Biomedical subjects

John Cornell

Publications and source records attributed to John Cornell.

12 recordsLinked to original sources

PubMed2006

Assessing potentially inappropriate prescribing in the elderly Veterans Affairs population using the HEDIS 2006 quality measure.

BACKGROUND: Studies have found that 20% to 25% of older patients receive drugs identified as inappropriate by the 1997 Beers criteria. After the addition of 22 new drugs to the 2003 Beers criteria, the National Committee on Quality Assurance convened an expert consensus panel to identify which drugs from the 2003 Beers criteria should always be avoided in the elderly. The resulting list of drugs to avoid was added to the 2006 Health Plan Employer Data and Information Set (HEDIS) to measure the quality of prescribing for the elderly. OBJECTIVE: To use HEDIS 2006 criteria to determine the rate of potentially inappropriate prescribing in the elderly (PIPE) and to determine if patient risk factors are similar to those found using Beers criteria. METHODS: This cross-sectional database study identified older patients receiving drugs included in the HEDIS 2006 criteria using national data from the Veterans Health Administration. Patients aged 65 years or older on October 1, 1999, with at least 2 outpatient visit days during fiscal year 2000, ending September 30, or outpatient visits in fiscal years 1999 and 2000 were included (N=1,096,361). Multivariable logistic regression analyses stratified by gender identified patient characteristics associated with increased risk of HEDIS 2006 drug exposure. Since oral estrogens were considered appropriate at the time of this study, they were excluded from the list of HEDIS 2006 drugs. RESULTS: Overall, 19.6% of older veterans were exposed to HEDIS 2006 drugs. 23.3% of older veteran women and 19.2% of older veteran men. The most commonly prescribed HEDIS 2006 drugs were antihistamines (received by 9.0% of men and 10.7% of women), opioid analgesics (received by 4.6% of men and 5.8% of women), and skeletal muscle relaxants (received by 4.3% of men and 5.3% of women). Propoxyphene was the most commonly used HEDIS 2006 drug, received by 4.5% of men and 5.7% of women, followed by diphenhydramine, received by 3.5% of men and 4.7% of women, and hydroxyzine, received by 3.2% of both men and women. Patients receiving 10 or more medications of any type were at greatest risk of exposure. Men were 8.2 times more likely to receive at least 1 HEDIS 2006 drug than those taking 1 to 3 drugs of any type (95% confidence interval [CI], 8.0-8.4), while women were 9.6 times more likely (95% CI, 8.2-11.2). CONCLUSIONS: Even though we included a slightly different list of drugs to avoid, results for the HEDIS 2006 measure were similar to those of the 1997 Beers criteria. The HEDIS 2006 drugs are commonly prescribed, and there is a distinct need for direct evidence linking HEDIS 2006 PIPE exposure to adverse patient outcomes. To reduce PIPE, it seems necessary to provide additional evidence for clinicians through the conducting of a well-designed study to assess patient outcomes associated with PIPE exposure as defined by the HEDIS criteria.

Aged↗

PubMed2005

Number needed to treat: a descriptor for weighing therapeutic options.

PURPOSE: The utility and limitations of the number needed to treat (NNT) are described and compared with those of alternative descriptors of therapeutic yield. SUMMARY: Pharmacists, physicians, and patients are more likely to launch interventions based on relative measures of therapeutic yield. The NNT is a simple way to express the absolute therapeutic yield of an intervention. It is essential to take baseline risk and length of follow-up into account when calculating and interpreting absolute or relative measures of therapeutic yield. Patients may have difficulty understanding what the NNT tells them about the benefits and harms associated with an intervention, and confidence intervals for the NNT can be difficult to interpret. Relative measures of benefits are advantageous for comparing benefits across populations with different risks. The use of absolute measures to describe therapeutic options leads to more conservative decision-making and is potentially more useful. Among the absolute measures, the absolute risk reduction may be easier to understand than the NNT. These measures are most helpful when the best options are not clear or when patient input is needed. Personal digital assistants and Web-based tools can assist with calculations. CONCLUSION: The NNT is a useful measure but is influenced by numerous variables and may not be easily understood by patients.

Algorithms↗

PubMed2004

Racial variations in processes of care for patients with community-acquired pneumonia.

BACKGROUND: Patients hospitalized with community acquired pneumonia (CAP) have a substantial risk of death, but there is evidence that adherence to certain processes of care, including antibiotic administration within 8 hours, can decrease this risk. Although national mortality data shows blacks have a substantially increased odds of death due to pneumonia as compared to whites previous studies of short-term mortality have found decreased mortality for blacks. Therefore we examined pneumonia-related processes of care and short-term mortality in a population of patients hospitalized with CAP. METHODS: We reviewed the records of all identified Medicare beneficiaries hospitalized for pneumonia between 10/1/1998 and 9/30/1999 at one of 101 Pennsylvania hospitals, and randomly selected 60 patients at each hospital for inclusion. We reviewed the medical records to gather process measures of quality, pneumonia severity and demographics. We used Medicare administrative data to identify 30-day mortality. Because only a small proportion of the study population was black, we included all 240 black patients and randomly selected 720 white patients matched on age and gender. We performed a resampling of the white patients 10 times. RESULTS: Males were 43% of the cohort, and the median age was 76 years. After controlling for potential confounders, blacks were less likely to receive antibiotics within 8 hours (odds ratio with 95% confidence interval 0.6, 0.4-0.97), but were as likely as whites to have blood cultures obtained prior to receiving antibiotics (0.7, 0.3-1.5), to have oxygenation assessed within 24 hours of presentation (1.6, 0.9-3.0), and to receive guideline concordant antibiotics (OR 0.9, 0.6-1.7). Black patients had a trend towards decreased 30-day mortality (0.4, 0.2 to 1.0). CONCLUSION: Although blacks were less likely to receive optimal care, our findings are consistent with other studies that suggest better risk-adjusted survival among blacks than among whites. Further study is needed to determine why this is the case.

Black or African American↗

PubMed2004

The effectiveness of depression care management on diabetes-related outcomes in older patients.

BACKGROUND: Depression frequently occurs in combination with diabetes mellitus, adversely affecting the course of illness. OBJECTIVE: To determine whether enhancing care for depression improves affective and diabetic outcomes in older adults with diabetes and depression. DESIGN: Preplanned subgroup analysis of the Improving Mood-Promoting Access to Collaborative Treatment (IMPACT) randomized, controlled trial. SETTING: 18 primary care clinics from 8 health care organizations in 5 states. PATIENTS: 1801 patients 60 years of age or older with depression; 417 had coexisting diabetes mellitus. INTERVENTION: A care manager offered education, problem-solving treatment, or support for antidepressant management by the patient's primary care physician; diabetes care was not specifically enhanced. MEASUREMENTS: Assessments at baseline and at 3, 6, and 12 months for depression, functional impairment, and diabetes self-care behaviors. Hemoglobin A(1c) levels were obtained for 293 patients at baseline and at 6 and 12 months. RESULTS: At 12 months, diabetic patients who were assigned to intervention had less severe depression (range, 0 to 4 on a checklist of 20 depression items; between-group difference, -0.43 [95% CI, -0.57 to -0.29]; P < 0.001) and greater improvement in overall functioning (range, 0 [none] to 10 [unable to perform activities]; between-group difference, -0.89 [CI, -1.46 to -0.32]) than did participants who received usual care. In the intervention group, weekly exercise days increased (between-group difference, 0.50 day [CI, 0.12 to 0.89 day]; P = 0.001); other self-care behaviors were not affected. At baseline, mean (+/-SD) hemoglobin A1c levels were 7.28% +/- 1.43%; follow-up values were unaffected by the intervention (P > 0.2). LIMITATIONS: Because patients had good glycemic control at baseline, power to detect small but clinically important improvements in glycemic control was limited. CONCLUSIONS: Collaborative care improves affective and functional status in older patients with depression and diabetes; however, among patients with good glycemic control, such care minimally affects diabetes-specific outcomes.

Aged↗

PubMed2004

Soluble adhesion molecule levels, neuropsychiatric lupus and lupus-related damage.

Nervous system dysfunction may occur in as many as 80% of patients with Systemic Lupus Erythematous (SLE) at some point in their disease course. Upregulation of adhesion molecules has been linked to acute SLE-related disease activity and chronic damage. We evaluated the relationship between soluble adhesion molecule levels and neuropsychiatric lupus (NPSLE) manifestations using the American College of Rheumatology (ACR) case definitions to investigate for evidence of a link between upregulation of adhesion molecules and NPSLE manifestations. Sera from the initial study visit of 133 SLE patients enrolled in the San Antonio Lupus Study of Neuropsychiatric Disease (SALUD) and 40 controls were evaluated for soluble adhesion molecule levels (VCAM-1, ICAM-1 and E-selectin) and antiphospholipid antibodies. A subset of 57 SLE patients were evaluated for soluble adhesion molecule levels and antiphospholipid antibodies on two subsequent study visits, as well. NPSLE manifestations at the time of sera ascertainment were recorded using ACR case definitions and SLE-related acute activity and damage were measured. Elevated levels of all three soluble adhesion molecules were seen in SLE patients compared to normal control values. Soluble VCAM-1 levels correlated with measures of current disease activity, NPSLE manifestations and deep venous thrombosis. Persistently positive levels of ICAM-1 and VCAM-1, but not E-selectin were association with increased SLE-related damage. Elevated levels of all soluble adhesion molecule levels correlated with abnormal levels of antiphospholipid antibodies, which are associated with some NPSLE manifestations and have been shown to upregulate adhesion molecule expression.

Adult↗

PubMed2004

The 13- and 20-item Hopkins Symptom Checklist Depression Scale: psychometric properties in primary care patients with minor depression or dysthymia.

OBJECTIVE: Depression scales that are responsive to changes in clinical symptoms are important for clinical monitoring and outcomes assessment in longitudinal studies. We evaluated the psychometric properties and responsiveness to clinical change of the 13- and 20-item versions of the Hopkins Symptom Checklist Depression Scale (HSCL-D). METHODS: A secondary data analysis from a large 11-week, multicenter clinical trial, comparing three treatments was performed. Adult patients with minor depression or dysthymia and a score of > or = 10 on the Hamilton Depression Rating Scale (HDRS) were recruited from primary care clinics. Item-total correlations and Cronbach alphas were computed for HSCL-D-13 and HSCL-D-20. Clinical response at 11 weeks was defined by a Hamilton Depression Rating Scale (HDRS) < 10, clinical remission by a HDRS < 7, and criterion symptom remission by < or = 1 DSM-III-R criterion symptoms. Standardized effect sizes and Guyatt's responsiveness statistic were determined for the 13- and 20-item HSCL-D. RESULTS: Of the 656 subjects enrolled, 511 (77.9%) had complete data and were included in the analysis. Patients were 61.1 +/- 15.0 years old; minor depression was diagnosed in 238, dysthymia in 273. Both scales had good internal consistency; Cronbach's alpha = 0.835 and 0.859 for the 13- and 20-items questionnaires respectively. Standardized effect sizes for clinical response (0.62 for the HSCL-D-13; 0.66 for the HSCL-D-20), clinical remission (0.69 and 0.70), and criterion symptom remission (0.65 and 0.67) showed moderate to large effects and did not differ significantly for the two versions. Responsiveness was virtually identical for patients with minor depression and dysthymia but responsiveness was substantially lower for ethnic minorities. CONCLUSION: The HSCL-D-13 and 20-item versions have similar responsiveness to change. For use in European Americans, we recommend the HSCL-D-13 if response burden is the preeminent consideration. To more fully capture DSM criterion symptoms, we recommend the HSCL-D-20.

Adolescent↗

PubMed2003

Comparative proteomics: characterization of a two-dimensional gel electrophoresis system to study the effect of aging on mitochondrial proteins.

To study the effect of aging and anti-aging strategies on mitochondria, we have characterized a two-dimensional polyacrylamide gel electrophoresis (2-D PAGE) system to analyze the profile of mitochondrial proteins. We have optimized the separation of proteins by 2-D PAGE and established the linearity and reproducibility of the system with mitochondria isolated from skeletal muscle of mice. Using total mitochondria protein ranging from 10 to 200 microg, we found that 74% of the proteins resolved by 2-D PAGE had coefficient of determination (R2) values greater than 0.8, showing a linear increase in fluorescence with increasing protein concentration. The coefficient of variation (CV) was less than 50% for at least 93% of the 424 spots analyzed for both gel-to-gel variance and animal-to-animal variance. Using mitochondrial protein fractions prepared from skeletal muscle of 18-month-old mice, we show that 10 animals will be sufficient to detect a 100% difference in the 97% (i.e. 505) of the proteins resolved by 2-D PAGE. Thus, 2-D PAGE provides a sensitive and reliable technique for analysis of protein expression in mitochondria.

Aging↗

PubMed2003

Depression care attitudes and practices of newer obstetrician-gynecologists: a national survey.

OBJECTIVE: The study was undertaken to assess attitudes and behavior of newer obstetricians/gynecologists in depression care. STUDY DESIGN: One thousand randomly selected physicians in their final year of training or recent practice received a survey about depression: training; related attitudes, responsibility, confidence; and self-reported care for the last depressed patient. RESULTS: Of those eligible, 437 (64%) returned the survey. Current residents reported more didactic mental health training, but practice patterns were similar to recent graduates. Overall, 94% felt responsible for recognition, whereas about half indicated asking about substance abuse, sexual abuse, or physical abuse, 37% expressed confidence in their ability to treat with medications, and 22% felt confident in their ability to manage depression overall. CONCLUSION: Residents are receiving more didactic mental health training, yet changes in training are not yet reflected in reported practice patterns or confidence. The use of antidepressant medications and assessment of contributing conditions such as abuse deserve more emphasis in training.

Adult↗

PubMedDate not supplied

Predictors of nonresponse to treatment in primary care patients with dysthymia.

Dysthymia is one of the most prevalent problems in primary care, especially in the elderly. In this study, we evaluated the demographic and clinical predictors of nonresponse to treatment in primary care patients with dysthymia. The study sample consisted of 338 primary care patients meeting DSMIII-R criteria for dysthymia from 4 diverse geographic sites in a randomized controlled 11-week trial of paroxetine, problem-solving therapy or placebo. Patients who attended at least 4 treatment sessions were used in the analysis. A score of less than 7 on the Hamilton was defined as a positive response to treatment. By Week 11, 52.2% of patients had a positive response to treatment. Patients with lower levels of education (odds ratio 0.44, 95% CI 0.23, 0.86), higher scores on the personality dimension of neuroticism (odds ratio 0.58, 95% CI 0.36, 0.92) and those with more severe medical illness (odds ratio 0.97, 95% CI 0.95, 0.99) were less likely to recover with either active or placebo treatments. Elderly women (>60 years of age; odds ratio 0.19, 95% CI 0.05, 0.66) were also less likely to respond to all treatments; however, females had a significantly higher response to placebo treatment compared to males. The factors associated with lack of response to treatment included lower-levels of education, high neuroticism, more severe medical illness and being an older female. This analysis is based on patients agreeing to participate in a randomized controlled trial, limiting representativeness of the sample, however, the demographic and clinical characteristics are common in elderly depressed primary care patients, and may signal the need for increased mental health specialty consultation.

Aged↗

PubMedDate not supplied

Correlates of remission in primary care patients treated for minor depression.

As minor depression is perhaps the most common form of mood disorder seen in primary care, we sought to explore the effects of both pharmacologic and psychosocial interventions for primary care patients with this condition. Three hundred and eighteen primary care patients meeting criteria for minor depression (defined as endorsing 3 or 4 of the nine DSM-IV symptoms of major depression, at least one of which was either depressed mood or anhedonia, for a period of at least four weeks, and scoring > or = 10 on the Hamilton Rating Scale for Depression) from 4 diverse geographic sites were enrolled in a randomized controlled 11 week trial of paroxetine, problem-solving therapy or placebo. Patients who attended at least 4 treatment sessions and who received a Hamilton score by an independent rater at either 6 or 11 weeks were used in the analysis (77% of enrolled patients). A score of < or = 6 on the Hamilton was defined as a positive response to treatment. Fifty four percent of patients met our criteria for remission (HRS-D < or = 6) by week 11, with no difference among treatments. Patients who were women, younger, of European descent, homemakers or retired persons (as opposed to unemployed) and who had lower baseline severity of depression were more likely to remit across all treatment conditions. Although explicitly addressed in the data analysis, differences in outcomes across the four sites of the investigations limit our confidence in the generalizabilty of our findings. In addition, patients with lower levels of educational attainment had a higher dropout rate, suggesting further caution about the generalizability of the findings. Defining remission in this categorical way, we found no differences among the interventions studied, but did find that outcome was related to demographic and clinical characteristics of the patients. While it is difficult to know why female patients were more likely to remit, this may be a function of the association in our subject populations between male gender and the likelihood (approximately .46) of being a patient in the VA system. The remaining variables associated with higher probability of remission appear to reflect social advantage and lower severity or complexity of illness.

Adult↗

PubMedDate not supplied

Processing of data generated by 2-dimensional gel electrophoresis for statistical analysis: missing data, normalization, and statistics.

Several high-throughput statistical methods were evaluated for processing data generated by two-dimensional polyacrylamide gel electrophoresis, including how to handle missing data, normalization, and statistical analysis of data obtained from 2-D gels. Quantile normalization combined with a nonparametric permutation test based on minimizing false discover rates gave the highest yield of proteins that changed with genotype and detected the anticipated 50% decrease in Mn-superoxide dismutase (MnSOD) protein levels in mitochondrial extracts obtained from MnSOD-deficient mice.

Animals↗

PubMedDate not supplied

Depression and comorbid illness in elderly primary care patients: impact on multiple domains of health status and well-being.

PURPOSE: Our objective was to examine the relative association of depression severity and chronicity, other comorbid psychiatric conditions, and coexisting medical illnesses with multiple domains of health status among primary care patients with clinical depression. METHODS: We collected cross-sectional data as part of a treatment effectiveness trial that was conducted in 8 diverse health care organizations. Patients aged 60 years and older (N = 1,801) who met diagnostic criteria for major depression or dysthymia participated in a baseline survey. A survey instrument included questions on sociodemographic characteristics, depression severity and chronicity, neuroticism, and the presence of 11 common chronic medical illnesses, as well as questions screening for panic disorder and posttraumatic stress disorder. Measures of 4 general health indicators (physical and mental component scales of the SF-12, Sheehan Disability Index, and global quality of life) were included. We conducted separate mixed-effect regression linear models predicting each of the 4 general health indicators. RESULTS: Depression severity was significantly associated with all 4 indicators of general health after controlling for sociodemographic differences, other psychological dysfunction, and the presence of 11 chronic medical conditions. Although study participants had an average of 3.8 chronic medical illnesses, depression severity made larger independent contributions to 3 of the 4 general health indicators (mental functional status, disability, and quality of life) than the medical comorbidities. CONCLUSIONS: Recognition and treatment of depression has the potential to improve functioning and quality of life in spite of the presence of other medical comorbidities.

Aged↗