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Biomedical subjects

K A Phillips

Publications and source records attributed to K A Phillips.

At least 109 records · Page 6Linked to original sources
PubMed1994

The cost-effectiveness of voluntary counseling and testing of hospital inpatients for HIV infection.

OBJECTIVE: To evaluate the cost-effectiveness of voluntary counseling and testing of US hospital inpatients for the human immunodeficiency virus (HIV). DATA SOURCES: Data for entry into the model were derived from a review of the literature, consultation with experts, and consensus of the authors. DATA EXTRACTION: We rated our confidence in these probabilities and costs by grading the data inputs using methods adapted from those of the US Preventive Services Task Force. DATA SYNTHESIS: Decision analysis models were developed to evaluate two outcomes: (1) cost per health care worker (HCW) HIV infection averted if measures are taken by the HCW to reduce his or her risk of acquiring HIV; and (2) cost per inpatient HIV infection detected. Sensitivity analyses were also conducted. Using baseline input values, testing to avert HCW infection may prevent 3.6 HIV infections per year at a total program cost of $2.7 billion, or a cost of $753 million per infection averted. At baseline assumptions (seroprevalence = 1%), testing to detect inpatient HIV infection would cost $16,104 per year per infection detected. Cost-effectiveness at baseline drops to $8353 per HIV infection detected if the seroprevalence is 10%. If testing is limited to hospitals with inpatient seroprevalences of at least 1%, approximately 5400 persons per year will be falsely labeled HIV-positive. CONCLUSIONS: This analysis provides no justification for testing inpatients to prevent HIV infection of HCWs. Screening inpatients to detect HIV infection may be justified at seroprevalences exceeding 1%, but issues of medical or social discrimination, false-positive results, informed consent, and logistics must be resolved first.

AIDS Serodiagnosis↗
PubMed1994

The cost-effectiveness of HIV testing of physicians and dentists in the United States.

OBJECTIVE: To evaluate the cost-effectiveness of alternative policies for human immunodeficiency testing (HIV) testing of physicians and dentists. METHODS: Decision analysis and cost-effectiveness analysis from a societal perspective were used. Data were derived from extensive literature review and consultation with experts. We conducted sensitivity analyses and also performed a cost-benefit analysis. ANALYSES: We analyzed policies for mandatory or voluntary testing of all physicians, surgeons, and dentists; for those testing positive, we analyzed mandatory or voluntary exclusion from practice, restriction from performance of invasive procedures, or requirements to inform patients of serostatus. MAIN OUTCOME MEASURE: Cost per patient infection averted. RESULTS: Although one-time mandatory testing of surgeons and dentists with mandatory restriction of those found to be HIV-positive is more cost-effective than other policies, the cost-effectiveness varies tremendously under different scenarios. Results were highly sensitive to several data inputs, especially HIV seroprevalence of surgeons and dentists and transmission risk. For example, under a medium seroprevalence and transmission risk scenario, mandatory testing of all surgeons might avert 25 infections at a total cost of $27.9 million or $1,115,000 per infection averted and an incremental cost of $291,000 compared with current testing; however, the incremental cost-effectiveness per patient infection averted ranges from $29,807,000 under a low-risk scenario to a savings of $81,000 under a high-risk scenario. CONCLUSION: Our analysis neither justifies nor precludes a mandatory testing policy. Further research on the key data inputs is needed. Given the ethical, social, and public health implications, mandatory testing policies should not be implemented without greater certainty as to their cost-effectiveness.

AIDS Serodiagnosis↗
PubMed1994

The Diagnostic Interview for Depressive Personality.

OBJECTIVE: The development of a new structured interview for depressive personality disorder is described. METHOD: A literature search yielded 32 traits associated with depressive personality; these traits were then used to develop the interview. Interrater reliability for the interview was tested in an initial group of 16 patients with longstanding depressive personality traits. Data from a second group of 67 subjects--54 with a possible clinical diagnosis of depressive personality and 13 normal volunteers--were used to examine the interview's psychometric properties and to modify its content. Factor analysis of the traits in the interview and modification of the instrument's structure was carried out on the basis of data from a third group of 526 subjects who were participating in a large epidemiologic study of mood disorders. RESULTS: The Diagnostic Interview for Depressive Personality, which emerged from this process, assess 30 personality traits that were shown to have satisfactory interrater reliability (kappa = 0.67), test-retest reliability (kappa = 0.41), and diagnostic reliability (kappa = 0.62). A cutoff score of 42 (from a total possible score of 60) on the interview offers a useful threshold for diagnosis. CONCLUSIONS: This interview provides a reliable method for assessing depressive personality traits and establishing the diagnosis of depressive personality disorder.

Adult↗
PubMed1994

A comparison of delusional and nondelusional body dysmorphic disorder in 100 cases.

A controversial issue that was debated for DSM-IV is whether body dysmorphic disorder (BDD)--a preoccupation with an imagined defect in appearance--can be psychotic. BDD is classified separately from its delusional counterpart (delusional disorder, somatic type) in DSM-IV, but does it have a psychotic variant that overlaps with, and may even be the same diagnostic entity as, its delusional disorder variant? One hundred consecutive patients with DSM-III-R-defined BDD or its delusional variant were assessed with a semistructured interview, the Structured Clinical Inverview for DSM-III-R, and a modified version of the Yale-Brown Obsessive Compulsive Scale (Y-BOCS). The 48 patients with nondelusional BDD were compared with the 52 patients with delusional BDD (i.e., delusional disorder, somatic type). The two groups did not differ significantly in terms of most variables examined, including demographics, phenomenology, course, associated features, comorbidity, and treatment response. Thus, BDD may have a psychotic subtype that significantly overlaps with, and may even be the same disorder as, its delusional disorder variant. However, delusional subjects had higher total scores on the modified Y-BOCS, suggesting that the delusional variant of BDD may be a more severe form of the disorder. Although preliminary, these findings have implications for BDD's treatment and classification, suggesting that inclusion of a delusional (psychotic) subtype of BDD should be considered for future editions of DSM.

Adolescent↗
PubMed1994

Rash complicating carbamazepine treatment.

Carbamazepine--widely used in the treatment of trigeminal neuralgia, seizure disorders, and more recently, manic-depressive illness--is generally safe and well tolerated. Although serious adverse reactions, such as hematologic toxicity, may occur rarely, we have found that carbamazepine-induced rash is common, occurring in 13 (12%) of 113 patients. We describe our experience with carbamazepine-induced rash, including clinical characteristics, demographic features, and associated laboratory findings. Integrating our findings with the literature, we also discuss incidence, possible mechanisms, and implications for treatment because these benign rashes can occasionally progress to more fulminant and life-threatening eruptions.

Adult↗
PubMed1994

Obsessive compulsive spectrum disorder.

A wide range of psychiatric and medical disorders have been hypothesized to be related to obsessive compulsive disorder (OCD) and thus, together, to form a family of disorders known as obsessive compulsive (or OCD) spectrum disorder. The grouping of these conditions is based on their phenomenological similarities with OCD (i.e., obsessive thinking and/or compulsive behaviors), as well as their having courses of illness, comorbidity and family history patterns, biological abnormalities, and treatment responses similar to OCD. Proposed OCD spectrum disorders have included body dysmorphic disorder, hypochondriasis, anorexia nervosa, trichotillomania, and some forms of delusional disorder, among others. However, conditions with impulsive features have also been hypothesized to belong to this family, including impulse control disorders in general, paraphilias and nonparaphilic sexual addictions, bulimia nervosa and binge eating disorder, and Tourette's disorder. We review the evidence supporting the grouping of these conditions into an OCD spectrum disorder family. We conclude that these disorders are different in some ways from OCD, but that they also have many similarities with OCD, and may therefore be related to one another and to OCD. In addition, we hypothesize that some of the differences among them may be explained in part by variation along a dimension of compulsivity versus impulsivity. Finally, because most of these conditions appear to be related to mood disorder, we hypothesize that the OCD spectrum disorder family may belong to the larger family of affective spectrum disorder.

Comorbidity↗
PubMed1994

The assessment and treatment of refractory depression.

Although treatment-refractory patients are well known to clinicians, refractory depression has received little empirical attention. Nonetheless, useful assessment and treatment strategies are available. First, it is important to determine whether a patient is truly treatment-refractory or simply has received inadequate treatment. Failure to provide adequate doses of medication for adequate periods of time is perhaps the most common cause of apparent treatment resistance. Other factors that may contribute to apparent treatment resistance are undiagnosed medical conditions, unrecognized depression subtypes, and unrecognized comorbid Axis I and II disorders. It is particularly important to detect the presence of "secret" comorbid disorders, which often go undiagnosed and contribute to refractory depression. Once the clinician has determined that a patient is truly treatment-refractory, many treatment approaches can be tried, including augmentation with lithium and perhaps other agents, combining antidepressants, and switching antidepressants. A modified treatment approach should be used for psychotic depression and perhaps for other depression subtypes as well (such as bipolar depression and atypical depression). Similarly, the depression associated with borderline personality disorder may best respond to a modified treatment approach. Finally, it is important to consider combining somatic treatments with psychosocial treatments in treating refractory patients.

Antidepressive Agents↗
PubMed1994

The relationship of 1988 state HIV testing policies to previous and planned voluntary use of HIV testing.

This study analyzed whether state HIV testing policies were related to individuals' previous and planned voluntary use of HIV testing. Testing plays an important role in the prevention and treatment of HIV infection, yet little is known about how policies are related to testing use. Most states mandate the conditions under which testing is performed, but states vary widely in their policies. This cross-sectional study analyzed individual-level data from the 1988 AIDS Knowledge and Attitudes Survey, which was merged with state-level data on testing policies and incidence of AIDS cases. A multivariate regression model was used to assess the relationship of state policies to testing use, holding state AIDS incidence and individual characteristics (sociodemographics, AIDS knowledge, and risk status) constant. Individuals in states with policies protective of individual rights (i.e., early adoption of comprehensive antidiscrimination laws restricting screening by insurers and employers; provision of voluntary, anonymous testing) were significantly more likely to have been tested than individuals in comparison states (odds ratio = 1.5). Individual characteristics such as risk status, however, had the strongest relationships to testing use. No evidence was found that name-reporting requirements were related to previous or planned use of testing. Future research must address emerging testing issues such as policies covering the use of new testing technologies.

AIDS Serodiagnosis↗
PubMed1993

Coronary angioplasty. Statewide experience in California.

BACKGROUND: This report describes the in-hospital experience with percutaneous transluminal coronary angioplasty (PTCA) for the state of California in 1989. Data are derived from the statewide hospital discharge abstracts. METHODS AND RESULTS: A total of 24,883 PTCAs were performed; most patients (70%) were men and most procedures were single vessel (87%). About one fifth (19%) of patients had a principal diagnosis of acute myocardial infarction (AMI). Overall mortality was 1.4% and was higher in the AMI group (4.2%) versus the non-AMI group (0.8%, P = .0001). Mortality was higher for AMI patients having PTCA on the day of or day after admission (5.5%) versus those treated later (2.6%, P = .0001). Five percent of patients had coronary artery bypass surgery (CABG) after PTCA; CABG was performed on the same day as PTCA in 61.7% of cases. Patients presenting with AMI were more likely to have CABG (7.1%) than non-AMI patients (4.5%, P = .0001). Mortality associated with CABG was 7.3% and was higher in the AMI group (12.0%) than in the non-AMI group (5.5%, P = .0001). Factors predictive of increased mortality by bivariate analysis included age > 63 years (2.1% mortality versus 0.8% < or = 63, P = .01), female sex (1.9% versus 1.2% for men, P < .01), and the presence of diabetes (1.9% versus 1.3% for nondiabetics, P < .05). Multiple logistic regression showed that timings of PTCA with respect to admission (P = .004) and age (P = .05) were predictors of mortality, but female sex was predictive only in the non-AMI group (P = .03). Mean hospital charges were $19,597 (+/- SD, $18,213). Forty-two percent of the 110 hospitals performed more than the recommended minimum of 200 cases per year. The requirement for CABG during the same admission or the combined adverse outcome of CABG and/or death was increased in the lower-volume centers for both AMI and non-AMI patients (P < .001), although mortality alone was not. CONCLUSIONS: The mortality and need for CABG surgery in the statewide California PTCA experience is higher than that generally reported in the literature. In patients with an admitting diagnosis of AMI, the overall mortality was higher, as was the need for CABG and the associated CABG mortality. Most hospitals performed fewer than 200 PTCAs per year. Rates of CABG surgery and the combination of CABG and/or mortality, adjusted only for the presence or absence of AMI, were increased at the low-volume institutions.

Adolescent↗
PubMed1993

Body dysmorphic disorder: 30 cases of imagined ugliness.

OBJECTIVE: Body dysmorphic disorder, preoccupation with an imagined defect in appearance, is included in DSM-III-R but has received little empirical study. The authors investigated the demographics, phenomenology, course, associated psychopathology, family history, and response to treatment in a series of 30 patients with the disorder. METHOD: The patients (including 12 whose preoccupation was of probable delusional intensity) were assessed with a semistructured interview and the Structural Clinical Interview for DSM-III-R, and their family histories were obtained. RESULTS: The 17 men and 13 women reported a lifetime average of four bodily preoccupations, most commonly "defects" of the hair, nose, and skin. The average age at onset of body dysmorphic disorder was 15 years, and the average duration was 18 years. Seventy-three percent of the patients reported associated ideas or delusions of reference; 73%, excessive mirror checking; and 63%, attempts to camouflage their "deformities." As a result of their symptoms, 97% avoided usual social and occupational activities, 30% had been housebound, and 17% had made suicide attempts. Ninety-three percent of the patients had an associated lifetime diagnosis of a major mood disorder; 33%, a psychotic disorder; and 73%, an anxiety disorder. The patients generally responded poorly to surgical, dermatologic, and dental treatments and to adequate trials of most psychotropic medications, with the exception of fluoxetine and clomipramine (to which more than half had a complete or partial response). CONCLUSIONS: This often secret, chronic disorder can cause considerable distress and impairment, may be related to obsessive-compulsive disorder or mood disorder, and may respond to serotonin reuptake-blocking antidepressants.

Adolescent↗
PubMed1993

Subjective knowledge of AIDS and use of HIV testing.

Increasing knowledge is an important goal of human immunodeficiency virus (HIV) prevention strategies, although increased knowledge may not be associated with increased preventive behaviors. This study examines the association of (1) objective and subjective acquired immunodeficiency syndrome (AIDS) knowledge, and (2) both objective and subjective AIDS knowledge with HIV testing use. Data are from the 1988 National Health Interview Survey. Objective and subjective knowledge were only moderately correlated. In regression analyses, higher subjective knowledge was significantly associated with higher testing use, but objective knowledge was not. The results are relevant to other preventive behaviors for which knowledge is an important factor.

AIDS Serodiagnosis↗
PubMed1993

Body dysmorphic disorder: does it have a psychotic subtype?

BACKGROUND: Although body dysmorphic disorder (BDD) is classified in DSM-III-R as a nonpsychotic somatoform disorder, controversy exists as to whether BDD can present with psychotic features. If it can, this raises the possibility that its DSM-III-R psychotic counterpart-delusional disorder, somatic type--may not be a separate disorder. The purpose of this study was to determine whether patients with nonpsychotic BDD (defined according to DSM-III-R criteria, i.e., with maintenance of some insight) were different from patients with psychotic BDD (those whose preoccupation was without insight and of delusional intensity). METHOD: Fifty consecutive patients meeting DSM-III-R criteria A and C for BDD were assessed with a semistructured interview and the Structured Clinical Interview for DSM-III-R (SCID). Family histories of psychiatric disorders were blindly assessed. The 24 patients with nonpsychotic BDD were compared with the 26 patients with psychotic BDD with respect to demographics, phenomenology, course of illness, associated features, comorbid psychiatric disorders, family history, and treatment response. RESULTS: Patients with psychotic BDD displayed a significantly higher rate of lifetime DSM-III-R psychotic disorder diagnoses than patients with nonpsychotic BDD. However, the two groups did not differ significantly on most other variables examined. For instance, both psychotic and nonpsychotic patients displayed significant morbidity; high comorbidity with mood, anxiety, and psychoactive substance use disorders; and apparent preferential response to serotonin reuptake inhibitors rather than to non-serotonin reuptake blocking antidepressants or antipsychotics. CONCLUSION: Body dysmorphic disorder may have a closely related psychotic subtype that significantly overlaps with, or may even be the same disorder as, the BDD variant of delusional disorder, somatic type. Inclusion of a psychotic subtype for BDD should be considered for future editions of DSM.

Adult↗