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Introduction: A novel randomized controlled trial tested the efficacy of a technology-assisted case management program in a low income, rural population previously where nurses titrated medication over the phone instead of in a clinic. The primary analysis showed significant improvement in glycemic control at 6 months post-randomization decreasing hemoglobin A1c by 1%. This study aimed to test if the intervention was also effective at decreasing blood pressure without compromising quality of life. Methods: A total of 113 adults with poorly controlled diabetes (hemoglobin A1c ≥ 8%) were randomly assigned to the technology-assisted case management intervention or usual care. Participants received a 2-in-1 telehealth system to monitor glycemic and blood pressure control, which was uploaded daily to a central server. A nurse case manager was trained to titrate medication under physician supervision every 2 weeks based on the readings. Outcomes were blood pressure and quality of life (12-item Short-Form Health Survey) at 6 months. Baseline adjusted mixed models using a random intercept were used to evaluate change at 6 months for the technology-assisted case management intervention group compared to usual care. Results: There were no statistically significant differences in systolic blood pressure, physical component of quality of life, or mental component of quality of life between the technology-assisted case management and control group. However, there was a significant change in diastolic blood pressure over time, with the technology-assisted case management group decreasing at 6 months (p =.05), whereas the control group remained stable. Conclusions: Technology-assisted case management by a nurse with medication titration under physician supervision was efficacious in improving diastolic blood pressure without compromising quality of life in low-income rural adults with diabetes. [ABSTRACT FROM AUTHOR]

Objective: To examine rates of medical and psychiatric disorders among 187 female veterans recruited at four Veterans Affairs Medical Centers (VAMCs), the recognition of such disorders by VAMC care providers, and the use of relevant medical and mental health services by women both within and outside of the VA setting. Methods: We used a cross-sectional, epidemiological design incorporating self-report measures, structured interviews, and chart reviews to obtain relevant information for analyses. Results: Forty-four percent (43.9%) of women met criteria for at least one psychiatric disorder; 34.0% of these women met criteria for two or more additional psychiatric diagnoses, and concordance rates between interview and chart diagnoses were low. Ninety-five percent (95.2%) of women had a medical condition noted in their charts; 86.6% had two or more additional medical conditions, and a significant number of women had both medical and psychiatric diagnoses. Forty-four percent (43.9%) of women with an identified mental health condition received specialized mental health care by the VA in the past year. Conclusions: Findings from this study suggest that female veterans treated in VAMCs had significant medical and psychiatric problems, and these women might not be getting their health care needs adequately met through the VA health care system. In light of our findings, we discuss relevant implications and future directions for research. doi:10.1300/ J013v43n03_03 KEYWORDS. Primary care, female veterans, PTSD, service use, psychiatric status, medical functioning

To link to full-text access for this article, visit this link: http://dx.doi.org/10.1016/j.brat.2005.02.002 Byline: Todd B. Kashdan (a), B. Christopher Frueh (b), Rebecca G. Knapp (b), Renee Hebert (b), Kathryn M. Magruder (b) Keywords: Social anxiety disorder; Post-traumatic stress disorder; Veterans; Comorbidity; Suicidality; Specificity Abstract: To examine the prevalence and correlates of social anxiety disorder (SAD) in veterans, 733 veterans from four VA primary care clinics were evaluated using self-report questionnaires, telephone interviews, and a 12-month retrospective review of primary care charts. We also tested the concordance between primary care providers' detection of anxiety problems and diagnoses of SAD from psychiatric interviews. For the multi-site sample, 3.6% met criteria for SAD. A greater rate of SAD was found in veterans with than without post-traumatic stress disorder (PTSD) (22.0% vs. 1.1%), and primary care providers detected anxiety problems in only 58% of veterans with SAD. The elevated rate of comorbid psychiatric diagnoses and suicidal risk associated with SAD was not attributable to PTSD symptom severity. Moreover, even after controlling for the presence of major depressive disorder, SAD retained unique, adverse effects on PTSD diagnoses and severity, the presence of other psychiatric conditions, and suicidal risk. These results attest to strong relations between SAD and PTSD, the inadequate recognition of SAD in primary care settings, and the significant distress and impairment associated with SAD in veterans. Author Affiliation: (a) Department of Psychology, George Mason University, MS 3F5, Fairfax, VA 22030, USA (b) Medical University of South Carolina, USA Article History: Received 27 May 2004; Revised 30 January 2005; Accepted 16 February 2005

To examine the prevalence and correlates of social anxiety disorder (SAD) in veterans, 733 veterans from four VA primary care clinics were evaluated using self-report questionnaires, telephone interviews, and a 12-month retrospective review of primary care charts. We also tested the concordance between primary care providers' detection of anxiety problems and diagnoses of SAD from psychiatric interviews. For the multisite sample, 3.6% met criteria for SAD. A greater rate of SAD was found in veterans with than without post-traumatic stress disorder (PTSD) (22.0% vs. 1.1%), and primary cafe providers detected anxiety problems in only 58% of veterans with SAD. The elevated rate of comorbid psychiatric diagnoses and suicidal risk associated with SAD was not attributable to PTSD symptom severity. Moreover, even after controlling for the presence of major depressive disorder, SAD retained unique, adverse effects on PTSD diagnoses and severity, the presence of other psychiatric conditions, and suicidal risk. These results attest to strong relations between SAD and PTSD, the inadequate recognition of SAD in primary care settings, and the significant distress and impairment associated with SAD in veterans. Keywords: Social anxiety disorder; Post-traumatic stress disorder; Veterans; Comorbidity; Suicidality; Specificity

Black and white American men have similar death rates from coronary heart disease is the same for black and white Americans. A 30-year study of 2,181 people conducted in the southeastern United States surveyed blood pressure, blood cholesterol, level of education, diabetes status, and whether or not participants were smokers. Causes of death were coded according to the International Classification of Diseases manual. No women, white or black, were recorded as dying from heart disease between the ages of 35 and 44. When age was taken into account and all causes of death were evaluated, black women had a higher mortality rate than white women, but black men did not have a higher rate than white men. Variables associated with death from causes other than coronary heart disease were high cholesterol levels, high systolic blood pressure, diabetes and smoking. These variables were significant for all groups.

Although concerns have been expressed that mortality from coronary disease and all other causes is greater among Blacks than Whites, we hypothesized that, when socioeconomic status is adequately considered, mortality inequalities between Blacks and Whites are insignificant. The study population was a random sampling of Black and White men who were 35 years of age or older when recruited into the Charleston Heart Study in 1960. Education level and occupational status at baseline were used to compare mortality over the ensuming 28 years between Black and White men, who were classified as low or high socioeconomic status. In no instance were Black-White differences in all-cause or coronary disease mortality rates significantly different when socioeconomic status was controlled. We conclude that socioeconomic status is an important predictor of mortality and that, when socioeconomic status is considered, differences in Black-White mortality rates may be small. (Am J Public Health, 1992;82:1133-1136)

Abstract Background An estimated 1 in 3 American adults will have diabetes by the year 2050. Nationally, South Carolina ranks 10th in cases of diagnosed diabetes compared to other states. In adults, type 2 diabetes (T2DM) accounts for approximately 90-95% of all diagnosed cases of diabetes. Clinically, provider and health system factors account for < 10% of the variance in major diabetes outcomes including hemoglobin A1c (HbA1c), lipid control, and resource use. Use of telemonitoring systems offer new opportunities to support patients with T2DM while waiting to be seen by their health care providers at actual office visits. A variety of interventions testing the efficacy of telemedicine interventions have been conducted, but the outcomes have yielded equivocal results, emphasizing the shortage of controlled, randomized trials in this area. This study provides a unique opportunity to address this gap in the literature by optimizing two strategies that have been shown to improve glycemic control, while simultaneously implementing clinical outcomes measures, using a sufficient sample size, and offering health care delivery to rural, underserved and low income communities with T2DM who are seen at Federally Qualified Health Centers (FQHCs) in coastal South Carolina. Methods We describe a four-year prospective, randomized clinical trial, which will test the effectiveness of technology-assisted case management in low income rural adults with T2DM. Two-hundred (200) male and female participants, 18 years of age or older and with an HbA1c ≥ 8%, will be randomized into one of two groups: (1) an intervention arm employing the innovative FORA system coupled with nurse case management or (2) a usual care group. Participants will be followed for 6-months to ascertain the effect of the interventions on glycemic control. Our primary hypothesis is that among indigent, rural adult patients with T2DM treated in FQHC's, participants randomized to the technology-assisted case management intervention will have significantly greater reduction in HbA1c at 6 months of follow-up compared to usual care. Discussion Results from this study will provide important insight into the effectiveness of technology-assisted case management intervention (TACM) for optimizing diabetes care in indigent, rural adult patients with T2DM treated in FQHC's. Trial Registration National Institutes of Health Clinical Trials Registry (http://ClinicalTrials.gov identifier# NCT01373489

Abstract Background Older adults who live in rural areas experience significant disparities in health status and access to mental health care. "Telepsychology," (also referred to as "telepsychiatry," or "telemental health") represents a potential strategy towards addressing this longstanding problem. Older adults may benefit from telepsychology due to its: (1) utility to address existing problematic access to care for rural residents; (2) capacity to reduce stigma associated with traditional mental health care; and (3) utility to overcome significant age-related problems in ambulation and transportation. Moreover, preliminary evidence indicates that telepsychiatry programs are often less expensive for patients, and reduce travel time, travel costs, and time off from work. Thus, telepsychology may provide a cost-efficient solution to access-to-care problems in rural areas. Methods We describe an ongoing four-year prospective, randomized clinical trial comparing the effectiveness of an empirically supported treatment for major depressive disorder, Behavioral Activation, delivered either via in-home videoconferencing technology ("Telepsychology") or traditional face-to-face services ("Same-Room"). Our hypothesis is that in-homeTelepsychology service delivery will be equally effective as the traditional mode (Same-Room). Two-hundred twenty-four (224) male and female elderly participants will be administered protocol-driven individual Behavioral Activation therapy for depression over an 8-week period; and subjects will be followed for 12-months to ascertain longer-term effects of the treatment on three outcomes domains: (1) clinical outcomes (symptom severity, social functioning); (2) process variables (patient satisfaction, treatment credibility, attendance, adherence, dropout); and (3) economic outcomes (cost and resource use). Discussion Results from the proposed study will provide important insight into whether telepsychology service delivery is as effective as the traditional mode of service delivery, defined in terms of clinical, process, and economic outcomes, for elderly patients with depression residing in rural areas without adequate access to mental health services. Trial registration National Institutes of Health Clinical Trials Registry (ClinicalTrials.gov identifier# NCT00324701).

Abstract Background Approximately 30% of intubated preterm infants with respiratory distress syndrome (RDS) will fail attempted extubation, requiring reintubation and mechanical ventilation. Although ventilator technology and monitoring of premature infants have improved over time, optimal extubation remains challenging. Furthermore, extubation decisions for premature infants require complex informational processing, techniques implicitly learned through clinical practice. Computer-aided decision-support tools would benefit inexperienced clinicians, especially during peak neonatal intensive care unit (NICU) census. Methods A five-step procedure was developed to identify predictive variables. Clinical expert (CE) thought processes comprised one model. Variables from that model were used to develop two mathematical models for the decision-support tool: an artificial neural network (ANN) and a multivariate logistic regression model (MLR). The ranking of the variables in the three models was compared using the Wilcoxon Signed Rank Test. The best performing model was used in a web-based decision-support tool with a user interface implemented in Hypertext Markup Language (HTML) and the mathematical model employing the ANN. Results CEs identified 51 potentially predictive variables for extubation decisions for an infant on mechanical ventilation. Comparisons of the three models showed a significant difference between the ANN and the CE (p = 0.0006). Of the original 51 potentially predictive variables, the 13 most predictive variables were used to develop an ANN as a web-based decision-tool. The ANN processes user-provided data and returns the prediction 0–1 score and a novelty index. The user then selects the most appropriate threshold for categorizing the prediction as a success or failure. Furthermore, the novelty index, indicating the similarity of the test case to the training case, allows the user to assess the confidence level of the prediction with regard to how much the new data differ from the data originally used for the development of the prediction tool. Conclusion State-of-the-art, machine-learning methods can be employed for the development of sophisticated tools to aid clinicians' decisions. We identified numerous variables considered relevant for extubation decisions for mechanically ventilated premature infants with RDS. We then developed a web-based decision-support tool for clinicians which can be made widely available and potentially improve patient care world wide.

Objective We evaluated the impact of telemedicine-delivered behaviour activation treatment (BAT) on glycemic control in a subgroup of older adults with diabetes who participated in a randomized controlled trial for depression. Research design and methods We randomized older adults with major depression to same-room or telemedicine BAT. Each group received eight weekly sessions. For the subgroup analysis, we identified individuals with type 2 diabetes and obtained hemoglobin A1c at baseline and 12 months' follow-up. We used mixed-effects models (MEM) for repeated measures analysis to compare the longitudinal mean A1c. We estimated model-derived mean A1c values and considered an adjusted model to account for baseline health status. Results We included 90 individuals with type 2 diabetes of the original 241 in the subgroup analysis (43 in telemedicine and 47 in same room). Treatment groups were not significantly different at baseline for demographics, depression, anxiety or A1c levels (telemedicine 6.9 vs. same room 7.3, p = 0.19). Baseline mean A1c for the telemedicine group remained at 6.9 (55 mmol/mol) at 12 months, whereas baseline mean A1c for the same-room group increased to 7.7 (61 mmol/mol). Longitudinal trajectories of model-derived mean A1c indicated a significant main effect of treatment group on mean A1c value at study end (difference = -0.82, 95% CI -1.41, -0.24). Adjusted analyses gave comparable results. Conclusions Telemedicine-delivered BAT was superior to same room in achieving lower mean A1c values in participants with type 2 diabetes, suggesting BAT-delivered via telemedicine is a viable treatment option for adults with diabetes. [ABSTRACT FROM AUTHOR]

A medical school survey examined student and faculty willingness to use computers and the prevalence of the attitudes that computers in medicine are a potential threat to employment, neither convenient nor responsive to physicians' needs, and potentially debasing to the human role in medical practice. (MSE)

Objective: The Prolonging Remission in Depressed Elderly (PRIDE) study evaluated the efficacy of right unilateral ultrabrief pulse electroconvulsive therapy (ECT) combined with venlafaxine for the treatment of geriatric depression.Method: PRIDE was a two-phase multisite study. Phase 1 was an acute course of right unilateral ultrabrief pulse ECT, combined with open-label venlafaxine at seven academic medical centers. In phase 2 (reported separately), patients who had remitted were randomly assigned to receive pharmacotherapy (venlafaxine plus lithium) or pharmacotherapy plus continuation ECT. In phase 1, depressed patients received high-dose ECT (at six times the seizure threshold) three times per week. Venlafaxine was started during the first week of treatment and continued throughout the study. The primary outcome measure was remission, assessed with the 24-item Hamilton Depression Rating Scale (HAM-D), which was administered three times per week. Secondary outcome measures were post-ECT reorientation and safety. Paired t tests were used to estimate and evaluate the significance of change from baseline in HAM-D scores.Results: Of 240 patients who entered phase 1 of the study, 172 completed it. Overall, 61.7% (148/240) of all patients met remission criteria, 10.0% (24/240) did not remit, and 28.3% (68/240) dropped out; 70% (169/240) met response criteria. Among those who remitted, the mean decrease in HAM-D score was 24.7 points (95% CI=23.4, 25.9), with a mean final score of 6.2 (SD=2.5) and an average change from baseline of 79%. The mean number of ECT treatments to remission was 7.3 (SD=3.1).Conclusions: Right unilateral ultrabrief pulse ECT, combined with venlafaxine, is a rapidly acting and highly effective treatment option for depressed geriatric patients, with excellent safety and tolerability. These data add to the evidence base supporting the efficacy of ECT to treat severe depression in elderly patients. [ABSTRACT FROM AUTHOR]

Objective: The randomized phase (phase 2) of the Prolonging Remission in Depressed Elderly (PRIDE) study evaluated the efficacy and tolerability of continuation ECT plus medication compared with medication alone in depressed geriatric patients after a successful course of ECT (phase 1).Method: PRIDE was a two-phase multisite study. Phase 1 was an acute course of right unilateral ultrabrief pulse ECT, augmented with venlafaxine. Phase 2 compared two randomized treatment arms: a medication only arm (venlafaxine plus lithium, over 24 weeks) and an ECT plus medication arm (four continuation ECT treatments over 1 month, plus additional ECT as needed, using the Symptom-Titrated, Algorithm-Based Longitudinal ECT [STABLE] algorithm, while continuing venlafaxine plus lithium). The intent-to-treat sample comprised 120 remitters from phase 1. The primary efficacy outcome measure was score on the 24-item Hamilton Depression Rating Scale (HAM-D), and the secondary efficacy outcome was score on the Clinical Global Impressions severity scale (CGI-S). Tolerability as measured by neurocognitive performance (reported elsewhere) was assessed using an extensive test battery; global cognitive functioning as assessed by the Mini-Mental State Examination (MMSE) is reported here. Longitudinal mixed-effects repeated-measures modeling was used to compare ECT plus medication and medication alone for efficacy and global cognitive function outcomes.Results: At 24 weeks, the ECT plus medication group had statistically significantly lower HAM-D scores than the medication only group. The difference in adjusted mean HAM-D scores at study end was 4.2 (95% CI=1.6, 6.9). Significantly more patients in the ECT plus medication group were rated "not ill at all" on the CGI-S compared with the medication only group. There was no statistically significant difference between groups in MMSE score.Conclusions: Additional ECT after remission (here operationalized as four continuation ECT treatments followed by further ECT only as needed) was beneficial in sustaining mood improvement for most patients. [ABSTRACT FROM AUTHOR]