Carman A. Ciervo

Use of the Beck Anxiety and Depression Inventories for Primary Care with Medical Outpatients.

The effectiveness of the Beck Anxiety (BAI-PC) and Depression (BDI-PC) Inventories for Primary Care for discriminating 56 primary care patients with and without revised, third edition Diagnostic and Statistical Manual of Mental Disorders (DSM-III-R) diagnosed anxiety and mood disorders was studied. The Anxiety and Mood modules from the Primary Care Evaluation of Mental Disorders (PRIME-MD) were used to establish diagnoses. The coefficient alphas for the BAI-PC and BDI-PC were, respectively, .90 and .88. A BAI-PC cutoff score of 5 and above yielded the highest clinical efficiency (82%) with 85% sensitivity and 81% specificity for identifying patients with and without panic, generalized anxiety, or both disorders, whereas a BDI-PC cutoff score of 6 and above afforded the highest clinical efficiency (92%) with 83% sensitivity and 95% specificity for detecting patients with and without major depressive disorders. The use of these instruments to screen primary care patients before conducting extensive diagnostic evaluations with them was discussed.

Pharmacokinetics of telithromycin: application to dosing in the treatment of community-acquired respiratory tract infections

ABSTRACT Introduction: Telithromycin is the first ketolide antibacterial approved for treating community-acquired pneumonia, acute exacerbations of chronic bronchitis, and acute bacterial sinusitis in adults. The purpose of this article is to review the main pharmacokinetic properties of telithromycin and their application to the treatment of these infections. Methods: Sources of information were identified through a Medline search (up to March 2005). Main findings: The absolute oral bioavailability of telithromycin is ≈ 57%, which is unaffected by food intake. At the recommended 800 mg once-daily oral dosing regimen, telithromycin reaches a steady-state concentration of ≈ 2 µg/mL in plasma and has an elimination half-life of ≈ 10 hours. Telithromycin shows extensive tissue distribution and penetrates effectively into bronchopulmonary tissue and epithelial lining fluid. Since elimination of telithromycin occurs via multiple pathways – the highest proportion (70%) through metabolism – impairment of a single pathway has a limited impact on telithromycin exposure. Dose adjustments are unnecessary in elderly patients or in individuals with hepatic impairment or mild to moderate renal impairment. A reduced dose could be recommended in patients with severe renal impairment. Telithromycin is metabolized primarily in the liver, approximately half of which is via the cytochrome P450 (CYP) 3A4 system. Telithromycin AUC(0–24 h) increased by 1.5- to 2.0‐fold in the presence of itraconazole and ketoconazole. Administration of telithromycin with drugs metabolized via CYP3A4 may result in increased exposure to the co-administered drug, as shown for simvastatin (5.3‐fold) and midazolam (6‐fold). Co-administration of telithromycin minimally increases (1.2- to 1.4‐fold) exposure to theophylline, digoxin, and metoprolol. Although telithromycin does not affect the pharmacokinetics of warfarin, consideration should be given to monitoring prothrombin times/INR in patients receiving telithromycin and oral anticoagulants simultaneously. Conclusion: Overall, the pharmacokinetic/pharmacodynamic properties of telithromycin indicate that this ketolide antibacterial is a valuable and convenient treatment option for community-acquired respiratory tract infections.

Increased prevalence of sensing types in men with cluster headaches.

To ascertain whether the percentage of men who suffer with cluster headaches and are classified as sensing types according to Jungs theory of psychological types was comparable to the percentage (74%) of Sensing types that was found by Gallagher, et al. among women who experience migraine headaches, the Myers-Briggs Type Indicator® was administered to 25 male cluster-headache patients. There were 19 (76%) male Sensing types, and this was comparable to the percentage of Sensing types for migrainous women. The results are discussed as supporting previous contentions that Sensing types may be prone to developing psychosomatic symptoms related to stress.

Suggested updated approaches to patient management

P INTRODUCTION A symposium organized by National Jewish Health and held in Denver, Colorado, on October 8, 2009, investigated the role of intranasal antihistamines for allergic rhinitis. It was titled Rethinking the Treatment of Allergic Rhinitis; the Role of Intranasal Antihistamines: “Me Too Drugs” or a Novel Class? Articles 1 through 4 in this supplement provide detailed information about the biology of histamine and the efficacy and cost-effectiveness of intranasal antihistamines in allergic rhinitis. This publication, based on that symposium, provides a summary of new recommendations and proposes an updated approach to the treatment of allergic rhinitis.

Diabetes Management Within Evolving Health Care Delivery Models: The Osteopathic Perspective

A Supplement to The Journal of the American Osteopathic Association April 2015 | Vol 115 | No. 4 | Supplement 1 Although the passage of the Patient Protection and Affordable Care Act (ACA) in 2010 marked the genesis of the official government initiative to improve health care quality and reduce costs, stakeholders had already enacted a transformation in health care delivery decades before. The “medical home” concept was first introduced in 1967, and the origins of the modern patient-centered medical home (PCMH) are rooted in the chronic care model introduced before the new millennium.1,2 Since then, the PCMH has evolved from concept to reality, and a number of programs across the country continue to report promising results.3 The PCMH model represents a framework of partnerships among clinicians, patients, and their families that puts patients’ needs above all else while striving to engage patients in their own care.4 The collaborative efforts of various clinicians are coordinated by a strategically centralized health care practitioner, most often a primary care physician. In the PCMH model, quality of care and patient safety are paramount considerations, with data captured and used for performance evaluation and provider accountability. All of the principles integral to the PCMH model align with those that served as the foundation for many of the components of the ACA, including the centerpiece of the ACA: accountable care organizations (ACOs). The goal of ACOs is to deliver seamless, high-quality care for Medicare beneficiaries, as opposed to the fragmented care that often results from a fee-for-service payment system in which different clinicians receive different, disconnected payments.5 In the nascent system, groups of providers and suppliers of services (eg, physicians and hospitals) agree to work together to coordinate care for the Medicare patients they serve, incentivized by shared savings.5 The most common program available to ACOs is the Medicare Shared Savings Program, in which the government sets a national benchmark that represents the amount of health care dollars allocated per patient per year.5 Regardless of the ownership of an ACO—whether it is a hospital, health care system, or physicians group—a 50% portion of shared savings is delivered to stakeholders on the basis of performance according to 33 nationally recognized measures assessed by the Centers for Medicare & Medicaid Services.6 However, “Before an ACO can share in any savings created, it must demonstrate that it met the quality performance standards for that year.”6 As more health care systems adopt the ACO model, Medicaid and commercial insurers are developing strategies to work with them. As of mid2014, approximately 4 million Medicare beneficiaries were under the care of an ACO, representing an estimated 14% of the US population.7 Furthermore, combined with the private sector, more than 428 provider groups had signed up to participate in an ACO as of mid-2014. Just as the ACO model aligns well with the PCMH, both of these models of From the Kennedy Health Alliance in Marlton, New Jersey (Dr Ciervo); the Touro University California, College of Osteopathic Medicine in Vallejo. (Dr Shubrook); and IBM Corporation in Armonk, New York (Dr Grundy).