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Biomedical subjects

Kurt Kroenke

Publications and source records attributed to Kurt Kroenke.

At least 55 records · Page 3Linked to original sources
PubMed2004

The outcome of physical symptoms with treatment of depression.

OBJECTIVE: This study examined the prevalence, impact on health-related quality of life (HRQoL), and outcome of physical symptoms in depressed patients during 9 months of antidepressant therapy. DESIGN: Open-label, randomized, intention-to-treat trial with enrollment occurring April through November 1999. SETTING: Thirty-seven primary care clinics within a research network. PATIENTS: Five hundred seventy-three depressed patients started on one of three selective serotonin reuptake inhibitors (SSRIs) by their primary care physician and who completed a baseline interview. INTERVENTIONS: Patients were randomized to receive fluoxetine, paroxetine, or sertraline. MEASUREMENTS AND MAIN RESULTS: Outcomes assessed included physical symptoms, depression, and multiple domains of HRQoL. Prevalence of physical symptoms was determined at baseline and after 1, 3, 6, and 9 months of treatment. Stepwise linear regression models were used to determine the independent effects of physical symptoms and depression on HRQoL domains. Of the 14 physical symptoms assessed, 13 were present in at least a third to half of the patients at baseline. Each symptom showed the greatest improvement during the initial month of treatment. In contrast, depression continued to show gradual improvement over a 9-month period. Physical symptoms had a predominant effect on pain (explaining 17% to 18% of the variance), physical functioning (13%), and overall health perceptions (13% to 15%). Depression had the greatest impact on mental (26% to 45%), social (14% to 32%), and work functioning (9% to 32%). CONCLUSIONS: Physical symptoms are prevalent in depressed patients and initially improve in the first month of SSRI treatment. Unlike depression, however, improvement in physical symptoms typically plateaus with minimal resolution in subsequent months.

Depressive Disorder↗
PubMed2004

Test-retest reliability of the Mirowsky-Ross 2 x 2 Index of the Sense of Control.

This study investigated the short-term stability of the 1991 Mirowsky-Ross 2 x 2 Index of the Sense of Control. From an ongoing longitudinal study, 304 subjects were randomly selected for test-retest interviews occurring 1 to 4 days after their regularly scheduled first follow-up interview. Test-retest reliability was assessed at the item level using percent agreement and weighted kappa. At the scale score level, reliability was assessed with the intraclass correlation coefficient (ICC). ICCs were also calculated within categories of demographic, socioeconomic, psychosocial, and functional status characteristics. There was moderate to substantial item-level agreement (mean weighted kappa = 51; weighted kappa range = .38 to .66). At the scale score level there was substantial agreement (ICC = .71). No appreciable differences in ICC values were found in the demographic, socioeconomic, psychosocial, and functional comparisons of status characteristics. Thus, this sense of control measure has acceptable test-retest reliability and is appropriate for use in longitudinal research.

Adult↗
PubMed2004

Suicidality as a Possible Side Effect of Antidepressant Treatment.

PHYSICIANS RESPOND TO THE FDA PUBLIC HEALTH ADVISORY ON WORSENING DEPRESSION AND SUICIDALITY IN PATIENTS BEING TREATED WITH ANTIDEPRESSANTS: On March 22, 2004, the U.S. Food and Drug Administration (FDA) issued a health advisory informing the public that manufacturers of several popular antidepressants have been asked to include a warning statement on product labeling. This warning statement recommends that antidepressant-treated patients-both children and adults-should be closely monitored for worsening of depression or emergence of suicidal behavior. The full text of the advisory, along with supporting information and presentations from the February 2004 meeting on which this advisory was based, can be found on the FDA's Web site at http://www.fda.gov/cder/drug/antidepressants/default.htm. Recently, the CME Institute, as a service to its members-you, the readers of this journal-and Larry Culpepper, M.D., Editor in Chief of the Primary Care Companion, assembled a group of psychiatrists and primary care physicians to discuss the FDA advisory and advise clinicians how it will affect their treatment of depressed patients. Their discussion and recommendations appear here. Faculty affiliations and disclosures appear at the end of this Commentary.

Journal Article↗
PubMed2003

Effect of improving depression care on pain and functional outcomes among older adults with arthritis: a randomized controlled trial.

CONTEXT: Depression and arthritis are disabling and common health problems in late life. Depression is also a risk factor for poor health outcomes among arthritis patients. OBJECTIVE: To determine whether enhancing care for depression improves pain and functional outcomes in older adults with depression and arthritis. DESIGN, SETTING, AND PARTICIPANTS: Preplanned subgroup analyses of Improving Mood-Promoting Access to Collaborative Treatment (IMPACT), a randomized controlled trial of 1801 depressed older adults (> or =60 years), which was performed at 18 primary care clinics from 8 health care organizations in 5 states across the United States from July 1999 to August 2001. A total of 1001 (56%) reported coexisting arthritis at baseline. INTERVENTION: Antidepressant medications and/or 6 to 8 sessions of psychotherapy (Problem-Solving Treatment in Primary Care). MAIN OUTCOME MEASURES: Depression, pain intensity (scale of 0 to 10), interference with daily activities due to arthritis (scale of 0 to 10), general health status, and overall quality-of-life outcomes assessed at baseline, 3, 6, and 12 months. RESULTS: In addition to reduction in depressive symptoms, the intervention group compared with the usual care group at 12 months had lower mean (SE) scores for pain intensity (5.62 [0.16] vs 6.15 [0.16]; between-group difference, -0.53; 95% confidence interval [CI], -0.92 to -0.14; P =.009), interference with daily activities due to arthritis (4.40 [0.18] vs 4.99 [0.17]; between-group difference, -0.59; 95% CI, -1.00 to -0.19; P =.004), and interference with daily activities due to pain (2.92 [0.07] vs 3.17 [0.07]; between-group difference, -0.26; 95% CI, -0.41 to -0.10; P =.002). Overall health and quality of life were also enhanced among intervention patients relative to control patients at 12 months. CONCLUSIONS: In a large and diverse population of older adults with arthritis (mostly osteoarthritis) and comorbid depression, benefits of improved depression care extended beyond reduced depressive symptoms and included decreased pain as well as improved functional status and quality of life.

Activities of Daily Living↗
PubMed2003

Depression and pain comorbidity: a literature review.

Because depression and painful symptoms commonly occur together, we conducted a literature review to determine the prevalence of both conditions and the effects of comorbidity on diagnosis, clinical outcomes, and treatment. The prevalences of pain in depressed cohorts and depression in pain cohorts are higher than when these conditions are individually examined. The presence of pain negatively affects the recognition and treatment of depression. When pain is moderate to severe, impairs function, and/or is refractory to treatment, it is associated with more depressive symptoms and worse depression outcomes (eg, lower quality of life, decreased work function, and increased health care utilization). Similarly, depression in patients with pain is associated with more pain complaints and greater impairment. Depression and pain share biological pathways and neurotransmitters, which has implications for the treatment of both concurrently. A model that incorporates assessment and treatment of depression and pain simultaneously is necessary for improved outcomes.

Antidepressive Agents↗
PubMed2003

Rheumatology patients' use of complementary therapies: results from a one-year longitudinal study.

OBJECTIVE: To examine the natural history of complementary and alternative medicine (CAM) use and its impact on outcomes within a cohort of rheumatology patients. METHODS: Consecutive patients were recruited from 3 university and 3 private rheumatology practices. Baseline chart reviews provided demographic information and rheumatic diagnoses. Patients answered questions on CAM use and health status during 1 year. We identified correlates of 4 CAM usage patterns (started, maintained, stopped, nonuse) and compared outcomes among these groups. RESULTS: Of 232 baseline participants, 203 (87%) and 177 (76%) responded to the 6- and 12-month surveys. In each survey, approximately 34% reported currently using CAM. During the year, 44% of patients remained nonusers whereas 12% started, 22% maintained, and 22% stopped use. The most frequent reasons for stopping CAM were lack of effectiveness and expense. CAM users and nonusers had no difference in outcomes. CONCLUSIONS: Arthritis patients' usage behavior varied substantially, but CAM use was not associated with a difference in outcomes.

Complementary Therapies↗
PubMed2003

Evaluation of acute knee pain in primary care.

BACKGROUND: The evaluation of acute knee pain often includes radiography of the knee. OBJECTIVE: To synthesize the literature to determine the role of radiologic procedures in evaluating common causes of acute knee pain: fractures, meniscal or ligamentous injuries, osteoarthritis, and pseudogout. DATA SOURCES: MEDLINE search from 1966 to October 2002. STUDY SELECTION: We included all published, peer-reviewed studies of decision rules for fractures. We included studies that used arthroscopy as the gold standard for measuring the accuracy of the physical examination and magnetic resonance imaging (MRI) for meniscal and ligamentous knee damage. We included all studies on the use of radiographs in pseudogout. DATA EXTRACTION: We extracted all data in duplicate and abstracted physical examination and MRI results into 2 x 2 tables. DATA SYNTHESIS: Among the 5 decision rules for deciding when to use plain films in knee fractures, the Ottawa knee rules (injury due to trauma and age >55 years, tenderness at the head of the fibula or the patella, inability to bear weight for 4 steps, or inability to flex the knee to 90 degrees) have the strongest supporting evidence. When the history suggests a potential meniscal or ligamentous injury, the physical examination is moderately sensitive (meniscus, 87%; anterior cruciate ligament, 74%; and posterior cruciate ligament, 81%) and specific (meniscus, 92%; anterior cruciate ligament, 95%; and posterior cruciate ligament, 95%). The Lachman test is more sensitive and specific for ligamentous tears than is the drawer sign. For meniscal tears, joint line tenderness is sensitive (75%) but not specific (27%), while the McMurray test is specific (97%) but not sensitive (52%). Compared with the physical examination, MRI is more sensitive for ligamentous and meniscal damage but less specific. When the differential diagnosis for acute knee pain includes an exacerbation of osteoarthritis, clinical features (age >50 years, morning stiffness <30 minutes, crepitus, or bony enlargement) are 89% sensitive and 88% specific for underlying chronic arthritis. Adding plain films improves sensitivity slightly but not specificity. Plain films for pseudogout are not sensitive or specific, according to limited-quality studies. CONCLUSIONS: We recommend the Ottawa knee rules to decide when to obtain plain films for suspected knee fracture. A careful physical examination should be sufficient to decide whether to refer patients with potential meniscal and ligament injuries, and we prefer clinical criteria rather than plain films for evaluating osteoarthritis. We do not recommend using plain films to diagnose pseudogout.

Arthralgia↗
PubMed2003

Patients presenting with somatic complaints: epidemiology, psychiatric comorbidity and management.

Somatic symptoms are the leading cause of outpatient medical visits and also the predominant reason why patients with common mental disorders such as depression and anxiety initially present in primary care. At least 33% of somatic symptoms are medically unexplained, and these symptoms are chronic or recurrent in 20% to 25% of patients. Unexplained or multiple somatic symptoms are strongly associated with coexisting depressive and anxiety disorders. Other predictors of psychiatric co-morbidity include recent stress, lower self-rated health and higher somatic symptom severity, as well as high healthcare utilization, difficult patient encounters as perceived by the physician, and chronic medical disorders. Antidepressants and cognitive-behavioural therapy are both effective for treatment of somatic symptoms, as well as for functional somatic syndromes such as irritable bowel syndrome, fibromyalgia, pain disorders, and chronic headache. A stepped care approach is described, which consists of three phases that may be useful in the care of patients with somatic symptoms.

Anxiety Disorders↗
PubMed2003

Clinically important differences in health-related quality of life for patients with asthma: an expert consensus panel report.

BACKGROUND: Standards for change in health-related quality of life (HRQoL) measures used among asthmatic patients have been established by considering only patient preferences to determine important differences and may not reflect an informed clinical evaluation of change. OBJECTIVE: To establish clinically important difference (CID) standards through the consensus of an expert physician panel for the Juniper Asthma Quality of Life Questionnaire (AQLQ) and Medical Outcomes Study Short-Form 36-Item Health Survey (SF-36, version 2) when used to measure HRQoL among asthmatic patients. METHODS: We organized an 8-person panel of physicians familiar with measuring HRQoL among asthmatic patients with the AQLQ and the SF-36. This expert panel participated in 2 rounds of a modified Delphi process before attending an in-person consensus meeting to establish the CID standards for small, moderate, and large changes in the AQLQ and the SF-36. After the consensus meeting, the panel used an iterative improvement process to cooperatively complete their final report. RESULTS: The expert panel's thresholds for detecting CIDs in the domains of the AQLQ were much higher than previously established levels using patient-perceived changes. CIDs for asthma were also ascertained on the scales of the SF-36, version 2, which were markedly greater than previously cited cross-sectional differences between patient groups. CONCLUSIONS: The CID standards established by this expert panel elucidate a potential distinction between patient and physician perspectives of important HRQoL changes. The many stakeholders of HRQoL difference standards should consider this distinction when adopting standards to evaluate patient change.

Asthma↗
PubMed2003

Clinically important changes in health-related quality of life for patients with chronic obstructive pulmonary disease: an expert consensus panel report.

OBJECTIVE: Without clinical input on what constitutes a significant change, health-related quality of life (HRQoL) measures are less likely to be adopted by clinicians for use in daily practice. Although standards can be determined empirically by within-person change studies based on patient self-reports, these anchor-based methods incorporate only the patients' perspectives of important HRQoL change, and do not reflect an informed clinical evaluation. The objective of this study was to establish clinically important difference standards from the physician's perspective for use of 2 HRQoL measures among patients with chronic obstructive pulmonary disease (COPD). DESIGN: We assembled a 9-person expert panel of North American physicians familiar with the use of the Chronic Respiratory Questionnaire (CRQ), a disease-specific HRQoL measure, or the generic Medical Outcomes Study Short-Form 36-Item Health Survey (SF-36, Version 2.0) among patients with COPD. RESULTS: Using 2 rounds of the Delphi process, 1 in-person meeting, and an iterative improvement process for circulating and correcting the final report, the expert panel established small, moderate, and large clinically important change levels for the CRQ and SF-36. CONCLUSIONS: For this expert physician panel, levels for detecting clinically important differences on the CRQ were equal to or slightly higher than previous studies based on patient-reported differences. Clinically important differences on the SF-36, Version 2.0, were noticeably larger than previous estimates based on cross-sectional differences between clinically defined patient groups.

Health Status Indicators↗
PubMed2003

Is the distal hyperplastic polyp a marker for proximal neoplasia?

CONTEXT: The current literature is unclear about the association between distal hyperplastic polyps and synchronous neoplasia (adenomatous polyps and cancer) in the proximal colon. OBJECTIVE: To estimate the prevalence of proximal neoplasia associated with distal hyperplastic polyps. DATA SOURCES: Database searches (medline and embase from 1966 to 2001) and manual search of the bibliographies of included and excluded studies, case reports, editorials, review articles, and textbooks of Gastroenterology. STUDY SELECTION: Studies describing the prevalence of proximal neoplasia in persons with distal hyperplastic polyps. DATA EXTRACTION: Demographics, clinical variables, study design, and prevalence of proximal neoplasia associated with various distal colorectal findings. DATA SYNTHESIS: Of 18 included studies, 12 involved asymptomatic individuals in which the pooled absolute risk of any proximal neoplasia associated with distal hyperplastic polyps was 25% (95% confidence interval [95% CI], 21% to 29%). In 4 studies where colonoscopy was performed irrespective of distal findings, the absolute risk was 21% (95% CI, 14% to 28%). The relative risk of finding any proximal neoplasia in persons with distal hyperplastic polyps was 1.3 (95% CI, 0.9 to 1.8) compared to those with no distal polyps. Among 6 studies of patients with symptoms or risk factors for neoplasia, the absolute risk of proximal neoplasia was 35% (95% CI, 32% to 39%) in persons with distal hyperplastic polyps. In 2 studies of screening colonoscopy, advanced proximal neoplasia (cancer, or a polyp with villous histology or severe dysplasia, or a tubular adenoma >/=1 cm) was present in 4% to 5% of persons with distal hyperplastic polyps, which was 1.5 to 2.6 times greater than in those with no distal polyps. CONCLUSIONS: In asymptomatic persons, a distal hyperplastic polyp is associated with a 21% to 25% risk for any proximal neoplasia and a 4% to 5% risk of advanced proximal neoplasia, and may justify examination of the proximal colon. Further study is needed to determine the risk of advanced proximal neoplasia associated with size and number of distal hyperplastic polyps.

Colonic Neoplasms↗
PubMed2003

Improving patient satisfaction with the transfer of care. A randomized controlled trial.

OBJECTIVE: To determine whether educational sessions with medical residents, with or without letters to their patients, improve patient satisfaction with transfer of their care from a departing to a new resident in an internal medicine clinic. DESIGN: Observational study in Year 1 to establish a historical control, with a randomized intervention in Year 2. SETTING: An internal medicine clinic in a teaching hospital. PATIENTS/PARTICIPANTS: Patients of departing residents completed questionnaires in the waiting room at their first visit with a new resident, with mail-administered questionnaires for patients not presenting to the clinic within 3 months after transfer of their care. In Year 1, 376 patients completed questionnaires without intervention. The following spring, we conducted interactive seminars with 12 senior residents to improve their transfer of care skills (first intervention). Half of their patients were then randomized to receive a letter from the new doctor informing them of the change (second intervention). We assessed the efficacy of the interventions by administering questionnaires to 437 patients in the months following the interventions. MEASUREMENTS AND MAIN RESULTS: Multivariate analysis of Year 1 results identified doctors personally informing patients prior to leaving as the single strongest predictor of patient satisfaction (partial R2=.41). In Year 2, our first intervention increased the percentage of patients informed by their doctors from 71% in 1991 to 79% in 1992 (P <.001). Mean satisfaction dramatically improved, with the fraction of fully satisfied patients increasing from 47% at baseline, to 61% with the first intervention alone, and 72% with both interventions (P <.0001). CONCLUSIONS: Simple methods such as resident education and direct mailings to patients significantly ease the difficult process of transferring patients from one physician to another. This has implications not only for residency programs, but for managed care networks competing to attract and retain patients.

Aged↗
PubMed2003

Differing symptoms of abused versus nonabused women in obstetric-gynecology settings.

OBJECTIVE: The purpose of this study was to document the prevalence rates of reported abuse in obstetric/gynecology settings and to characterize physical symptoms, function, and psychologic distress of women who report abuse. STUDY DESIGN: This was a descriptive study of 118 patients who reported physical or sexual abuse in the past year and 2800 patients who reported no abuse at seven obstetric/gynecology practices. The Patient Health Questionnaire measured psychiatric diagnoses, somatic complaints, and psychosocial stressors. The Medical Outcomes Study Short Form 20 assessed health status, and self-reported health care use was measured. RESULTS: Four percent of women reported recent abuse. Patients who reported abuse had more psychiatric diagnoses, more severe psychologic distress, more somatic symptoms, more psychosocial stressors, more physician visits, and poorer reported health status compared with nonreporters of abuse. CONCLUSION: Enhanced recognition of possible abuse through screening may identify women in need of intervention and help to reduce the need for continued medical intervention.

Adult↗
PubMed2003

9-11, personal stress, mental health, and sense of control among older adults.

OBJECTIVES: We assessed whether the events of 9-11 affected the personal stress, mental health, or sense of control of older adults participating in an ongoing longitudinal study, and whether baseline characteristics were associated with the magnitude of any such changes. METHODS: Personal stress, mental health, and sense of control were measured at baseline and at six bimonthly follow-up interviews among 1662 patients. Of these, 437 had the opportunity to complete three interviews before and after 9-11, with 291 (67%) completing all six. We performed graphic comparisons, paired t tests, classification based on standard errors of measurement (SEMs), and multiple linear regressions for patients who completed all six interviews. RESULTS: No noticeable changes in aggregate trends for personal stress or mental health were associated with 9-11. However, 9-11 was associated with an aggregate decline in sense of control. This decline in sense of control was greater among those who were working for pay, had more comfortable incomes, and reported greater religiosity. DISCUSSION: Older adults more closely resembling those who died during 9-11 and those with greater levels of religiosity were most likely to have their sense of control affected by this catastrophic event.

Activities of Daily Living↗
PubMed2003

Age, aging, and the sense of control among older adults: a longitudinal reconsideration.

OBJECTIVES: The purpose of this study was to first estimate the crude cross-sectional and longitudinal associations between age and the sense of control, and then to partition any joint variance attributable to a theoretically specified set of potential confounders. METHODS: Sense of control was measured at baseline and at each of six bimonthly follow-up interviews among 1,662 patients at two medical centers. Potential confounders were measured at baseline. Analyses include descriptive assessments of level and normative stability, repeated measures analysis of covariance, and hierarchical multiple linear and change score regressions. RESULTS: Although the sense of control is relatively stable between any two successive waves of data collection, significant gradual changes are observed over a 1-year period. Compelling evidence is found for statistically and substantively significant associations between age and the sense of control at baseline, and between age and changes in the sense of control over time. The only other major predictor of the sense of control is mental well-being. DISCUSSION: Longitudinal studies with repeated assessments over prolonged observation periods are now needed to elucidate age-related trajectories in the sense of control.

Adult↗
PubMed2003

Unexplained symptoms after terrorism and war: an expert consensus statement.

Twelve years of concern regarding a possible "Gulf War syndrome" has now given way to societal concerns of a "World Trade Center syndrome" and efforts to prevent unexplained symptoms following the most recent war in Iraq. These events serve to remind us that unexplained symptoms frequently occur after war and are likely after terrorist attacks. An important social priority is to recognize, define, prevent, and care for individuals with unexplained symptoms after war and related events (eg, terrorism, natural or industrial disasters). An international, multidisciplinary, and multiinstitutional consensus project was completed to summarize current knowledge on unexplained symptoms after terrorism and war.

Causality↗