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Clinical response and remission for the treatment of depression has been shown to be improved utilizing collaborative care management (CCM). Prior studies have indicated that the presence of mental health comorbidities noted by self-rated screening tools at the intake for CCM are associated with worsening outcomes; few have examined directly the impact of age on clinical response and remission. The hypothesis was that when controlling for other mental health and demographic variables, the age of the patient at implementation of CCM does not significantly impact clinical outcome, and that CCM shows consistent efficacy across the adult age spectrum. We performed a retrospective chart analysis of a cohort of 574 patients with a clinical diagnosis of major depression (not dysthymia) treated in CCM who had 6 months of follow-up data. Using the age group as a categorical variable in logistic regression models demonstrated that while maintaining control of all other variables, age grouping remained a nonsignificant predictor of clinical response (P ≥ 0.1842) and remission (P ≥ 0.1919) after 6 months of treatment. In both models, a lower Generalized Anxiety Disorder-7 score and a negative Mood Disorder Questionnaire score were predictive of clinical response and remission. However, the initial Patient Health Questionnaire-9 score was a statistically significant predictor only for clinical remission (P = 0.0094), not for response (P = 0.0645), at 6 months. In a subset (n = 295) of the study cohort, clinical remission at 12 months was also not associated with age grouping (P ≥ 0.3355). The variables that were predictive of remission at 12 months were the presence of clinical remission at 6 months (odds ratio [OR], 7.4820; confidence interval [CI], 3.9301-14.0389; P < 0.0001), clinical response (with persistent symptoms) (OR, 2.7722; CI, 1.1950-6.4313; P = 0.0176), and a lower initial Patient Health Questionnaire-9 score (OR, 0.9121; CI, 0.8475-0.9816; P = 0.0140). Our study suggests that using CCM for depression treatment may transcend age-related differences in depression and result in positive outcomes regardless of age.

Background: Frequent missed patient appointments in resident continuity clinic is a well-documented problem, but whether rates of missed appointments are disproportionate to standard academic practice, what patient factors contribute to these differences, and health care outcomes of patients who frequently miss appointments are unclear., Methods: The overall population for the study was composed of patients in an academic internal medicine continuity clinic with 5 or more office visits between January 2006 and December 2008. We randomly selected 325 patients seen by resident physicians and 325 patients cared for by faculty. Multivariate linear regression was used to examine the relationship between patient factors and missed appointments. Health outcomes were compared between patients with frequent missed appointments and the remainder of the study sample, using Cox regression analysis., Results: Resident patients demonstrated significantly higher rates of missed appointments than faculty patients, but this difference was explained by patient factors. Factors associated with more missed appointments included use of a medical interpreter, Medicaid insurance, more frequent emergency department visits, less time impanelled in the practice, and lower proportion of office visits with the primary care provider. Patients with frequent missed appointments were less likely to be up to date with preventive health services and more likely to have poorly controlled blood pressure and diabetes., Conclusions: We found that the disproportionate frequency of missed appointments in resident continuity clinic is explained by patient factors and practice discontinuity, and that patients with frequent missed appointments demonstrated worse health care outcomes.

Objective: Sex hormones underlie the lower incidence of cardiovascular disease in premenopausal women. Vascular inflammation is involved in the pathogenesis of several cardiovascular diseases and it has been reported that sex hormones modulate inflammatory responses but mechanisms responsible for these effects are not yet fully established. Herein, we assessed whether sex differences in leukocyte recruitment might exist and investigated the underlying mechanisms involved in this response., Methods and Results: Treatment with interleukin-1β (IL-1β) or tumor necrosis factor-α caused leukocyte rolling, adhesion, and emigration in mesenteric postcapillary venules in vivo that was substantially reduced in female mice compared with male mice; this difference was abolished by ovariectomy and partially restored by estrogen replacement. Deletion of endothelial nitric oxide (NO) synthase or cyclooxygenase-1 alone or in combination did not alter the leukocyte recruitment in IL-1β-treated females but significantly enhanced this response in male mice. Treatment of murine pulmonary endothelial cells with IL-1β increased expression of P-selectin in male but not female cells., Conclusions: We have demonstrated a profound estrogen-dependent and NO and prostacyclin-independent suppression of leukocyte recruitment in females.

In 2008, the Institute for Clinical Systems Improvement (ICSI) in Minnesota implemented a model of collaborative care management (CCM) for treatment of depression in primary care. This resulted in significant improvements on both clinical response and remission over usual care, although an increase in utilization metrics has been observed. Mental health comorbidities have previously been significantly associated with an increased likelihood of not responding to initial treatment. This retrospective study hypothesized that patients with mental health comorbidities are more likely to be associated with patients who were readmitted into CCM with recurrent depression. A total of 145 patients who had completed CCM were studied; of these, 32 were diagnosed with recurrent depression and were readmitted to CCM, and 113 were in remission for at least 4 months. There were no statistically significant demographic differences between the 2 groups. The initial screening GAD-7 score for anxiety was significantly increased in the readmission group (12.81 vs 9.20, P = .001) as was the average length of treatment from initial diagnosis to remission (168.09 vs 120.99 days, P = .002). All other initial screening tests were not different between the groups. When controlling for the independent variables by multiple logistic regression, the odds ratio for GAD-7 was 1.1156 (CI = 1.0.192 to 1.2212, P = .0177) and for days of treatment in CCM was 1.0123 (CI = 1.0041 to 1.0206, P = .0033). Patients who are readmitted to CCM for recurrent depression have a statistically increased risk of associated anxiety and a longer treatment course than those who have remained in remission for at least 4 months.

Background: acute otitis media (AOM) often occurs as a complication of upper respiratory tract infection (URI)., Objective: to describe otoscopic findings during URI, the full clinical spectrum of AOM, and outcome of cases managed with watchful waiting., Methods: : In a prospective study of 294 healthy children (6 months-3 years), characteristics of AOM complicating URI were studied. Otoscopic findings were categorized by tympanic membrane (TM) position, color, translucency, and mobility. Otoscopic score was assigned based on McCormick otoscopy scale (OS)-8 scale., Results: during days 1 to 7 of URI, otoscopic findings at 1114 visits were consistent with AOM in 22%; myringitis (inflamed TM, no fluid) was diagnosed in 7%. In AOM episodes diagnosed within 28 days of URI onset, TM position was described as: nonbulging (19%), mild bulging (45%), bulging (29%), and TM perforation occurred in (6%). OS-8 scale showed mild TM inflammation (OS, 2-3) in 6%, moderate (OS, 4-5) in 59%, and severe (OS, 6-8) in 35%. In 54% of 126 bilateral AOM episodes, inflammation of both TMs was at different stages. Of 28 cases of nonsevere AOM managed with watchful waiting, 4 progressed and 3 later required an antibiotic., Conclusions: AOM is a spectrum of infection that may present at various stages, even in the same child with bilateral disease. During URI, otoscopic changes are observed from the first day of onset. Understanding the wide clinical spectrum of AOM is needed to help with future clinical trial design and development of a scoring system to establish treatment criteria that will minimize antibiotic use.

The hypothesis for this paper is that adult patients who have higher screening scores for mental health co-morbidities and depression have a greater likelihood of not responding to treatment with collaborative care management (CCM) for their depression within six months.For the 334 patients in this study, the primary endpoints were if the patient was in remission at six months (PHQ-9 score <5) or if they were non-responsive (NR) (PHQ-9 >50% of baseline score). Initial evaluation included screening for alcoholism (AUDIT), anxiety (GAD-7) and bipolar disorders (MDQ).The differences in marital status, percentage of minority patients, gender, initial PHQ-9 and AUDIT scores were not statistically significant. Mood Disorders Questionnaire (MDQ) screening was more likely to be negative for the group in remission (96.2% vs 90.0%, P=0.049) and positive for the NR group (8.0% vs 2.1%, P=0.026). GAD-7 screening was significantly lower in the remission group (9.85) than in the NR group (11.53, P=0.009).Results of multiple logistic regression analysis demonstrated that age, gender, race, marital status, PHQ-9 score and AUDIT score were not related to the odds of being NR. A one-point higher GAD-7 score was associated with approximately 6% higher adjusted odds of being NR. Patients with a positive MDQ were associated with elevated odds of non-response (adjusted OR=3.4714, P=0.044) when controlling for all other variables.A higher initial screening score for anxiety or bipolar disorder is associated with a statistically significant increase in the relative risk of patients in CCM not responding to current treatments for depression within six months.

The collaborative care management (CCM) model has been demonstrated to be significantly more effective compared to usual care (UC) in depression management although an initial increase in cost measures was seen. In this paper, cost measures as well as clinical response were analyzed on patients with available follow-up data at six months. Records of 219 patients with follow-up data in CCM group and 119 in UC group were reviewed. At six months, there was a statistically significant clinical response rate among patients in CCM compared to UC group (P < 0.0001). Likewise, 65% in CCM group was "symptom-free" at 6 months vs. 31.9% in UC group (P < 0.0001). Among the responders in both groups, there was no statistical difference in cost measures. However, cost measures were significantly higher among non-responders compared to responders within CCM. Between the two models, the non-responders in UC had lower cost measures than the non-responders under CCM.

The high prevalence of no-shows in residents' primary care clinic acts as a barrier to continuity of care, results in loss of outpatient learning opportunities, and may result in more emergency department (ED) visits. The authors seek to identify if high rates of no-shows correlate with more ED visits. In a selected primary care internal medicine (PCIM) continuity clinic, 650 patients were randomly selected, with 325 patients each from the faculty and resident practices. The number of ED visits between January 1, 2006, and December 30, 2008, was recorded. Demographic characteristics of the population were obtained, and comparisons between the faculty and resident groups were performed using Student t test. Linear multiple regression analysis was performed to compare frequency of ED visits between the faculty and the resident groups, controlling for age, interpreter requirement, number of ED visits, proportion of no-shows, and insurance type. A P value <.05 was considered statistically significant. During 2006-2008, the average number of ED visits per patient in the faculty's practice was 2.1 compared with 4.1 in the resident's practice (P < .001). A multiple linear regression model showed that patients who had more ED visits were likely to be younger (P = .004), had shorter duration of care in the PCIM clinic (P < .001), and had a higher proportion of no-shows to the PCIM clinic (P < .001). There was no statistical difference between faculty and resident practice after adjusting for the above-mentioned variables. Shorter duration in the PCIM clinic and higher proportion of missed appointments were associated with more ED visits, but the use of interpreters and Medicaid insurance did not result in more ED visits. Future interventions are necessary to reduce the no-show rate in the clinic as this may result in a reduction of ED visits.

Neointimal hyperplasia (NIH) can lead to restenosis after clinical vascular interventions. NIH results from complex and poorly understood interactions between signaling cascades in the extracellular matrix and the disrupted endothelium, which lead to vessel occlusion. Quantitative trait loci (QTLs) were reported previously on rat chromosomes 3 and 6 through linkage analysis of postinjury NIH in midiliac arterial sections. In the current study, substitution mapping validated the RNO3 NIH QTL but not the RNO6 NIH QTL. The SHR.BN3 congenic strain had a 3-fold increase in the percentage of NIH compared with the parental spontaneously hypertensive rat strain. A double congenic study of RNO3+RNO6 NIH QTL segments suggested less than additive effects of these 2 genomic regions. To test the hypothesis that changes in vessel dynamics account for the differences in NIH formation, we performed vascular reactivity studies in the Brown Norway (BN), spontaneously hypertensive rat (SHR), SHR.BN3, and SHR.BN6 strains. De-endothelialized left common carotid artery rings of the SHR.BN3 showed an increased vascular responsiveness when treated with serotonin or prostaglandin F2(alpha), with significant differences in EC(50) and maximum effect (P<0.01) values compared with the spontaneously hypertensive rat parental strain. Because both vascular reactivity and percentage of NIH formation in the SHR.BN3 strain are significantly higher than the SHR strain, we postulate that these traits may be associated and are controlled by genetic elements on RNO3. In summary, these results confirm that the RNO3 NIH QTL carries the gene(s) contributing to postinjury NIH formation.

Rationale: Atherosclerotic lesions express matrix metalloproteinase (MMP)8, which possesses proteolytic activity on matrix proteins particularly fibrillar collagens and on nonmatrix proteins such as angiotensin (Ang) I., Objective: We studied whether MMP8 plays a role in atherogenesis., Methods and Results: In atherosclerosis-prone apolipoprotein E-deficient mice, inactivating MMP8 resulted in a substantial reduction in atherosclerotic lesion formation. Immunohistochemical examinations showed that atherosclerotic lesions in MMP8-deficient mice had significantly fewer macrophages but increased collagen content. In line with results of in vitro assays showing that Ang I cleavage by MMP8 generated Ang II, MMP8 knockout mice had lower Ang II levels and lower blood pressure. In addition, we found that products of Ang I cleavage by MMP8 increased vascular cell adhesion molecule (VCAM)-1 expression and that MMP8-deficient mice had reduced VCAM-1 expression in atherosclerotic lesions. Intravital microscopy analysis showed that leukocyte rolling and adhesion on vascular endothelium was reduced in MMP8 knockout mice. Furthermore, we detected an association between MMP8 gene variation and extent of coronary atherosclerosis in patients with coronary artery disease. A relationship among MMP8 gene variation, plasma VCAM-1 level, and atherosclerosis progression was also observed in a population-based, prospective study., Conclusions: These results indicate that MMP8 is an important player in atherosclerosis.

Many primary care physicians understand the challenges of taking care of patients with depression. Care management models for depression have been described as more effective than usual practice. The implementation of such a model requires a clinic manager to be able to predict how this new process might impact staffing and clinical demand. This study was designed to evaluate the initial impact of the implementation of a depression care manager (CM) model on the utilization of outpatient visits. The hypothesis is that the introduction of a CM model for depression in a primary care practice would be associated with an increased utilization of health care resources when compared to usual care (UC). There were 38 patients enrolled during the initial 2 months of implementation of the CM model. Using a retrospective medical record review, the CM population was compared to a similar group receiving UC (N = 49), and a significant increase in the percentage of patients who were seen for any reason in the CM population was found (65.8% vs. 36.7%, P = 0.01). The average CM patient had 1.24 outpatient visits for any reason vs. 0.69 for the UC group (P = 0.01). When specifically focusing on outpatient visits for depression, the CM group averaged 0.95 visits per patient as compared to the UC patients having 0.55 visits per patient (P = 0.04). This study suggests that the initial implementation of a CM model for treatment of depression will increase outpatient utilization. .

Although genetic determinants protecting against the development of elevated blood pressure (BP) are well investigated, less is known regarding their impact on longevity. We concomitantly assessed genomic regions of rat chromosomes 3 and 7 (RNO3 and RNO7) carrying genetic determinants of BP without known epistasis, for their independent and combinatorial effects on BP and the presence of genetic determinants of survival using Dahl salt-sensitive (S) strains carrying congenic segments from Dahl salt-resistant (R) rats. Although congenic and bicongenic S.R strains carried independent BP quantitative trait loci within the RNO3 and RNO7 congenic regions, only the RNO3 allele(s) independently affected survival. The bicongenic S.R strain showed epistasis between R-rat RNO3 and RNO7 alleles for BP under salt-loading conditions, with less-than-additive effects observed on a 2% NaCl diet and greater-than-additive effects observed after prolonged feeding on a 4% NaCl diet. These RNO3 and RNO7 congenic region alleles had more-than-additive effects on survival. Increased survival of bicongenic compared with RNO3 congenic rats was attributable, in part, to maintaining lower BP despite chronic exposure to an increased dietary salt (4% NaCl) intake, with both strains showing delays in reaching highest BP. R-rat RNO3 alleles were also associated with superior systolic function, with the S.R bicongenic strain showing epistasis between R-rat RNO3 and RNO7 alleles leading to compensatory hypertrophy. Whether these alleles affect survival by additional actions within other BP-regulating tissues/organs remains unexplored. This is the first report of simultaneous detection of independent and epistatic loci dictating, in part, longevity in a hypertensive rat strain.

Background: The design of new diagnostic tests would benefit from knowing patients' preferences for the collection of bodily fluids. These preferences, however, are unknown. The authors assessed patients' preferences for the collection of saliva, urine and blood as diagnostic fluids., Methods: The authors handed out surveys adult outpatients who sought treatment at two medical care sites and one dental care site at a medical center regarding the comfort, convenience and ease of collection of saliva, urine and blood for diagnostic testing., Results: A total of 413 surveys were completed. Subjects regarded the donation of saliva as more comfortable and convenient than that of blood or urine at the doctor's (physician's or dentist's) office, and they reported that saliva and urine are easiest to collect at home compared with blood. Male subjects and subjects who had ever donated saliva were more likely to perceive saliva donation in the doctor's office favorably. Subjects at all care sites regarded the donation of saliva as more comfortable and convenient than that of blood or urine; however, subjects at the dental care site perceived saliva donation more favorably than did subjects at the medical care sites. In addition, respondents said they were more willing to participate in research and medical testing if it required saliva donation rather than urine or blood collection., Conclusions: In terms of convenience and comfort, saliva compared well with blood and urine as a diagnostic fluid for clinical and research testing. Patients who sought care at both medical and dental sites shared these perceptions., Clinical Implications: Given strong patient preferences, saliva may be the fluid of choice for the development and implementation of patient-centered diagnostic tests in research and practice.

Primary care physicians are more likely to see patients with depression than with any other disorder except hypertension, and its management poses a challenge to busy primary care practices. The Patient Health Questionnaire-9, a simple self-administered tool of proven validity and reliability, is a commonly used screening instrument for depression in primary care practice. This review article provides a system-based approach to depression management using the Patient Health Questionnaire-9 to guide clinicians in the identification and treatment of depression and its follow-up care.

This article explores e government inequalities to searching Medicare and Medicaid information online. Telehealth, a branch of e government, can bring public health service and insurance information to the citizen. The Centers for Medicare and Medicaid Services website, among others, has critical information for potential beneficiaries and recipients of services. Using Pew survey data and multivariate regression analysis we find people in most need of Medicare and Medicaid information online (the elderly and poor) are accessing it, and people with years of online experience are strong proponents of online searches. Despite being less likely to have broadband services, individuals in rural areas were not found to be less likely to search for information online. In conclusion, some disparities are narrowing as the elderly and poor in need of access to public health insurance are searching for it online. However, people without Internet access and experience (perhaps the oldest and poorest) remain disadvantaged with respect to accessing critical information that can link them to needed health care services.

The multifaceted process of immune cell recruitment to sites of tissue injury is key to the development of an inflammatory response and involved in the pathogenesis of numerous cardiovascular disorders. We recently identified C-type natriuretic peptide (CNP) as an important endothelium-derived mediator that regulates vascular tone and protects against myocardial ischemia/reperfusion injury. Herein, we investigated whether CNP inhibits leukocyte recruitment and platelet aggregation and thereby exerts a potential antiinflammatory influence on the blood vessel wall. We assessed the effects of CNP on leukocyte-endothelial cell interactions in mouse mesenteric postcapillary venules in vivo in animals with high basal leukocyte activation (endothelial nitric oxide synthase knockout mice, eNOS(-/-)) or under acute inflammatory conditions (induced by interleukin-1beta or histamine). CNP suppressed basal leukocyte rolling in eNOS(-/-) mice in a rapid, reversible, and concentration-dependent manner. These effects of CNP were mimicked by the selective natriuretic peptide receptor-C agonist cANF(4-23). CNP also suppressed leukocyte rolling induced by IL-1beta or histamine, inhibited platelet-leukocyte interactions, and prevented thrombin-induced platelet aggregation of human blood. Furthermore, analysis of human umbilical vein endothelial cells, leukocytes, and platelets revealed that CNP selectively attenuates expression of P-selectin. Thus, CNP is a modulator of acute inflammation in the blood vessel wall characterized by leukocyte and platelet activation. These antiinflammatory effects appear to be mediated, at least in part, via suppression of P-selectin expression. These observations suggest that endothelial CNP might maintain an anti-atherogenic influence on the blood vessel wall and represent a target for therapeutic intervention in inflammatory cardiovascular disorders.

Background: Endothelium-dependent dilatation is mediated by 3 principal vasodilators: nitric oxide (NO), prostacyclin (PGI2), and endothelium-derived hyperpolarizing factor (EDHF). To determine the relative contribution of these factors in endothelium-dependent relaxation, we have generated mice in which the enzymes required for endothelial NO and PGI2 production, endothelial NO synthase (eNOS) and cyclooxygenase-1 (COX-1), respectively, have been disrupted (eNOS-/- and COX-1-/- mice)., Methods and Results: In female mice, the absence of eNOS and COX-1 had no effect on mean arterial blood pressure (BP), whereas BP was significantly elevated in eNOS-/-/COX-1-/- males compared with wild-type controls. Additionally, endothelium-dependent relaxation remained intact in the resistance vessels of female mice and was associated with vascular smooth muscle hyperpolarization; however, these responses were profoundly suppressed in arteries of male eNOS-/-/COX-1-/- animals. Similarly, the endothelium-dependent vasodilator bradykinin produced dose-dependent hypotension in female eNOS-/-/COX-1-/- animals in vivo but had no effect on BP in male mice., Conclusions: These studies indicate that EDHF is the predominant endothelium-derived relaxing factor in female mice, whereas NO and PGI2 are the predominant mediators in male mice. Moreover, the gender-specific prevalence of EDHF appears to underlie the protection of female eNOS-/-/COX-1-/- mice against hypertension.