Clinical Services

San Antonio, TX, United States

Clinical Services

San Antonio, TX, United States
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Klepser M.E.,Ferris State University | Klepser D.G.,University of Nebraska Medical Center | Dering-Anderson A.M.,University of Nebraska Medical Center | Morse J.A.,Meijer | And 2 more authors.
Journal of the American Pharmacists Association | Year: 2016

Objectives: To examine the effectiveness of collaborative physicianecommunity pharmacist programs to treat influenza-like illness (ILI) with respect to clinical outcomes and health care utilization. Design: Prospective multicenter cohort study. Setting: Fifty-five pharmacies in Michigan, Minnesota, and Nebraska. Patients: Adult patients presenting to the pharmacy with ILI during the 2013-14 influenza season (October 1, 2013 to May 30, 2014). Intervention: Pharmacists screened adult patients presenting with ILI, completed a brief physical assessment, performed a point-of-care rapid influenza diagnostic test (RIDT), and provided appropriate referral or treatment per an established collaborative practice agreement (CPA) with a licensed prescriber. Pharmacists followed-up with patients 24 to 48 hours after the encounter to assess patient status and possible need for further intervention. Main outcome measures: Number of patients screened, tested, and treated for influenza. Results: Of the 121 patients screened, 45 (37%) were excluded and referred to their primary care provider or an urgent care facility for management. Of the 75 patients (62%) eligible for participation, 8 (11%) had a positive RIDT and were managed according to the CPA. Of the patients tested, 34.6% had no primary care physician and 38.7% visited the pharmacy outside of normal office hours. Only 3% of patients reported feeling worse at follow-up. Conclusion: This study describes a physician-pharmacist collaborative model for treating ILI. Using an evidence-based CPA, pharmacists were able to provide timely treatment to patients with and without influenza. © 2016 American Pharmacists Association®.

Beckmann K.R.,University of Adelaide | Roder D.M.,University of South Australia | Hiller J.E.,Australian Catholic University | Farshid G.,Clinical Services | Lynch O.W.,University of Adelaide
Journal of Medical Screening | Year: 2013

Objectives: There is considerable interest in whether mammography screening leads to over-diagnosis of breast cancer. However self-selection into screening programmes may lead to risk differences that affect estimates of over-diagnosis. This study compares the breast cancer risk profiles of participants and non-participants of population-based mammography screening. Risk profiles are also compared between those who have and have not used private screening services. Setting: This study involved 1162 women aged 40-84 who participated in the 2012 Health Omnibus, an annual face-to-face interview-based survey of a representative sample of the population in the state of South Australia. Methods: Data were collected on participation in mammography screening, demographic characteristics and breast cancer risk factors (including reproductive, familial and lifestyle factors). Missing data were multiply imputed. Factors independently associated with ever having been screened were identified using multivariable logistic regression, for population-based and ad hoc, private mammography screening separately. Results: Compared with non-participants, participants of population-based screening were more likely to have used hormone replacement therapy (odds ratio [OR] 1/4 3.72), experienced breast biopsy or surgery (OR 1/4 2.22), and be overweight or obese (OR 1/4 1.57). They were less likely to be sufficiently active (OR 1/4 0.57) or be born in a non-English speaking country (OR 1/4 0.50) or aged under 50 (OR 1/4 0.09). Women who were screened privately were more likely to have a family history of breast cancer (OR 1/4 1.66) and have experienced breast biopsy or surgery (OR 1/4 3.17) than those who had not. Conclusions: South Australian women who participated in the population-based mammography screening have a slightly higher prevalence of breast cancer risk factors. This also applies to those who undertook private screening.

Beckmann K.R.,University of Adelaide | Farshid G.,Clinical Services | Roder D.M.,University of South Australia | Hiller J.E.,Australian Catholic University | Lynch J.W.,University of Adelaide
Cancer Causes and Control | Year: 2013

Purpose: This study aims to measure the impact of HRT use at the time of screening on rates of screen-detected invasive breast cancer (IBC) and ductal carcinoma in situ (DCIS), interval cancers and investigative procedures, within a well-established population-based mammography screening program. Methods: Using South Australian BreastScreen data from 1998 to 2009 pertaining to 819,722 screening episodes, Poisson regression models were undertaken to estimate the incidence risk ratios (IRR) for various screening outcomes at both the first and subsequent screening rounds, among women who had been using HRT in the 6 months prior to screening compared with those who had not. Results: Current HRT use was associated with increased risk of recall for assessment, biopsy procedures, and breast cancer diagnosis among BreastScreen participants. Risk of screen-detected breast cancer was increased at subsequent screening rounds (IRR = 1.30, 95 % confidence interval 1.18-1.34), but not at women's first screening round (1.05, 0.88-1.25). This increased risk applied to IBC (1.35, 1.27-1.45), but not to DCIS (1.04, 0.89-1.23). Interval cancer risk was elevated among HRT users following both the first screen (1.77, 1.33-2.37) and subsequent screening episodes (1.92, 1.72-2.15). Conclusions: Increased risks of recall, biopsy rates, screen-detected, and interval cancers among HRT users have important implications for population-based breast cancer screening programs. Our findings support the concept that HRT use may increase the growth of preexisting cancers. Lack of effect on DCIS could imply different etiology or time frames for DCIS and IBC development or increased transition from preinvasive to invasive disease due to HRT use. © 2013 Springer Science+Business Media Dordrecht.

Beckmann K.R.,University of Adelaide | Roder D.M.,University of South Australia | Hiller J.E.,Clinical Services | Farshid G.,University of Adelaide | Lynch J.W.,University of Adelaide
Asian Pacific Journal of Cancer Prevention | Year: 2014

Purpose: To examine breast cancer (BC) incidence trends in relation to mammographic screening and risk factor prevalence in South Australia (SA). Materials and Methods:Trends in annual BC incidence rates were calculated using direct standardisation and compared with projected incidence derived from Poisson regression analysis of pre-screening rates. Annual percentage change and change time points were estimated using Joinpoint software. Biennial mammography screening participation rates were calculated using data from BreastScreen SA. Trends in overweight/obesity, alcohol use and hormone replacement therapy (HRT) use were examined using 1991-2009 Health Omnibus Survey data. Trends in total fertility were examined using data from the Australian Bureau of Statistics. Results: BC incidence increased around the time BreastScreen commenced and then stabilised in the mid-1990s. However rates have remained higher than projected, even though the proportion and age distribution of first time screening attendees stabilised around 1998. A decrease in BC incidence was observed among women aged 50-59yrs from the late-1990's but not among older women. Obesity and alcohol use have increased steadily in all age groups, while HRT use declined sharply from the late-1990s. Conclusions: BC incidence has remained higher than projected since mammography screening began. The sustained elevation is likely to be due to lead time effects, though over-diagnosis cannot be excluded. Declining HRT use has also impacted incidence trends. Implications: Studies using individual level data, which can account for changes in risk factor prevalence and lead time effects, are required to evaluate 'over-diagnosis' due to screening.

Finley P.R.,University of California at San Francisco | Bluml B.M.,APhA Foundation | Bunting B.A.,Clinical Services | Kiser S.N.,Community Health Enhancement and Health Education Center
Journal of the American Pharmacists Association | Year: 2011

Objective: To assess the clinical and economic impact of a pharmacist-focused health management program for patients with depression. Design: Prospective, nonrandomized, proof-of-concept investigation. Setting: Asheville, NC, from July 2006 through December 2007. Participants: Employees or adult dependents with depressive symptoms who agreed to enroll in an employer-sponsored treatment program conducted at two ambulatory clinics where consultative services were provided. Participants were included in the analysis if they participated in the program for at least 1 year and had two or more documented visits with a pharmacist. Intervention: Outpatient-based pharmacists provided assessment, self-management services follow-up, and treatment recommendations to primary care providers within a collaborative care management model. Main outcome measures: Changes in severity of depressive symptoms and impact on overall health care costs for employers and beneficiaries. Results: Of the 151 beneficiaries referred to the program, 130 (82%) remained under pharmacist care for a minimum of 1 year and were included in the aggregate analysis. Statistically significant improvements were observed for Patient Health Questionnaire (PHQ)-9 scores from baseline to endpoint (11.5 ± 6.6 to 5.3 ± 4.7 [mean ± SD], P < 0.0001). The clinical response rate was 68% with a 56% remission rate. In economic subgroup analysis (n = 48), annual medical costs decreased from an average of $6,351 per enrollee to $5,876, which was lower than the projected value ($7,195). Total health care costs to the employer increased from $7,935 per enrollee to $8,040, which was lower than the projected value ($9,023). Conclusion: Patients in the first year of the program had significant improvement in the PHQ-9 clinical indicator of depression severity. Total health care costs per patient per year were reduced compared with projected costs without the program. Employers expressed their appreciation for this collaborative care program and continued to offer this voluntary health benefit after the study's conclusion.

Evans A.M.,La Trobe University | Evans A.M.,University of Auckland | Perveen R.,Clinical Services | Ford-Powell V.A.,LAMB Project | Barker S.,Royal Aberdeen Childrens Hospital
Journal of Foot and Ankle Research | Year: 2014

Background: 'Walk for Life' (WFL) is the sustainable clubfoot program in Bangladesh, where there are many challenges in implementing the Ponseti technique in a poor and highly populated country. The relapsing tendency of congenital clubfoot deformity means that initial results may well differ from those of the medium and longer term. Over 10000 children with16668 clubfeet have been treated by WFL since its inception in 2009. Such a large project provides both the need to evaluate each individual child's case, and also the opportunity to evaluate the wider WFL program results. Such systematic review requires a measure that is sufficiently robust, yet contextually practical, hence the aim of this work was to develop a tool for this purpose, and to report the examiner reliability.Methods: The Bangla clubfoot tool was largely developed from components of existing validated clubfoot assessment measures, and adapted for local use. Three areas of examination are included: parent satisfaction, gait, clinical examination of the clubfoot. A same-subject repeated measures study design was used to assess the intra-rater reliability of a local WFL physiotherapist, and a visiting WFL volunteer. The inter-rater reliability was also assessed, which is relevant for other examiners and other clubfoot projects undertaking evaluation of medium and longer term results.Results: The reliability study was conducted in 37 children who had commenced treatment for congenital clubfoot deformity using Ponseti method within the previous two years. The mean age of the children was 2.6 years, with gender 28 male: 9 female. The intra-rater reliability results [ICCs (95% CI)] were: 0.87 (0.76 - 0.93) for the local WFL examiner, and 0.82 (0.64 - 0.91) for the visiting examiner. Inter-rater reliability results [ICCs (95% CI)] were: 0.92 (0.88 - 0.96). Hence the tool showed very good intra-rater and inter-rater reliability, rendering it suitable for use.Conclusions: The Bangla clubfoot tool has been developed to suit the context of the large WFL clubfoot program in Bangladesh, and shown to be a very reliable evaluation instrument. © 2014 Evans et al.; licensee BioMed Central Ltd.

Ford-Powell V.A.,Walk for Life Ponseti | Barker S.,Royal Aberdeen Childrens Hospital | Khan M.S.I.,Clinical Services | Evans A.M.,University of Auckland | And 2 more authors.
Journal of Pediatric Orthopaedics | Year: 2013

Background: Bangladesh is one of the most populous countries in the world at 160 million with 1/3 existing below the poverty line. With an annual birth rate of approximately 3.2 million, an estimated incidence of 1:900 live births, the country has approximately 5000 new cases of idiopathic congenital talipes equinovarus per annum. The Bangladesh sustainable clubfoot program, Walk for Life (WFL), was conceived to respond to this unmet need. Methods: WFL started in 2009 and has rapidly grown to 35 clinics. Overseas experts initially increased local capacity by training a team of national paramedical staff. Government support enabled integration with the public hospital system and enhanced sustainability. WFL has supplied materials, educational, administrative, and clinical support throughout. All recruited cases underwent Ponseti casting. Demographic, Pirani scores, cast, tenotomy, and bracing data have been prospectively collected from all patients. Detailed review has been undertaken for 1040 patients after 12 months of treatment in 3 divisions of Bangladesh. Results: Between 2009 and 2011, 6069 feet (3922 patients) were recruited to the project. Of these 1643 feet (1040 patients) have completed a minimum of 1-year follow-up. The male:female ratio was 2.7:1 with a mean age of 22 months at presentation (range, 0 to 36). Typical idiopathic congenital talipes equinovarus responded in a median of 5 casts (range, 1 to 25) with 76% undergoing tenotomy. Thirteen percent were atypical feet requiring a median of 5 casts. The percentage of patients missing at the 12-month point was 12%. Two percent of patients experienced complications. Conclusions: The Bangladesh clubfoot program demonstrates that rapid case ascertainment is possible in a developing world setting with appropriate logistical support. The use of local physiotherapists and paramedics yielded good clinical outcomes in an environment with full access to clinical review and ongoing training. A higher than expected number of atypical cases have been noted, requiring modified Ponseti treatment. Complications have been few at this early stage. Copyright © 2013 by Lippincott Williams & Wilkins.

Chitre M.,Clinical Services | Shechter D.,Scientific Affairs | Grauer A.,Amgen Inc.
American Journal of Health-System Pharmacy | Year: 2011

Purpose. The pharmacologic properties, clinical efficacy, and safety profile of the injectable agent denosumab for the treatment of postmenopausal women with osteoporosis are reviewed. Summary. Denosumab, a human monoclonal antibody that targets a key protein mediator of bone resorption, was approved by the Food and Drug Administration in June 2010 for the treatment of postmenopausal women with osteoporosis who are at high risk for fracture, including "patients who have failed or are intolerant to other available osteoporosis therapy." Available in a 60-mg prefilled syringe, denosumab should be administered subcutaneously by a health care professional at six-month intervals. In Phase III clinical efficacy trials involving nearly 10,000 postmenopausal women, the use of denosumab was associated with a number of significant benefits: reduced bone resorption, increased bone mass, and reduced rates of vertebral, nonvertebral, and hip fractures. Results of two comparison studies indicated that denosumab therapy increased bone mineral density (BMD) at various skeletal sites to a significantly greater extent than alendronate therapy. In the largest clinical trial of the drug to date, adverse effects occurring significantly more often with denosumab versus placebo included eczema-related effects and cellulitis; long-term safety evaluations are ongoing. Conclusion. Denosumab has been shown to decrease bone resorption; increase BMD at all skeletal sites measured; and significantly reduce rates of vertebral, nonvertebral, and hip fractures in postmenopausal women with osteoporosis. Denosumab appears to have a favorable risk:benefit profile and provides a new treatment option for many patients in this population. Copyright © 2011, American Society of Health-System Pharmacists, Inc. All rights reserved.

Harrop E.,Paediatric Palliative Care | Edwards C.,Clinical Services
Archives of Disease in Childhood: Education and Practice Edition | Year: 2013

Specialist paediatric palliative care is a relatively new area of paediatrics, and the interface with other disciplines can occasionally pose challenges for referrers due to lack of information about the diverse services available. Although services vary on a regional basis, there are common principles which may be used to guide and support referrals. Children may be referred to palliative care services via a number of routes from community-based primary care to regional tertiary centres. Identifying those most likely to benefit from the finite resources available can be a challenge, and healthcare professional's negative attitudes to palliative care have been further identified as a potentially modifiable barrier. This article aims to clarify the role of specialist paediatric palliative care, identify who should be eligible for such care, describe the services available (including those from children's hospices) and provide a tool for assessing some of the most challenging referrals. Many of the documents referenced can be downloaded from the Together for Short Lives website, and in many cases, there is no charge.

Brown Jr. J.S.,Clinical Services | Brown Jr. J.S.,Virginia Commonwealth University
Schizophrenia Bulletin | Year: 2011

The author previously described a theoretical cause of schizophrenia based on the effects of estrogenic endocrine disruption. In the current review, the author describes how increased estrogen during pregnancy increases susceptibility to certain viral infections associated with increased risk for schizophrenia. The review further discusses how prenatal estrogen exposure could explain associations of schizophrenia with autoimmune diseases, urban environments, and stress. Based on the association of increased estrogen with schizophrenia risk factors, the author proposes increased prenatal estrogen as a unifying factor, perhaps the primary event, in the etiology of schizophrenia. © 2011 The Author.

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