An empirical analysis of cost outcomes of the Texas Medication Algorithm Project.

Objective: Disease management systems that incorporate medication algorithms have been proposed as cost-effective means to offer optimal treatment for patients with severe and chronic mental illnesses. The Texas Medication Algorithm Project was designed to compare health care costs and clinical outcomes between patients who received algorithm-guided medication management or usual care in 19 public mental health clinics.

Methods: This longitudinal cohort study for patients with major depression (N=350), bipolar disorder (N=267), and schizophrenia (N=309) applied a multi-part declining-effects cost model.

Case report and summary of literature: giant perineal keloids treated with post-excisional radiotherapy.

Background: Keloids are common benign tumors of the dermis, typically arising after insult to the skin. While typically only impinging on cosmesis, large or recurrent keloids may require therapeutic intervention. While no single standardized treatment course has been established, several series report excellent outcomes for keloids with post-surgery radiation therapy.

A simian virus 5 (SV5) P/V mutant is less cytopathic than wild-type SV5 in human dendritic cells and is a more effective activator of dendritic cell maturation and function.

Human epithelial cells infected with the parainfluenza virus simian virus 5 (SV5) show minimal activation of host cell interferon (IFN), cytokine, and cell death pathways. In contrast, a recombinant SV5 P/V gene mutant (rSV5-P/V-CPI-) overexpresses viral gene products and is a potent inducer of IFN, proinflammatory cytokines, and apoptosis in these cells. In this study, we have compared the outcomes of wild-type (WT) SV5 and rSV5-P/V-CPI- infections of primary human dendritic cells (DC), important antigen-presenting cells for initiating adaptive immune responses.

Unforeseen inpatient mortality among veterans with schizophrenia.

Background: Patients with schizophrenia have co-occurring medical conditions, like other patients, but may lack the capacity to provide good self-care or to work with their providers to ensure appropriate medical treatment. We hypothesized that death among patients with schizophrenia occurs more frequently after minimal care of comorbid conditions.

Methods: All patients who died in veterans affairs (VA) hospitals during FY02 were categorized as to type of death: unforeseen (age <80 years, 1-2 inpatient days past year), cancer, organ failure (heart, lungs, kidneys), frailty (dementias, hip fractures, dehydration, etc.

Assessing BRCA carrier probabilities in extended families.

Purpose: Carrier prediction models estimate the probability that a person has a BRCA mutation. We evaluated the accuracy of the BOADICEA model and compared its performance with that of other models (BRCAPRO, Myriad I and II, Couch, and Manchester Scoring System). We also studied the effect of extended family information on risk estimation using BOADICEA.

Synthesis and characterization of side-bound aryldiazo and end-bound nitrosyl complexes of nickel.

Structural characterization of a nickel aryldiazo complex supported by the bulky 1,2-bis(di-tert-butylphosphino)ethane ligand reveals square-planar Ni geometry and an unusual side-on coordination mode for the N2R moiety, while the related nitrosyl complex displays trigonal-planar geometry at Ni and end-on coordination of the NO ligand.

Does provider adherence to a treatment guideline change clinical outcomes for patients with bipolar disorder? Results from the Texas Medication Algorithm Project.

Background: Despite increasing adoption of clinical practice guidelines in psychiatry, there is little measurement of provider implementation of these recommendations, and the resulting impact on clinical outcomes. The current study describes one effort to measure these relationships in a cohort of public sector out-patients with bipolar disorder.

Method: Participants were enrolled in the algorithm intervention of the Texas Medication Algorithm Project (TMAP).

Drug adherence: effects of decreased visit frequency on adherence to clozapine therapy.

Objective: To study the effects of visit frequency on drug-adherence parameters subsequent to the change in the United States Food and Drug Administration (FDA)-mandated monitoring of white blood cell counts from weekly to every 2 weeks (biweekly) after 6 months of clozapine therapy.

Methods: Paid prescription claims records for clozapine from September 1, 1995-August 31, 2001, were extracted from the Texas Medicaid Vendor Drug Program database. Two groups of subjects were identified: subjects treated before and those treated after the FDA labeling change in monitoring frequency, which occurred on April 1, 1998.

Brief psychiatric rating scale expanded version: How do new items affect factor structure?

Our goal was to suggest a factor structure for the Brief Psychiatric Rating Scale Expanded Version (BPRS-E) based upon a large and diverse sample and to determine which of the new items improved the factors derived from the 18-item version of the scale that have been used in clinical research for decades. We investigated the consistency of our proposed model over time and across demographic groups. As part of the Texas Medication Algorithm Project, the BPRS-E was administered to a total of 1440 psychiatric outpatients in three different diagnostic groups on multiple occasions.

Abortive versus productive viral infection of dendritic cells with a paramyxovirus results in differential upregulation of select costimulatory molecules.

Dendritic cells are the most potent antigen-presenting cell for priming naive T cells. Optimal activation of T cells requires that dendritic cells undergo a process of maturation resulting in the increased expression of costimulatory molecules, such as CD40, CD86, and CD80, and the production of cytokines. In this study we analyzed the effect of infection of dendritic cells obtained from two strains of mice, BALB/c and C57BL/6, with the paramyxovirus simian virus 5 (SV5).

Modulation of CD8+ T cell avidity by increasing the turnover of viral antigen during infection.

The increased potency of high avidity CD8+ T cells for the clearance of viral infections has been well documented. We have previously reported the novel finding that intranasal infection with the paramyxovirus SV5 induces a CD8+ T cell response to the SV5 P protein that is almost exclusively of high avidity. Based on our results that the level of peptide presentation is a critical factor in the selective expansion of high versus low avidity cells in vitro, we hypothesized that the avidity of the anti-viral response generated in vivo could be altered by increasing the turnover of the P protein during viral infection through linkage to ubiquitin (UbP).

Tattoo pigment in sentinel lymph nodes: a mimicker of metastatic malignant melanoma.

Tattoo pigment in the sentinel lymph nodes of melanoma patients represents a clinical challenge. If a tattoo is present in the area of the primary melanoma, the draining lymph nodes are likely to contain tattoo pigment, as well as being the site for metastatic deposits of melanoma. We describe a case report involving an elderly Caucasian male diagnosed with a Clark level-4 nodular malignant melanoma, wherein intraoperatively we encounter a darkly pigmented lymph node highly suspicious for metastatic disease.

Locally advanced duodenal gangliocytic paraganglioma treated with adjuvant radiation therapy: case report and review of the literature.

BACKGROUND: Gangliocytic paraganglioma are rare neoplasms that predominantly arise in periampulary region. Though considered benign the disease can spread to regional lymphatics. CASE PRESENTATION: A 49 year old woman presented with melena and was found to have a periampullary mass.

Altered function in CD8+ T cells following paramyxovirus infection of the respiratory tract.

For many respiratory pathogens, CD8+ T cells have been shown to play a critical role in clearance. However, there are still many unanswered questions with regard to the factors that promote the most efficacious immune response and the potential for immunoregulation of effector cells at the local site of infection. We have used infection of the respiratory tract with the model paramyxovirus simian virus 5 (SV5) to study CD8+ T-cell responses in the lung.

The Texas medication algorithm project: clinical results for schizophrenia.

In the Texas Medication Algorithm Project (TMAP), patients were given algorithm-guided treatment (ALGO) or treatment as usual (TAU). The ALGO intervention included a clinical coordinator to assist the physicians and administer a patient and family education program. The primary comparison in the schizophrenia module of TMAP was between patients seen in clinics in which ALGO was used (n = 165) and patients seen in clinics in which no algorithms were used (n = 144).

High-avidity CD8+ T cells: optimal soldiers in the war against viruses and tumors.

The primary goal of vaccination is the establishment of protective immunity. Thus there has been significant effort put toward the identification of attributes of the immune response that are associated with optimal protection. Although the number of virus-specific cells elicited is unquestionably important, recent studies have identified an additional parameter, functional avidity, as critical in determining the efficiency of viral clearance.

Demonstration of a specific Escherichia coli SecY-signal peptide interaction.

Protein translocation in Escherichia coli is initiated by the interaction of a preprotein with the membrane translocase composed of a motor protein, SecA ATPase, and a membrane-embedded channel, the SecYEG complex. The extent to which the signal peptide region of the preprotein plays a role in SecYEG interactions is unclear, in part because studies in this area typically employ the entire preprotein. Using a synthetic signal peptide harboring a photoaffinity label in its hydrophobic core, we examined this interaction with SecYEG in a detergent micellar environment.

A brief cognitive assessment for use with schizophrenia patients in community clinics.

Cognitive impairment is a prominent feature of schizophrenia. The availability of very brief measures may increase the use of cognitive assessment in routine care settings. We examined the reliability and validity of the brief cognitive assessment (BCA), a battery that takes approximately 15 min to administer and score, and that was designed to be sensitive to changes in cognition with novel antipsychotics.

Combination treatments for schizophrenia.

Combination treatments, especially combinations of antipsychotics, are used frequently for schizophrenia, despite a paucity of evidence regarding their safety and efficacy. Because the literature basis is weak and expert recommendations are largely lacking, providers should be vigilant in documenting improved outcomes for patients thought to benefit from combination treatments. Target symptoms that have been studied include psychosis, cognitive deficits, and negative symptoms.

Physical health monitoring of patients with schizophrenia.

Objective: Schizophrenia is associated with several chronic physical illnesses and a shorter life expectancy, compared with life expectancy in the general population. One approach to improving the health of patients with schizophrenia is to improve the monitoring of physical health that occurs in psychiatric settings. The authors discuss a consensus panel's recommendations for improving the physical health monitoring of patients with schizophrenia who are treated in outpatient settings.

Clinical results for patients with major depressive disorder in the Texas Medication Algorithm Project.

Context: The Texas Medication Algorithm Project is an evaluation of an algorithm-based disease management program for the treatment of the self-declared persistently and seriously mentally ill in the public mental health sector.

Objective: To present clinical outcomes for patients with major depressive disorder (MDD) during 12-month algorithm-guided treatment (ALGO) compared with treatment as usual (TAU).

Design: Effectiveness, intent-to-treat, prospective trial comparing patient outcomes in clinics offering ALGO with matched clinics offering TAU.

Positive margins following surgical resection of breast carcinoma: analysis of pathologic correlates.

Background And Objectives: Histologic margin positivity represents a significant source of adverse clinical outcome affecting breast conservation therapy for in situ or invasive malignancy. Elucidation of factors associated with positive margin status might clarify and improve local therapy strategies. In order to define our experience with margin positivity and to identify relevant pathologic criteria, we retrospectively analyzed the cases of 143 patients who underwent resections for carcinoma with intent of breast conservation between 1995 and 1999.

High avidity CD8+ T cells generated from CD28-deficient or wildtype mice exhibit a differential dependence on lipid raft integrity for activation.

CD28 has been shown to play an important role in T cell activation. Among the downstream events associated with CD28 engagement is the reorganization of the cytoskeleton resulting in lipid raft aggregation. In our previous studies we investigated the involvement of lipid rafts in the activation of high avidity CD8+ T lymphocytes, which recognize cells bearing very low levels of peptide antigen, versus low avidity cells, which require high levels of peptide antigen.

The Texas Medication Algorithm Project antipsychotic algorithm for schizophrenia: 2003 update.

Background: The Texas Medication Algorithm Project (TMAP) has been a public-academic collaboration in which guidelines for medication treatment of schizophrenia, bipolar disorder, and major depressive disorder were used in selected public outpatient clinics in Texas. Subsequently, these algorithms were implemented throughout Texas and are being used in other states. Guidelines require updating when significant new evidence emerges; the antipsychotic algorithm for schizophrenia was last updated in 1999.