.4% greater than adults without SMI, but only 23.6% of costs were SMI-related. Greater costs were associated with Medicaid-Medicare dual-eligibility, multiple SMI diagnoses, and medical comorbidities. The results support cross-program efforts such as joint Medicaid-Medicare managed care and integrated care.
Background and Purpose— Bone marrow–derived mononuclear cells (BMMNCs) offer the promise of augme... more Background and Purpose— Bone marrow–derived mononuclear cells (BMMNCs) offer the promise of augmenting poststroke recovery. There is mounting evidence of safety and efficacy of BMMNCs from preclinical studies of ischemic stroke; however, their pooled effects have not been described. Methods— Using Preferred Reporting Items for Systematic Review and Meta-Analysis guidelines, we conducted a systematic review of preclinical literature for intravenous use of BMMNCs followed by meta-analyses of histological and behavioral outcomes. Studies were selected based on predefined criteria. Data were abstracted by 2 independent investigators. After quality assessment, the pooled effects were generated using mixed-effect models. Impact of possible biases on estimated effect size was evaluated. Results— Standardized mean difference and 95% confidence interval for reduction in lesion volume was significantly beneficial for BMMNC treatment (standardized mean difference: −3.3; 95% confidence interval...
sofosbuvir regimen and the ombitasvir/paritaprevir/ ritonavir and dasabuvir regimen, we may now b... more sofosbuvir regimen and the ombitasvir/paritaprevir/ ritonavir and dasabuvir regimen, we may now be in the era of all-pill regimens for HCV. Until this development, interferon-alpha along with Ribavirin has remained part of the standard of care for HCV patients. That regimen necessitates psychosocial assessment of factors affecting treatment eligibility, including interferon-alpharelated depressive symptoms, confounding psychiatric conditions, and social aspects such as homelessness affecting treatment eligibility. These factors have delayed as much as 70% of otherwise eligible candidates from interferon-based treatment, and have required treating physicians to monitor psychiatric as well as medical side effects throughout treatment. Allpill DAA regimens with the efficaciousness that would preclude reliance upon interferon-alpha or ribavirin have been anticipated for years. Efficacy studies for these recently approved DAA regimens provide evidence to assess the degree that psychosocial assessment and monitoring will be required. With shorter treatment timelines, greatly reduced side effect profiles, and easier regimens, psychosocial contraindications are greatly reduced. However, current or recent psychiatric comorbidity, and drug-drug interactions with psychiatric drugs, will require some level of clinical attention. Evidence from these efficacy studies tentatively demonstrate that the era of needing significant psychosocial assessment and monitoring may be at an end, as long as a manageable handful of clinical issues are managed.
Journal of Integrative Psychology and Therapeutics, 2014
Background: It is well-recognized that behavioral health problems are underdetected and undertrea... more Background: It is well-recognized that behavioral health problems are underdetected and undertreated in primary care. Medical settings have been identified as likely settings to detect and address these problems, but any such efforts would require a strategic approach based on needs in the treated population. Obstetric settings are being encouraged to detect and address behavioral health needs. Methods: An EMR-based approach for developing an initial estimate of the portion in need, and the range of conditions present, was developed for the obstetric setting. A list was developed of behavioral health diagnoses and prescriptions that could be queried using the electronic medical record (EMR). For diagnoses, the ICD-9 set of "mental disorder" diagnoses (codes 290-319) was used. For prescriptions, a list of behavioral health medications published by NIMH was used, augmented with the behavioral health medications noted in a recent "Top 200" prescription list published by Verispan, a commercial firm. Results: Of this cohort of 3,290 women beginning pregnancy care in a one-year time span, this EMR query indicated that 394 (12.0%) had a behavioral health need; 5.2% were prescribed a medication alone, 3.1% had a diagnosis alone, and 3.6% had both. This is likely an underestimate, but the efficient EMR method serves as a helpful starting place for determining behavioral health needs to be addressed. Conclusions: These data indicate that screening for these conditions will likely yield modest, but steady, numbers of patients with behavioral health needs that could be integrated with obstetric care. Readily available data regarding most common diagnoses and most frequently prescribed drugs can be used to develop an initial estimate of the burden of behavioral health need in obstetrics. Other primary care settings could readily replicate this approach as an initial step for addressing behavioral health burden in primary care.
have emerged. These significantly boost the likelihood of sustained viral response, including for... more have emerged. These significantly boost the likelihood of sustained viral response, including for genotype 1, and do not seem to have the side effects of interferonalpha or ribavirin. Relevant data are reviewed to assess the degree that these new treatments might reduce the portion not eligible for treatment due to psychiatric comorbidities, and might reduce the emergence of psychiatric symptoms during treatment. Several organizations have recently released evidence-based treatment recommendation guidelines. It is apparent that interferon-alpha continues to be a standard of care, with the new drugs added to this recognized regimen in order to shorten treatment and to boost efficacy. Clinical settings must continue to assess appropriateness for treatment, including current or recent psychiatric comorbidities, and must continue to closely monitor patients for the emergence of psychiatric side effects. The newly developed hepatitis C treatments may affect the metabolism of several categories of psychiatric drugs, and so drug-drug interactions must also be considered and monitored. With many promising drugs under development, an all-pill regimen, with no interferon-alpha and no ribavirin, may emerge in the near future. This will greatly change the challenge of treatment decision-making, and should expand the portion of patients able to successfully complete a treatment regimen.
Postpartum depression continues to be undertreated. This project identified state policies that h... more Postpartum depression continues to be undertreated. This project identified state policies that have been enacted regarding peripartum mental health and assessed how effective they might be. A systematic search strategy was used to detect state-level legislative initiatives. Legislative tracking resources were used to determine which were enacted. Policies were sorted into categories. Related evidence was reviewed to gauge the impact of each category. Thirteen states have enacted one or more state-level peripartum mental health policies. Categories include patient education mandates, depression screening mandates, mandated task force, and public awareness campaigns. Those mandating screening include Illinois, Massachusetts, New Jersey, and West Virginia. Related outcomes evidence suggests a very limited impact. Several states have enacted policies addressing peripartum mental health, but these are probably not influencing clinical outcomes. Home visits with a mental health component...
Study Purposes. This study examined whether melanonychia was more prevalent in 1) HIV positive in... more Study Purposes. This study examined whether melanonychia was more prevalent in 1) HIV positive individuals compared to HIV negative persons, 2) HIV positives exposed to zidovudine and/or stavudine and 3) those with darker skin pigmentation. Procedures. 267 HIV positive and 273 HIV negative patients were examined for presence or absence of melanonychia and level of skin pigmentation using the Fitzgerald scale. Pharmacy records were examined for determining exposure to zidovudine or stavudine. Chi square, odds ratios and logistic regression were used to examine the study questions Main Findings. Melanonychia appeared in 49.1% of 267 HIV positive and 21.8% of 273 HIV negative subjects. Adjusting for skin pigmentation, HIV positives were 4.1 times more likely to have melanonychia than HIV negatives. Melanonychia was present in 54% of those receiving zidovudine and in 42% of those receiving stavudine (OR = 2.73, p = 0.05). In a multivariate model in HIV positives which included skin type, prescription of zidovudine and/or Stavudine, only dark skin (OR = 14.62, p < 0.001) and zidovudine (OR = 2.65, p < 0.03) were significant. Principal Conclusions. HIV infected persons are prone to melanonychia. This is more frequent in darker skinned persons and is enhanced in those exposed to zidovudine.
We present an inventive method that generates intramolecular controls for SNP analysis, termed Mi... more We present an inventive method that generates intramolecular controls for SNP analysis, termed Mirror SNPs. Using the ovine diseases of callipyge and scrapie as examples, we describe the PCR-driven production of balanced heterozygote copies of the various SNPs implicated in these diseases. In the absence of a callipyge-positive control DNA, we generated a balanced heterozygote Mirror SNP that represents both the wild-type and mutant forms of the causal polymorphism. Simultaneous analysis of this artificial Mirror SNP and the Real (target) SNP was used to prove the absence of the mutant form of the nucleotide at the Real SNP position in tested samples. Scrapie susceptibility was assessed using a PCR-driven system which generated four separate Mirror SNPs, and these enabled the confirmation of an apparent departure from 'balanced' heterozygote appearance at Real SNPs tested. Mirror SNP technology is generic and will enable the accurate assessment of rare and medically important SNP variants, more accurate frequency determinations, and the potential assessment of SNPs in 'mixed template' samples common in forensic analyses.
This study was developed to evaluate the feasibility of implementing systematic depression screen... more This study was developed to evaluate the feasibility of implementing systematic depression screening in a large obstetric practice and to evaluate the degree that detection and referral led to linkage with behavioral healthcare. Depression screening was conducted using the Edinburgh Postnatal Depression Scale, administered at the initial pregnancy care appointment. Patients at or above a predetermined score of 14 were advised to seek further behavioral health assessment through the patient's behavioral healthcare coverage. Within 4 weeks of screening, those referred were contacted by telephone, by clinic staff, to determine whether they had pursued behavioral healthcare as recommended. Limited available data for newly established postdelivery screening were similarly evaluated. All 2,199 newly presenting pregnant women who were seen in our obstetric clinics from September 2008 to May 2009 were screened for depression, and 102 (4.6%) scored at or above an EPDS of 14. Follow-up calls revealed that none had pursued further behavioral health assessments. Of these 2,199, screening and follow-up data were available for 569 women at their 6-week postdelivery visit. Of these, 28 (4.9%) were above EPDS of 14, and 5 (17.9%) reported pursuit of further behavioral healthcare following screening and referral. Peripartum depression can be addressed with systematic screening, and the electronic medical record can readily be used to monitor results. Detection and referral at the beginning of pregnancy did not lead to intended linkage with behavioral healthcare, but detection and referral postdelivery had a modest influence. Barriers to pursuing behavioral healthcare need to be discovered and addressed.
Depression is often a side effect of interferon-alpha treatment for hepatitis C, and is recognize... more Depression is often a side effect of interferon-alpha treatment for hepatitis C, and is recognized as a cause for treatment discontinuation. When detected, antidepressant treatment begins promptly. In contrast to this rescue approach, prophylactic antidepressant treatment has been considered as a superior approach. While studies indicate that depression is lower with prophylaxis, no study has prospectively evaluated the degree that treatment completion might be boosted by the prophylactic strategy. A structured literature search was conducted to discover all trials of antidepressant prophylaxis for patients undergoing antiviral treatment for chronic hepatitis C. Selection criteria included: antidepressant prophylaxis study; report of depression treatment outcome; report of numbers discontinuing and reason for discontinuation (including any of the following: discontinuation data for medical side effects (i.e., thrombocytopenia); discontinuation due to lack of antiviral response; disc...
Objective: Postpartum depression continues to be under-treated. This project identified state pol... more Objective: Postpartum depression continues to be under-treated. This project identified state policies that have been enacted regarding peripartum mental health and assessed how effective they might be. Methods: A systematic search strategy was used to detect state-level legislative initiatives. Legislative tracking resources were used to determine which were enacted. Policies were sorted into categories. Related evidence was reviewed to gauge the impact of each category. Results: Thirteen states have enacted one or more state-level peripartum mental health policies. Categories include patient education mandates, depression screening mandates, mandated task force, and public awareness campaigns. Those mandating screening include Illinois, Massachusetts, New Jersey, and West Virginia. Related outcomes evidence suggests a very limited impact. Conclusions: Several states have enacted policies addressing peripartum mental health, but these are probably not influencing clinical outcomes. Home visits with a mental health component are effective for postpartum depression; state policies could support home visits.
Chronic hepatitis C virus (HCV) is a global concern. With the 2014 Food and Drug Administration a... more Chronic hepatitis C virus (HCV) is a global concern. With the 2014 Food and Drug Administration approvals of two direct-acting antiviral (DAA) regimens, ledipasvir/sofosbuvir regimen and the ombitasvir/paritaprevir/ritonavir and dasabuvir regimen, we may now be in the era of all-pill regimens for HCV.
Until this development, interferon-alpha along with Ribavirin has remained part of the standard of care for HCV patients. That regimen necessitates psychosocial assessment of factors affecting treatment eligibility, including interferon-alpharelated depressive symptoms, confounding psychiatric conditions, and social aspects such as homelessness affecting treatment eligibility. These factors have delayed as much as 70% of otherwise eligible candidates from interferon-based treatment, and have required treating physicians to monitor psychiatric as well as medical side effects throughout treatment.
All-pill DAA regimens with the efficaciousness that would preclude reliance upon interferon-alpha or ribavirin have been anticipated for years. Efficacy studies for these recently approved DAA regimens provide evidence to assess the degree that psychosocial assessment and monitoring will be required. With shorter treatment timelines, greatly reduced side effect profiles, and easier regimens, psychosocial contraindications are greatly reduced. However, current or recent psychiatric comorbidity, and drug-drug interactions with psychiatric drugs, will require some level of clinical attention.
Evidence from these efficacy studies tentatively demonstrate that the era of needing significant psychosocial assessment and monitoring may be at an end, as long as a manageable handful of clinical issues are managed.
There were significant reductions in risk in 12 of 17 studies of cardiovascular outcomes (risk re... more There were significant reductions in risk in 12 of 17 studies of cardiovascular outcomes (risk reductions ranging from 28% to 58%), in seven of eight studies of diabetes (14% to 46%), in seven of ten studies of breast cancer (11% to 67%), in two of two studies of endometrial cancer (68% to 90%), and in one of three studies of colorectal cancer (31% to 46%). There was mixed evidence for PA preventing gestational diabetes (three studies) and a range of other cancers (13 studies). Protective benefits for cardiovascular disease and diabetes were reported with as little as 60 minutes of moderate-intensity physical activity per week (240 Metabolic Equivalent (MET) minutes or 4 MET hours), with walking and moderate-intensity physical activity providing risk reductions comparable to those for the equivalent energy expenditure from more vigorous-intensity physical activity.
PURPOSE: Depression is a risk factor for incident coronary heart disease (CHD), and predicts poor... more PURPOSE: Depression is a risk factor for incident coronary heart disease (CHD), and predicts poor prognosis for patients post-myocardial infarction (MI). Few population-based, prospective studies have tested a gradient risk for depressive symptoms on CHD incidence. METHODS: The sample (n Z 1302) was derived from the Nova Scotia Health Survey-1995 (NSHS95), an age-and sex-stratified, random, population-based health survey. All subjects were 45 years or older, free of overt CHD at baseline, and completed the Center for Epidemiological Studies-Depression (CES-D) scale. Covariates included age, sex, body mass index, physical activity level, family history of premature CHD, diastolic blood pressure, lipids, smoking, alcohol use, diabetes, and education level. For the 4 years following NSHS95, MI-related hospitalizations (ICD-9-CM code 410) and CHD-related deaths (ICD-9-CM codes 410-414) were extracted from the provincial, universal healthcare registry. RESULTS: Fifty-two participants experienced a CHD event. A one standard-deviation increase in CES-D score was associated with a 1.32 hazard risk (confidence interval, 1.01-1.71) of CHD events, controlling for established CHD risk factors. CONCLUSIONS: An independent, gradient association between depression and incident CHD was detected in a population-based sample with complete 4-year CHD data. This evidence supports the value of investigating mechanisms linking depression and CHD. Ann Epidemiol 2005;15:316-320. Ó 2004 Elsevier Inc. All rights reserved.
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Papers by Paul Rowan
Until this development, interferon-alpha along with Ribavirin has remained part of the standard of care for HCV patients. That regimen necessitates psychosocial assessment of factors affecting treatment eligibility, including interferon-alpharelated depressive symptoms, confounding psychiatric conditions, and social aspects such as homelessness affecting treatment eligibility. These factors have delayed as much as 70% of otherwise eligible candidates from interferon-based treatment, and have required treating physicians to monitor psychiatric as well as medical side effects throughout treatment.
All-pill DAA regimens with the efficaciousness that would preclude reliance upon interferon-alpha or ribavirin have been anticipated for years. Efficacy studies for these recently approved DAA regimens provide evidence to assess the degree that psychosocial assessment and monitoring will be required. With shorter treatment timelines, greatly reduced side effect profiles, and easier regimens, psychosocial contraindications are greatly reduced. However, current or recent psychiatric comorbidity, and drug-drug interactions with psychiatric drugs, will require some level of clinical attention.
Evidence from these efficacy studies tentatively demonstrate that the era of needing significant psychosocial assessment and monitoring may be at an end, as long as a manageable handful of clinical issues are managed.
Until this development, interferon-alpha along with Ribavirin has remained part of the standard of care for HCV patients. That regimen necessitates psychosocial assessment of factors affecting treatment eligibility, including interferon-alpharelated depressive symptoms, confounding psychiatric conditions, and social aspects such as homelessness affecting treatment eligibility. These factors have delayed as much as 70% of otherwise eligible candidates from interferon-based treatment, and have required treating physicians to monitor psychiatric as well as medical side effects throughout treatment.
All-pill DAA regimens with the efficaciousness that would preclude reliance upon interferon-alpha or ribavirin have been anticipated for years. Efficacy studies for these recently approved DAA regimens provide evidence to assess the degree that psychosocial assessment and monitoring will be required. With shorter treatment timelines, greatly reduced side effect profiles, and easier regimens, psychosocial contraindications are greatly reduced. However, current or recent psychiatric comorbidity, and drug-drug interactions with psychiatric drugs, will require some level of clinical attention.
Evidence from these efficacy studies tentatively demonstrate that the era of needing significant psychosocial assessment and monitoring may be at an end, as long as a manageable handful of clinical issues are managed.