Biomedical subjects

Mark Sullivan

Publications and source records attributed to Mark Sullivan.

11 recordsLinked to original sources

PubMed2003

The new subjective medicine: taking the patient's point of view on health care and health.

Calls to respect patient autonomy and produce patient-centered outcomes have recently brought the patient's point of view back into the center of clinical medicine. Bioethics has argued that patient values must be respected in health care decisions. But it has generally not questioned medicine's goals, including its definition of health. For bioethics, health has remained an objective biological fact. However, pressures to improve the cost-effectiveness of medical care have increased interest in the subjective health and quality of life of patients. Perceived health, health-related quality of life, and health-state utilities bring health assessment progressively closer to the patient's perspective. Now even death's harm to patients is qualified by the value patients place on their health state. Medicine's epidemiological transition from acute to chronic disease is thus prompting an epistemological transition from primarily objective to primarily subjective evidence of health and health care effectiveness. Now some of the most important patient outcomes, like patient choices before them, are valid because they are subjective. Pathophysiology is appropriately becoming a means to produce health as it is defined from the patient's point of view. The physicians' job description will be changed to focus on patients' lives rather than patients' bodies. Definitive evaluations of medical effectiveness will occur within patients' lives rather than within doctors' hospitals. This further incorporation of patient subjectivity should carry us well beyond informed consent and the other protections for patient autonomy bequeathed to us by bioethics.

Bioethics↗

PubMed2003

The relationship of attachment style to depression, catastrophizing and health care utilization in patients with chronic pain.

Attachment theory and research suggest that patterns of interpersonal relationships may be important determinants of illness behavior, care seeking, and treatment response in individuals with chronic health problems, including chronic pain. Attachment styles have been shown to be associated with psychological adjustment in the context of chronic illness, but little research has been conducted so far examining these relationships in patients with chronic pain. We assessed 111 patients with chronic pain participating in a multidisciplinary pain treatment program to determine if attachment style is associated with pain, depression, catastrophizing and physical disability at pre-treatment and 12-month follow-up, and with change in health care utilization pre-treatment to follow-up. At both pre-treatment and follow-up, fearful attachment style was associated with significantly greater depression and catastrophizing, and secure attachment was associated with significantly lower levels of depression. Preoccupied attachment style was associated with greater than weekly pain-related visits at 12 months follow-up, even after controlling for depression, catastrophizing and pre-treatment pain-related health care utilization. The findings suggest that attachment style may be a useful construct for examining factors affecting adjustment and treatment response of patients with chronic pain.

Adult↗

PubMed2003

Oxygen cost of exercise is increased in heart failure after accounting for recovery costs.

STUDY OBJECTIVES: The oxygen cost during exercise has been reported to be decreased in patients with congestive heart failure (CHF), implying an increased efficiency (lower oxygen uptake [VO(2)] per Watt [VO(2)/W]); however, these studies ignored the oxygen debt that is increased in heart failure. SUBJECTS: The primary aim of this research was to evaluate the total oxygen cost (work VO(2)/W) during exercise and recovery in patients with heart failure as compared with healthy adults. DESIGN AND PATIENTS: We performed a retrospective analysis comparing the exercise VO(2)/W, the recovery VO(2)/W, the work VO(2)/W, and the VO(2)/W relationship above and below the ventilatory threshold (VT) in 11 healthy control subjects and 45 patients with CHF. RESULTS: The exercise VO(2)/W was decreased by 29% (p < 0.0001) in patients with CHF; however, the recovery VO(2)/W was increased by 167% (p < 0.0001) and the work VO(2)/W was increased by 14% in patients with CHF (p = 0.014). The VO(2)/W slope increased above the VT (+ 27%, p = 0.0017) in both normal subjects and patients with CHF, suggesting a decrease in efficiency above the VT. There was an inverse correlation (r = 0.646, p < 0.0001) between exercise VO(2)/W and recovery VO(2)/W, implying that subjects with a low exercise VO(2)/W were not efficient but rather accumulated a large oxygen debt that was repaid following completion of exercise. CONCLUSIONS: Heart failure is associated with lower exercise VO(2)/W; however, the patient with heart failure is not efficient, but rather accumulating a large oxygen debt (recovery VO(2)/W) that is repaid following exercise. In addition, the work VO(2)/W (including both exercise and recovery) is increased in patients with heart failure in comparison to control subjects, and correlates inversely with the percentage of predicted VO(2). The large recovery VO(2)/W is likely due to impaired oxygen delivery to exercising muscle during exercise. The increase in the work VO(2)/W is probably due to changes in skeletal muscle fiber type that occur in patients with heart failure (type I to type IIb).

Adult↗

PubMed2002

Depression-related costs in heart failure care.

BACKGROUND: Behavioral factors may play a role in heart failure (HF) care costs by increasing hospital readmission rates. This study sought to estimate the effect of depression on health care costs for patients hospitalized for HF. METHODS: A 3-year retrospective cohort study of a staff-model health maintenance organization. Following a first hospitalization with a primary diagnosis of HF, 1098 health maintenance organization patients were evaluated. Median annualized health care costs for 3 depression groups were identified: (1) no depression (n = 672; cost, $7474), (2) antidepressant prescription only (n = 312; cost, $11 012), and (3) antidepressant prescription and depression diagnosis recorded (n = 114; cost, $9550). Depression and HF status were determined through diagnostic, laboratory, and pharmacy records. Actual utilization and cost values were derived from administrative data. RESULTS: After adjusting for age, sex, medical comorbidity, and length of stay at index hospitalization (as proxy for HF severity), costs were 26% higher in the antidepressant prescription only group and 29% higher in the antidepressant prescription and depression diagnosis recorded group when compared with the no depression group (both P<.001). Increased inpatient and outpatient utilization contributed to the increased costs. CONCLUSION: Costs of care for patients hospitalized for HF are significantly higher for patients with evidence of depression.

Aged↗

PubMed2002

The elevated plasma lipoprotein(a) concentrations in preeclampsia do not precede the development of the disorder.

We sought to determine whether maternal plasma lipoprotein(a) [Lp(a)] levels are elevated in the second trimester, before the development of preeclampsia and other obstetrical complications, in women at risk. In the first part of the study (cross-sectional), plasma concentrations of Lp(a) were compared among 16 women with preeclampsia, 35 normotensive pregnant women and 18 healthy nonpregnant women. In the second part (nested case-control), blood samples were collected prospectively from 82 women at risk of preeclampsia, at 14-24 weeks of gestation, and Lp(a) levels were compared between those in whom preeclampsia or other obstetrical complications developed and those in whom they did not. In the cross-sectional study, plasma concentrations of Lp(a) were significantly higher in women with preeclampsia than in normotensive pregnant and healthy nonpregnant women (41 +/- 31 vs. 24 +/- 16 and 15 +/- 10 mg/dl, respectively; P=.001). Of the 82 women in the second part of the study, 9 (11%) developed preeclampsia and 19 (23%) had complications such as intrauterine growth restriction, preterm delivery and fetal or neonatal loss. There were no differences in plasma Lp(a) concentrations between the women with preeclampsia and those without complications, though Lp(a) levels were significantly higher in women with other complications than in those with either preeclampsia or uncomplicated pregnancies (40 +/- 29 vs. 17 +/- 13 or 28 +/- 18 mg/dl, respectively; P=.05). In conclusion, elevated plasma levels of Lp(a), associated with clinically established preeclampsia, are not detected before the appearance of the disorder in pregnant women at risk.

Adult↗

PubMed2002

Response styles among patients with minor depression and dysthymia in primary care.

Ruminative responses to depression have predicted duration and severity of depressive symptoms. The authors examined how response styles change over the course of treatment for depression and as a function of type of treatment. They also examined the ability of response styles to predict treatment outcome and status at follow-up. Primary care patients (n = 96) with dysthymia or minor depression were randomly assigned to problem-solving therapy, paroxetine, or placebo. Patients' depressive symptoms and rumination, but not distraction, decreased over time. Pretreatment rumination and distraction were associated with more depressive symptoms at the conclusion of treatment; the latter finding was not consistent with the response style theory of depression. Results are discussed in terms of their implications for this theory.

Adolescent↗

PubMed2002

Temporal and reciprocal relationship between IADL/ADL disability and depressive symptoms in late life.

A strong association between functional disability and depressive symptoms in older people has frequently been reported. Some studies attribute this association to the disabling effects of depression, others to the depressogenic effects of physical health-related disability. The authors examined the reciprocal effects between depressive symptoms and functional disability and their temporal character in a community-based cohort of 753 older people with physical limitations who were assessed at yearly intervals. They compared structural equation models that differed in terms of direction and speed of effects between patient-reported disability in instrumental and basic activities of daily living (IADL/ADLs) and depressive symptoms. The association between disability and depression could be separated into three components: (a) a strong contemporaneous effect of change in disability on depressive symptoms, (b) a weaker 1-year lagged effect of change in depressive symptoms on disability (probably indirect through physical health), and (c) a weak correlation between the trait (or stable) components of depression and disability. IADL/ADL disability and depressive symptoms are thus mutually reinforcing over time. Compensatory forces like effective treatment and age-related adaptation may protect elders against this potential downward trend. To improve quality of life in elderly adults, treatment should target disability when it is new and depression when it is persistent.

Activities of Daily Living↗

PubMed2002

Depressive symptoms and severity of illness in multiple sclerosis: epidemiologic study of a large community sample.

OBJECTIVE: Previous research has shown high prevalence rates of depression in multiple sclerosis patients seen in specialty clinics. The relationships among depressive symptoms and severity, duration, and course of multiple sclerosis are controversial. METHOD: A survey was mailed to members of the Multiple Sclerosis Association of King County (Wash.). Of the 1,374 eligible participants, 739 returned the survey, a response rate of 53.8%. Data about demographic characteristics, employment, and duration and course of multiple sclerosis were collected. Severity of multiple sclerosis was determined by the Expanded Disability Status Scale, self-report version. Severity of depressive symptoms was evaluated with the Center for Epidemiologic Studies Depression Scale (CES-D Scale). Analysis of covariance was used to compare mean CES-D Scale scores across categories of multiple sclerosis, and logistic regression was used to identify variables associated with clinically significant depression. RESULTS: Clinically significant depressive symptoms (CES-D Scale score > or =16) were found in 41.8% of the subjects, and 29.1% of the subjects had moderate to severe depression (score > or =21). Subjects with advanced multiple sclerosis were much more likely to experience clinically significant depressive symptoms than subjects with minimal disease. Shorter duration of multiple sclerosis was associated with a greater likelihood of significant depressive symptoms, but the pattern of illness progression was not. CONCLUSIONS: In this large community sample, the severity of multiple sclerosis was more strongly associated with depressive symptoms than was pattern of illness. Clinicians should evaluate depression in patients with recent diagnoses of multiple sclerosis, major changes in functioning, or limited social support.

Activities of Daily Living↗

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

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Civil Rights↗