Walsh J.P.,Indiana University |
Walsh J.P.,Roudebush Veterans Affairs Medical Center |
Kitchens A.C.,Indiana University
Trends in Cardiovascular Medicine | Year: 2015
Endogenous testosterone levels are inversely associated with cardiovascular risk in older men and men with cardiovascular disease. Current data on cardiovascular outcomes of testosterone therapy include only observational studies and adverse event monitoring in short-term trials that were not designed to measure cardiovascular outcomes. These studies have yielded conflicting results, and some have raised concerns that testosterone therapy may increase cardiovascular risk. A well-designed, adequately powered, prospective trial will ultimately be required to clarify whether testosterone therapy impacts cardiovascular outcomes. This review describes the findings and limitations of recent studies of cardiovascular risk in older men on testosterone therapy and discusses some of the mechanisms through which testosterone may modify cardiovascular risk. © 2015 .
Doebbeling B.N.,Roudebush Veterans Affairs Medical Center |
Doebbeling B.N.,University of Indianapolis |
Doebbeling B.N.,Indiana University |
Flanagan M.E.,University of Indianapolis |
Flanagan M.E.,Indiana University
Medical Care | Year: 2011
Background: U.S. healthcare requires major redesign of its delivery systems, finances, and incentives. Healthcare operations, leadership, and payors are increasingly recognizing the need for community-business-research partnerships to transform healthcare. New models of continuous learning, research, and development should help focus and sustain redesign efforts. Purpose: This study summarizes suggested strategies for transformational change in healthcare and identifies needed areas for research to inform, spread, and sustain transformational change. Methods: We developed these recommendations based on a series of review papers, invited expert discussion, and a subsequent review in the context of a health system transformation research conference (The Regenstrief Biennial Research Conference). The multidisciplinary audience included health systems researchers, clinicians, informaticians, social and engineering scientists, and operational and business leaders. FINDINGS: Conference participants and literature reviews identified key strategies for system redesign with the following themes: using the framework of complex adaptive systems; fostering organizational redesign; developing appropriate performance measures and incentives; creating continuous learning organizations; and integrating health information, technology, and communication into practice. Sustained investment in research and development in these areas is crucial. Conclusions: Multiple issues influence the likelihood that healthcare leaders will make transformational changes in their healthcare systems. Healthcare leaders, clinicians, researchers, journals, and academic institutions, in partnership with payors, government and multiple other stakeholders, should apply the recommendations relevant to their own setting to redesign healthcare delivery, improve cognitive support, and sustain transformation. Fostering further research investments in these areas will increase the impact of transformation on the health and healthcare of the public. © 2011 by Lippincott Williams & Wilkins.
Chumbler N.R.,Roudebush Veterans Affairs Medical Center |
Chumbler N.R.,Indiana University – Purdue University Indianapolis |
Haggstrom D.,Roudebush Veterans Affairs Medical Center |
Haggstrom D.,Indiana University Center for Health Services and Outcomes Research |
And 2 more authors.
Medical Care | Year: 2011
The Institute of Medicine report, Crossing the Quality Chasm, called for significant improvements in 6 elements of healthcare performance: safety, effectiveness, patient centeredness, timeliness, efficiency, and equity. To meet the changing care needs of older veterans, many of whom are trying to manage the complexities of their chronic diseases in their own homes, the Veterans Health Administration (VHA) has promoted many of the Institute of Medicine elements by implementing health information technology (health IT), such as telehealth and a personal health record (PHR). To that end, approximately 5 years ago, VHA created the Office of Care Coordination and in particular a patient-centered Care Coordination/Home Telehealth (CCHT) program, which uses telehealth technologies (eg, messaging devices) to coordinate care directly from a patients home to help self-manage their chronic diseases. VHA has also developed a PHR, My HealtheVet, which is a secure web-based portal that provides veterans the capability to access and manage health information. This article discusses the mechanisms by which these forms of health IT have been implemented to improve access to care and improve health. For telehealth, we present the outcomes from some of the published literature. For PHRs, we outline what is known to date and future research directions. The article also examines some structural, policy-related, and organizational barriers to health IT implementation and offers suggestions for future research. © 2011 by Lippincott Williams & Wilkins.
Matthias M.S.,Roudebush Veterans Affairs Medical Center
Psychiatric rehabilitation journal | Year: 2012
Patient-centered communication has been linked to patient satisfaction, treatment adherence and outcomes. Shared decision making (SDM) has been advocated as an important and ethically essential aspect of patient-centered care, but SDM has received relatively little attention in mental health care, despite studies indicating that consumers want to be involved in making decisions. This is particularly important in a recovery-oriented system, where consumers are active participants in their treatment and rehabilitation. Because medication management is a key component of recovery from severe mental illnesses, this study explores how consumers and providers make decisions in medication management consultations. Four providers (3 psychiatrists, 1 nurse practitioner) and 40 consumers with severe mental illness (10 consumers per provider) were recruited from a community mental health center with a recovery-oriented focus. We directly observed 40 medication management appointments. Observations were audio recorded and transcribed. We used emergent thematic analysis to characterize decision making processes. Providers initiated most decisions, although they often invited consumers to participate in decision making. Decisions initiated by consumers elicited a greater degree of discussion and disagreement, but also frequently resulted in consumers' preferences prevailing. Consultations generally exhibited more characteristics of person-centeredness than SDM. While we observed a high degree of person-centeredness, SDM was not prevalent. Interventions helping consumers to take greater initiative when working with service providers may be helpful. For example, programs using tools such as peer instruction, Internet-based software, and individual case-manager instruction all have shown promise for enhancing SDM in mental health treatment. Further research is needed to determine the degree of SDM in other settings (e.g., with case managers) and the impact of SDM on consumers' recovery.
Kedlaya R.,Indiana University |
Veera S.,Indiana University |
Horan D.J.,Indiana University |
Horan D.J.,Roudebush Veterans Affairs Medical Center |
And 11 more authors.
Science Translational Medicine | Year: 2013
Osteoporosis pseudoglioma syndrome (OPPG) is a rare genetic disease that produces debilitating effects in the skeleton. OPPG is caused by mutations in LRP5, a WNT co-receptor that mediates osteoblast activity. WNT signaling through LRP5, and also through the closely related receptor LRP6, is inhibited by the protein sclerostin (SOST). It is unclear whether OPPG patients might benefit from the anabolic action of sclerostin neutralization therapy (an approach currently being pursued in clinical trials for postmenopausal osteoporosis) in light of their LRP5 deficiency and consequent osteoblast impairment. To assess whether loss of sclerostin is anabolic in OPPG, we measured bone properties in a mouse model of OPPG (Lrp5-/-), a mouse model of sclerosteosis (Sost-/-), and in mice with both genes knocked out (Lrp5 -/-;Sost-/-). Lrp5-/-;Sost-/- mice have larger, denser, and stronger bones than do Lrp5-/- mice, indicating that SOST deficiency can improve bone properties via pathways that do not require LRP5. Next, we determined whether the anabolic effects of sclerostin depletion in Lrp5-/- mice are retained in adult mice by treating 17-week-old Lrp5-/- mice with a sclerostin antibody for 3 weeks. Lrp5+/+ and Lrp5-/- mice each exhibited osteoanabolic responses to antibody therapy, as indicated by increased bone mineral density, content, and formation rates. Collectively, our data show that inhibiting sclerostin can improve bone mass whether LRP5 is present or not. In the absence of LRP5, the anabolic effects of SOST depletion can occur via other receptors (such as LRP4/6). Regardless of the mechanism, our results suggest that humans with OPPG might benefit from sclerostin neutralization therapies. Copyright 2013 by the American Association for the Advancement of Science; all rights reserved.
Goldzweig Dr. C.L.,Veterans Affairs Greater Los Angeles Healthcare System |
Orshansky Dr. G.,Veterans Affairs Greater Los Angeles Healthcare System |
Paige Dr. N.M.,Veterans Affairs Greater Los Angeles Healthcare System |
Towfigh Dr. A.A.,Veterans Affairs Greater Los Angeles Healthcare System |
And 4 more authors.
Annals of Internal Medicine | Year: 2013
Background: Patient portals tied to provider electronic health record (EHR) systems are increasingly popular. Purpose: To systematically review the literature reporting the effect of patient portals on clinical care. Data Sources: PubMed and Web of Science searches from 1January 1990 to 24 January 2013. Study Selection: Hypothesis-testing or quantitative studies of patient portals tethered to a provider EHR that addressed patient outcomes, satisfaction, adherence, efficiency, utilization, attitudes, and patient characteristics, as well as qualitative studies of barriers or facilitators, were included. Data Extraction: Two reviewers independently extracted data andaddressed discrepancies through consensus discussion. Data Synthesis: From 6508 titles, 14 randomized, controlled trials; 21 observational, hypothesis-testing studies; 5 quantitative, descriptive studies; and 6 qualitative studies were included. Evidence is mixed about the effect of portals on patient outcomes and satisfaction although they may be more effective when used with case management. The effect of portals on utilization and efficiency is unclear, although patient race and ethnicity, education level or literacy, and degree of comorbid conditions may influence use. Limitation: Limited data for most outcomes and an absence of reporting on organizational and provider context and implementation processes. Conclusion: Evidence that patient portals improve health outcomes, cost, or utilization is insufficient. Patient attitudes are generally positive, but more widespread use may require efforts to overcome racial, ethnic, and literacy barriers. Portals represent a new technology with benefits that are still unclear. Better understanding requires studies that include details about context, implementation factors, and cost. © 2013 American College of Physicians.
Hsueh C.-H.,Indiana University |
Chen N.X.,Indiana University |
Lin S.-F.,Indiana University |
Chen P.-S.,Indiana University |
And 5 more authors.
Journal of the American Society of Nephrology | Year: 2014
Patients with CKD have an increased risk of cardiovascular mortality from arrhythmias and sudden cardiac death. We used a rat model of CKD (Cy/+) to study potential mechanisms of increased ventricular arrhythmias. Rats with CKD showed normal ejection fraction but hypertrophic myocardium. Premature ventricular complexes occurredmore frequently in CKDrats than normal rats (42%versus 11%, P =0.18). By optical mapping techniques, action potential duration (APD) at 80% of repolarization was longer in CKD rats (78±4ms) than normal rats (63±3ms, P<0.05) at a 200-ms pacing cycle length. Calcium transient (CaT) duration was comparable. Pacing cycle length thresholds to induce CaT alternans or APD alternans were longer in CKD rats than normal rats (100±7 versus 80±3 ms and 93±6 versus 76±4 ms for CaT and APD alternans, respectively, P<0.05), suggesting increased vulnerability to ventricular arrhythmia. Ventricular fibrillation was induced in 9 of 12 CKD rats and 2 of 9 normal rats (P<0.05); early afterdepolarization occurred in two CKD rats but not normal rats. The mRNA levels of TGF-Β, microRNA-21, and sodium calcium-exchanger type 1 were upregulated, whereas the levels of microRNA-29, L-type calcium channel, sarco/endoplasmic reticulum calcium-ATPase type 2a, Kv1.4, and Kv4.3 were downregulated in CKD rats. Cardiac fibrosis was mild and not different between groups. We conclude that cardiac ion channel and calcium handling are abnormal in CKD rats, leading to increased vulnerability to early afterdepolarization, triggered activity, and ventricular arrhythmias. Copyright © 2014 by the American Society of Nephrology.
Bond G.R.,Dartmouth College |
Kukla M.,Roudebush Veterans Affairs Medical Center
Psychiatric Services | Year: 2011
Objective: The individual placement and support (IPS) model has helped clients with severe mental illness obtain competitive jobs, but questions have been raised whether job tenure is brief. This study examined job tenure over 24 months among clients of high-fidelity IPS enrolled between November 2005 and June 2007. Methods: Monthly data about job tenure were collected for 82 clients upon beginning competitive employment (prospective sample) and from 60 clients who had begun competitive employment in the preceding six months (retrospective sample). Results: The 142 clients worked a mean of 12.86 months overall and 9.96 months at their first job; compared with the prospective sample, the retrospective sample worked for more months (13.69 versus 11.02; p<.05) and worked more months at the first job (12.63 versus 8.01; p<.01). Conclusions: Job tenure among employed clients of high-fidelity IPS was twice as long as previously reported, and about 40% became steady workers over two years.
Moe S.M.,Indiana University |
Moe S.M.,Roudebush Veterans Affairs Medical Center |
Zidehsarai M.P.,Indiana University |
Chambers M.A.,Indiana University |
And 5 more authors.
Clinical Journal of the American Society of Nephrology | Year: 2011
Background and objectives: Patients with advanced chronic kidney disease (CKD) are in positive phosphorus balance, but phosphorus levels are maintained in the normal range through phosphaturia induced by increases in fibroblast growth factor-23 (FGF23) and parathyroid hormone (PTH). This provides the rationale for recommendations to restrict dietary phosphate intake to 800 mg/d. However, the protein source of the phosphate may also be important. Design, setting, participants, & measurements: We conducted a crossover trial in nine patients with a mean estimated GFR of 32 ml/min to directly compare vegetarian and meat diets with equivalent nutrients prepared by clinical research staff. During the last 24 hours of each 7-day diet period, subjects were hospitalized in a research center and urine and blood were frequently monitored. Results: The results indicated that 1 week of a vegetarian diet led to lower serum phosphorus levels and decreased FGF23 levels. The inpatient stay demonstrated similar diurnal variation for blood phosphorus, calcium, PTH, and urine fractional excretion of phosphorus but significant differences between the vegetarian and meat diets. Finally, the 24-hour fractional excretion of phosphorus was highly correlated to a 2-hour fasting urine collection for the vegetarian diet but not the meat diet. Conclusions: In summary, this study demonstrates that the source of protein has a significant effect on phosphorus homeostasis in patients with CKD. Therefore, dietary counseling of patients with CKD must include information on not only the amount of phosphate but also the source of protein from which the phosphate derives. Copyright © 2011 by the American Society of Nephrology.
Moe S.M.,Indiana University |
Moe S.M.,Roudebush Veterans Affairs Medical Center |
Saifullah A.,Indiana University |
LaClair R.E.,Indiana University |
And 2 more authors.
Clinical Journal of the American Society of Nephrology | Year: 2010
Background and objectives: The optimal treatment of secondary hyperparathyroidism in chronic kidney disease (CKD) is unknown. Design, setting, participants, & measurements: We conducted a randomized, blinded, 3-month trial in vitamin D-deficient CKD stage 3 and 4 patients with parathyroid hormone (PTH) values above the Kidney Disease Outcomes Quality Initiative target, comparing cholecalciferol (4000 IU/d x 1 month, then 2000 IU/d; n = 22) to doxercalciferol (1 μg/d; n = 25). Results: There was no difference in baseline demographics or lab tests, except a slightly higher estimated GFR (eGFR) in the doxercalciferol group. There was a significant increase in vitamin D level in the cholecalciferol group (14 ± 6 to 37 ± 10 ng/ml; P < 0.001) but no change in the doxercalciferol group. The PTH decreased by 27% ± 34% in the doxercalciferol group (P = 0.002) and decreased by 10% ± 31% in the cholecalciferol group (P = 0.16), but the difference between treatments was NS (P = 0.11). Similar results were found when absolute PTH change from baseline to end point was analyzed in a repeated-measures ANOVA model. The serum calcium and urine calcium excretions were not different. Additional non-mineral-related end points, albuminuria, and BP were evaluated, and although trends were present, this did not reach significance. Conclusions: This prospective, randomized trial demonstrated a within-group reduction in PTH in the doxercalciferol-treated patients but no significant difference between the doxercalciferol and cholecalciferol patients. Larger, long-term studies are needed to demonstrate efficacy of mineral-related and non-mineral-related end points and safety. Copyright © 2010 by the American Society of Nephrology.