Development of a Telehealth Intervention to Improve Access to Live Donor Kidney Transplantation.

BACKGROUND: Live donor kidney transplantation (LDKT) is underutilized by patients with end-stage kidney disease due to knowledge, communication, and logistical barriers. MATERIAL AND METHODS: The Talking About Live Kidney Donation Social Worker Intervention (TALK-SWI) is a previously validated intervention demonstrated to improve patients' access to and pursuit of LDKT through in-person delivery of education and social support. To help overcome logistical barriers to LDKT, we adapted TALK-SWI into a telehealth intervention employing digital (ie, tablet, smartphone) and telephone technologies. We studied the usability and acceptability of both the mobile device and telephone counseling portions of the intervention among people with kidney disease. For the digital portion, we assessed critical (ie, inability to complete a task) and non-critical (ie, ability to complete a task utilizing an alternative method) errors participants encountered when using the program and their preferences regarding digital materials. Simultaneously, we assessed participants' satisfaction with telephone-adapted counseling compared to the original, in-person counseling. RESULTS: The 15 participants testing the digital technology made 25 critical errors and 29 non-critical errors, while they easily completed 156 tasks (out of 210). A majority of participants (73%) preferred the tablet/smart phone education application over traditional materials, and most (80%) indicated they would be more likely to utilize the mobile platform over traditional materials. Participants testing the telephone-adapted (n = 45) and in-person (n = 125) social worker counseling all reported high satisfaction with the intervention. CONCLUSION: We successfully adapted a validated educational and behavioral intervention to improve access to LDKT into a usable and acceptable telehealth intervention.

Putting patients at the center of kidney care transitions: PREPARE NOW, a cluster randomized controlled trial.

Care for patients transitioning from chronic kidney disease to kidney failure often falls short of meeting patients' needs. The PREPARE NOW study is a cluster randomized controlled trial studying the effectiveness of a pragmatic health system intervention, 'Patient Centered Kidney Transition Care,' a multi-component health system intervention designed to improve patients' preparation for kidney failure treatment. Patient-Centered Kidney Transition Care provides a suite of new electronic health information tools (including a disease registry and risk prediction tools) to help providers recognize patients in need of Kidney Transitions Care and focus their attention on patients' values and treatment preferences. Patient-Centered Kidney Transition Care also adds a 'Kidney Transitions Specialist' to the nephrology health care team to facilitate patients' self-management empowerment, shared-decision making, psychosocial support, care navigation, and health care team communication. The PREPARE NOW study is conducted among eight [8] outpatient nephrology clinics at Geisinger, a large integrated health system in rural Pennsylvania. Four randomly selected nephrology clinics employ the Patient Centered Kidney Transitions Care intervention while four clinics employ usual nephrology care. To assess intervention effectiveness, patient reported, biomedical, and health system outcomes are collected annually over a period of 36 months via telephone questionnaires and electronic health records. The PREPARE NOW Study may provide needed evidence on the effectiveness of patient-centered health system interventions to improve nephrology patients' experiences, capabilities, and clinical outcomes, and it will guide the implementation of similar interventions elsewhere. TRIAL REGISTRATION: NCT02722382.

Molecular analyses of circadian gene variants reveal sex-dependent links between depression and clocks.

An extensive literature links circadian irregularities and/or sleep abnormalities to mood disorders. Despite the strong genetic component underlying many mood disorders, however, previous genetic associations between circadian clock gene variants and major depressive disorder (MDD) have been weak. We applied a combined molecular/functional and genetic association approach to circadian gene polymorphisms in sex-stratified populations of control subjects and case subjects suffering from MDD. This approach identified significant sex-dependent associations of common variants of the circadian clock genes hClock, hPer3 and hNpas2 with major depression and demonstrated functional effects of these polymorphisms on the expression or activity of the hCLOCK and hPER3 proteins, respectively. In addition, hCLOCK expression is affected by glucocorticoids, consistent with the sex-dependency of the genetic associations and the modulation of glucocorticoid-mediated stress response, providing a mechanism by which the circadian clock controls outputs that may affect psychiatric disorders. We conclude that genetic polymorphisms in circadian genes (especially hClock and hPer3, where functional assays could be tested) influence risk of developing depression in a sex- and stress-dependent manner. These studies support a genetic connection between circadian disruption and mood disorders, and confirm a key connection between circadian gene variation and major depression.

Oestrogen receptor beta contributes to the transient sex difference in tyrosine hydroxylase expression in the mouse locus coeruleus.

Oestrogen receptors (ERs) are important for sexual differentiation of the brain. Previous studies in rats have reported that the locus coeruleus (LC), a catecholaminergic nucleus in the brain stem, is sexually dimorphic such that females have more neurones than males. We hypothesised that ERs may be important for sexual differentiation of this nucleus in mice. Because previous studies reported conflicting results regarding ER protein expression in the mouse LC, we evaluated ER alpha and ER beta gene expression by in situ hybridisation and the real-time reverse transcription-polymerase chain reaction. We demonstrated that both ER alpha and ER beta mRNAs are present in tyrosine hydroxylase-immunoreactive (TH-ir) cells in the male LC. In the female LC, ER alpha mRNA is present at levels similar to males, whereas ER beta mRNA expression is significantly lower than in males. Similar to rats, male mice have fewer TH-ir cells in the LC than females at 60 days after birth, but the difference is absent at 120 days after birth when females exhibit a similar reduction in TH-ir cells. The transient sex difference is ER beta-dependent because is it absent in ER beta knockout mice, and is due to regulation of TH expression and not from death of TH-ir cells. Testicular hormones produced at adolescence are necessary for the regulation of TH expression in the male LC because orchidectomy of pre-pubertal males prevented the decrease in TH-ir cells, whereas treatment of gonadectomized males with testosterone or its metabolite, 5 alpha-androstan-3beta,17beta-diol, restored the intact male phenotype. Overall, these studies indicate that ER beta is important in regulating TH expression in the mouse LC.

Modelling covariance structure in the analysis of repeated measures data.

The term 'repeated measures' refers to data with multiple observations on the same sampling unit. In most cases, the multiple observations are taken over time, but they could be over space. It is usually plausible to assume that observations on the same unit are correlated. Hence, statistical analysis of repeated measures data must address the issue of covariation between measures on the same unit. Until recently, analysis techniques available in computer software only offered the user limited and inadequate choices. One choice was to ignore covariance structure and make invalid assumptions. Another was to avoid the covariance structure issue by analysing transformed data or making adjustments to otherwise inadequate analyses. Ignoring covariance structure may result in erroneous inference, and avoiding it may result in inefficient inference. Recently available mixed model methodology permits the covariance structure to be incorporated into the statistical model. The MIXED procedure of the SAS((R)) System provides a rich selection of covariance structures through the RANDOM and REPEATED statements. Modelling the covariance structure is a major hurdle in the use of PROC MIXED. However, once the covariance structure is modelled, inference about fixed effects proceeds essentially as when using PROC GLM. An example from the pharmaceutical industry is used to illustrate how to choose a covariance structure. The example also illustrates the effects of choice of covariance structure on tests and estimates of fixed effects. In many situations, estimates of linear combinations are invariant with respect to covariance structure, yet standard errors of the estimates may still depend on the covariance structure.

The effects of selective response preparation on corticospinal excitability.

OBJECTIVE: Both motor imagery and selective motor cues enhance performance. Motor cortex is activated during motor imagery. We wanted to learn if selective motor cueing also activates motor cortex. METHODS: We gave normal right-handed subjects information about which hand to use to respond to an imperative stimulus (selective intention) or where in space an imperative stimulus would occur (selective attention). To minimize anticipatory responses, warning stimulus validity was 80%. During this choice reaction time task, we recorded magnetic motor evoked potentials. Imperative stimuli and transcranial magnetic stimulation were presented randomly to assess the effect of warning cues on reaction times and corticospinal excitability. RESULTS: Selective intentional and attentional warning cues reduced reaction times, but neither stimulus altered motor evoked potentials. CONCLUSIONS: These results suggest that unlike motor imagery, selective intention to respond to an imperative stimulus and shifting spatial attention to an imperative stimulus do not alter corticospinal excitability.

Patients' perceptions of the benefits of pharmaceutical care.

OBJECTIVE: To investigate patients' perceptions of the benefits of regular participation in pharmaceutical care services. DESIGN: Written survey of a convenience sample. SETTING: Pharmacist-run anticoagulation clinic in a Veterans Administration Medical Center. PATIENTS: 154 patients who had regularly scheduled appointments in the clinic. INTERVENTIONS: Patients were asked to complete a written survey. The survey was read to those who had trouble reading it. MAIN OUTCOME MEASURES: Patients' perceptions about the benefit of services provided in the clinic and the relationship between those services and reduced risks of medication-related problems. RESULTS: All components of anticoagulant-related pharmaceutical care were rated as at least fairly beneficial. Monitoring of warfarin blood levels and information on the appropriate use of warfarin were rated highest. The perceived benefits of the pharmaceutical care components were associated with patients' perceptions of the extent to which pharmaceutical care reduced their risk of experiencing blood clots or warfarin-related problems. Patients also perceived that their risk of developing blood clots or bleeding problems would be higher if they did not regularly visit the anticoagulation clinic. CONCLUSION: Patients' perceptions of the benefits of pharmaceutical care were associated with the perceived threat reduction capacity of the pharmacist's services. Pharmaceutical care providers may be able to enhance patient participation in their services by educating patients on the risks of medication-related problems and how frequent monitoring of key clinical indicators may help reduce those risks.

A rodent model of spontaneous stereotypy: initial characterization of developmental, environmental, and neurobiological factors.

Stereotypies are patterns of motor behavior that are repetitive, excessive, topographically invariant, and that lack any obvious function or purpose. In humans, stereotyped behaviors are associated with psychiatric, neurological, and developmental disorders. In animals, stereotypy has been frequently associated with adverse environmental circumstances and often related to alterations in striatal dopamine. To assess the development of stereotyped behaviors and to test the hypothesis that these behaviors are associated with environmental restriction, deer mice were housed in either standard laboratory cages or larger, enriched cages, and the development of stereotypy was followed from weaning over a 17-week period. Standard-caged deer mice engaged in stereotyped behaviors at a higher rate and developed these behaviors more quickly when compared to animals in enriched caging. Additionally, enriched caging was associated with higher rates of patterned running, whereas jumping and backward somersaulting were typically observed in standard cages. In addition, there was a significant effect of litter, but no effect of sex or cage, on the time to develop stereotypy. No differences were found in the density of either striatal D1 or D2 dopamine receptors or the concentration of striatal dopamine or its metabolites as a function of rearing condition or as a function of whether the animals developed stereotypy. These results characterize the development of stereotypies in this species, demonstrate the importance of environmental conditions in the genesis of stereotypy, and suggest that alterations in striatal dopamine content or dopamine receptor density do not account for the expression of stereotyped behaviors in this model.

Dietary caffeine, fluid intake and urinary incontinence in older rural women.

Forty-one women completed the first phase (self-monitoring) of the Behavioral Management for Continence (BMC) intervention, while working with a nurse during home visits to reduce involuntary urine loss as part of the parent study involving older, rural women living at home. A decrease in dietary caffeine intake and an increase in fluid intake were most frequently recommended. The relationship between a decrease in the amount of dietary caffeine consumed and fewer daytime episodes of involuntary urine loss approached significance -P = 0.0744- whereas an increase in the average amount of fluid intake was significantly related to an increase in the average volume of urine voided -P = 0.0479- and not to involuntary urine loss.

Issues related to using a short-form of the Center for Epidemiological Studies-Depression Scale.

The study examined the reliability and validity, including the factor structure, of a 10-item abbreviated version of the Center for Epidemiological Studies-Depression (CES-Depression) scale when administered as part of a mail questionnaire. It also examined patterns of nonresponse to items and the effects of imputation of data for missing items on the factor structure of the inventory. A problem of missing data has been reported even with interview administration of the CES-Depression. Researchers have varied considerably in the amount of imputation used to replace missing datapoints. In this study, factor structures varied when items were imputed. In addition, those subjects with complete data were compared with those with up to two imputed datapoints. Those subjects with imputed data were more likely to be female, have lower functional status scores, lower self-reported health status, more advanced age, and a greater number of depressive symptoms than those with no missing data. While the estimate of coefficient alpha of .78 indicated the inventory was reliable, the effects of missing data on construct validity were problematic.

Children's health care use in the Healthy Kids Program.

BACKGROUND: In 1990, the Florida Legislature established the Florida Healthy Kids Corporation to implement the concept of school enrollment-based health insurance coverage for children. The county school districts are used as a grouping mechanism to negotiate health insurance policies. The Florida Healthy Kids Corporation negotiates contracts with health maintenance organizations (HMOs) to assume financial risk and to provide health care services at each program site. In 1994, there were five sites with four different participating HMOs. Assessing quality of care is particularly important when contracting with HMOs because of the perception that financial and utilization review arrangements may restrict the enrollees' access to needed health care. One essential component of health care quality is the extent to which health care services are used in a manner consistent with the expected pattern of use for the population of enrolled children. The purpose of this study is to compare children's health care use across five different Florida Healthy Kids Program sites. Specifically, we compare the enrollees' actual health care use across HMO settings and program sites to the expected health care use based on the enrollees' case-mix. METHODS: Each HMO provided child-specific health care use data including Physician's Current Procedural Terminology codes and International Classification of Diseases, 9th Revision codes. We used the Ambulatory Care Groups (ACGs) software to compare the children's actual health care use to the expected health care use at each site adjusted for case-mix. Several steps were then taken to determine if the children were receiving the anticipated number of health care visits based on their diagnoses. First, we divided the average number of encounters at each site by the group average across all of the sites, without adjusting for the case-mix of the enrollees. We then divided the average number of visits at each site by the expected number of visits based on the case-mix adjustment. A value of 1.00 means that the actual use and the expected use are identical. Values below 1 indicate underuse and values over 1 indicate overuse of health care services. Statistical comparisons of the actual versus expected average health care use across the five sites were performed by deriving the appropriate chi2 statistics. RESULTS: A census of all children (N = 14 688) enrolled in the Florida Healthy Kids Program at each of the sites for 6 months or longer were included in the analysis. The average number of health care encounters across all sites for a 12-month time period was 2.98 +/- 4.6 visits. After adjusting for the case-mix of the enrollees in each site using the ACG software, several of the five sites differed from one in a statistically significant way. However, these statistical assessments must be tempered with assessing the practical magnitude of the observed differences. CONCLUSIONS: The number of public and private efforts to insure children who are not eligible for Medicaid and whose parents cannot purchase private insurance has grown dramatically. These programs are vital for ensuring financial access to care for uninsured children. However, it is essential that such programs are not viewed as merely cost containment efforts. Assessing the degree to which children receive the health care services they need across multiple delivery settings is an essential yet challenging component of quality assurance. Generally, our analysis indicates that children in the Florida Healthy Kids Program are receiving the amount of health care expected based on their health care needs; which is one component of a high-quality health care program.

The School Enrollment-Based Health Insurance program: socioeconomic factors in enrollees' use of health services.

OBJECTIVES: The School Enrollment-Based Health Insurance program is designed to reduce financial barriers to children's health care use. This study sought to determine if any socioeconomic measures differed between enrollees with at least one health care encounter and those with no encounters. METHODS: Logistic regression was used to assess the impact of various predictors on the odds that a child would use health care services. RESULTS: Children receiving free insurance premiums were less likely to use health care than those receiving partial subsidy. African-American and Hispanic children were less likely than Whites to use health care. Age, sex, and months enrolled also influenced the likelihood of health care use. CONCLUSIONS: Financial and non-financial factors must be considered when developing children's health care programs.

Role orientation and community pharmacists' participation in a project to improve patient care.

Community pharmacists are being assigned increased responsibility in assuring the appropriateness and effectiveness of drug therapy. This increased responsibility is reflected in recently passed legislation (OBRA '90) in the United States that requires pharmacists to counsel patients about prescriptions received and to engage in prospective drug use review for Medicaid recipients. The potential impact of this legislation is unclear due to a dearth of research evaluating the effects of community pharmacists' activities on medication use. In addition, there is little research on pharmacists' willingness to assume increased responsibility. Research that would demonstrate the effectiveness of community pharmacists in improving therapeutic outcomes is hampered by problems inherent in conducting experimentally designed research in field settings. This paper examines two issues of concern in such studies--namely, the extent to which those who agree to participate in a demonstration project differ from those who decline to participate and the extent to which differential dropout from treatment and control conditions compromise the comparability of the two groups. Specifically, this report examines pharmacist characteristics related to participation in a demonstration project to improve the care of elderly patients. Community pharmacists in Florida who had earlier been asked to participate in a demonstration project (N = 418) were sent mail questionnaires to assess their attitudinal, demographic and employment characteristics. In particular, researchers were interested in the role orientation of pharmacists in regard to patient counseling and physician consultation, satisfaction with current jobs and career choices, employment settings and treatment vs control group assignment as predictors of participation in the research project. Demographic characteristics were also examined as possible predictors of participation.(ABSTRACT TRUNCATED AT 250 WORDS)