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Rubenstein J.H.,Veterans Affairs Center for Clinical Management Research | Rubenstein J.H.,University of Michigan | Shaheen N.J.,University of North Carolina at Chapel Hill
Gastroenterology | Year: 2015

Esophageal adenocarcinoma (EAC) is rapidly increasing in incidence in Western cultures. Barrett's esophagus is the presumed precursor lesion for this cancer. Several other risk factors for this cancer have been described, including chronic heartburn, tobacco use, white race, and obesity. Despite these known associations, most patients with EAC present with symptoms of dysphagia from late-stage tumors; only a small number of patients are identified by screening and surveillance programs. Diagnostic analysis of EAC usually commences with upper endoscopy followed by cross-sectional imaging. Endoscopic ultrasonography is useful to assess the local extent of disease as well as the involvement of regional lymph nodes. T1a EAC may be treated endoscopically, and some patients with T1b disease may also benefit from endoscopic therapy. Locally advanced disease is generally managed with esophagectomy, often accompanied by neoadjuvant chemoradiotherapy or chemotherapy. The prognosis is based on tumor stage; patients with T1a tumors have an excellent prognosis, whereas few patients with advanced disease have long-term survival. © 2015 by the AGA Institute. Source

Rubenstein J.H.,Veterans Affairs Center for Clinical Management Research | Rubenstein J.H.,University of Michigan | Chen J.W.,University of Michigan
Gastroenterology Clinics of North America | Year: 2014

The prevalence of gastroesophageal reflux disease (GERD) symptoms increased approximately 50% until the mid-1990s, when it plateaued. The incidence of complications related to GERD including hospitalization, esophageal strictures, esophageal adenocarcinoma, and mortality also increased during that time period, but the increase in esophageal adenocarcinoma has since slowed, and the incidence of strictures has decreased since the mid-1990s. GERD is responsible for the greatest direct costs in the United States of any gastrointestinal disease, and most of those expenditures are for pharmacotherapy. Risk factors for GERD include obesity, poor diet, lack of physical activity, consumption of tobacco and alcohol, and respiratory diseases. © 2014. Source

Sripada R.K.,University of Michigan | Sripada R.K.,Veterans Affairs Center for Clinical Management Research | Garfinkel S.N.,Brighton and Sussex Medical School | Liberzon I.,University of Michigan
Frontiers in Human Neuroscience | Year: 2013

Convergent evidence suggests that individuals with posttraumatic stress disorder (PTSD) exhibit exaggerated avoidance behaviors as well as abnormalities in Pavlonian fear conditioning. However, the link between the two features of this disorder is not well understood. In order to probe the brain basis of aberrant extinction learning in PTSD, we administered a multimodal classical fear conditioning/extinction paradigm that incorporated affectively relevant information from two sensory channels (visual and tactile) while participants underwent fMRI scanning. The sample consisted of fifteen OEF/OIF veterans with PTSD. In response to conditioned cues and contextual information, greater avoidance symptomatology was associated with greater activation in amygdala, hippocampus, vmPFC, dmPFC, and insula, during both fear acquisition and fear extinction. Heightened responses to previously conditioned stimuli in individuals with more severe PTSD could indicate a deficiency in safety learning, consistent with PTSD symptomatology. The close link between avoidance symptoms and fear circuit activation suggests that this symptom cluster may be a key component of fear extinction deficits in PTSD and/or may be particularly amenable to change through extinction-based therapies. © 2013 Sripada, Garfinkel and Liberzon. Source

Levy H.,University of Michigan | Janke A.T.,Wayne State University | Langa K.M.,University of Michigan | Langa K.M.,Veterans Affairs Center for Clinical Management Research
Journal of General Internal Medicine | Year: 2015

Background: Among the requirements for meaningful use of electronic medical records (EMRs) is that patients must be able to interact online with information from their records. However, many older Americans may be unprepared to do this, particularly those with low levels of health literacy. Objective: The purpose of the study was to quantify the relationship between health literacy and use of the Internet for obtaining health information among Americans aged 65 and older. Design: We performed retrospective analysis of 2009 and 2010 data from the Health and Retirement Study, a longitudinal survey of a nationally representative sample of older Americans. Participants: Subjects were community-dwelling adults aged 65 years and older (824 individuals in the general population and 1,584 Internet users). Main Measures: Our analysis included measures of regular use of the Internet for any purpose and use of the Internet to obtain health or medical information; health literacy was measured using the Rapid Estimate of Adult Literacy in Medicine–Revised (REALM-R) and self-reported confidence filling out medical forms. Key Results: Only 9.7 % of elderly individuals with low health literacy used the Internet to obtain health information, compared with 31.9 % of those with adequate health literacy. This gradient persisted after controlling for sociodemographic characteristics, health status, and general cognitive ability. The gradient arose both because individuals with low health literacy were less likely to use the Internet at all (OR = 0.36 [95 % CI 0.24 to 0.54]) and because, among those who did use the Internet, individuals with low health literacy were less likely to use it to get health or medical information (OR = 0.60 [95 % CI 0.47 to 0.77]). Conclusion: Low health literacy is associated with significantly less use of the Internet for health information among Americans aged 65 and older. Web-based health interventions targeting older adults must address barriers to substantive use by individuals with low health literacy, or risk exacerbating the digital divide. © 2014, Society of General Internal Medicine. Source

Kahn J.M.,University of Pittsburgh | Cicero B.D.,University of Pittsburgh | Wallace D.J.,University of Pittsburgh | Iwashyna T.J.,University of Michigan | Iwashyna T.J.,Veterans Affairs Center for Clinical Management Research
Critical Care Medicine | Year: 2014

OBJECTIVE:: ICU telemedicine is a novel approach for providing critical care services from a distance. We sought to study the extent of use and patterns of adoption of this technology in U.S. ICUs. DESIGN:: Retrospective study combining a systematic listing of ICU telemedicine installations with hospital characteristic data from the Centers for Medicare and Medicaid Services. We examined adoption over time and compared hospital characteristics between facilities that have adopted ICU telemedicine and those that have not. SETTING:: U.S. ICUs. SETTING:: U.S. hospitals from 2002 to 2010. INTERVENTIONS:: None. MEASUREMENTS AND MAIN RESULTS:: The number of hospitals using ICU telemedicine increased from 16 (0.4% of total) to 213 (4.6% of total) between 2003 and 2010. The number of ICU beds covered by telemedicine increased from 598 (0.9% of total) to 5,799 (7.9% of total). The average annual rate of ICU bed coverage growth was 101% per year in the first four study years but slowed to 8.1% per year over the last four study years (p < 0.001 for difference in linear trend). Compared with non-adopting hospitals, hospitals adopting ICU telemedicine were more likely to be large (percentage with > 400 beds: 11.1% vs 3.7%, p < 0.001), teaching (percentage with resident coverage: 31.4% vs 21.9%, p = 0.003), and urban (percentage located in metropolitan statistical areas with more than 1 million residents: 45.3% vs 30.1%, p < 0.001). CONCLUSIONS:: ICU telemedicine adoption was initially rapid but recently slowed. Efforts are needed to uncover the barriers to future growth, particularly regarding the optimal strategy for using this technology most effectively and efficiently. © 2013 by the Society of Critical Care Medicine and Lippincott. Source

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