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Biomedical subjects

Robert C Smith

Publications and source records attributed to Robert C Smith.

18 recordsLinked to original sources
PubMed2026

Transcranial Alternating Current Stimulation at 40 Hz Improves Social Functioning in Children With Autism Spectrum Disorder: A Randomized Clinical Trial.

BACKGROUND: Autism spectrum disorder (ASD) lacks rapid and effective interventions for its core social difficulties. The right temporoparietal junction (rTPJ), a critical hub for social cognition, together with gamma band abnormalities implicated in ASD, provides a promising neuromodulation target. METHODS: In this randomized, double-blind, sham-controlled trial, 47 children with ASD (39 male; mean [SD] age = 8.79 [2.71] years) were assigned to receive either 21 sessions of 40-Hz high-definition transcranial alternating current stimulation (tACS) targeting the rTPJ (3 sessions/day for 7 days) or sham stimulation, with assessments conducted at baseline, postintervention (week 1), and a 3-week follow-up (week 4). The primary outcome was change in Ohio State University Autism Rating Scale-DSM-5 (OARS-5) total scores. Secondary outcomes included the Aberrant Behavior Checklist-Second Edition, Social Responsiveness Scale-Second Edition, and Short Sensory Profile. Eye-tracking metrics during Frith-Happ&#xe9; animations were exploratory measures of theory of mind (ToM)-related social cognitive processing. RESULTS: The active group demonstrated significant improvements in OARS-5 total scores at week 1 (mean difference = -1.13, 95% CI [-1.78 to -0.47], p < .001) and week 4 (mean difference = -1.47, 95% CI [-2.20 to -0.74], p < .001). Improvements in selected behavioral and sensory domains were observed. Average fixation duration during ToM animations showed a significant group &#xd7; time interaction. No serious adverse events occurred. CONCLUSIONS: These findings suggest that 40-Hz tACS targeting the rTPJ may be associated with rapid improvements in ASD symptom severity, particularly social functioning, in children with ASD, while being well tolerated. Clinical significance requires further evaluation.

Humans↗
PubMed2006

Multisomatoform disorder: agreement between patient and physician report of criterion symptom explanation.

OBJECTIVE: To determine the level of agreement between patients and expert physicians in whether criterion multisomatoform (MSD) symptoms are explained. METHODS: We systematically collected reports from 280 primary care patients about whether they had suffered from any of 15 criterion MSD symptoms in the past month and whether they had received a medical explanation from a physician for positive criterion symptoms. The research team compared MSD symptom diagnoses derived from patient report with MSD symptom diagnoses derived from an expert physician report. RESULTS: MSD symptom diagnoses derived from patient report had 98.7% sensitivity, 97.9% specificity, 89.3% positive predictive value, and 99.7% negative predictive value compared with MSD symptom diagnoses derived from an expert physician report. Analysis demonstrated that 15.0% of patients met symptom criteria for MSD, according to patient and physician report; 83.0% failed to meet symptom criteria for MSD, according to patient and physician report; 1.8% of patients met symptom criteria for MSD, according to patient report but not physician report, while 0.2% met symptom criteria for MSD according to physician report but not by patient report. CONCLUSION: Patients demonstrated high agreement with a physician expert in somatization about whether criterion MSD symptoms are explained, suggesting revised screeners may accurately identify somatizing patients.

Adolescent↗
PubMed2006

Effects of nicotine nasal spray on cognitive function in schizophrenia.

Schizophrenics have among the highest rates of cigarette smoking. Some studies indicate that cigarette smoking or nicotine may ameliorate some of the cognitive or theoretically related neurophysiological deficits seen in schizophrenic patients. This study investigated the effects of nicotine nasal spray on measures of attention, verbal memory, and visual-spatial memory in schizophrenic patients who were chronic smokers, using a double-blind placebo-controlled pre-post experimental design. Compared to placebo, active nicotine spray significantly decreased reaction time on the Conner's CPT and improved scores on a measure purported to reflect spatial working memory on a dot task. There were trends for the increased number of hits and decreased number of errors in pre-post comparisons on the CPT task in the active nicotine session. There were no effects of active nicotine nasal spray on verbal memory. Our results suggest that nicotine may modestly enhance attention and spatial working memory in schizophrenic patients who are cigarette smokers and have been abstinent overnight.

Adult↗
PubMed2006

Primary care clinicians treat patients with medically unexplained symptoms: a randomized controlled trial.

OBJECTIVE: There is no proven primary care treatment for patients with medically unexplained symptoms (MUS). We hypothesized that a long-term, multidimensional intervention by primary care providers would improve MUS patients' mental health. DESIGN: Clinical trial. SETTING: HMO in Lansing, MI. PARTICIPANTS: Patients from 18 to 65 years old with 2 consecutive years of high utilization were identified as having MUS by a reliable chart rating procedure; 206 subjects were randomized and 200 completed the study. INTERVENTION: From May 2000 to January 2003, 4 primary care clinicians deployed a 12-month intervention consisting of cognitive-behavioral, pharmacological, and other treatment modalities. A behaviorally defined patient-centered method was used by clinicians to facilitate this treatment and the provider-patient relationship. MAIN OUTCOME MEASURE: The primary endpoint was an improvement from baseline to 12 months of 4 or more points on the Mental Component Summary of the SF-36. RESULTS: Two hundred patients averaged 13.6 visits for the year preceding study. The average age was 47.7 years and 79.1% were females. Using intent to treat, 48 treatment and 34 control patients improved (odds ratio [OR]=1.92, 95% confidence interval [CI]: 1.08 to 3.40; P=.02). The relative benefit (relative "risk" for improving) was 1.47 (CI: 1.05 to 2.07), and the number needed to treat was 6.4 (95% CI: 0.89 to 11.89). The following baseline measures predicted improvement: severe mental dysfunction (P<.001), severe body pain (P=.039), nonsevere physical dysfunction (P=.003), and at least 16 years of education (P=.022); c-statistic=0.75. CONCLUSION: The first multidimensional intervention by primary care clinicians led to clinically significant improvement in MUS patients.

Adult↗
PubMed2005

Clozapine, risperidone, olanzapine, and conventional antipsychotic drug effects on glucose, lipids, and leptin in schizophrenic patients.

Some reports have indicated increased rates of diabetes and increased prevalence of glucose and lipid abnormalities during treatment with second-generation antipsychotics, with most concern raised about clozapine and olanzapine. Most of the findings have come from case reports, retrospective examination of laboratory values, and analysis of health-care claims databases. This study investigated fasting levels of glucose, lipids, and leptin in a non-randomized, cross- sectional study of 210 patients, with schizophrenic or schizoaffective disorder, treated with a single antipsychotic medication - clozapine, risperidone, olanzapine, or a conventional antipsychotic. Glucose tolerance tests (GTT), with a 75-g glucose load, were preformed in a subset of patients. In this sample most mean fasting glucose and lipid levels were within the normal range and were not significantly different across the four drug treatment groups. Patients treated with clozapine and olanzapine had higher triglyceride levels than risperidone patients. In patients receiving a GTT, risperidone-treated patients had higher glucose levels at 1 h than patients treated with olanzapine, and there were more patients on risperidone who met American Diabetes Association glucose metabolic criteria for diagnosis of diabetes. Although there were no significant differences in age or body mass index among the four drug groups, we cannot rule out some potential biasing factors we did not assess which could potentially influence our results. These include unknown physician preference in drug selection based on their beliefs about the weight-inducing or diabetes potential of different antipsychotics, differences in visceral fat, and differences in patients' antipsychotic drug history.

Adult↗
PubMed2005

Teaching personal awareness.

Educators rarely consider the attitudes that determine whether a learner will use the clinical skills we teach. Nevertheless, many learners and practitioners exhibit negative attitudes that can impede the use of patient-centered skills, leading to an isolated focus upon disease and impairing the provider-patient relationship. The problem is compounded because these attitudes often are incompletely recognized by learners and therefore are difficult to change without help. We present a research-based method for teaching personal awareness of unrecognized and often harmful attitudes. We propose that primary care clinicians without mental health training can follow this method to teach students, residents, faculty, and practitioners. Such teachers/mentors need to possess an abiding interest in the personal dimension, patience with a slowly evolving process of awareness, and the ability to establish strong, ongoing relationships with learners. Personal awareness teaching may occur during instruction in basic interviewing skills but works best if systematically incorporated throughout training.

Attitude of Health Personnel↗
PubMed2004

Normal ureter size on unenhanced helical CT.

OBJECTIVE: Unenhanced helical CT is the imaging method of choice when evaluating patients with acute flank pain and suspected ureterolithiasis. In addition to directly identifying stones in the lumen of the ureter, CT secondary signs of obstruction such as ureteral dilatation are frequently present and can be helpful in establishing a diagnosis. The purposes of this study were to define ureteral dilatation on unenhanced helical CT and determine the range of normal ureter size. MATERIALS AND METHODS: We retrospectively reviewed the unenhanced helical CT studies of 212 consecutive patients with acute flank pain whose CT scans showed acute ureterolithiasis. The size of the ureter was determined on the asymptomatic side as well as on the obstructed side. Mean ureteral diameter was determined as the largest transverse dimension along the course of the ureter beginning 1-2 cm below the ureteropelvic junction. RESULTS: The mean size of ureters on the asymptomatic side was 1.8 mm with a standard deviation (SD) of 0.9 mm. The mean size of ureters on the obstructed side was 7 mm with an SD of 3.2 mm. In 96% of patients, the ureter diameter on the asymptomatic side was 3 mm or smaller. CONCLUSION: Three millimeters should be considered the upper limit of normal size for nonobstructed ureters on unenhanced helical CT.

Dilatation, Pathologic↗
PubMed2003

Building Research Relationships With Managed Care Organizations: Issues and Strategies.

Managed care is now the dominant form of healthcare in the United States. The need for clinical research about the organization, delivery, and outcomes of primary care services in managed care models is high, yet access to managed care organizations as sites for clinical research may be problematic. The purpose of this article is to describe issues involved in obtaining access to managed care settings for clinical research and practical strategies for successful collaboration using literature review and case description. Three steps for developing collaborative relationships with managed care organizations (MCOs) are presented: 1) assessment of organizational structure, history, and culture; 2) finding common ground; and 3) project implementation. These steps are discussed within the context of MCO systems issues and a relationship-centered approach to communication between researchers and individuals from the MCO. Successful relationships with MCOs for clinical research are possible when careful attention is paid to inclusion of MCOs as collaborators in the development of the research questions and design, and as partners in the research implementation process.

Journal Article↗
PubMed2003

Treating patients with medically unexplained symptoms in primary care.

BACKGROUND: There are no proven, comprehensive treatments in primary care for patients with medically unexplained symptoms (MUS) even though these patients have high levels of psychosocial distress, medical disability, costs, and utilization. Despite extensive care, these common patients often become worse. OBJECTIVE: We sought to identify an effective, research-based treatment that can be conducted by primary care personnel. DESIGN: We used our own experiences and files, consulted with experts, and conducted an extensive review of the literature to identify two things: 1). effective treatments from randomized controlled trials for MUS patients in primary care and in specialty settings; and 2). any type of treatment study in a related area that might inform primary care treatment, for example, depression, provider-patient relationship. MAIN RESULTS: We developed a multidimensional treatment plan by integrating several areas of the literature: collaborative/stepped care, cognitive-behavioral treatment, and the provider-patient relationship. The treatment is designed for primary care personnel (physicians, physician assistants, nurse practitioners) and deployed intensively at the outset; visit intervals are progressively increased as stability and improvement occur. CONCLUSION: Providing a comprehensive treatment plan for chronic, high-utilizing MUS patients removes one barrier to treating this common problem effectively in primary care by primary care personnel.

Anxiety↗
PubMed2002

Effects of cigarette smoking and nicotine nasal spray on psychiatric symptoms and cognition in schizophrenia.

Schizophrenic patients have among the highest rates of smoking of any group of patients. Previous studies have identified psychophysiological and potential nicotinic receptor abnormalities which may be associated with this phenomenon. The effects of acute smoking or acute administration of nicotine nasal spray, after smoking abstinence, on negative symptoms and neurocognitive function have been less extensively studied in experimental designs. This study investigated the effects of smoking of high nicotine or denicotinized cigarettes, and receiving active or placebo nicotine nasal sprays, on positive and negative symptoms and cognitive functions in schizophrenic patients. The study utilized a placebo controlled crossover experimental design with pre- and post-drug evaluations on each experimental day. Smoking high nicotine cigarettes decreased negative symptoms more than denicotinized cigarettes, but smoking neither cigarette changed scores of positive symptoms, anxiety, or depression. Active nicotine nasal spray did not differentially decrease negative symptoms compared with placebo, but did improve performance on a spatial organization task, and tended to improve some measures of verbal memory and two-choice reaction time in schizophrenic patients. Both high and denicotinized cigarettes improved performance on the spatial processing task, but there was no statistically significant differential drug (Cigarette type) effect. These results suggest that acute smoking of cigarettes may transiently decrease negative symptoms in patients with schizophrenia, but it is unclear whether this effect is attributable to nicotine, other components of cigarettes, or the act of smoking. Nicotine nasal spray may modestly improve some selected aspects of cognitive function in schizophrenia.

Administration, Intranasal↗
PubMed2002

Relationship of spontaneous passage of ureteral calculi to stone size and location as revealed by unenhanced helical CT.

OBJECTIVE: Prior studies using radiography have examined the relationship of ureteral stone size and location to the probability of spontaneous passage. Given the improved accuracy and new role of unenhanced CT in the diagnosis of acute ureterolithiasis, we studied the relationship of stone size and location as determined by unenhanced CT to the rate of spontaneous passage. MATERIALS AND METHODS: Over a 29-month period, 850 patients with acute flank pain were evaluated with unenhanced CT. Confirmation of the CT diagnosis was obtained retrospectively for 172 patients with ureteral stones: 115 stones passed spontaneously and 57 required intervention. Stone size was defined as the maximum diameter within the plane of the axial CT section. Stone location was classified as proximal ureter (above the sacroiliac joints), mid ureter (overlying the sacroiliac joints), distal ureter (below the sacroiliac joints), and ureterovesical junction. RESULTS: The spontaneous passage rate for stones 1 mm in diameter was 87%; for stones 2-4 mm, 76%; for stones 5-7 mm, 60%; for stones 7-9 mm, 48%; and for stones larger than 9 mm, 25%. Spontaneous passage rate as a function of stone location was 48% for stones in the proximal ureter, 60% for mid ureteral stones, 75% for distal stones, and 79% for ureterovesical junction stones. CONCLUSION: The rate of spontaneous passage of ureteral stones does vary with stone size and location as determined by CT. These rates are similar to those previously published based on radiography.

Adolescent↗
PubMed2002

Minor acute illness: a preliminary research report on the "worried well".

OBJECTIVES: Our objectives were to determine how patients who make frequent use of the medical system (high users) with medically unexplained symptoms met our chart-rating criteria for somatization and minor acute illness and what the stability of such diagnoses were over time. STUDY DESIGN: A chart review was performed at baseline and 1 and 2 years; we re-rated the charts of patients initially rated as having somatization, as well as a 15% sample of those with minor acute illness. POPULATION: We obtained a random sample of high-use patients (= 6 visits/year) aged 21 to 55 years who were identified from the management information system. OUTCOMES: We measured chart review designations as organic disease, somatization, or minor acute illness. RESULTS: Among 883 high users at baseline, 35% had organic diseases; 14% had somatization; and 51% had minor acute illness as their primary problems. No patients with initial minor acute diagnoses were reclassified as having somatization 1 or 2 years later, and all but 2 patients had minor acute illness in 1 or both follow-up years. CONCLUSIONS: Minor acute illness was more common among high users than somatization and organic diseases combined. It has not previously been studied but probably has been recognized by clinicians as the "worried well." Diagnoses of somatization were unstable over 2 years follow-up, while minor acute diagnoses were stable, supporting the latter as a valid entity.

Adult↗
PubMedDate not supplied

Using nurse practitioners to implement an intervention in primary care for high-utilizing patients with medically unexplained symptoms.

Patients with medically unexplained symptoms (MUS) often are a source of frustration for clinicians, and despite high quality biomedical attention and frequent diagnostic tests, they have poor health outcomes. Following upon progress in depression treatment approaches, we developed a multidimensional treatment protocol for deployment by primary care personnel. This multi-faceted intervention for MUS patients emphasized cognitive-behavioral principles, the provider-patient relationship, pharmacological management, and treating comorbid medical diseases. We deployed it in an HMO using nurse practitioners (NP) to deliver the intervention to 101 patients, while 102 controls continued to receive medical care from their usual primary care physician. Successful deployment of the intervention required training the NPs, continuing support for the NPs in their management of this difficult population, and establishing strong communication links with the HMO. This paper addresses the practical considerations of using primary care personnel to implement a complex intervention in primary care, and it includes a discussion of special challenges encountered as well as solutions developed to overcome them.

Adolescent↗
PubMedDate not supplied

Exploration of DSM-IV criteria in primary care patients with medically unexplained symptoms.

OBJECTIVES: Investigators and clinicians almost always rely on Diagnostic and Statistical Manual of Mental Disorder, 4th edition's (DSM-IV) somatoform disorders (and its derivative diagnoses) to characterize and identify patients with medically unexplained symptoms (MUS). Our objective was to evaluate this use by determining the prevalence of DSM-IV somatoform and nonsomatoform disorders in patients with MUS proven by a gold standard chart review. METHODS: In a community-based staff model HMO, we identified subjects for a clinical trial using a systematic and reliable chart rating procedure among high-utilizing MUS patients. Only baseline data are reported here. The World Health Organization Composite International Diagnostic Interview provided full and abridged DSM-IV diagnoses. Patients with full or abridged DSM-IV somatoform diagnoses were labeled "DSM somatoform-positive," whereas those without them were labeled "DSM somatoform-negative." RESULTS: Two hundred six MUS patients averaged 13.6 visits in the year preceding study, 79.1% were females, and the average age was 47.7 years. We found that 124 patients (60.2%) had a nonsomatoform ("psychiatric") DSM-IV diagnosis of any type; 36 (17.5%) had 2 full nonsomatoform diagnoses, and 41 (19.9%) had >2; 92 (44.7%) had some full anxiety diagnosis and 94 (45.6%) had either full depression or minor depression diagnoses. However, only 9 of 206 (4.4%) had any full DSM-IV somatoform diagnosis, and only 39 (18.9%) had abridged somatization disorder. Thus, 48 (23.3%) were "DSM somatoform-positive" and 158 (76.7%) were "DSM somatoform-negative." The latter exhibited less anxiety, depression, mental dysfunction, and psychosomatic symptoms (all p <.001) and less physical dysfunction (p = .011). Correlates of this DSM somatoform-negative status were female gender (p = .007), less severe mental (p = .007), and physical dysfunction (p = .004), a decreased proportion of MUS (p <.10), and less psychiatric comorbidity (p <.10); c-statistic = 0.77. CONCLUSION: We concluded that depression and anxiety characterized MUS patients better than the somatoform disorders. Our data suggested radically revising the somatoform disorders for DSM-V by incorporating a new, very large group of now-overlooked DSM somatoform-negative patients who were typically women with less severe dysfunction.

Anxiety Disorders↗
PubMedDate not supplied

A method for rating charts to identify and classify patients with medically unexplained symptoms.

BACKGROUND: As part of conducting a randomized control trial (RCT) to treat chronically high utilizing patients with medically unexplained symptoms (MUS), we developed the chart rating method reported here to identify and classify MUS subjects. METHOD: Intended at this point only as a research tool, the method is comprehensive, uses explicit guidelines, and requires clinician raters. It distinguishes primary organic disease patients from those with primary MUS, quantifies medical comorbidities in primary MUS patients, and also distinguishes subgroups among MUS patients that we call somatization (resembles DSM-IV somatoform disorders) and minor acute illness (MAI) which differs from DSM-IV somatoform definitions. Scoring rules are used to generate the diagnoses above. The rules may be set according to the investigator's needs, from highly sensitive to highly specific. RESULTS: We found high levels of agreement with the gold standard for MUS vs. organic disease (97.6%) and among raters for the key individual chart elements rated (92-96%). The method identified 206 MUS subjects and the extent of their medical comorbidities for entry into a RCT. It also identified somatization and MAI; the latter supports the validity of this newly reported MAI syndrome. CONCLUSION: We concluded that this method offered research potential for identifying MUS patients, for quantifying their medical comorbidities, and for classifying MUS subgroups.

Comorbidity↗