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Biomedical subjects

T Bush

Publications and source records attributed to T Bush.

At least 19 recordsLinked to original sources
PubMed2006

Overview and implementation of an intervention to prevent adherence failure among HIV-infected adults initiating antiretroviral therapy: lessons learned from Project HEART.

Project HEART, an acronym for Helping Enhance Adherence to Retroviral Therapy, was a prospective, controlled study to develop, implement, and evaluate a clinic-based behavioural intervention to prevent adherence failure among HIV-infected adults beginning their first highly active antiretroviral therapy (HAART) regimen (N = 227). In this paper, we describe the conceptualisation of the Project HEART adherence intervention, characteristics of the participants, and lessons learned implementing HEART in an inner-city clinic setting. A multi-component intervention, HEART combined enhanced education, reminders, adherence feedback, social support and adherence-focused problem solving in an integrated manner to address common cognitive, motivational, and social barriers to adherence. Unique components of the intervention included use of participant-identified adherence support partners and a standardized adherence barriers assessment to develop and implement individualised adherence plans. Lessons learned regarding the feasibility of using participant-identified support partners were as follows. Few participants eligible for the study had trouble identifying a support partner. Over 90% of support partners attended at least one intervention visit. Support partners were most available and amenable to participate early in the initiation of therapy. Participants' experiences as the 'supported' partner were generally positive. Though many participants faced barriers not easily addressed by this intervention (for example, housing instability), formally integrating support partners into the intervention helped to address many other common adherence barriers. Family and friends are an under-utilised resource in HIV medication adherence. Enlisting the help of support partners is a practical and economical approach to adherence counselling.

Adult↗
PubMed2003

Behavioural factors associated with symptom outcomes in a primary care-based depression prevention intervention trial.

BACKGROUND: A randomized trial of a primary care-based intervention to prevent depression relapse resulted in improved adherence to long-term antidepressant medication and depression outcomes. We evaluated the effects of this intervention on behavioural processes and identified process predictors of improved depressive symptoms. METHOD: Patients at high risk for depression recurrence or relapse following successful acute phase treatment (N=386) were randomly assigned to receive a low intensity 12-month intervention or continued usual care. The intervention combined education about depression, shared decision-making regarding use of maintenance pharmacotherapy and cognitive-behavioural strategies to promote self-management. Baseline, 3, 6, 9 and 12-month interviews assessed patients' self-care practices, self-efficacy for managing depression and depressive symptoms. RESULTS: Intervention patients had significantly greater self-efficacy for managing depression (P<0.01) and were more likely to keep track of depressive symptoms (P<0.0001), monitor early warning signs (P<0.0001), and plan for coping with high risk situations (P<0.0001) at all time points compared to usual care control patients. Self-efficacy for managing depression (P<0.0001), keeping track of depressive symptoms (P=0.05), monitoring for early warning signs (P=0.01), engaging in pleasant activities (P<0.0001) and engaging in social activities (P<0.0001) positively predicted improvements in depression symptom scores. CONCLUSIONS: A brief intervention designed to target cognitive-behavioural factors and promote adherence to pharmacotherapy in order to prevent depression relapse was highly successful in changing several behaviours related to controlling depression. Improvements in self-efficacy and several self-management behaviours that were targets of the intervention were significantly related to improvements in depression outcome.

Antidepressive Agents↗
PubMed2001

A randomized trial of relapse prevention of depression in primary care.

BACKGROUND: Despite high rates of relapse and recurrence, few primary care patients with recurrent or chronic depression are receiving continuation and maintenance-phase treatment. We hypothesized that a relapse prevention intervention would improve adherence to antidepressant medication and improve depression outcomes in high-risk patients compared with usual primary care. METHODS: Three hundred eighty-six patients with recurrent major depression or dysthymia who had largely recovered after 8 weeks of antidepressant treatment by their primary care physicians were randomized to a relapse prevention program (n = 194) or usual primary care (n = 192). Patients in the intervention group received 2 primary care visits with a depression specialist and 3 telephone visits over a 1-year period aimed at enhancing adherence to antidepressant medication, recognition of prodromal symptoms, monitoring of symptoms, and development of a written relapse prevention plan. Follow-up assessments were completed at 3, 6, 9, and 12 months by a telephone survey team blinded to randomization status. RESULTS: Those in the intervention group had significantly greater adherence to adequate dosage of antidepressant medication for 90 days or more within the first and second 6-month periods and were significantly more likely to refill medication prescriptions during the 12-month follow-up compared with usual care controls. Intervention patients had significantly fewer depressive symptoms, but not fewer episodes of relapse/recurrence over the 12-month follow-up period. CONCLUSIONS: A relapse prevention program targeted to primary care patients with a high risk of relapse/recurrence who had largely recovered after antidepressant treatment significantly improved antidepressant adherence and depressive symptom outcomes.

Adolescent↗
PubMed2001

Effects of lower doses of conjugated equine estrogens and medroxyprogesterone acetate on plasma lipids and lipoproteins, coagulation factors, and carbohydrate metabolism.

OBJECTIVE: To determine the effects of lower doses of conjugated equine estrogens (CEE) alone or CEE and medroxyprogesterone acetate (MPA) on lipoproteins, carbohydrate metabolism, and coagulation/fibrinolytic factors. DESIGN: Randomized, double-blind, placebo-controlled study. SETTING: Multicenter substudy of the Women's HOPE trial. PATIENT(S): Seven hundred and forty-nine healthy, postmenopausal women. INTERVENTION(S): Women were randomized to receive the following doses in milligrams per day: 0.625 CEE; 0.625 CEE/2.5 MPA; 0.45 CEE; 0.45 CEE/2.5 MPA; 0.45 CEE/1.5 MPA; 0.3 CEE; 0.3 CEE/1.5 MPA; or placebo. MAIN OUTCOME MEASURE(S): Assessment of lipids, lipoproteins, glucose tolerance, and coagulation/fibrinolytic factors at baseline, cycle 6, and year 1. RESULT(S): One year of treatment with any of the CEE or CEE/MPA regimens studied increased high-density lipoprotein cholesterol (HDL-C); the 10% increase in HDL-C for the CEE 0.45/MPA 1.5 group was similar to the CEE 0.625/MPA 2.5 group. Low-density lipoprotein cholesterol was significantly reduced in all of the active treatment groups except the CEE 0.3/MPA 1.5 group at cycle 13. Apolipoprotein A-I and triglyceride levels increased and apolipoprotein B levels decreased in all groups. The lipoprotein (a) level was reduced in the CEE 0.45/MPA 2.5, CEE 0.45/MPA 1.5, and CEE 0.625/MPA 2.5 groups. Minimal changes were observed in carbohydrate metabolism for all groups. Fibrinogen and PAI-1 activity decreased and plasminogen activity increased in all groups. Decreases in antithrombin III and protein S activities were significant for all active treatment groups except the CEE 0.3/MPA 1.5 group. CONCLUSION(S): Lower doses of CEE and CEE/MPA induce favorable changes in lipids, lipoproteins, and hemostatic factors with minimal changes in carbohydrate metabolism.

Adult↗
PubMed2001

Executive functioning and olfactory identification in young adults with attention deficit-hyperactivity disorder.

Young adults with attention deficit-hyperactivity disorder (ADHD; N = 105) were compared with a control group (N = 64) on 14 measures of executive function and olfactory identification using a 2 (group) X 2 (sex) design. The ADHD group performed significantly worse on 11 measures. No Group X Sex interaction was found on any measures. No differences were found in the ADHD group as a function of ADHD subtype or comorbid oppositional defiant disorder. Comorbid depression influenced the results of only 1 test (Digit Symbol). After IQ was controlled for, some group differences in verbal working memory, attention, and odor identification were no longer significant, whereas those in inhibition, interference control, nonverbal working memory, and other facets of attention remained so. Executive function deficits found in childhood ADHD exist in young adults with ADHD and are largely not influenced by comorbidity but may be partly a function of low intelligence.

Adolescent↗
PubMed2001

Time perception and reproduction in young adults with attention deficit hyperactivity disorder.

Adults with attention deficit hyperactivity disorder (ADHD; n = 104) were compared with a control group (n = 64) on time estimation and reproduction tasks. Results were unaffected by ADHD subtype or gender. The ADHD group provided larger time estimations than the control group, particularly at long intervals. This became nonsignificant after controlling for IQ. The ADHD group made shorter reproductions than did the control group (15- and 60-s intervals) and greater reproduction errors (12-, 45-, 60-s durations). These differences remained after controlling for IQ and comorbid oppositional defiant disorder, depression, and anxiety. Only the level of anxiety contributed to errors (at 12-s duration) beyond the level of ADHD. Results extended findings on time perception in ADHD children to adults and ruled out comorbidity as the basis of the errors.

Adult↗
PubMed2001

Cost-effectiveness of a collaborative care program for primary care patients with persistent depression.

OBJECTIVE: The authors evaluated the incremental cost-effectiveness of stepped collaborative care for patients with persistent depressive symptoms after usual primary care management. METHOD: Primary care patients initiating antidepressant treatment completed a standardized telephone assessment 6-8 weeks after the initial prescription. Those with persistent major depression or significant subthreshold depressive symptoms were randomly assigned to continued usual care or collaborative care. The collaborative care included systematic patient education, an initial visit with a consulting psychiatrist, 2-4 months of shared care by the psychiatrist and primary care physician, and monitoring of follow-up visits and adherence to medication regimen. Clinical outcomes were assessed through blinded telephone assessments at 1, 3, and 6 months. Health services utilization and costs were assessed through health plan claims and accounting data. RESULTS: Patients receiving collaborative care experienced a mean of 16.7 additional depression-free days over 6 months. The mean incremental cost of depression treatment in this program was $357. The additional cost was attributable to greater expenditures for antidepressant prescriptions and outpatient visits. No offsetting decrease in use of other health services was observed. The incremental cost-effectiveness was $21.44 per depression-free day. CONCLUSIONS: A stepped collaborative care program for depressed primary care patients led to substantial increases in treatment effectiveness and moderate increases in costs. These findings are consistent with those of other randomized trials. Improving outcomes of depression treatment in primary care requires investment of additional resources, but the return on this investment is comparable to that of many other widely accepted medical interventions.

Adult↗
PubMed2000

Racial differences in tamoxifen metabolism.

PURPOSE: A recent study indicates that black women may have a higher risk/benefit ratio from tamoxifen than white women. Several reports in the literature indicate that racial differences in the risks/benefits from other pharmaceutical agents may be partially due to racial differences in drug metabolism. Thus, we explore the hypothesis that the racial difference in the tamoxifen risk/benefit ratio may be due, in part, to racial differences in tamoxifen metabolism.METHODS: We conducted a pilot study in which we recruited 6 white and 4 black breast cancer patients from the Baltimore, Maryland area. All patients were taking tamoxifen for at least 30 days. Each provided a blood sample that was used to measure tamoxifen metabolites by high performance liquid chromatography.RESULTS: Our results indicate that the black women had significantly higher levels of the tamoxifen metabolite, N-desmethyltamoxifen (N-DMT) than the white women (0.585 µg/ml vs 0.199 µg/ml, p < 0.05). There were no differences in the serum levels of tamoxifen in black and white women (0.809 vs 0.699, p > 0.1).CONCLUSIONS: These data suggest that both black and white breast cancer patients reach steady state tamoxifen levels, but that black women are more likely to metabolize tamoxifen to N-DMT or to maintain higher levels of N-DMT (i.e., less excretion of N-DMT) than white women. N-DMT is thought to be less effective in breast cancer treatment than tamoxifen. N-DMT also has been associated with excess proliferation in breast cancer cells. Thus, it is possible that the relatively high tamoxifen risk/benefit in black women occurs because tamoxifen is readily converted to N-DMT in black women, but not in white women. Although the data reported here are from a pilot study, it is important to note that significant racial differences in tamoxifen metabolism were observed with only a few participants. We urge other investigators to confirm these findings using a large population of breast cancer patients.

Journal Article↗
PubMed2000

Predictors of outcome in a primary care depression trial.

OBJECTIVE: Previous treatment trials have found that approximately one third of depressed patients have persistent symptoms. We examined whether depression severity, comorbid psychiatric illness, and personality factors might play a role in this lack of response. DESIGN: Randomized trial of a stepped collaborative care intervention versus usual care. SETTING: HMO in Seattle, Wash. PATIENTS: Patients with major depression were stratified into severe (N = 149) and mild to moderate depression (N = 79) groups prior to randomization. INTERVENTIONS: A multifaceted intervention targeting patient, physician, and process of care, using collaborative management by a psychiatrist and primary care physician. MEASUREMENTS AND MAIN RESULTS: Patients with more severe depression had a higher risk for panic disorder (odds ratio [OR], 5.8), loneliness (OR, 2.6), and childhood emotional abuse (OR, 2.1). Among those with less severe depression, intervention patients showed significantly improved depression outcomes over time compared with those in usual care (z = -3.06, P<.002); however, this difference was not present in the more severely depressed groups (z = 0.61, NS). Although the group with severe depression showed differences between the intervention and control groups from baseline to 3 months that were similar to the group with less severe depression (during the acute phase of the intervention), these differences disappeared by 6 months. CONCLUSIONS: Initial depression severity, comorbid panic disorder, and other psychosocial vulnerabilities were associated with a decreased response to the collaborative care intervention. Although the intervention was appropriate for patients with moderate depression, individuals with higher levels of depression may require a longer continuation phase of therapy in order to achieve optimal depression outcomes.

Adult↗
PubMed2000

Are there detectable differences in quality of care or outcome of depression across primary care providers?

OBJECTIVE: The objective of this work was to determine whether there are detectable differences among primary care physicians in measures of quality of care or clinical outcome for depressed patients during the first 2 months of treatment with antidepressant medication. METHODS: We studied 1,599 depressed primary care patients initiating antidepressant treatment from 63 family physicians in 4 primary care clinics of a staff-model health maintenance organization. Patients were interviewed 6 to 8 weeks after initiating antidepressant medication with a telephone structured interview that included the Structural Clinical Interview for DSM-IV Diagnoses (SCID). Automated databases of the HMO were used to examine 3 quality-of-care measures: (1) the percentage of patients who had a refill of their antidepressant by 6 weeks, (2) the percentage of patients who had a return visit by 3 weeks, and (3) the percentage of patients having a return visit by 6 weeks. The percentage of patients in each primary care physician panel who had > or =4 persistent DSM-IV depressive symptoms at 6 to 8 weeks was the main clinical outcome variable. To adjust for case-mix differences between physician panels, patient age, gender, and medical comorbidity were controlled for in the analyses. Two covariates were used to adjust for differences in patients' clinical severity: self-report of > or =2 prior depressive episodes and an SCID diagnosis of major depression during the patient's worst episode in the last 2 years. Physician age, gender, and part-time versus full-time practice were also used as covariates. RESULTS: The wide observed range of variability in quality-of-care and clinical outcome measures by physician practice decreased markedly in the statistical model that controlled for patient-level covariates and differences in the number of patients seen per provider. We did not detect differences in physician practice for the percentage of patients who had a return visit by 3 or 6 weeks, the percentage of patients who had a refill of their antidepressant prescription by 6 weeks, or the percentage of patients with an adverse clinical outcome of depression. CONCLUSIONS: We did not find important differences in measures of quality of care or patient outcomes by physician. These results may have implications for the use of physician profiling and other forms of physician report cards.

Adolescent↗
PubMed2000

The design, implementation, and acceptance of a primary care-based intervention to prevent depression relapse.

OBJECTIVE: This article describes the conceptual underpinnings, implementation, and participation rates of a twelve-month low-intensity primary care-based intervention to prevent depression relapse. The intervention was designed to address the inherent problems in delivery of effective maintenance treatment in a population based sample of primary care patients. METHODS: Patients at high risk of relapse based on psychiatric history who recovered from depression six to eight weeks after initiation of pharmacotherapy by their primary care physician were eligible; 194 were randomized to receive the intervention. The intervention combined education about depression, motivation-enhancing shared decision-making regarding the use of maintenance pharmacotherapy, and cognitive-behavioral strategies. The program included two visits with a Depression Prevention Specialist working in tandem with the primary care physician at the primary care clinic, with supervision and back up from a consulting psychiatrist, proactive follow-up telephone calls and mailed personalized feedback. RESULTS: Ninety-three percent of patients attended both in-person visits; 97 percent attended one visit. Eighty percent of patients completed all three follow-up telephone calls, and 85 percent returned at least one mailed feedback form; 48 percent returned all four forms. Offered a menu of options for self-management, most patients chose medication as well as a variety of behavioral strategies. At six months, 72 percent ofpatients and at twelve months 62 percent of patients remained on antidepressant medication. CONCLUSIONS: We conclude that it is feasible to integrate a low intensity, twelve-month relapse prevention intervention for depression into a primary care clinic.

Antidepressive Agents↗
PubMed1999

Effects of estrogen and estrogen-progestin on mammographic parenchymal density. Postmenopausal Estrogen/Progestin Interventions (PEPI) Investigators.

BACKGROUND: In longitudinal studies, greater mammographic density is associated with an increased risk for breast cancer. OBJECTIVE: To assess differences between placebo, estrogen, and three estrogen-progestin regimens on change in mammographic density. DESIGN: Subset analysis of a 3-year, multicenter, double-blind, randomized, placebo-controlled trial. SETTING: Seven ambulatory study centers. PARTICIPANTS: 307 of the 875 women in the Postmenopausal Estrogen/Progestin Interventions Trial. Participants had a baseline mammogram and at least one follow-up mammogram available, adhered to treatment, had not taken estrogen for at least 5 years before baseline, and did not have breast implants. INTERVENTION: Treatments were placebo, conjugated equine estrogens (CEE), CEE plus cyclic medroxyprogesterone acetate (MPA), CEE plus daily MPA, and CEE plus cyclic micronized progesterone (MP). MEASUREMENTS: Change in radiographic density (according to American College of Radiology Breast Imaging Reporting and Data System grades) on mammography. RESULTS: Almost all increases in mammographic density occurred within the first year. At 12 months, the percentage of women with density grade increases was 0% (95% CI, 0.0% to 4.6%) in the placebo group, 3.5% (CI, 1.0% to 12.0%) in the CEE group, 23.5% (CI, 11.9% to 35.1%) in the CEE plus cyclic MPA group, 19.4% (CI, 9.9% to 28.9%) in the CEE plus daily MPA group, and 16.4% (CI, 6.6% to 26.2%) in the CEE plus cyclic MP group. At 12 months, the odds of an increase in mammographic density were 13.1 (95% CI, 2.4 to 73.3) with CEE plus cyclic MPA, 9.0 (CI, 1.6 to 50.1) with CEE plus daily MPA, and 7.2 (CI, 1.3 to 40.0) with CEE plus cyclic micronized progesterone compared with CEE alone. CONCLUSIONS: Further study of the magnitude and meaning of increased mammographic density due to use of estrogen and estrogen-progestins is warranted because mammographic density may be a marker for risk for breast cancer.

Breast↗
PubMed1999

Stepped collaborative care for primary care patients with persistent symptoms of depression: a randomized trial.

BACKGROUND: Despite improvements in the accuracy of diagnosing depression and use of medications with fewer side effects, many patients treated with antidepressant medications by primary care physicians have persistent symptoms. METHODS: A group of 228 patients recognized as depressed by their primary care physicians and given antidepressant medication who had either 4 or more persistent major depressive symptoms or a score of 1.5 or more on the Hopkins Symptom Checklist depression items at 6 to 8 weeks were randomized to a collaborative care intervention (n = 114) or usual care (n = 114) by the primary care physician. Patients in the intervention group received enhanced education and increased frequency of visits by a psychiatrist working with the primary care physician to improve pharmacologic treatment. Follow-up assessments were completed at 1, 3, and 6 months by a telephone survey team blinded to randomization status. RESULTS: Those in the intervention group had significantly greater adherence to adequate dosage of medication for 90 days or more and were more likely to rate the quality of care they received for depression as good to excellent compared with usual care controls. Intervention patients showed a significantly greater decrease compared with usual care controls in severity of depressive symptoms over time and were more likely to have fully recovered at 3 and 6 months. CONCLUSIONS: A multifaceted program targeted to patients whose depressive symptoms persisted 6 to 8 weeks after initiation of antidepressant medication by their primary care physician was found to significantly improve adherence to antidepressants, satisfaction with care, and depressive outcomes compared with usual care.

Antidepressive Agents↗
PubMed1999

Journalling and the teaching of spirituality.

This paper examines the development of a teaching format suitable for teaching spirituality and spiritual care to a group of mature age nurses, all of whom are older than the age of 25 years. A teacher's journal was kept that assisted in the identification of classroom activities, which aided in relating these experiences to concepts and practices of adult learning. These principles of learning included the use of the students' preparedness to learn, respect for the student as a learner and the use of the group processes to facilitate the exchanges of experiences and learning between the educator and the students. Whilst these precepts were valuable as a means of resolving teaching concerns, it was the journal entries that identified the issues relating to the teaching process. Some of these issues were the use of student and educator experiences as a medium for reflection, the willingness of the educator to follow students' wishes to discuss apparently unrelated material, the facilitator will be apart from the group as well as part of the group, and the necessity for journal entries to be made as soon as possible after the completion of the class.

Adult↗
PubMed1999

Patterns of care for depressed older adults in a large-staff model HMO.

The authors examined automated pharmacy and visit data for 502 members of a large-staff model health maintenance organization (HMO) who had been diagnosed with depression and started on antidepressants by their primary-care providers. Older patients (age >/=60; n=110) were less likely than younger adults (age 18-59, n=110) to receive adequate doses of antidepressant medications for 30 or 90 days. Older adults were also less likely than younger adults to receive more than two primary-care visits for depression in the 12 weeks after receiving a new antidepressant prescription and were less likely to receive specialty mental health care in the 6 months after receiving a new antidepressant prescription.

Adolescent↗
PubMed1999

Can we get it right? Barriers to effective acute pain management with opioid analgesics.

Acute pain management is a complex process that requires nurses to rethink current practices. This paper details the barriers confronting nurses as they attempt to provide effective, acute pain management. An exploration of these barriers reveals the misconceptions commonly associated with opioid analgesic use and factors affecting pain assessment.

Acute Disease↗