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Biomedical subjects

R J Anderson

Publications and source records attributed to R J Anderson.

At least 55 records · Page 3Linked to original sources
PubMed2000

Patient desire and reasons for specialist referral in a gatekeeper-model managed care plan.

OBJECTIVE: To describe patient desire and reasons for specialist referrals in a gatekeeper-model managed care plan. STUDY DESIGN: Cross-sectional prospective study. PATIENTS AND METHODS: We developed a patient questionnaire to gather demographic data and to gauge patients' desire for specialist referral and their reasons for seeking such referral. The survey was administered at 2 sites--an ambulatory care facility of a university hospital and an internal medicine clinic in a suburban ambulatory care site. Patients asked to complete the questionnaire at the university hospital site were enrolled in a gatekeeper-model managed care plan (called CU Gold); those seen at the internal medicine clinic were enrolled in a group-model health maintenance organization. Patients were asked to complete the 1-page questionnaire in the waiting room before being seen by their primary care physician. RESULTS: Among the 860 CU Gold patients who met the inclusion criteria during the 3-month study period (September to December 1997), 112 (13%) reported a definite desire to see a specialist and 274 (32%) indicated a possible desire to see a specialist at the time of their primary care visit. Compared with the CU Gold patients, significantly fewer patients in the health maintenance organization indicated a definite desire to see a specialist (3% versus 13%), but a similar percentage expressed a possible desire to see a specialist (30% versus 32%). The difference in definite desire for referral between the 2 groups could not be explained by patient or primary care physician characteristics. The principal health concerns for which patients sought referral were musculoskeletal, genitourinary or gynecologic, or dermatologic problems. Need for reassurance (cited by 67% of patients), seeing a specialist before (56%), and believing the primary care physician lacked expertise (49%) were the primary reasons patients sought referral. Seventy-four percent of patients referred by their primary care provider and 54% of those not referred agreed it was a good idea to see their primary care physician first before seeing a specialist. CONCLUSIONS: Patients have a significant desire for specialist referral, driven by their need for reassurance, previous specialist referral, and belief that their primary care physician does not have the requisite expertise. Patients' expectations for referral varied significantly, depending on the healthcare system (academic primary care clinic or health maintenance organization) in which they were enrolled.

Adult↗
PubMed2000

Involuntary disenrollment from a Medicare managed care plan at an academic medical center: effect on patients.

OBJECTIVES: Little is known about the impact of mandatory (involuntary) disenrollment of patients from Medicare managed care organization (MCO) plans. We hypothesized that involuntary disenrollment raises significant concerns for patients, that younger enrollees (aged less than 65, "Medicare disabled") have different concerns than older patients, and that younger patients respond to termination of their plan within the MCO differently from older patients. We also examined other factors associated independently with enrollee decisions to stay in the MCO or return to Medicare fee-for-service. DESIGN: A cross-sectional telephone questionnaire. SETTING: A Medicare managed care plan at two outpatient clinics at an academic medical center in Denver, Colorado. PARTICIPANTS: Four hundred fifty enrollees recently notified of termination of their clinic's contract with a Medicare managed care plan were surveyed. MEASUREMENTS: Survey questions on demographics, patient concerns about disenrollment, and factors associated with staying at the academic medical center or switching to another clinic or plan associated with the MCO. RESULTS: Of 371 respondents, 57% switched to another plan within the MCO, including 65% of the Medicare disabled enrollees and 57% of the Medicare nondisabled enrollees. More than 60% of both Medicare disabled and older patients who switched felt that it was a significant problem for them. By multivariate analysis, age was not associated with switching, but a distant relationship with one's physician was associated with switching (odds ratio (OR) = 10.2; confidence interval (CI), 1.13-91.09) and having received care at the academic medical center for 1 year or longer (OR = 0.35, 95% CI, 0.17-0.69), postcollege education (OR = 0.34; CI, 0.16-0.69), and black race (OR = 0.29; CI, 0.13-0.68) were independently associated with not switching. Older and younger patients cited similar concerns raised by switching, but financial issues were identified as a major concern by more younger patients than older patients (P = .001). CONCLUSIONS: Involuntary disenrollment raised significant concerns for patients in a Medicare managed care plan.

Academic Medical Centers↗
PubMed2000

The use of a geographical information system in investigating dental services.

OBJECTIVE: To determine the value of a geographical information system (GIS) in investigating the provision of dental care. DESIGN: Information about dental need and provision of dental services was obtained from districts within the West Midlands. A Geographical Information System (Atlas GIS) was used to answer three different questions about dental services provision within the West Midlands. A GIS is an interactive system that allows data to be analysed according to regular or irregular geographical areas. Once the system is established, it is fairly simple and quick to use. However, the financial and training issues mean that it may not be viable for such a system to be available within each health trust or district, but more appropriately as a central facility which can be accessed by several users. CASE STUDIES: The way in which this system was used to answer three different questions about dental service provision within the West Midlands is demonstrated and evaluated. CONCLUSIONS: Use of a GIS presents information in a way that increases its usefulness in the planning of dental services.

Cleft Lip↗
PubMed1999

Sulfation of iodothyronines by recombinant human liver steroid sulfotransferases.

Sulfation is an important pathway in the metabolism of thyroid hormones. Sulfated iodothyronines are elevated in nonthyroidal illnesses and in the normal human fetal circulation. We assayed and characterized COS-1 cell expressed recombinant human liver dehydroepiandrosterone sulfotransferase (DHEA ST or SULT2A1) and estrogen sulfotransferase (EST or SULT1E1) activities for the first time with triiodothyronine (T(3)) as the substrate. Several biochemical properties that included apparent K(m) values, thermal stabilities, and responses to the inhibitors 2, 6-dichloro-4-nitrophenol and NaCl were tested. SULT2A1, a member of the hydroxysteroid sulfotransferase family, used 3,3'-T(2) more readily than T(3) and 3,5-T(2) as substrates, but had the lowest apparent K(m) value for T(3) of any reported human SULT. SULT1E1, a member of the phenol sulfotransferase family, used 3,3'-T(2) and rT(3) more readily than T(3), and also displayed the greatest specificity for T(4) among human SULTs. SULT2A1 may contribute more to iodothyronine sulfation than previously suspected. Potential roles of both steroid sulfotransferases in the enhanced sulfation of nonthyroidal illnesses and fetal development invite further investigation.

Animals↗
PubMed1999

Attenuated deltaguaBA Salmonella typhi vaccine strain CVD 915 as a live vector utilizing prokaryotic or eukaryotic expression systems to deliver foreign antigens and elicit immune responses.

Attenuated Salmonella typhi strain CVD 915, harboring a deletion in guaBA that interrupts the biosynthesis of guanine nucleotides, was evaluated as a live vector vaccine for delivering foreign antigens utilizing prokaryotic or eukaryotic expression systems. Plasmids pTETnir15 and pcDNA3tetC encoding fragment C (Frag C) of tetanus toxin under the control of prokaryotic or eukaryotic promoters, respectively, were introduced into CVD 915 and administered intranasally to mice. Purified pcDNA3tetC and Frag C were given intramuscularly. High titers of serum IgG1, IgG2a, and IgG2b antibodies against Frag C were elicited by CVD 915(pTETnir15) and CVD 915(pcDNA3tetC). These responses were significantly higher than those induced by pcDNA3tetC. Proliferative responses and IL-2 and IFN-gamma production were observed in splenocytes exposed to S. typhi antigens and Frag C. We conclude that CVD 915 is a highly efficient live vector to carry foreign genes under eukaryotic or prokaryotic control and elicit potent immune responses.

Administration, Intranasal↗
PubMed1999

Visual acuity impairment in patients with retinitis pigmentosa at age 45 years or older.

OBJECTIVE: To determine the severity of visual acuity impairment in patients, age 45 years or older, with either isolated or identifiable genetic subtypes of retinitis pigmentosa (RP) and Usher syndrome. DESIGN: Multicenter, retrospective, cross-sectional analysis. PARTICIPANTS: Visual acuity data were obtained on 999 patients with different genetic subtypes of RP and Usher syndrome, age 45 years or older, from 4 major eye care centers in the United States. INTERVENTION: The best-corrected visual acuity obtained on these patients from the eye with better vision on their most recent visit was used for the analysis. MAIN OUTCOME MEASURE: Best-corrected visual acuity was the main parameter analyzed for the study, and it was obtained with Snellen or Feinbloom low vision charts or with a B-VAT II monitor (Mentor). RESULTS: The final analyses were done on 982 patients (17 patients with a sector form of RP were analyzed separately). Of the 982 patients, 506 (52%) had a visual acuity of 20/40 or better, and 678 (69%) had a visual acuity of 20/70 or better in at least one eye. There were 243 (25%) patients who had a visual acuity of 20/200 or worse in both eyes. Five (0.5%) patients had no light perception in both eyes. The odds ratio for any patient having a visual acuity of 20/200 or worse in this population was 1.4 for each difference of 10 years of age. Similarly, the odds ratio of a patient having a visual acuity of 20/40 or better in at least one eye was 0.95 for a 10-year age difference. CONCLUSIONS: In this large population of patients with RP and Usher syndrome from four centers, it was rare for such patients to lose all vision in both eyes. One fourth of the patients had a visual acuity of 20/200 or worse in both eyes, and more than half of the population had a visual acuity of 20/40 or better in at least one eye. These data can be used to counsel such patients on the extent of potential visual acuity impairment from their disease.

Aged↗
PubMed1999

'Stalkitis' in a pregnant 32-year-old woman: a rare cause of diabetes insipidus.

A case of lymphocytic infundibulo-neurohypophysitis (LINH) or 'stalkitis' in a 32-year-old woman who presented with diabetes insipidus (DI) during pregnancy is reported here. The diagnosis was made with MR imaging. The clinical and radiological features of this rare disorder and the differential diagnosis of infundibular mass lesions are discussed. The differentiation from lymphocytic adenohypophysitis (LAH) is made. No improvement of the DI accompanying LINH is achieved with trans-sphenoidal surgery. Hence, recognition of typical cases with MR imaging and appropriate medical management avoids unnecessary neurosurgery. This is the second reported case of LINH associated with pregnancy and may suggest an association.

Adult↗
PubMed1999

Rosiglitazone monotherapy improves glycaemic control in patients with type 2 diabetes: a twelve-week, randomized, placebo-controlled study.

AIM: Rosiglitazone is the most potent of the thiazolidinediones, a novel class of oral antidiabetic agents that reduce blood glucose levels by sensitizing peripheral tissues to insulin. This study was designed to identify doses of rosiglitazone that would lower fasting plasma glucose (FPG) in patients with type 2 diabetes. METHODS: In this 12-week, double-blind, multicentre study, 380 patients with FPG values > or =7.8 mmol/L (140 mg/dL) and < or =13.3 mmol/L (240 mg/dL) were randomly assigned to receive treatment with placebo or rosiglitazone, 0.05, 0.25, 1.0, or 2.0 mg twice daily. The primary efficacy parameter was changed in FPG from baseline after 12 weeks of treatment. Secondary endpoints were changes in HbA1c, fructosamine, C peptide, insulin, lipid levels, and body weight (b.w.). Safety monitoring included clinical laboratory evaluations, electrocardiography, and echocardiography. RESULTS: Rosiglitazone 1.0 and 2.0 mg b.i.d. produced significant decreases in FPG (p=0.0001). Fructosamine also decreased in patients treated with these two dosages (p=0.003 in the 2.0 mg b.i.d. group). Rosiglitazone 2.0 mg b.i.d. significantly reduced plasma insulin levels (p=0.0044) and free fatty acids (p=0.0014) compared with placebo. Total cholesterol (p=0.0001), HDL (p=0.0009), and LDL (p=0.0001) increased in the rosiglitazone 2.0 mg b.i.d. group, but there was no significant change in the total cholesterol/HDL ratio or triglyceride levels in any rosiglitazone treatment group. Clinically insignificant dose-dependent increases in b.w. were observed in the rosiglitazone 1.0 and 2.0 mg b.i.d. treatment groups. CONCLUSIONS: Twelve weeks of treatment with rosiglitazone 2.0 mg b.i.d. significantly decreases fasting plasma glucose, fructosamine, plasma insulin, and free fatty acids in patients with type 2 diabetes. Longer studies using higher doses will be needed to assess the efficacy and safety of rosiglitazone in patients with type 2 diabetes mellitus.

Adult↗
PubMed1999

Renal failure predisposes patients to adverse outcome after coronary artery bypass surgery. VA Cooperative Study #5.

BACKGROUND: More than 600,000 coronary artery bypass graft (CABG) procedures are done annually in the United States. Some data indicate that 10 to 20% of patients who are undergoing a CABG procedure have a serum creatinine of more than 1.5 mg/dl. There are few data on the impact of a mild increase in serum creatinine concentration on CABG outcome. METHODS: We analyzed a Veterans Affairs database obtained prospectively from 1992 through 1996 at 14 of 43 centers performing heart surgery. We compared the outcome after CABG in patients with a baseline serum creatinine of less than 1.5 mg/dl (median 1.1 mg/dl, N = 3271) to patients with a baseline serum creatinine of 1.5 to 3.0 mg/dl (median 1.7, N = 631). RESULTS: Univariate analysis revealed that patients with a serum creatinine of 1.5 to 3.0 mg/dl had a higher 30-day mortality (7% vs. 3%, P < 0.001) requirement for prolonged mechanical ventilation (15% vs. 8%, P = 0.001), stroke (7% vs. 2%, P < 0.001), renal failure requiring dialysis at discharge (3% vs. 1%, P < 0.001), and bleeding complications (8% vs. 3%, P < 0.001) than patients with a baseline serum creatinine of less than 1.5 mg/dl. Multiple logistic regression analyses found that patients with a baseline serum creatinine of less than 1.5 mg/dl had significantly lower (P < 0.02) 30-day mortality and postoperative bleeding and ventilatory complications than patients with a serum creatinine of 1.5 to 3.0 mg/dl when controlling for all other variables. CONCLUSION: These results demonstrate that mild renal failure is an independent risk factor for adverse outcome after CABG.

Aged↗
PubMed1999

Population models of genomic imprinting. I. Differential viability in the sexes and the analogy with genetic dominance.

Many single-locus, two-allele selection models of genomic imprinting have been shown to reduce formally to one-locus Mendelian models with a modified parameter for genetic dominance. One exception is the model where selection at the imprinted locus affects the sexes differently. We present two models of maternal inactivation with differential viability in the sexes, one with complete inactivation, and the other with a partial penetrance for inactivation. We show that, provided dominance relations at the imprintable locus are the same in both sexes, a globally stable polymorphism exists for a range of viabilities that is independent of the penetrance of imprinting. The conditions for a polymorphism are the same as in previous models with differential viability in the sexes but without imprinting and in a model of the paternal X-inactivation system in marsupials. The model with incomplete inactivation is used to illustrate the analogy between imprinting and dominance by comparing equilibrium bifurcation plots for fixed values of dominance and penetrance. We also derive a single expression for the dominance parameter that leaves the frequency and stability of equilibria unchanged for all levels of inactivation. Although an imprinting model with sex differences does not formally reduce to a nonimprinting scheme, close theoretical parallels clearly exist.

Animals↗
PubMed1999

Carrying out the Medicine/Public Health Initiative: the roles of preventive medicine and community-responsive care.

Leaders in medicine and public health, recognizing the inherent interdependency of these fields, established the Medicine/Public Health Initiative in the mid-1990s as "an evolving forum in which representatives of both sectors can explore their mutual interests in improving health and [can] define collaborative mechanisms to achieve that goal." The Initiative's participants developed six goals that they and others in medicine and public health across the nation should implement: engage the community; change the education process; create joint research efforts by clinical, public health, and preventive medicine investigators; develop a shared view of illness between medicine and public health; work together to provide health care; and work jointly to develop health care assessment measures. The authors describe the six goals in depth and explain the important combined roles of clinically-oriented preventive medicine and community-oriented preventive medicine--as practiced in a model of health care delivery called community-oriented primary care (COPC)--in implementing the Initiative's goals. They then report recent efforts, including two in Boston and Dallas, to merge medicine and public health, and state that academic health centers, which are in the process of reshaping themselves, can help themselves as well as the public by embracing their key role in the effort to integrate medicine and public health. In particular, they can expand and strengthen existing training programs in preventive medicine and COPC or add these programs to their curricula.

Academic Medical Centers↗
PubMed1999

The effect of patients' race on their attitudes toward medical students' participation in ambulatory care visits.

PURPOSE: To ascertain the preconceptions of ambulatory patients seeking care in internal medicine practices toward medical students' participation in their care. METHOD: The authors developed a self-administered, seven-item survey that sought patients' demographic information and their attitudes toward medical students' participation in their ambulatory care. In 1998, this survey was given to patients seen at four distinct internal medicine ambulatory clinic settings. RESULTS: Analysis of 516 completed surveys found neutral responses to the statement: "I would benefit from having a medical student involved in my care." Respondents indicated a lack of comfort in having medical students either answer their questions or examine them in the absence of a doctor. The responses did not differ when analyzed as a function of clinic site, age, gender, education, or annual income. Non-Caucasian respondents rated the benefit of having a student present significantly lower than did Caucasian respondents. They also indicated greater concern about being examined by a student alone, that the presence of a student would make the visit last longer, and that the gender of the student was important to them. CONCLUSIONS: Patients generally have neutral feelings as to whether they would benefit from medical students' participation in their ambulatory care. Caucasian patients are significantly more favorably inclined to medical student involvement than are non-Caucasian patients.

Adult↗
PubMed1999

Lymphocytic alveolitis, bronchoalveolar lavage viral load, and outcome in human immunodeficiency virus infection.

Lymphocytic alveolitis portends a poor prognosis in human immunodeficiency virus (HIV)-infected subjects. Because alveolar lymphocytes consist predominantly of HIV-specific CD8(+) cytotoxic T lymphocytes (CTL), they could represent an appropriate immune response to infected cells in the lung, and be a surrogate marker for a high pulmonary viral burden. We assessed long-term outcome in a cohort of asymptomatic HIV-infected subjects who underwent bronchoscopy between 1990 and 1993 and had bronchoalveolar lavage fluid (BALF) available for determination of viral load by reverse transcription-polymerase chain reaction. The ability to detect HIV in BALF increased with disease progression. Lymphocytic alveolitis, although present at all stages of HIV infection, was most pronounced in patients with middle stage disease. The HIV viral load as measured by bronchoalveolar lavage correlated with the percentage of alveolar lymphocytes in patients with peripheral blood CD4(+) cell counts above 200/microliter. Including patients with CD4(+) cell counts < 200/microliter weakened this correlation, possibly because of replacement of CD8(+) CTL by CD8(+) suppressor cells in advanced disease. Free virus in BALF was a stronger predictor of HIV disease progression than was lymphocytic alveolitis. These data suggest that lymphocytic alveolitis in HIV-infected subjects occurs in response to viral antigens in the lung and that the poor prognosis associated with lymphocytic alveolitis reflects a high pulmonary viral burden.

Adult↗
PubMed1998

Age-race subgroup compared with renin profile as predictors of blood pressure response to antihypertensive therapy. Department of Veterans Affairs Cooperative Study Group on Antihypertensive Agents.

CONTEXT: Renin profiling and age-race subgroup may help select single-drug therapy for stage 1 and stage 2 hypertension. OBJECTIVE: To compare the plasma renin profiling and age-race subgroup methods as predictors of response to single-drug therapy in men with stage 1 and 2 hypertension as defined by the Joint National Committee on Prevention, Detection, Evaluation and Treatment of High Blood Pressure. DESIGN: The Veterans Affairs Cooperative Study on Single-Drug Therapy of Hypertension, a randomized controlled trial. SETTING: Fifteen Veterans Affairs hypertension centers. PATIENTS: A total of 1105 ambulatory men with entry diastolic blood pressure (DBP) of 95 to 109 mm Hg, of whom 1031 had valid plasma and urine samples for renin profiling. INTERVENTIONS: Randomization to 1 of 6 antihypertensive drugs: hydrochlorothiazide, atenolol, captopril, clonidine, diltiazem (sustained release), or prazosin. MAIN OUTCOME MEASURE: Treatment response as assessed by percentage achieving goal DBP (<90 mm Hg) in response to a single drug that corresponded to patients' renin profile vs a single drug that corresponded to patients' age-race subgroup. RESULTS: Clonidine and diltiazem had consistent response rates regardless of renin profile (76%, 67%, and 80% for low, medium, and high renin, respectively, for clonidine and 83%, 82%, and 83%, respectively, for diltiazem for patients with baseline DBP of 95-99 mm Hg). Hydrochlorothiazide and prazosin were best in low- and medium-renin profiles; captopril was best in medium- and high-renin profiles (low-, medium-, and high-renin response rates were 82%, 78%, and 14%, respectively, for hydrochlorothiazide; 88%, 67%, and 40%, respectively, for prazosin; and 51%, 83%, and 100%, respectively, for captopril for patients with baseline DBP of 95-99 mm Hg). Response rates for patients with baseline DBP of 95 to 99 mm Hg by age-race subgroup ranged from 70% for clonidine to 90% for prazosin for younger black men, from 50% for captopril to 97% for diltiazem for older black men, from 70% for hydrochlorothiazide to 92% for atenolol for younger white men, and from 84% for hydrochlorothiazide to 95% for diltiazem for older white men. Patients with a correct treatment for their renin profile but incorrect for age-race subgroup had a response rate of 58.7%; patients with an incorrect treatment for their renin profile but correct for age-race subgroup had a response rate of 63.1% (P = .30). After controlling for DBP and interactions with treatment group, age-race subgroup (P<.001) significantly predicted response to single-drug therapy, whereas renin profile was of borderline significance (P= .05). CONCLUSIONS: In these men with stage 1 and stage 2 hypertension, therapeutic responses were consistent with baseline renin profile, but age-race subgroup was a better predictor of response.

Adult↗