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PubMedDate not supplied

Treatment outcome of an outpatient treatment program for dually-diagnosed veterans: the Cincinnati Veterans Affairs Medical Center.

The Dual Diagnosis Clinic at the Cincinnati VA Medical Center is an integrated treatment program for veterans who have an Axis I psychiatric illness in addition to a substance dependence problem. With a high staff-to-patient ratio and an individualized approach, the DDC treats many dual diagnosis patients effectively. To demonstrate the effectiveness of this approach, an outcome study was conducted looking at the psychiatric emergency room visits, hospitalization rates, and the average length of stay for 557 DDC patients. Patients were divided into two groups: those who completed the assessment period, and those who did not. Equal periods of time before and after this assessment period were studied. Those who completed were more likely to have had fewer psychiatric emergency room visits (p < 0.000001) after the assessment period than before when compared to dropouts. The engaged group had the same or more hospital admissions after the assessment period than before, while the dropout group had fewer. This suggests that there is a significant disorder of engagement for the dual diagnosis populations, and that the first impact of successful treatment is engagement.

Ambulatory Care↗
PubMed2001

Clinical results of an investigation of paediatric upper limb myoelectric prosthesis fitting at the Quebec Rehabilitation Institute.

This study was designed to investigate the satisfaction level of young users of myoelectric prostheses who received an upper limb myoelectric prosthesis, to assess their dropout rate and to identify which factors influence the use or non-use of the upper limb myoelectric prosthesis in the eastern part of Quebec (Canada). The users were fitted between 1990 and 1999 at the Quebec Rehabilitation Institute, a major rehabilitation centre located in the province of Quebec. This rehabilitation centre provides cutting-edge expertise not only for the eastern part of Quebec, but also across the entire province, because it is one of only two highly specialised centres serving all of Quebec. A literature review was completed to compile the results obtained in other rehabilitation centres and to identify factors influencing the use or non-use of paediatric upper limb myoelectric prostheses. The Quebec User Evaluation of Satisfaction with Assistive Technology (QUEST) was used in order to assess the degree to which the children were satisfied with their prostheses. Eighteen (18) children were fitted and trained to use an upper limb myoelectric prosthesis. A total of 10 children and parents agreed to participate. Some 80% of participants said that they were satisfied with their prostheses. A dropout rate of 53% for the overall group (participants and non-participants) seems high compared with that of other studies. Recommendations linked to factors identified in the literature are made. The authors conclude that a multidisciplinary team and structured training and follow-up can improve the clinical results pertaining to all the factors proposed in the literature.

Adolescent↗
PubMed2006

Cognitive behavioural therapy for depression, panic disorder and generalized anxiety disorder: a meta-regression of factors that may predict outcome.

OBJECTIVE: To determine which factors impact on the efficacy of cognitive behavioural therapy (CBT) for depression and anxiety. Factors considered include those related to clinical practice: disorder, treatment type, duration and intensity of treatment, mode of therapy, type and training of therapist and severity of patients. Factors related to the conduct of the trial were also considered, including: year of study, country of study, type of control group, language, number of patients and percentage of dropouts from the trial. METHOD: We used the technique of meta-analysis to determine an overall effect size (standardized mean difference calculated using Hedges' g) and meta-regression to determine the factors that impact on this effect size. We included randomized controlled trials with a wait list, pill placebo or attention/psychological placebo control group. Study participants had to be 18 years or older and all have diagnosed depression, panic disorder (with or without agoraphobia) or generalized anxiety disorder (GAD). Outcomes of interest included symptom, functioning and health-related quality of life measures, reported as continuous variables at post-treatment. RESULTS: Cognitive behavioural therapy for depression, panic disorder and GAD had an effect size of 0.68 (95% CI=0.51-0.84, n=33 studies, 52 comparisons). The heterogeneity in the effect sizes was fully explained by treatment, duration of therapy, inclusion of severe patients in the trial, year of study, country of study, control group, language and number of dropouts from the control group. Disorder was not a significant predictor of the effect size. CONCLUSIONS: Cognitive behavioural therapy is significantly less effective for severe patients and trials that compared CBT to a wait-list control group found significantly larger effect sizes than those comparing CBT to an attention placebo, but not to a pill placebo. Further research is needed to determine whether CBT is effective when provided by others than psychologists and whether it is effective for non-English-speaking patient groups.

Anxiety Disorders↗
PubMed2004

Making inferences about projected completors in longitudinal studies.

In this article, we present methodology for making inferences about projected completors in the presence of attrition. The approach is motivated by a clinical trial that investigates a treatment for disability among individuals who sustain severe head injuries. Although most studies attempt to make inferences about the entire study population, our application poses important scientific questions targeting individuals who are likely to complete the study or to remain on protocol for a specified time period. We propose using measures of each individual's dropout inclination to identify projected completors and then building a stratified response model based on projected completion status. We present several prediction measures along with procedures for evaluating accuracy with respect to observed dropout. Estimation of model parameters proceeds using maximum likelihood and restricted maximum likelihood methods. We illustrate the utility of our proposed analysis by using the motivating disability data example.

Algorithms↗
PubMed2005

Radiolabeled lipiodol therapy for hepatocellular carcinoma in patients awaiting liver transplantation: pathology of the explant livers and clinical outcome.

BACKGROUND: Liver transplantation has become an important curative treatment option for hepatocellular carcinoma (HCC). Criteria for transplantation are strict and, therefore, it is crucial that patients awaiting transplantation do not suffer disease progression. One of the therapeutic options to achieve disease stabilization is neoadjuvant radiolabeled lipiodol treatment. This study aimed to document the dropout rate on the waiting list, the pathological findings on the explant livers, and the long-term outcome of patients treated with radionuclide therapy while awaiting transplantation. METHODS: Patients eligible for transplantation were treated with 2.1 GBq (131)I-lipiodol or 4.1 GBq (188)Re-HDD/lipiodol by transfemoral catheterization of the hepatic arteries. Tumor necrosis was assessed in the explant livers and follow-up data, such as dropout from the waiting list, recurrence, and survival following transplantation were retrospectively documented. RESULTS: In 5 of 22 explants, necrosis exceeded 90%. Two patients died while on the waiting list (10%) and 4 of 20 transplanted patients (20%) suffered recurrent disease. The overall recurrence-free survival was 19.7 months (range, 1.75-56), with a mean follow-up of 20.1 months. CONCLUSION: Our data support the evaluation on larger patient numbers to confirm the benefit of radiolabeled lipiodol in candidates for liver transplantation who are suffering from HCC.

Carcinoma, Hepatocellular↗
PubMed1995

Efficacies of dexfenfluramine and fluoxetine in preventing weight gain after smoking cessation.

We tested whether 14 wk of dexfenfluramine (30 mg) or fluoxetine (40 mg) treatment would prevent weight gain after subjects quit smoking. Normal-weight women (n = 144) were randomly assigned to drug or placebo on a double-blind basis for 2 wk before quitting smoking and 12 wk thereafter. The fluoxetine group had more dropouts (28/49, 57.1%) than the dexfenfluramine group (17/47, 36.2%), with an intermediate number of dropouts from the placebo group (21/48, 43.8%). All groups gained weight during treatment, but their amount and pattern of weight gain differed. In the first month after quitting smoking, the placebo group gained more weight than either the dexfenfluramine or fluoxetine group (P < 0.05). By 2 mo postcessation, dexfenfluramine still suppressed weight gain in comparison with placebo (P < 0.05); weight gain with fluoxetine was not differentiable from either dexfenfluramine or placebo. By 3 mo postcessation, the dexfenfluramine group had gained 1.0 +/- 0.7 kg, significantly less than either the placebo (3.5 +/- 0.7 kg) or fluoxetine (2.7 +/- 0.5 kg) groups. Three months after drug discontinuation, formerly medicated, but not placebo patients, showed additional weight gain, eliminating differences between groups. Results indicate that weight gain, an adverse accompaniment of smoking cessation, can be minimized to some degree by serotoninergic drugs, although only for the duration of drug treatment.

Adult↗
PubMed1998

Parents as the exclusive agents of change in the treatment of childhood obesity.

BACKGROUND: Excessive weight in childhood is a serious public health concern because of its costly health consequences and its increasing prevalence. OBJECTIVE: Our objective was to compare the efficacy of a family-based approach for the treatment of childhood obesity, in which the parents served as the exclusive agents of change, with that of the conventional approach, in which the children served as the agents of change. DESIGN: This study had a randomized, longitudinal prospective design and lasted 1 y. Sixty obese children aged 6-11 y were randomly allocated to the experimental (parents as agents of change) or control (children as agents of change) group. Anthropometric and biochemical measurements were determined at the start and end of the study. A sociodemographic questionnaire and a family eating and activity habits questionnaire were completed by both parents. Hour-long support and educational sessions were conducted by a clinical dietitian: 14 sessions for the parents in the experimental group and 30 sessions for the children in the control group. RESULTS: The dropout rate was nine times greater in the control group (n = 9) than in the experimental group (n = 1). Mean percentile weight reduction was significantly (P < 0.03) higher in children in the experimental group (14.6%) than in the control group (8.1%). CONCLUSIONS: Treatment of childhood obesity with parents as the exclusive agents of change was superior to the conventional approach, as indicated by the dropout rate and the percentage weight loss of the children during the 1-y intervention.

Adult↗
PubMed2005

Noninvasive genotyping and Mendelian analysis of microsatellites in African savannah elephants.

We obtained fresh dung samples from 202 (133 mother-offspring pairs) savannah elephants (Loxodonta africana) in Samburu, Kenya, and genotyped them at 20 microsatellite loci to assess genotyping success and errors. A total of 98.6% consensus genotypes was successfully obtained, with allelic dropout and false allele rates at 1.6% (n = 46) and 0.9% (n = 37) of heterozygous and total consensus genotypes, respectively, and an overall genotyping error rate of 2.5% based on repeat typing. Mendelian analysis revealed consistent inheritance in all but 38 allelic pairs from mother-offspring, giving an average mismatch error rate of 2.06%, a possible result of null alleles, mutations, genotyping errors, or inaccuracy in maternity assignment. We detected no evidence for large allele dropout, stuttering, or scoring error in the dataset and significant Hardy-Weinberg deviations at only two loci due to heterozygosity deficiency. Across loci, null allele frequencies were low (range: 0.000-0.042) and below the 0.20 threshold that would significantly bias individual-based studies. The high genotyping success and low errors observed in this study demonstrate reliability of the method employed and underscore the application of simple pedigrees in noninvasive studies. Since none of the sires were included in this study, the error rates presented are just estimates.

Animals↗
PubMed2000

Extensive injury of descending neurons demonstrated by retrograde labeling in a virus-induced murine model of chronic inflammatory demyelination.

Persistent Theiler's virus infection of SJL/J mice was used as a model to quantitatively assess the extent of descending neuron injury by chronic inflammatory demyelination of the spinal cord. By 9 months postinfection, inflammatory demyelinating lesions were present throughout the spinal cord, affecting up to 31% of the cross-sectional area of the ventrolateral columns. Axon dropout was evident in the lesions by electron microscopy and by quantitation of axons in normal-appearing white matter. Axon number in the ventrolateral columns at L1/L2 was reduced by 23% and total axon area was reduced by 37%, compared with uninfected mice. The most informative data on descending neuron injury, however, was a reduction in retrograde. Fluoro-Gold labeling. Labeling from T11/T12 of rubrospinal, reticulospinal/raphespinal, and vestibulospinal neurons was reduced by 60%, 70%, and 93%, respectively. Retrograde responses to axonal injury were observed, consisting of atrophied cell bodies, indented nuclei, and abundant lipofuscin, but cell body dropout was minimal. The number of cell bodies of vestibulospinal neurons was reduced by only 35%, whereas the number of cell bodies of rubrospinal neurons was unchanged. These results demonstrate that chronic inflammatory demyelination can severely injure axons and emphasize the need to design neuroprotective therapies in human multiple sclerosis.

Animals↗
PubMed2003

Predicting attrition in a pediatric asthma intervention study.

OBJECTIVES: To operationalize a comprehensive description of attrition, including pre-inclusion, dropout, and attrition due to intermittent missing data, and to test a predictive model of attrition using a data set from a randomized controlled intervention in pediatric asthma. METHODS: Participants included children, ages 4-12, diagnosed with asthma and their caregivers. Demographic variables and outcome measures of asthma morbidity were examined in 327 families to determine their association with attrition. RESULTS: Families who did not complete randomization and the intervention tended to have younger caregivers than did completers. Caregiver age emerged as the most consistent predictor of pre-inclusion and dropout attrition. There were no significant predictors of attrition due to intermittent missing data. CONCLUSION: Younger caregivers may be at particular risk for attrition in pediatric asthma intervention studies and warrant special attention by investigators.

Asthma↗
PubMed2006

Inherent high peritoneal transport and ultrafiltration deficiency: their mid-term clinical relevance.

BACKGROUND: High peritoneal transport has been associated with poorer outcome in peritoneal dialysis (PD) patients, but not necessarily because of PD-dependent conditions. Our primary objective was to analyse the influences of baseline peritoneal small solute transport and ultrafiltration (UF) capacity on patient and technique survival, after adjusting for comorbid conditions. A secondary objective was to determine whether high transport was associated with basal comorbidity. METHODS: In this prospective observational patient/technique survival study, we followed 410 patients who started PD. At the baseline, we collected data to define comorbidities, tally the Charlson index, determine the baseline mass transfer area coefficients (MTAC) of urea and creatinine, net UF, plasma albumin and residual renal function (RRF). No data other than the information on patient and technique survival were recorded after baseline. RESULTS: The mean follow-up was 33 +/- 28 months. Dropouts during the study were due to renal transplantation in 140 cases, death in 142 cases and transfer to haemodialysis (HD) in 77 cases. Patients with inherent UF deficiency, high transport rate or both were not significantly different in the survival analysis from the rest. In the Cox hazards analysis, only age, Charlson index and a lower RRF were the significant mortality risk factors. None of the baseline parameters studied was a predictor of technique failure. High transporter patients had lower plasma albumin and UF capacity, comorbidity and more frequent liver diseases than the rest. Moderate to severe liver disease (n = 14) was significantly associated with the inherent high transport status, but was never accompanied by UF failure (UFF). UFF patients showed higher RRF, creatinine-MTAC and age. CONCLUSIONS: Neither the high transport nor the inherent UFF status has any influence on patient and technique survival. The inherent high small solute transport status is associated with hypoalbuminaemia and a greater comorbidity index. The Charlson index, age and lower RRF are the only independent predictors of mortality. Technique dropout is not predicted by any of the variables studied at the baseline.

Aged↗
PubMed1997

Microvascular abnormalities in patients with vibration white finger.

In vivo nailfold capillary microscopy was performed on 10 men with vibration white finger (VWF) and 10 age-matched male controls. The observed nailfold capillaries required adaptation of Maricq's classifications and addition of new morphological scoring systems. These new classifications produced numerical scores for assessing capillary: dropout, tortuosity, elongation, visualization of subpapillary venular plexus, and the degree of disarrangement of nailfold capillary polarity. Application of these new scores showed, for the first time, a complex pattern of abnormal-nailfold capillaries in patients with VWF. Capillary dropout was evident in 7/10 patients, with an associated disarrangement in nailfold capillary polarity in five. All 10 controls had normal capillary morphology. Tortuosity of the capillary loops and elongation of their length was observed in 30% of patients. These significant morphological alterations seen in VWF suggest a local small-vessel vasculitis.

Adult↗
PubMed2000

False alarms and sensitivity of conventional pulse oximetry versus the Masimo SET technology in the pediatric postanesthesia care unit.

UNLABELLED: We compared the incidence and duration of false alarms (FA)and the sensitivity of conventional pulse oximetry (CPO) with Masimo Signal Extraction Technology (Masimo SET; Masimo Corporation, Irvine, CA) in children in the postanesthesia care unit. Disposable oximeter sensors were placed on separate digits of one extremity. Computerized acquisition of synchronous data included electrocardiograph heart rate, SpO(2), and pulse rate via CPO and Masimo SET. Patient motion, respiratory, and other events were simultaneously documented. SpO(2) tracings conflicting with clinical observations and/or documented events were considered false. These were defined as 1) Data dropout, complete interruption in SpO(2) data; 2) False negative, failure to detect SpO(2) </= 90% detected by another device or based on observation/intervention; 3) FA, SpO(2) </= 90% considered artifactual; and 4) True alarm (TA), SpO(2) </= 90% considered valid. Seventy-five children were monitored for 35 +/- 22 min/patient (42 h total). There were 27 TAs, all of which were identified by Masimo SET and only 16 (59%) were identified by CPO (P < 0.05). There was twice the number of FAs with CPO (10 vs 4 Masimo SET; P < 0.05). The incidence and duration of data dropouts were similar between Masimo SET and CPO. Masimo SET reduced the incidence and duration of FAs and identified a more frequent incidence of TAs compared with CPO. IMPLICATIONS: Pulse oximetry that incorporates Masimo Signal Extraction Technology (Masimo Corporation, Irvine, CA) may offer an advantage over conventional pulse oximetry by reducing the incidence of false alarms while identifying a higher number of true alarms in children in the postanesthesia care unit.

Anesthesia↗
PubMed1992

Early enteral feeding, compared with parenteral, reduces postoperative septic complications. The results of a meta-analysis.

This two-part meta-analysis combined data from eight prospective randomized trials designed to compare the nutritional efficacy of early enteral (TEN) and parenteral (TPN) nutrition in high-risk surgical patients. The combined data gave sufficient patient numbers (TEN, n = 118; TPN, n = 112) to adequately address whether route of substrate delivery affected septic complication incidence. Phase I (dropouts excluded) meta-analysis confirmed data homogeneity across study sites, that TEN and TPN groups were comparable, and that significantly fewer TEN patients experienced septic complications (TEN, 18%; TPN, 35%; p = 0.01). Phase II meta-analysis, an intent-to-treat analysis (dropouts included), confirmed that fewer TEN patients developed septic complications. Further breakdown by patient type showed that all trauma and blunt trauma subgroups had the most significant reduction in septic complications when fed enterally. In conclusion, this meta-analysis attests to the feasibility of early postoperative TEN in high-risk surgical patients and that these patients have reduced septic morbidity rates compared with those administered TPN.

Adult↗
PubMed2004

All cause mortality in the Swiss HIV Cohort Study from 1990 to 2001 in comparison with the Swiss population.

DESIGN: Mortality within the Swiss HIV Cohort Study for the years 1990-2001 was compared with the mortality of the general Swiss population. METHODS: Standardized mortality ratios (SMR) and life tables were calculated for strata defined by combinations of gender and HIV transmission group. The effect of dropouts was investigated with a sensitivity analysis and by analysing CD4 cell counts before dropout. RESULTS: During the study period 10 977 individuals had at least one cohort visit with a median observation time of 46 months. A total of 3630 patients died and 2290 dropped out. SMR decreased from 79.3 [95% confidence interval (CI), 77.2-81.5] before the introduction of highly active antiretroviral treatment (HAART) in 1996 to 15.3 (95% CI, 14.2-16.4) thereafter. For persons who acquired HIV infection by injecting drug use (IDUs), the SMR decreased from 98.2 (95% CI, 94.9-103.5) to 40.9 (95% CI, 37.0-44.8) after 1996; for all other HIV transmission groups the SMR decreased from 69.2 (95% CI, 66.9-71.6) to 9.4 (95% CI, 8.5-10.4). Thus, IDUs had significantly lower survival in comparison with other patient groups after 1996. Patients who had started HAART during the time period in which this treatment was available, had even lower SMRs. CONCLUSIONS: Although overall survival has improved considerably since the introduction of HAART, cohort life expectancy remains below that of the Swiss population. We noted, however, substantial differences in mortality among subgroups, and the results indicate that the additional risk related to injection drug use before 1996 had been masked by HIV-associated mortality.

Adolescent↗
PubMed1999

Long-term opioid analgesic therapy for severe refractory lumbar spine pain.

OBJECTIVES: To determine the effect of opioid analgesics on pain and function in patients with severe, refractory low back pain and to see if any benefits were sustained long term. DESIGN: Longitudinal evaluation was conducted in two stages. Stage I was an opioid trial, and stage II was long-term treatment. Treated patients were compared with dropouts and trial failures. OUTCOME MEASURES: Pain was measured by the Numerical Rating Scale (NRS) and function was measured by the Oswestry Low Back Disability Score (OSW). Outcomes were evaluated by patient questionnaire and therefore not subject to investigator bias. SETTING: Private office practice. METHODS: Patients were treated for 6-12 weeks with a long-acting or sustained-release opioid. Those who improved significantly were treated long term. The treatment group was compared with dropouts and failures. RESULTS: Thirty-three patients underwent opioid trial. Treatment was discontinued because of intolerable side effects in 5 patients. In the remaining 28, mean NRS improved from 8.6 to 5.9 (p < 0.001), and mean OSW improved from 64 to 54 (p < 0.001). There were 21 patients treated long term (mean, 32 months). NRS improved from 8.45 to 4.90 (p < 0.001), and OSW improved from 64 to 50 (p < 0.001). Two patients returned to work. The changes in pain and function in the treatment group were significantly better than the comparison group. There was no drug diversion, addictive behavior, or organ toxicity. Doses remained stable. CONCLUSION: Long-term opioid analgesic therapy is reasonable treatment for some well-selected patients with refractory low back pain who have failed all other forms of care.

Humans↗
PubMedDate not supplied

Frequency, reasons, and risk factors of entacapone discontinuation in Parkinson disease.

OBJECTIVES: To determine the rate of and identify reasons for discontinuation of entacapone treatment in Parkinson disease patients. METHODS: A retrospective study design was used, including medical record reviews and telephone call to the patient as needed. RESULTS: Two hundred and twenty-two Parkinson disease patients were started on entacapone over a period of 3 years. One hundred and twenty-two patients (56%) had discontinued the medication by the end of the follow up period. Reasons for discontinuation included lack of efficacy (46%), worsening of parkinsonian symptoms (28%), worsened cognition (20%), dyskinesia (17%), nausea (11%), diarrhea (9%), cost (4%), other side effect (8%), and other, non-medication related reasons (19%). Presence of wearing off at the time of initial treatment and male sex were associated with decreased dropout rates, while the presence of orthostatic hypotension increased the likelihood of discontinuation. Patient age, disease duration, Hoehn and Yahr stage, Unified Parkinson's Disease Rating Scale section II score, presence of dementia, hallucinations, dyskinesias, or depression, number of daily L-dopa doses, and concomitant treatment with dopamine agonists did not affect dropout rate. CONCLUSIONS: Lack of efficacy seems to be the main reason for entacapone discontinuation. Male patients with wearing off and no orthostatic hypotension seem to tolerate the medication better. Advanced disease stage, presence of cognitive dysfunction, and presence of dyskinesia should not necessarily preclude patients from being treated with entacapone, when otherwise indicated.

Aged↗
PubMed1991

Meibomian gland dysfunction in chronic blepharitis.

We examined 57 patients with symptoms of chronic blepharitis using meibomian gland expression, meibography, tear osmolarity, and the Schirmer's test. We also performed meibography on 20 normal patients free of chronic blepharitis. We found that 42 blepharitis patients (74%) had evidence of meibomian gland loss, whereas only four of 20 normal patients (20%) had any gland dropout. We performed cluster analysis on the data from the patients with blepharitis and found that these patients tended to fall into distinct groups with clinically relevant characteristics. We also found that tear osmolarity correlated positively with gland dropout (+0.413) and negatively with excreta volume (-0.499). This study demonstrates that an objective analysis of meibomian gland function may be used to assess chronic blepharitis and define subsets of blepharitis with measurable differences. It also supports the significance of meibomian gland dysfunction on tear osmolarity and the evaporative state of the eye.

Adult↗