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Biomedical subjects

James Young

Publications and source records attributed to James Young.

At least 19 recordsLinked to original sources
PubMed2006

Prevalence and influence of diagnostic tests for acute respiratory tract infections in primary care.

BACKGROUND: General practitioners (GPs) use diagnostic tests to help distinguish between viral and bacterial acute respiratory tract infections (ARTI). We investigated the prevalence of these tests, and how tests are associated with diagnosis, treatment and patient satisfaction. METHODS: As part of a clinical trial, 45 GPs screened 1108 patients with ARTI and collected information on signs and symptoms, diagnostic test results, and subsequent diagnosis and treatment. A sample of 636 patients was interviewed after 7 days and their opinions recorded. We used multivariate mixed models to estimate associations between the use of tests and (1) baseline characteristics, (2) subsequent antibiotic treatment, and (3) patient satisfaction. RESULTS: GPs carried out at least one test in 42% of the 1108 patients screened. The tests used were (percentage of patients): CRP (35%), leucocyte count (17%), rapid Strep A (9%), chest X-ray (5%), sinus X-ray (1%), and throat culture (1%). The use of tests was associated with increasing patient age, education, and degree of discomfort. Antibiotic therapy was strongly associated with a positive test, with odds ratios of 26 (95% CI, 10-67) for a CRP above 50 mg/l; 9.6 (95% CI, 3.6-26) for a leucocyte count above 10,000/microl; and 122 (4.4-3435) for a positive StrepA test. There was no evidence of an association between the use of tests and patient satisfaction. CONCLUSIONS: Nearly half of these patients with ARTI received a diagnostic test. Older patients, those with higher education and those in more discomfort were more likely to get tests. A positive test was strongly associated with antibiotic treatment.

Acute Disease↗
PubMed2005

Heart failure observation units: optimizing care.

Heart failure causes substantial morbidity and mortality in the United States and accounts for a higher proportion of Medicare costs than any other disease. Most of these costs result from the high rate of hospital admissions and protracted length of stay associated with episodes of acute decompensation of heart failure. Thus, effective clinical strategies to obviate hospitalization and readmission can result in substantial savings. A specialized heart failure observation unit, in which patients receive rapid, goal-directed emergency care for heart failure symptoms, can be a critical component in this effort, providing intensive therapeutic monitoring and education. In institutions with specialized heart failure observation units, patients are triaged to this setting shortly after presentation to the emergency department (ED), and clinic referrals can be directed to this unit after minimal ED evaluation. Aggressive follow-up is also arranged at discharge. Recent additions to the therapeutic armamentarium and future advances in diagnostics and monitoring will continue to improve patient care and prevent avoidable hospitalizations.

Coronary Care Units↗
PubMed2005

Broad modulation of tissue responses (immune activation) by celacade may favorably influence pathologic processes associated with heart failure progression.

Immune activation and inflammation contribute to the progression of chronic heart failure (CHF), but therapeutic approaches directed against these processes have been largely unsuccessful. This clinical study evaluated a novel, nonpharmacologic immune modulation therapy, shown experimentally to reduce inflammatory and increase anti-inflammatory cytokines. A total of 75 patients with New York Heart Association (NYHA) functional class III or IV CHF were randomized to receive either Celacade (immune modulation therapy) or placebo (n = 38 and n = 37, respectively) in a double-blind trial for 6 months, during which standard therapy for CHF was maintained. Patients were evaluated using the 6-minute walk test, changes in NYHA class, cardiac function, and quality-of-life assessments, and were observed for the occurrence of death and hospitalization. There was no between-treatment difference in the 6-minute walk test results, but 15 Celacade-treated patients (compared with 9 placebo-treated patients) improved NYHA classification by > or = 1 class (p = 0.140). Kaplan-Meier survival analysis showed that Celacade significantly reduced the risk of death (p = 0.022) and hospitalization (p = 0.008). Analysis of a clinical composite score demonstrated a significant between-group difference (p = 0.006). There was no difference in left ventricular ejection fraction between groups, but there was a trend toward improved quality of life favoring the Celacade-treated group (p = 0.110). These preliminary findings are consistent with the hypothesis that immune activation is important in the pathogenesis of CHF, and they establish the basis for a phase 3 trial to define the benefit of Celacade in CHF.

Aged↗
PubMed2005

Patient selection for cardiac resynchronization therapy: from the Council on Clinical Cardiology Subcommittee on Electrocardiography and Arrhythmias and the Quality of Care and Outcomes Research Interdisciplinary Working Group, in collaboration with the Heart Rhythm Society.

Cardiac resynchronization therapy (CRT) is a relatively new therapy for patients with symptomatic heart failure resulting from systolic dysfunction. CRT is achieved by simultaneously pacing both the left and right ventricles. Biventricular pacing resynchronizes the timing of global left ventricular depolarization and improves mechanical contractility and mitral regurgitation. Published clinical trials have demonstrated that CRT results in improved clinical status and lower mortality rate when selected patients with systolic ventricular dysfunction and heart failure are treated with CRT. This advisory identifies appropriate candidates for CRT on the basis of the inclusion criteria and results from the published clinical trials.

Arrhythmias, Cardiac↗
PubMed2005

Responding to the rofecoxib withdrawal crisis: a new model for notifying patients at risk and their health care providers.

BACKGROUND: We decided to inform our patients of the withdrawal of rofecoxib, one of the largest drug withdrawals in United States history, and instruct them to contact their providers for guidance. OBJECTIVE: To identify and inform patients and providers affected by the rofecoxib withdrawal. DESIGN: Descriptive observational study. SETTING: Tertiary care center with an electronic medical record (EMR) system. PATIENTS: Patients with an active rofecoxib prescription within the EMR. INTERVENTION: Existing information technology and traditional communication resources were used to automate the identifying and notifying of patients and providers and to deactivate rofecoxib prescriptions in the EMR. MEASUREMENTS: Characteristics of patients receiving rofecoxib at our institution, details of their prescription and provider, number of EMR alerts, and medication discontinuations. RESULTS: The 11,699 patients with a rofecoxib prescription in our practice were sent notifications within 24 hours of the withdrawal. LIMITATIONS: We did not directly measure the effect of our notification on patients or providers. CONCLUSIONS: Information technology enabled our institution to rapidly identify and notify individual patients and their providers about an important drug withdrawal. The methods modeled a feasible way for health care organizations with EMRs to participate in notification processes that may be applicable in a variety of situations.

Adult↗
PubMed2005

Association between adherence measurements of metoprolol and health care utilization in older patients with heart failure.

OBJECTIVE: Data from electronic dosing monitors and published pharmacokinetic parameters were used to derive medication adherence measures for immediate-release metoprolol and examine their association with health care utilization of outpatients aged 50 years or older with heart failure. METHODS: We used a 1-compartment model and published population pharmacokinetic parameters to estimate mean plasma metoprolol concentrations for patients treated for 6 to 12 months. In the absence of directly measured plasma concentrations, we calculated the intended mean plasma concentration (Cp'(ave)) under the assumption of perfect adherence to the prescribed dose and frequency of administration. Projected mean plasma concentrations (Cp(ave)) were estimated by use of data from recorded dosing times. In addition to taking adherence (percentage of dose taken) and scheduling adherence (percentage of doses taken on schedule), we calculated the deviation from the intended exposure (DeltaCp(ave) = Cp'(ave) - Cp(ave)) and the proportion of intended exposure achieved by the patient (Cp(ave) /Cp'(ave)). We assessed the association between the adherence measures and the numbers of emergency department visits and hospital admissions experienced by the patients. RESULTS: Patients (N = 80) were aged 62 +/- 8 years. Mean DeltaCp(ave) and Cp(ave)/Cp'(ave) were 7.9 ng/mL (SD, 10.7) and 0.6 (SD, 0.3), respectively. Log-linear models adjusted for patient functional status indicated that greater deviation from the intended metoprolol exposure (DeltaCp(ave)) was associated with increased numbers of emergency department visits ( P < .0001) and hospital admissions (P < .0001). A higher proportion of intended exposure (Cp(ave) /Cp'(ave)) corresponded to a reduced number of emergency department visits (P = .0204) and hospital admissions (P = .0093). Taking adherence was univariately associated with both emergency department visits and hospital visits (P < .0001 and P = .0010, respectively). Scheduling adherence was associated with the number of emergency department visits (P = .0181) but not with the number of hospital admissions (P = .1602). Model selection procedures consistently chose the proposed measures over taking adherence and scheduling adherence. CONCLUSION: Deviation from the intended exposure and proportion of intended exposure achieved by the patient are valid adherence measures for immediate-release metoprolol and are associated with health care utilization. The potential utility of these measures for other beta-adrenergic antagonists and perhaps other cardiovascular drugs should be investigated.

Aged↗
PubMed2005

Improving medication knowledge among older adults with heart failure: a patient-centered approach to instruction design.

PURPOSE: We investigated whether patient-centered instructions for chronic heart failure medications increase comprehension and memory for medication information in older adults diagnosed with chronic heart failure. DESIGN AND METHODS: Patient-centered instructions for familiar and unfamiliar medications were compared with instructions for the same medications from a chain pharmacy (standard pharmacy instructions). Thirty-two adults (age, M = 63.8) read and answered questions about each instruction, recalled medication information (free recall), and then answered questions from memory (cued recall). RESULTS: Patient-centered instructions were better recalled and understood more quickly than the standard instructions. Instructions for the familiar medications also were better recalled. Patient-centered instructions were understood more accurately for the unfamiliar medications, but standard instructions were understood more accurately for the familiar medications. However, the recall measures showed that the advantage of the standard format for familiar medications was short lived. IMPLICATIONS: The findings suggest that the patient-centered format may improve printed medication instructions available in many pharmacies, which should help older adults to better understand how to take their medications.

Aged↗
PubMed2004

Association of medication adherence, knowledge, and skills with emergency department visits by adults 50 years or older with congestive heart failure.

PURPOSE: The association of medication adherence, knowledge, and skills with emergency department (ED) visits by patients 50 years of age or older with congestive heart failure (CHF) was studied. METHODS: The patients in this study were enrolled in the usual care group of an ongoing trial of patients with CHF to determine the effects of a pharmacy-based intervention on relevant outcomes. Participants' medication knowledge and skills were assessed during individual interviews. Medication knowledge assessed patients' knowledge of the dosage, frequency, and indication of each of their CHF medications. The medications skills assessment evaluated patients' dexterity (ability to open medication bottles), literacy (ability to read labels), and ability to distinguish colors of tablets and capsules. Medication adherence to CHF drugs was calculated from electronic monitors and prescription-refill records over a six-month period. The primary outcomes of this study were the numbers of all-cause cardiovascular and CHF-specific ED visits during a six-month period. Log-linear regression models were used to analyze the effects of medication knowledge, skill, and adherence on ED visits. RESULTS: Sixty-one patients participated in this study. Multivariate log-linear models adjusted for demographic variables showed that lower medication adherence (p < 0.001) and an inability to read standard prescription and auxiliary labels (p = 0.002) were associated with an increased number of cardiovascular-related ED visits. Knowledge of the prescribed dose was associated with CHF-specific ED visits (p < 0.001). CONCLUSION: Greater medication knowledge, skills, and adherence were associated with fewer ED visits among patients 50 years of age or older with CHF in an urban, teaching medical center.

Adult↗
PubMed2004

Effects of a novel immune modulation therapy in patients with advanced chronic heart failure: results of a randomized, controlled, phase II trial.

OBJECTIVE: We sought to determine whether a novel, non-pharmacological form of immune modulation therapy (IMT), shown experimentally to reduce inflammatory and increase anti-inflammatory cytokines, improved outcomes in patients with advanced heart failure (HF). BACKGROUND: Immune activation contributes to the progression of HF, but treatments directed against inflammation have been largely unsuccessful. METHODS: Seventy-five HF patients (New York Heart Association [NYHA] functional class III to IV) were randomized to receive either IMT (n = 38) or placebo (n = 37) in a double-blind trial for six months, with continuation of standard HF therapy. Patients were evaluated using the 6-min walk test, changes in NYHA functional class, cardiac function, and quality of life assessments, as well as occurrence of death and hospitalization. RESULTS: There was no between-group difference in 6-min walk test, but 15 IMT patients (compared with 9 placebo) improved NYHA functional classification by at least one class (p = 0.140). The Kaplan-Meier survival analysis showed that IMT significantly reduced the risk of death (p = 0.022) and hospitalization (p = 0.008). Analysis of a clinical composite score demonstrated a significant between-group difference (p = 0.006). There was no difference in left ventricular ejection fraction, but there was a trend toward improved quality of life (p = 0.110). CONCLUSIONS: These preliminary findings are consistent with the hypothesis that immune activation is important in the pathogenesis of HF and establish the basis for a phase III trial to define the benefit of IMT in chronic HF.

Aged↗
PubMed2004

Protease inhibitor-sparing simplified maintenance therapy: a need for perspective.

Body fat changes and metabolic abnormalities such as hyperlipidaemia and diabetes have been increasingly reported following the successful introduction of highly active antiretroviral therapy (HAART). These side effects were attributed initially to the use of protease inhibitors (PIs). As a consequence, a series of trials were conducted where patients with well-controlled HIV viraemia either continued on PIs or were switched to a simplified maintenance therapy (SMT) without PIs. Evidence from these trials is still insufficient to show that switching from PIs to either abacavir, nevirapine or efavirenz is safe. However, patients with suboptimal pre-HAART treatment are at increased risk of virological failure if switched to an SMT. Patients switched from PI regimens tend to stay longer on an SMT and those switched to abacavir show a reduction in total cholesterol, but there is no evidence of any additional benefit from non-PI-based SMT. There is a clear need for a better understanding of HAART-related lipodystrophy and metabolic toxicity, and pharmacogenetic tests to identify those patients most at risk. The advent of simpler formulations for all drug classes, and new PIs with less metabolic toxicity, is likely to reshape completely the role of SMT.

Antiretroviral Therapy, Highly Active↗
PubMed2004

Clinical outcomes of primary stenting versus balloon angioplasty in patients with myocardial infarction: a meta-analysis of randomized controlled trials.

PURPOSE: To examine whether primary stenting as compared with primary balloon angioplasty reduces clinical outcomes in patients with myocardial infarction. METHODS: Major medical databases from 1979 to March 2002 were searched for randomized controlled trials that compared primary stenting with balloon angioplasty in patients with myocardial infarction. Two independent reviewers selected and extracted data from identified trials. The outcomes were mortality at 30 days, 6 months, and 12 months; recurrent events; and bleeding. RESULTS: Nine trials with a total of 4433 patients fulfilled the inclusion criteria. The odds ratios for mortality after stenting as compared with balloon angioplasty were 1.17 (95% confidence interval [CI]: 0.78 to 1.74) at 30 days, 1.07 (95% CI: 0.76 to 1.52) at 6 months, and 1.09 (95% CI: 0.80 to 1.50) at 12 months (P for heterogeneity >0.1 for each comparison). The odds ratios for reinfarction after stenting as compared with balloon angioplasty were 0.52 (95% CI: 0.31 to 0.87) at 30 days, 0.67 (95% CI: 0.45 to 1.00) at 6 months, and 0.67 (95% CI: 0.45 to 0.99) at 12 months; for target vessel revascularization, they were 0.46 (95% CI: 0.34 to 0.61) at 30 days, 0.42 (95% CI: 0.35 to 0.51) at 6 months, and 0.48 (95% CI: 0.39 to 0.59) at 12 months (P for heterogeneity >0.1 for all estimates with the exception of reinfarction at 12 months where P=0.08). The odds ratio for postinterventional bleeding complications after stenting as compared with balloon angioplasty was 1.34 (95% CI: 0.95 to 1.88; P for heterogeneity >0.1). CONCLUSION: Compared with balloon angioplasty, primary stenting is not associated with lower mortality, but is associated with a lower risk of reinfarction and target vessel revascularization.

Angioplasty, Balloon↗
PubMed2004

Global mapping of the yeast genetic interaction network.

A genetic interaction network containing approximately 1000 genes and approximately 4000 interactions was mapped by crossing mutations in 132 different query genes into a set of approximately 4700 viable gene yeast deletion mutants and scoring the double mutant progeny for fitness defects. Network connectivity was predictive of function because interactions often occurred among functionally related genes, and similar patterns of interactions tended to identify components of the same pathway. The genetic network exhibited dense local neighborhoods; therefore, the position of a gene on a partially mapped network is predictive of other genetic interactions. Because digenic interactions are common in yeast, similar networks may underlie the complex genetics associated with inherited phenotypes in other organisms.

Amino Acid Sequence↗
PubMed2004

Organized Program to Initiate Lifesaving Treatment in Hospitalized Patients with Heart Failure (OPTIMIZE-HF): rationale and design.

Heart failure (HF) affects >5 million patients in the United States, and its prevalence is increasing every year. Despite the compelling scientific evidence that angiotensin-converting enzyme inhibitors and beta-blockers reduce hospitalizations and mortality rates in patients with HF, these lifesaving therapies continue to be underused. Several studies in a variety of clinical settings have documented that a significant proportion of eligible patients with HF are not receiving treatment with these guideline-recommended, evidence-based therapies. In patients hospitalized with HF, who are at particularly high risk for re-hospitalization and death, the initiation of beta-blockers is often delayed because of concern that early initiation of these agents may exacerbate HF. Recent studies suggest that beta-blockers can be safely and effectively initiated in patients with HF before hospital discharge and that clinical outcomes are improved. The Initiation Management Predischarge Process for Assessment of Carvedilol Therapy for Heart Failure (IMPACT-HF) trial demonstrated that pre-discharge initiation of carvedilol was associated with a higher rate of beta-blocker use after hospital discharge, with no increase in hospital length of stay. In addition, there was no increase in the risk of worsening of HF. Studies of hospital-based management systems that rely on early (pre-discharge) initiation of evidence-based therapies for patients with cardiovascular disease have also found increases in post-discharge use of therapy and a reduction in the rates of mortality and hospitalization. On the basis of these pivotal studies, the Organized Program to Initiate Lifesaving Treatment in Hospitalized Patients with Heart Failure (OPTIMIZE-HF) program is designed to improve medical care and education of hospitalized patients with HF and accelerate the initiation of evidence-based HF guideline recommended therapies by administering them before hospital discharge. A registry component, planned as the most comprehensive database of the hospitalized HF population focusing on admission to discharge and 60- to 90-day follow-up, is designed to evaluate the demographic, pathophysiologic, clinical, treatment, and outcome characteristics of patients hospitalized with HF. The ultimate aim of this program is to improve the standard of HF care in the hospital and outpatient settings and increase the use of evidence-based therapeutic strategies to save lives.

Adrenergic beta-Antagonists↗
PubMed2004

Nesiritide in congestive heart failure associated with acute coronary syndromes: a pilot study of safety and efficacy.

BACKGROUND: To compare the safety and efficacy of nesiritide versus intravenous nitroglycerin (NTG) in patients with acute coronary syndromes enrolled in the Vasodilation in the Management of Acute Congestive heart failure trial. Methods and results Retrospective review of Vasodilation in the Management of Acute Congestive heart failure trial data for heart failure associated with prospectively diagnosed acute coronary syndromes. Sixty-one patients were included; 34 received nesiritide and 27 received NTG. Pulmonary capillary wedge pressure was measured in right heart-catheterized patients (11 nesiritide, 9 NTG). Death at 6 months occurred in 2 nesiritide and 5 NTG patients (P>.2). Hypotension occurred in 4 nesiritide and 3 NTG patients (P>.6). At 24 hours, pulmonary capillary wedge pressure improvements persisted (P=.001) in the nesiritide group, whereas the NTG group had returned to baseline (P>.1). In non-right heart-catheterized patients, 24-hour dyspnea scores were at least moderately improved in all nesiritide and 71% of NTG (P=.031). At least minimal dyspnea improvement was seen in 100% of nesiritide versus 71% of NTG patients (P>.3), and 6-hour global clinical scores were at least moderately better in 75% of nesiritide versus 32% of NTG (P=.031). In non-right heart-catheterized patients, there were no 30-day readmissions with nesiritide versus 17% with NTG (P>.2). CONCLUSIONS: Nesiritide is as safe as NTG in heart failure patients with acute coronary syndromes.

Acute Disease↗
PubMed2004

Clinical outcomes of stents versus balloon angioplasty in non-acute coronary artery disease. A meta-analysis of randomized controlled trials.

AIMS: To evaluate whether stents as compared to balloon angioplasty reduce mortality in patients with non-acute coronary artery disease. METHODS AND RESULTS: We identified randomized controlled trials comparing stents to balloon angioplasty for the treatment of non-acute coronary artery disease by searching major medical databases from 1979 to March 2002. Two independent reviewers selected and extracted data from trials that had to report data on death and myocardial infarction. Nineteen trials, with a total of 8004 patients, fulfilled our inclusion criteria. For 1000 patients treated with stents rather than balloon angioplasty, 3 (95% CI 0-6), 5 (95% CI 0-9), and 6 (95% CI -1-12) additional lives were saved at 30 days, 6 and 12 months. At 12 months, for 1000 patients treated with stents rather than balloon angioplasty 46 (95% CI 25-66) additional target vessel revascularizations were avoided, but 25 (95% CI 15-34) additional bleeding complications with need for blood transfusion or surgical intervention occurred. In sensitivity analysis 11 (95% CI 2-20) and 2 (95% CI -4-7) deaths were avoided per 1000 patients treated with stents rather than PTCA in trials that routinely used compared to trials that did not use glycoprotein IIb/IIIa inhibitors. CONCLUSION: In non-acute coronary disease stents may reduce overall mortality, but this benefit seems to be limited to stents used in conjunction with glycoprotein IIb/IIIa inhibitors. Stents compared to PTCA reduce target vessel revascularizations, but increase the risk of bleeding complications.

Angioplasty, Balloon, Coronary↗
PubMed2004

Differences in tachyarrhythmia detection and implantable cardioverter defibrillator therapy by primary or secondary prevention indication in cardiac resynchronization therapy patients.

INTRODUCTION: Although numerous trials have shown benefit of implantable cardioverter defibrillators (ICDs) for either primary or secondary prevention, no trial has prospectively enrolled patients from both indications and analyzed ICD utilization between groups. METHODS AND RESULTS: We performed a retrospective review of MIRACLE ICD, a randomized, prospective double-blind trial of cardiac resynchronization therapy (CRT) in the ICD population. Both secondary prevention (N = 563) and primary prevention patients (N = 415) were enrolled. Subgroup analysis for frequency of ventricular tachycardia (VT) and ventricular fibrillation (VF) episodes and detection accuracy revealed that primary prevention patients had a significantly lower frequency of appropriate episodes (0.09 vs 0.43 episodes/month) at significantly faster cycle lengths (303 +/- 54 ms vs 366 +/- 71 ms, P < 0.0001). These episodes were more likely to be classified as VF by the device and thus receive shock therapy (42% by device classification vs 19% in secondary prevention, P < 0.0001). The absolute rate of inappropriate detections in the primary prevention group per month of follow-up was lower but constituted a much higher proportion of all episodes (30% vs 14%, P < 0.0001). Most inappropriate detections in the secondary prevention group were due to rapidly conducted atrial fibrillation; most in the primary prevention patients were due to sinus tachycardia. CONCLUSION: Patients receiving an ICD for CRT therapy with primary prevention indications have a different clinical arrhythmia course than patients with a history of spontaneous VT/VF. This has implications for the optimal programming of ICDs. Longer-term, prospective evaluation of these differences is warranted and should be investigated in the broader ICD patient population.

Aged↗