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Polk C, Sampson M, Fairman RT, DeWitt ME, Leonard M, Neelakanta A, Davidson L, Roshdy D, Branner C, McCurdy L, Ludden T, Tapp H, Passaretti C. Evaluation of a health system's implementation of a monkeypox care model under the RE-AIM framework. Ther Adv Infect Dis 2023; 10:20499361231158463. [PMID: 36911268 PMCID: PMC9996722 DOI: 10.1177/20499361231158463] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2022] [Accepted: 02/02/2023] [Indexed: 03/10/2023] Open
Abstract
Objective Emerging infectious diseases challenge healthcare systems to implement new models of care. We aim to evaluate the rapid implementation of a new care model for monkeypox in our health system. Design This is a retrospective case series evaluation under the Reach, Effectiveness, Adoption, Implementation, and Maintenance (RE-AIM) framework of implementation of a testing and care model for monkeypox in a large, integrated health system. Methods Atrium Health implemented education of providers, testing protocols, and management of potential monkeypox cases using electronic health record (EHR) data capabilities, telehealth, and collaboration between multiple disciplines. The first 4 weeks of care model implementation were evaluated under the RE-AIM framework. Results One hundred fifty-three patients were tested for monkeypox by 117 unique providers at urgent care, emergency departments, and infectious disease clinics in our healthcare system between 18 July 2022 and 14 August 2022. Fifty-eight monkeypox cases were identified, compared with 198 cases in the state during the time period, a disproportionate number compared with the health system service area, and 52 patients were assessed for need for tecovirimat treatment. The number of tests performed and providers sending tests increased during the study period. Conclusion Implementation of a dedicated care model leveraging EHR data support, telehealth, and cross-disciplinary collaboration led to more effective identification and management of emerging infectious diseases and is important for public health. Plain Language Summary Impact of care model implementation on monkeypox New infectious diseases challenge health systems to implement new care practices. Our health system responded to this challenge by implementing a care model for education, testing, and clinical care of monkeypox patients. We analyzed results from implementing the model. We were able to identify a disproportionate number of monkeypox cases compared with the rest of our state by using our model to educate medical providers, encourage testing, and ensure patients had access to best disease care. Implementation of care models for testing and management of new diseases will improve patient care and public health.
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Affiliation(s)
- Christopher Polk
- Division of Infectious Diseases, Atrium Health, 1225 Harding Place, Suite 200, Charlotte, NC 28204, USA.,Center for the Study of Microbial Ecology and Emerging Diseases, Wake Forest University School of Medicine, Winston-Salem, NC, USA
| | - Mindy Sampson
- Division of Infectious Diseases, Atrium Health, Charlotte, NC, USA.,Center for the Study of Microbial Ecology and Emerging Diseases, Wake Forest University School of Medicine, Winston-Salem, NC, USA
| | - Robert T Fairman
- Division of Infectious Diseases, Atrium Health, Charlotte, NC, USA.,Center for the Study of Microbial Ecology and Emerging Diseases, Wake Forest University School of Medicine, Winston-Salem, NC, USA.,Department of Health Policy & Behavioral Sciences, School of Public Health, Georgia State University, Atlanta, GA, USA
| | - Michael E DeWitt
- Center for the Study of Microbial Ecology and Emerging Diseases, Wake Forest University School of Medicine, Winston-Salem, NC, USA.,Section on Infectious Diseases, Department of Internal Medicine, Wake Forest University School of Medicine, Winston-Salem, NC, USA
| | - Michael Leonard
- Division of Infectious Diseases, Atrium Health, Charlotte, NC, USA
| | | | - Lisa Davidson
- Division of Infectious Diseases, Atrium Health, Charlotte, NC, USA
| | - Danya Roshdy
- Division of Pharmacy, Atrium Health, Charlotte, NC, USA
| | | | - Lewis McCurdy
- Division of Infectious Diseases, Atrium Health, Charlotte, NC, USA
| | - Tom Ludden
- Division of Family Medicine, Atrium Health, Charlotte, NC, USA
| | - Hazel Tapp
- Division of Family Medicine, Atrium Health, Charlotte, NC, USA
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Wierzba TF, Sanders JW, Herrington D, Espeland MA, Williamson J, Mongraw-Chaffin M, Bertoni A, Alexander-Miller MA, Castri P, Mathews A, Munawar I, Seals AL, Ostasiewski B, Ballard CAP, Gurcan M, Ivanov A, Zapata GM, Westcott M, Blinson K, Blinson L, Mistysyn M, Davis D, Doomy L, Henderson P, Jessup A, Lane K, Levine B, McCanless J, McDaniel S, Melius K, O’Neill C, Pack A, Rathee R, Rushing S, Sheets J, Soots S, Wall M, Wheeler S, White J, Wilkerson L, Wilson R, Wilson K, Burcombe D, Saylor G, Lunn M, Ordonez K, O’Steen A, Wagner L, Runyon MS, McCurdy LH, Gibbs MA, Taylor YJ, Calamari L, Tapp H, Ahmed A, Brennan M, Munn L, Dantuluri KL, Hetherington T, Lu LC, Dunn C, Hogg M, Price A, Leonidas M, Manning M, Rossman W, Gohs FX, Harris A, Priem JS, Tochiki P, Wellinsky N, Silva C, Ludden T, Hernandez J, Spencer K, McAlister L, Weintraub W, Miller K, Washington C, Moses A, Dolman S, Zelaya-Portillo J, Erkus J, Blumenthal J, Barrientos RER, Bennett S, Shah S, Mathur S, Boxley C, Kolm P, Franklin E, Ahmed N, Larsen M, Oberhelman R, Keating J, Kissinger P, Schieffelin J, Yukich J, Beron A, Teigen J, Kotloff K, Chen WH, Friedman-Klabanoff D, Berry AA, Powell H, Roane L, Datar R, Reilly C, Correa A, Navalkele B, Min YI, Castillo A, Ward L, Santos RP, Anugu P, Gao Y, Green J, Sandlin R, Moore D, Drake L, Horton D, Johnson KL, Stover M, Lagarde WH, Daniel L, Maguire PD, Hanlon CL, McFayden L, Rigo I, Hines K, Smith L, Harris M, Lissor B, Cook V, Eversole M, Herrin T, Murphy D, Kinney L, Diehl P, Abromitis N, Pierre TS, Heckman B, Evans D, March J, Whitlock B, Moore W, Arthur S, Conway J, Gallaher TR, Johanson M, Brown S, Dixon T, Reavis M, Henderson S, Zimmer M, Oliver D, Jackson K, Menon M, Bishop B, Roeth R, King-Thiele R, Hamrick TS, Ihmeidan A, Hinkelman A, Okafor C, Bray Brown RB, Brewster A, Bouyi D, Lamont K, Yoshinaga K, Vinod P, Peela AS, Denbel G, Lo J, Mayet-Khan M, Mittal A, Motwani R, Raafat M, Schultz E, Joseph A, Parkeh A, Patel D, Afridi B, Uschner D, Edelstein SL, Santacatterina M, Strylewicz G, Burke B, Gunaratne M, Turney M, Zhou SQ, Tjaden AH, Fette L, Buahin A, Bott M, Graziani S, Soni A, Diao G, Renteria J, Mores C, Porzucek A, Laborde R, Acharya P, Guill L, Lamphier D, Schaefer A, Satterwhite WM, McKeague A, Ward J, Naranjo DP, Darko N, Castellon K, Brink R, Shehzad H, Kuprianov D, McGlasson D, Hayes D, Edwards S, Daphnis S, Todd B, Goodwin A, Berkelman R, Hanson K, Zeger S, Hopkins J, Reilly C, Minnesota UO, Edwards K, Gayle H, Redd S. The COVID-19 Community Research Partnership: a multistate surveillance platform for characterizing the epidemiology of the SARS-CoV-2 pandemic. Biol Methods Protoc 2022; 7:bpac033. [PMID: 36589317 PMCID: PMC9789889 DOI: 10.1093/biomethods/bpac033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2022] [Revised: 11/10/2022] [Accepted: 11/14/2022] [Indexed: 11/29/2022] Open
Abstract
The COVID-19 Community Research Partnership (CCRP) is a multisite surveillance platform designed to characterize the epidemiology of the Severe Acute Respiratory Syndrome Coronavirus-2 (SARS-COV-2) pandemic. This article describes the CCRP study design and methodology. The CCRP includes two prospective cohorts, one with six health systems in the mid-Atlantic and southern USA, and the other with six health systems in North Carolina. With enrollment beginning in April 2020, sites invited persons within their healthcare systems as well as community members to participate in daily surveillance for symptoms of COVID-like illnesses, testing, and risk behaviors. Participants with electronic health records (EHRs) were also asked to volunteer data access. Subsets of participants, representative of the general population and including oversampling of populations of interest, were selected for repeated at-home serology testing. By October 2021, 65 739 participants (62 261 adult and 3478 pediatric) were enrolled, with 89% providing syndromic data, 74% providing EHR data, and 70% participating in one of the two serology sub-studies. An average of 62% of the participants completed a daily survey at least once a week, and 55% of the serology kits were returned. The CCRP provides rich regional epidemiologic data and the opportunity to more fully characterize the risks and sequelae of SARS-CoV-2 infection.
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Polk C, Sampson MM, Jacobs A, Kooken B, Ludden T, Passaretti CL, Leonard M. Cholecystitis as a Possible Immunologic Consequence of COVID-19; Case Series from a Large Healthcare System. Am J Med Sci 2022; 363:456-458. [PMID: 35085530 PMCID: PMC8785331 DOI: 10.1016/j.amjms.2022.01.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2021] [Revised: 01/21/2022] [Accepted: 01/21/2022] [Indexed: 11/23/2022]
Affiliation(s)
- Christopher Polk
- Division of Infectious Diseases, Atrium Health, Charlotte, NC, USA.
| | | | - Anna Jacobs
- Department of Medicine, Atrium Health, Charlotte, NC, USA
| | - Banks Kooken
- Department of Medicine, Atrium Health, Charlotte, NC, USA
| | - Tom Ludden
- Department of Family Medicine, Atrium Health, Charlotte, NC, USA
| | | | - Michael Leonard
- Department of Family Medicine, Atrium Health, Charlotte, NC, USA
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Baldwin LM, Mollis B, Witwer E, Halladay JR, Ludden T, Elder N, Tapp H, Donahue KE, Johnson D, Mottus K, Olson AL, Waddell EN, Dolor RJ. Increasing collaboration on substance use disorder research with primary care practices through the National Drug Abuse Treatment Clinical Trials Network. J Subst Abuse Treat 2020; 112S:34-40. [PMID: 32220408 PMCID: PMC7513836 DOI: 10.1016/j.jsat.2020.02.009] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2019] [Revised: 02/09/2020] [Accepted: 02/10/2020] [Indexed: 01/12/2023]
Abstract
BACKGROUND The National Drug Abuse Treatment Clinical Trials Network (CTN) called for its national nodes to promote the translation of evidence-based interventions from substance use disorder (SUD) research into clinical practices. This collaborative demonstration project engaged CTN-affiliated practice-based research networks (PBRNs) in research that describes aspects of opioid prescribing in primary care. METHODS Six PBRNs queried electronic health records from a convenience sample of 134 practices (84 participants) to identify the percent of adult patients with an office visit who were prescribed an opioid medication from October 1, 2015, to September 30, 2016, and, of those, the percent also prescribed a sedative in that year. Seven PBRNs sent an e-mail survey to a convenience sample of 108 practices (58 participants) about their opioid management policies and procedures during the project year. RESULTS Of 561,017 adult patients with a visit to one of the 84 clinics in the project year, 22.9% (PBRN range 3.1%-25.4%) were prescribed opioid medications, and 52.1% (PBRN range 8.5%-60.6%) of those were prescribed a sedative in the same year. Of the 58 practices returning a survey (45.3% response rate), 98.1% had formal written treatment agreements for chronic opioid therapy, 68.5% had written opioid prescribing policies, and 43.4% provided reports to providers with feedback on opioid management. Only 24.1% were providing buprenorphine for OUD. CONCLUSION CTN-affiliated PBRNs demonstrated their ability to collaborate on a project related to opioid management; results highlight the important role for PBRNs in OUD treatment, research, and the need for interventions and additional policies addressing opioid prescribing in primary care practice.
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Affiliation(s)
- Laura-Mae Baldwin
- Department of Family Medicine, University of Washington, United States of America.
| | - Brenda Mollis
- Department of Family Medicine, University of Washington, United States of America
| | | | - Jacqueline R Halladay
- Department of Family Medicine, University of North Carolina at Chapel Hill, United States of America; Cecil G. Sheps Center for Health Services Research, University of North Carolina at Chapel Hill, United States of America
| | - Tom Ludden
- Department of Family Medicine, Atrium Health, United States of America
| | - Nancy Elder
- Oregon Rural Practice-based Research Network, Oregon Health & Science University, United States of America
| | - Hazel Tapp
- Department of Family Medicine, Atrium Health, United States of America
| | - Katrina E Donahue
- Department of Family Medicine, University of North Carolina at Chapel Hill, United States of America; Cecil G. Sheps Center for Health Services Research, University of North Carolina at Chapel Hill, United States of America
| | - Deborah Johnson
- Dartmouth Geisel School of Medicine, United States of America
| | - Kathleen Mottus
- Cecil G. Sheps Center for Health Services Research, University of North Carolina at Chapel Hill, United States of America
| | - Ardis L Olson
- Department of Pediatrics and Community and Family Medicine, Dartmouth Geisel School of Medicine, United States of America
| | | | - Rowena J Dolor
- Division of General Internal Medicine, Duke University Medical Center, United States of America
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Lubanski E, Rozario N, Moore CG, Mulder HP, Dulin M, Ludden T, Rossman W, Ashby A, McWilliams A. Traditional Risk Indices as Predictors of Future Utilization and Charges in the Context of Population Health for an Uninsured Cohort. EGEMS (Wash DC) 2017; 5:11. [PMID: 29930959 PMCID: PMC5994958 DOI: 10.5334/egems.220] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
INTRODUCTION The uninsured population presents unique challenges to the application of an integrated approach to population health. Our objective is to compare and test population risk indices for identifying a cohort of uninsured patients at high-risk for avoidable healthcare utilization and costs. METHODS Patients who had a least one visit at a safety-net clinic, had a primary address in Mecklenburg County, were aged 18-74, and had the most recent healthcare visit coded as 'uninsured' were identified in the baseline period. The five risk indices used were: the HHS Hierarchical Conditions Category (HCC), the Charlson Comorbidity Index (CCI), Total Cost Index, Total Inpatient Visits Index, and Total Emergency Department Visits Index. First, agreement across the five indices was analyzed. Then, the accuracy of the five risk indices was tested in predicting future utilization and costs for the subsequent 12-month follow-up period. RESULTS Kappa statistics and percent overlap values showed below average to poor agreement between indices when comparing scorers.The strongest predictors of being in the 90th percentile of total cost during the 12 months follow-up period were the Total Cost Index at baseline (C statistic=0.75) and the HCC (C-statistic=0.73). The CCI and Total Inpatient Visit Index's demonstrated the lowest accuracy for predicting an unnecessary ED visit (C-statistic=0.51, for both). DISCUSSION/CONCLUSION Prior cost and ED utilization were key in predicting their corresponding 12-month metrics. In contrast, the Total Inpatient Visit Index had the worst predictive performance for future hospitalization rates. Some indices were similarly predictive as compared to insured cohorts but others showed contrasting results.
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Tapp H, Kuhn L, Alkhazraji T, Steuerwald M, Ludden T, Wilson S, Mowrer L, Mohanan S, Dulin MF. Adapting community based participatory research (CBPR) methods to the implementation of an asthma shared decision making intervention in ambulatory practices. J Asthma 2014; 51:380-90. [PMID: 24350877 PMCID: PMC4002642 DOI: 10.3109/02770903.2013.876430] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2013] [Revised: 11/26/2013] [Accepted: 12/12/2013] [Indexed: 01/05/2023]
Abstract
OBJECTIVE Translating research findings into clinical practice is a major challenge to improve the quality of healthcare delivery. Shared decision making (SDM) has been shown to be effective and has not yet been widely adopted by health providers. This paper describes the participatory approach used to adapt and implement an evidence-based asthma SDM intervention into primary care practices. METHODS A participatory research approach was initiated through partnership development between practice staff and researchers. The collaborative team worked together to adapt and implement a SDM toolkit. Using the RE-AIM framework and qualitative analysis, we evaluated both the implementation of the intervention into clinical practice, and the level of partnership that was established. Analysis included the number of adopting clinics and providers, the patients' perception of the SDM approach, and the number of clinics willing to sustain the intervention delivery after 1 year. RESULTS All six clinics and physician champions implemented the intervention using half-day dedicated asthma clinics while 16% of all providers within the practices have participated in the intervention. Themes from the focus groups included the importance of being part the development process, belief that the intervention would benefit patients, and concerns around sustainability and productivity. One year after initiation, 100% of clinics have sustained the intervention, and 90% of participating patients reported a shared decision experience. CONCLUSIONS Use of a participatory research process was central to the successful implementation of a SDM intervention in multiple practices with diverse patient populations.
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Affiliation(s)
- Hazel Tapp
- Department of Family Medicine, Carolinas Healthcare SystemCharlotte, NCUSA
| | - Lindsay Kuhn
- Department of Family Medicine, Carolinas Healthcare SystemCharlotte, NCUSA
| | - Thamara Alkhazraji
- Department of Family Medicine, Carolinas Healthcare SystemCharlotte, NCUSA
| | - Mark Steuerwald
- Department of Family Medicine, Carolinas Healthcare SystemCharlotte, NCUSA
| | - Tom Ludden
- Department of Family Medicine, Carolinas Healthcare SystemCharlotte, NCUSA
| | - Sandra Wilson
- Department of Health Services Research, Palo Alto Medical Foundation Research InstitutePalo Alto, CAUSA
| | - Lauren Mowrer
- Department of Family Medicine, Carolinas Healthcare SystemCharlotte, NCUSA
| | - Sveta Mohanan
- Department of Family Medicine, Carolinas Healthcare SystemCharlotte, NCUSA
| | - Michael F. Dulin
- Department of Family Medicine, Carolinas Healthcare SystemCharlotte, NCUSA
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Hutmacher MM, Nestorov I, Ludden T, Zitnik R, Banfield C. Modeling the Exposure-Response Relationship of Etanercept in the Treatment of Patients With Chronic Moderate to Severe Plaque Psoriasis. J Clin Pharmacol 2013; 47:238-48. [PMID: 17244775 DOI: 10.1177/0091270006295062] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Modeling exposure-response relationships adds significant value to comprehending and interpreting both efficacy and safety data. An exposure-response model was developed using generalized nonlinear mixed-effects methodologies to correlate etanercept exposure with a 75% or greater reduction from baseline in the psoriasis area and severity index (PASI75). Three randomized trials of psoriasis patients were pooled for analysis. Three empirical exposure measures-cumulative dose, predicted cumulative area under the curve, and predicted trough concentration-were evaluated for their predictive capabilities. The predicted cumulative area under the curve model demonstrated the best ability via simulation to reproduce the data and was used to assess the following covariates: age, baseline psoriasis area and severity index, duration of psoriasis disease, prior systemic or phototherapy, race, sex, and weight. The final model was composed by scrutinizing the confidence intervals of a nonparametric bootstrap and included race and sex effects on baseline logit, baseline psoriasis area and severity index and prior systemic or phototherapy effects on maximum drug effect, a weight effect on apparent potency, and an age effect on the rate of drug effect. The model identified covariates predictive of data trends and adequately characterized by simulation the PASI75 over the entire clinical trial design space. In combination with a statistical subgroup analysis, the exposure-response model indicated that dose adjustment was not necessary for etanercept in any patient subpopulation with moderate to severe plaque psoriasis.
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Dulin MF, Tapp H, Smith HA, de Hernandez BU, Coffman MJ, Ludden T, Sorensen J, Furuseth OJ. A trans-disciplinary approach to the evaluation of social determinants of health in a Hispanic population. BMC Public Health 2012; 12:769. [PMID: 22966865 PMCID: PMC3490764 DOI: 10.1186/1471-2458-12-769] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2012] [Accepted: 08/30/2012] [Indexed: 12/29/2022] Open
Abstract
Background Individual and community health are adversely impacted by disparities in health outcomes among disadvantaged and vulnerable populations. Understanding the underlying causes for variations in health outcomes is an essential step towards developing effective interventions to ameliorate inequalities and subsequently improve overall community health. Working at the neighborhood scale, this study examines multiple social determinates that can cause health disparities including low neighborhood wealth, weak social networks, inadequate public infrastructure, the presence of hazardous materials in or near a neighborhood, and the lack of access to primary care services. The goal of this research is to develop innovative and replicable strategies to improve community health in disadvantaged communities such as newly arrived Hispanic immigrants. Methods/design This project is taking place within a primary care practice-based research network (PBRN) using key principles of community-based participatory research (CBPR). Associations between social determinants and rates of hospitalizations, emergency department (ED) use, and ED use for primary care treatable or preventable conditions are being examined. Geospatial models are in development using both hospital and community level data to identify local areas where interventions to improve disparities would have the greatest impact. The developed associations between social determinants and health outcomes as well as the geospatial models will be validated using community surveys and qualitative methods. A rapidly growing and underserved Hispanic immigrant population will be the target of an intervention informed by the research process to impact utilization of primary care services and designed, deployed, and evaluated using the geospatial tools and qualitative research findings. The purpose of this intervention will be to reduce health disparities by improving access to, and utilization of, primary care and preventative services. Discussion The results of this study will demonstrate the importance of several novel approaches to ameliorating health disparities, including the use of CBPR, the effectiveness of community-based interventions to influence health outcomes by leveraging social networks, and the importance of primary care access in ameliorating health disparities.
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Affiliation(s)
- Michael F Dulin
- Department of Family Medicine, Carolinas HealthCare System, 2001 Vail Avenue, Charlotte, NC 28207, USA
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Abstract
The objective of this analysis was to describe the pharmacokinetic characteristics of anidulafungin in patients with serious fungal disease based on pharmacokinetic data collected during four recently completed or ongoing Phase II/III clinical studies. A total of 600 anidulafungin plasma samples from 225 patients across the four studies were available for analysis. Patients received daily intravenous infusions of 50, 75, or 100 mg anidulafungin, preceded by a loading dose that was twice the daily dose. The analysis population consisted of 129 patients with esophageal candidiasis, 87 with invasive candidiasis, 7 with invasive aspergillosis, and 2 with azole refractory mucosal candidiasis. A population analysis approach was used to develop a steady-state pharmacokinetic model for anidulafungin, assess the significance of possible covariates, and determine the amount of intersubject and random residual variability. A two-compartment model with first-order elimination provided the best fit to the data. The clearance of anidulafungin was influenced by weight and gender, and subjects in the invasive candidiasis study had a typical clearance that was approximately 30% higher than subjects from other studies. Weight was determined to be a predictor of the central volume of distribution. The covariates on clearance accounted for less than 20% of the intersubject variability and therefore are deemed to be of little clinical relevance. There was no evidence that the presence of rifampin or metabolic substrates, inhibitors, or inducers of cytochrome p450 influenced the clearance of anidulafungin. This indicates that dosing adjustments are not necessary when anidulafungin is administered in the presence of medications falling into these classifications.
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Affiliation(s)
- James A Dowell
- Vicuron Pharmaceuticals, 455 South Gulph Road, King of Prussia, PA 19406, USA
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Hossain M, Wright E, Baweja R, Ludden T, Miller R. Nonlinear mixed effects modeling of single dose and multiple dose data for an immediate release (IR) and a controlled release (CR) dosage form of alprazolam. Pharm Res 1997; 14:309-15. [PMID: 9098872 DOI: 10.1023/a:1012041920119] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
PURPOSE NONMEM was applied to single dose and multiple dose bioavailability data for an immediate release (IR) and a controlled release (CR) dosage form of alprazolam to acquire additional information from the data which are not easily obtainable by traditional means. METHODS The objective function value (OBJ) and diagnostic plots were used as measures of goodness of fit of the model to the data. A change in the OBJ value of 7.9 was necessary to show statistical significance (p < 0.005) between two models when the two models differed by 1 parameter. RESULTS A two-compartment linear model with first-order absorption and elimination best describes the data. Including a lag time, two different rates of absorption (KAIR and KACR), and bioavailability for the CR relative to the IR dosage form significantly improved the fit of the model to the data. Cigarette smoking was associated with a 100% increase in clearance of alprazolam as compared to non-smokers. The higher residual variability observed in this study, where interoccasion variability (IOV) was not initially modeled, could be explained to a large extent by the presence of significant interoccasion variability (IOV). CONCLUSIONS Since alprazolam has been suggested to be mainly metabolized by the CYP3A4 isozyme in humans, it appears that tobacco could be an inducer of CYP3A4 and/or alprazolam may be metabolized by other isozyme(s) (specifically, CYP1A1/1A2) that are induced by cigarette smoke. The population pharmacokinetic model approach combined with exploratory graphical data analysis is capable of identifying important covariates from well-controlled "data rich" Phase I studies early in drug development.
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Affiliation(s)
- M Hossain
- Office of Clinical Pharmacology and Biopharmaceutics, Center for Drug Evaluation and Research, FDA, Rockville, Maryland 20857, USA
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Peck CC, Barr WH, Benet LZ, Collins J, Desjardins RE, Furst DE, Harter JG, Levy G, Ludden T, Rodman JH. Opportunities for integration of pharmacokinetics, pharmacodynamics, and toxicokinetics in rational drug development. J Clin Pharmacol 1994; 34:111-9. [PMID: 8163710 DOI: 10.1002/j.1552-4604.1994.tb03974.x] [Citation(s) in RCA: 42] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Affiliation(s)
- C C Peck
- Center for Drug Evaluation and Research, FDA, Rockville, Maryland 20857
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Peck CC, Barr WH, Benet LZ, Collins J, Desjardins RE, Furst DE, Harter JG, Levy G, Ludden T, Rodman JH. Opportunities for integration of pharmacokinetics, pharmacodynamics, and toxicokinetics in rational drug development. J Pharm Sci 1992; 81:605-10. [PMID: 1355792 DOI: 10.1002/jps.2600810630] [Citation(s) in RCA: 27] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Affiliation(s)
- C C Peck
- Center for Drug Evaluation and Research, FDA, Rockville, MD 20857
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Peck CC, Barr WH, Benet LZ, Collins J, Desjardins RE, Furst DE, Harter JG, Levy G, Ludden T, Rodman JH. Opportunities for integration of pharmacokinetics, pharmacodynamics, and toxicokinetics in rational drug development. Pharm Res 1992; 9:826-33. [PMID: 1409369 DOI: 10.1023/a:1015824110164] [Citation(s) in RCA: 30] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Affiliation(s)
- C C Peck
- Center for Drug Evaluation and Research, FDA, Rockville, Maryland 20857
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Peck CC, Barr WH, Benet LZ, Collins J, Desjardins RE, Furst DE, Harter JG, Levy G, Ludden T, Rodman JH. Opportunities for integration of pharmacokinetics, pharmacodynamics, and toxicokinetics in rational drug development. Clin Pharmacol Ther 1992; 51:465-73. [PMID: 1563216 DOI: 10.1038/clpt.1992.47] [Citation(s) in RCA: 138] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Affiliation(s)
- C C Peck
- Center for Drug Evaluation and Research, U.S. Food and Drug Administration, Rockville, MD 20857
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Mungall D, Raskob G, Coleman R, Rosenbloom D, Ludden T, Hull R. Pharmacokinetics and dynamics of heparin in patients with proximal vein thrombosis. J Clin Pharmacol 1989; 29:896-900. [PMID: 2592581 DOI: 10.1002/j.1552-4604.1989.tb03251.x] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Affiliation(s)
- D Mungall
- College of Pharmacy, Ferris State University, MI
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Geary RS, Swynnerton NF, Miller MA, Mangold DJ, Ludden T. Intraduodenal administration of ethiofos (WR-2721): dose proportionality study in the rhesus monkey. Res Commun Chem Pathol Pharmacol 1989; 65:147-59. [PMID: 2555852] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
A dose progression crossover study of ethiofos (WR-2721) was conducted in three healthy male rhesus monkeys. Each subject was tested with three single intraduodenal doses containing 150, 300, and 600 mg/kg. Blood samples were drawn as a function of time and the concentrations of ethiofos, WR-1065 (free thiol metabolite), and total drug convertible to the free thiol (total WR-1065) were determined by HPLC using electrochemical detection. Ethiofos levels in plasma were usually below quantifiable limits of detection (0.23 mumol/L) at all three dose levels, but free WR-1065 plasma levels increased with increasing dose. Analysis of the free WR-1065 bioavailability values indicated large variability and an unpredictable dose response among subjects. Bound WR-1065 appears to reach saturable levels over the dose range, suggesting a saturable pool of binding sites in plasma. The time-to-peak plasma levels for WR-1065 were variable regardless of the administered dose and ranged from 1.0-2.5 hours. The high variability in the data may be a result of poor permeability or absorption of the parent compound (ethiofos), saturable binding to a variable pool of binding sites in plasma and/or high first-pass metabolism of ethiofos involving the gut lumen, gut wall (epithelium), and liver.
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Affiliation(s)
- R S Geary
- Southwest Research Institute, San Antonio, Texas 78284
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Abstract
We studied the pharmacodynamics of warfarin in chronically treated patients. Two methods were used to estimate the pharmacodynamic parameters M/Kd and Cmax (mg/L). In Method 1 the prothrombin time response was modeled directly without use of warfarin concentrations and Method 2 used warfarin concentrations and prothrombin time response to estimate M/Kd and Cmax. The mean Cmax and M/Kd for Method 1 (n = 88) were 5.5 +/- 2.3 mg/L and 51 +/- 46 and for Method 2 (n = 27) 6.3 +/- 2.8 mg/L and 35.4 +/- 13. When Method 1 was applied to the same 27 patients in Method 2, the mean Cmax and M/Kd were 5.7 +/- 3.3 mg/L and 36.1 +/- 14.9. These differences were not significant. Multiple regression analysis revealed that the value of Cmax and M/Kd varied between medical centers. No other patient characteristics were found to be significant. We conclude that modeling steady-state prothrombin time response directly adequately describes pharmacodynamic response to warfarin.
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Hall AH, Doutre WH, Ludden T, Kulig KW, Rumack BH. Nitrite/thiosulfate treated acute cyanide poisoning: estimated kinetics after antidote. J Toxicol Clin Toxicol 1987; 25:121-33. [PMID: 3586082 DOI: 10.3109/15563658708992618] [Citation(s) in RCA: 29] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
A 34 year old, 73 kg man ingested a 1 gram potassium cyanide pellet in a suicide attempt. Within one hour, coma, apnea, metabolic acidosis, and seizures developed. Sodium nitrite and sodium thiosulfate were administered. Dramatic improvement in the clinical condition occurred by the completion of antidote infusion. Methemoglobin level was 2% immediately after nitrite administration. Serial whole blood cyanide levels were obtained, documenting a highest measured level of 15.68 mcg/mL. Estimations of toxicokinetic parameters including terminal half-life (t 1/2) (19 hours), clearance (163 mL/minute), and volume of distribution (Vd) (0.41 L/kg) were calculated. The nitrite/thiosulfate combination was clinically efficacious in this case and resulted in complete recovery.
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Vozeh S, Hillman R, Wandell M, Ludden T, Sheiner L. Computer-assisted drug assay interpretation based on Bayesian estimation of individual pharmacokinetics: application to lidocaine. Ther Drug Monit 1985; 7:66-73. [PMID: 3838832 DOI: 10.1097/00007691-198503000-00011] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
A microcomputer program for individualized drug level prediction based on Bayesian forecasting is presented. It is written so that the clinician can integrate patient demographics and drug levels to design a new dosage regimen tailored to an individual patient. The program's great flexibility and robustness make it appropriate for realistic clinical settings. A validation with a data set of lidocaine concentrations measured in 18 patients revealed that the program can predict serum lidocaine levels accurately enough to enhance individual patient dosage adjustment within a few hours after a dosage regimen is started.
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Abstract
To establish whether there is a difference between infants and adults in the relationship of serum levels of digoxin to dosage or the ratio of myocardial to serum digoxin levels, the concentrations of digoxin in right atrial appendage (RAA) and serum were measured in 12 infants and 17 adults undergoing open heart surgery. Although the daily digoxin dose per weight for the infant was significantly greater than that for adults, there was no difference in the serum digoxin levels for the two groups. We found, however, a considerable difference in myocardial digoxin levels. The RAA digoxin levels were 211.8 +/- 72.1 ng/g of wet weight in infants and 35.1 +/- 7.7 ng/g of wet weight in adults. Similarly, the RAA-serum digoxin ratio was much higher in infants (149 +/- 30) than in adults (28 +/- 5). These data indicate discrepancies between infants and adults in the pharmacokinetics of digoxin, especially with respect to myocardial uptake.
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Abstract
There is marked interindividual variation in hypotensive response to intravenous hydralazine (H). We examined the determinants of response in patients with hypertension. After a single intravenous dose of 0.3 mg/kg H, response was correlated independently (r = 0.8364) with both predrug blood pressure and acetylator index (AI). Intravenous dose ranging studies showed that response also depended on the amount of H in the systemic circulation. Although plasma H levels depend on AI after oral doses, this is not so after intravenous administration. AI must therefore affect response to H by an alternative, presumably nonmetabolic mechanism which, not related to AI, perhaps indicating specificity of this effect for H. These data reinforce the potential usefulness of determining AI before giving H to a patient.
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Abstract
We examined the hemodynamic actions of clinically relevant i.v. doses (20 mg/kg and 10 mg/kg) of n-acetyl procainamide (NAPA) in conscious dogs preinstrumented with a left ventricular (LV) micromanometer, LV and aortic catheters, and ultrasonic crystals for measurement of LV internal diameter shortening (% delta D). Within 30 seconds after the 20-mg/kg dose, there were significant increases in heart rate (27 +/- 7 beats/min, mean +/- SEM; n = 6), maximum dP/dt (655 +/- 206 mm Hg/sec), and % delta D (2.2 +/- 0.9%; all p less than or equal to 0.05). However, by 6 hours after the dose there were reductions compared with control in peak LV pressure (19 +/- 9 mm Hg), dP/dt (610 +/- 210 mm Hg/sec), and % delta D (2.3 +/- 0.6%; all p less than or equal to 0.05). In contrast, equimolar doses of procainamide or drug vehicle alone evoked no response, as did NAPA after pretreatment with reserpine (0.25 mg/kg/day for 2 days) or hexamethonium (10-15 mg/kg). These data suggest NAPA produces a biphasic hemodynamic response with enhancement of LV performance early and a decrease later; this response is different from that of the parent compound, procainamide. These effects are likely mediated by the adrenergic nervous system at either a ganglionic or a central level.
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Stavchansky S, Ludden T, Allen JP, Wu P. Correlation of the e.m.i.t. diphenylhydantoin assay in blood plasma with a g.l.c. and a spectrophotometric method. Anal Chim Acta 1977; 92:213-6. [PMID: 329711 DOI: 10.1016/s0003-2670(01)84591-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
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