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- Interventions To Improve Cardiovascular Risk Factors in People With Serious Mental Illness
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- Research Review Apr. 22, 2013
Related Products for this Topic
- Research Protocol Jan. 17, 2012
- Disposition of Comments Report Aug. 9, 2013
Executive Summary – Apr. 22, 2013
Interventions To Improve Cardiovascular Risk Factors in People With Serious Mental Illness
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Archived: This report is greater than 3 years old. Findings may be used for research purposes, but should not be considered current.
Table of Contents
- Background
- Scope and Key Questions
- Methods
- Results
- Discussion
- Conclusions
- References
- Glossary
- Full Report
Serious mental illness (SMI) is defined generally as a major mental or behavioral disorder, causing substantial impairment in multiple areas of daily functioning. SMI affects about 4 to 8 percent of adults1-3 and includes disorders such as schizophrenia and bipolar disorder but not isolated substance abuse or developmental disorders. Individuals with SMI have shortened life expectancies relative to the general population to an extent that is not explained by suicide and accidents alone.4,5 This population experiences higher rates of morbidity from multiple general medical conditions, including diabetes6-8 and cardiovascular disease (CVD).9-11 Among patients using the public mental health system, heart disease was the leading cause of death.12 This excess of CVD-related mortality may be due to a number of factors, including direct effects of the illness, medications used to treat SMI, modifiable behavioral risk factors, and disparities in access and quality of health care.
For CVD, mental illness may be an independent risk factor that acts both directly through physiological effects such as underlying genetic vulnerabilities, or indirectly through effects on an individual's access to or interaction with the health care system.13-15 Modifiable CVD risk factors, such as smoking,16 obesity,17,18 and physical inactivity19,20 are highly prevalent among adults with SMI. Adverse effects of psychotropic drugs (notably second-generation antipsychotics) also may contribute to the development of CVD by increasing the risk of conditions such as hyperglycemia, hyperlipidemia, and obesity.21 Lower socioeconomic status is more common in individuals with SMI22,23 and may limit access to healthy food, opportunities for physical exercise (e.g., walkable neighborhoods and access to fitness facilities), and high-quality medical care. Numerous studies have demonstrated disparities in the quality of general medical care provided to individuals with SMI.24-28 In contrast to individuals with less severe mental disorders, who largely receive mental health treatment in primary care settings, most individuals with SMI receive mental health treatment in specialized mental health settings. Consequently, people with SMI receive fewer preventive medical services24,25 and less frequent guideline-concordant treatment to manage chronic physical illnesses such as diabetes26,27 and CVD.28 Given these issues, identifying intervention strategies that address CVD risk in individuals with SMI is a pressing priority to avoid early morbidity and mortality.
Scope and Key Questions
This comparative effectiveness review was funded by the Agency for Healthcare Research and Quality (AHRQ). The review was designed to evaluate strategies to improve CVD risk factors in adults with SMI. SMI has been defined variously by different groups over time.29 For the purposes of this evidence review, people with SMI are defined as individuals who have: (1) schizophrenia or schizoaffective disorder (or other related primary psychotic disorder), (2) bipolar disorder, or (3) current major depression with psychotic features. We also included studies that enrolled adults with SMI or severe and persistent mental illness (SPMI) but did not specify diagnoses. Individuals with a primary diagnosis of substance abuse, dementia, personality disorder, or mental retardation are excluded from this definition.
To prioritize interventions for review, we examined published systematic reviews of strategies to improve CVD risk factors in individuals with SMI and consulted with our Key Informants. Because we identified recent high-quality reviews of general health advice, interventions for smoking cessation, and models to provide integrated mental health–general medical care, we elected not to cover these interventions again in our review.30-34 We included randomized controlled trials (RCTs) of the pharmacological and patient-focused behavioral strategies along with peer and family support interventions. For patient-level intervention strategies, RCTs yield the highest quality evidence. We included both active and control comparators. Major outcomes of interest for this report are primary CVD risk factors (excluding tobacco use, as explained above), physical functioning or health-related quality of life, adverse effects, and all-cause mortality.
Key Questions
With input from our Technical Expert Panel (TEP), we constructed Key Questions (KQs) using the general approach of specifying the population of interest, interventions, comparators, outcomes, timing of outcomes, and settings (PICOTS). The KQs considered in this comparative effectiveness review were:
KQ 1: What is the effectiveness of weight-management behavioral interventions (e.g., behavioral counseling, health education), peer or family support interventions, pharmacological treatments (e.g., orlistat, topiramate), antipsychotic medication–-switching to an antipsychotic with a low or neutral impact on weight, or their combination on weight control and related physical health outcomes (e.g., health-related quality of life, mortality) compared with each other or with usual care (or other control) among adults with serious mental illness (SMI) who are overweight, obese, or taking antipsychotics?
KQ 2: What is the effectiveness of diabetes-management behavioral interventions (e.g., behavioral counseling, health education), peer or family support interventions, pharmacological treatments (e.g., rosiglitazone, metformin), antipsychotic medication–switching to an antipsychotic with a low or neutral impact on glucose level, or their combination on glucose-level control and related physical health outcomes (e.g., health-related quality of life, mortality) compared with each other or with usual care (or other control) among adults with SMI who have diabetes or are taking antipsychotics?
KQ 3: What is the effectiveness of dyslipidemia-management behavioral interventions (e.g., behavioral counseling, health education), peer or family support interventions, pharmacological treatments (e.g., statins), antipsychotic medication–switching to an antipsychotic with a low or neutral impact on lipid levels, or their combination on lipid-level control and related physical health outcomes (e.g., health-related quality of life, mortality) compared with each other or with usual care (or other control) among adults with SMI who have dyslipidemia or are taking antipsychotics?
KQ 4: What is the effectiveness of multicondition lifestyle interventions (e.g., combinations of smoking cessation, physical activity, and nutrition counseling with or without medication management) on cardiovascular risk factors and related physical health outcomes (e.g., health-related quality of life, mortality) among adults with SMI who have cardiovascular disease, elevated cardiovascular risk (e.g., hypertension), or are taking antipsychotics?
Analytic Framework
Figure A depicts the KQs in the context of the PICOTS.
CVD = cardiovascular disease; KQ = Key Question
The methods for this comparative effectiveness review follow those suggested in the AHRQ "Methods Guide for Effectiveness and Comparative Effectiveness Reviews"(available at www.effectivehealthcare.ahrq.gov/methodsguide.cfm; hereafter referred to as the Methods Guide).35
During the topic refinement stage, we solicited input from Key Informants representing clinicians, patient advocates, scientific experts, and payers to help define the Key Questions (KQs). The KQs were then posted for a 4-week public comment period, and the comments received were considered in the development of the research protocol. We next convened a TEP comprising clinical, content, and methodological experts to provide input in defining populations, interventions, comparisons, and outcomes, as well as identifying particular studies or databases to search. TEP members were invited to provide feedback on an initial draft of the review protocol, which was then refined based on their input, reviewed by AHRQ, and posted for public access at the AHRQ Effective Health Care Web site.36
Literature Search Strategy
To identify the relevant published literature, we searched MEDLINE®, Embase®, PsycINFO®, and the Cochrane Database of Systematic Reviews. Where possible, we used existing validated search filters (such as the Clinical Queries Filters in PubMed®). An experienced search librarian guided all searches. Exact search strings and dates are included in the appendix to the main report. We supplemented the electronic searches with a manual search of citations from a set of key primary and review articles. The reference lists for these articles were manually reviewed and cross-referenced against our library of search results, and additional potentially relevant citations were retrieved for screening. All citations were imported into an electronic database (EndNote® X4; Thomson Reuters, Philadelphia, PA).
We used two approaches to identify relevant gray literature: (1) a request for scientific information packets submitted to drug manufacturers and (2) a search of trial records listed in ClinicalTrials.gov. The search of ClinicalTrials.gov was also used as a mechanism to ascertain publication bias by identifying completed but unpublished studies.
Inclusion and Exclusion Criteria
Criteria used to screen articles for inclusion/exclusion at both the title-and-abstract and full-text screening stages are detailed in the main report. In brief, eligibility criteria were English-language RCTs that assess patient-focused behavioral interventions, peer or family support interventions, pharmacological treatments (including antipsychotic switching), multicondition lifestyle interventions, or their combination targeting weight control, glucose levels, lipid levels, or CVD risk profile among adults with SMI at elevated risk of CVD. We excluded articles describing studies that: (1) had as their primary goal improving psychiatric outcomes, (2) assessed only mass media strategies, (3) evaluated pharmacological agents not currently available on the U.S. market, or (4) took place in hospital or inpatient settings. Outcomes of interest were weight control (KQ 1); glucose level (i.e., hemoglobin A1c) (KQ 2); lipid level (i.e., change in low-density lipoprotein [LDL]) (KQ 3); CVD risk profile (e.g., Framingham CVD scores) or multiple individual components of modifiable CVD risk (e.g., lipid values, blood pressure, smoking status) (KQ 4); and health-related quality of life, all-cause mortality, physical function, serious adverse effects, and adverse effects (KQs 1–4).
Study Selection
Using the prespecified inclusion and exclusion criteria described in Table 2 of the full report, two investigators independently reviewed titles and abstracts for potential relevance to the KQs. Articles included by either reviewer underwent full-text screening. At the full-text screening stage, two investigators independently reviewed each article to determine if it met eligibility criteria, and indicated a decision to "include" or "exclude" the article for data abstraction. When the paired reviewers arrived at different decisions about whether to include or exclude an article, or about the reason for exclusion, they reconciled the difference through review and discussion, or through a third-party arbitrator if needed. Articles meeting our eligibility criteria were included for data abstraction. Relevant review articles and meta-analyses were flagged for manual searching of references and cross-referencing against the library of citations identified through electronic database searching. For citations retrieved by searching the gray literature, the above-described procedures were modified such that a single screener initially reviewed all search results; final eligibility of citations for data abstraction was determined by duplicate screening review. All screening decisions were made and tracked in a DistillerSR database (Evidence Partners Inc, Manotick, ON, Canada).
Data Extraction
The investigative team created data abstraction forms and evidence table templates for abstracting data for the KQs. Based on clinical and methodological expertise, a pair of investigators was assigned to abstract data from each eligible article. One investigator abstracted the data, and the second reviewed the article and the accompanying completed abstraction form to check for accuracy and completeness. Quality ratings and efficacy–effectiveness ratings (see below) were completed independently by two investigators. Disagreements were resolved by consensus, or by obtaining a third reviewer's opinion if consensus could not be reached. To aid in both reproducibility and standardization of data collection, researchers received data abstraction instructions directly on each form created specifically for this project within the DistillerSR database.
We designed the data abstraction forms for this project to collect the data required to evaluate the specified eligibility criteria for inclusion in this review, as well as demographic and other data needed for determining outcomes. We gave particular attention to describing the details of the interventions (e.g., pharmacotherapy used, intensity of behavioral interventions), patient characteristics (e.g., SMI diagnosis), and comparators that may be related to outcomes. Data necessary for assessing quality and applicability, as described in the Methods Guide,35 were also abstracted. When critical data were missing, we contacted study authors. Of the seven authors contacted, five replied with the requested information.
Quality Assessment of Individual Studies
We evaluated the quality of individual studies using the key criteria for RCTs described in the Methods Guide.35 Criteria of interest included methods of randomization and allocation concealment, similarity of groups at baseline, extent to which outcomes were described, blinding of subjects and providers, blinded assessment of the outcome(s), intention-to-treat analysis, differential loss to followup between the compared groups or overall high loss to followup, and conflicts of interest.
To indicate the summary judgment of the quality of the individual studies, we used the summary ratings of good, fair, or poor based on their adherence to well-accepted standard methodologies and adequate reporting. For each study, two investigators independently assigned a summary quality rating; disagreements were resolved by consensus or by discussion with a third investigator if agreement could not be reached. Quality ratings were assigned separately for "hard" outcomes (e.g., mortality, laboratory measurements) and all other outcomes (e.g., health-related quality of life); thus, a given study may have been categorized differently for two individual outcomes reported within that study.
Data Synthesis
We began by summarizing key features of the included studies for each Key Question. We then determined the feasibility of completing a quantitative synthesis (i.e., meta-analysis). Feasibility depended on the volume of relevant literature (≥3 studies), conceptual homogeneity of the studies, and completeness of the reporting of results. When a meta-analysis was appropriate, we used random-effects models to quantitatively synthesize the available evidence. For other outcomes we analyzed the results qualitatively. The outcomes amenable to meta-analysis were continuous; we therefore summarized these outcomes by a weighted difference of the means when the same scale (e.g., weight) was used and a standardized mean difference when the scales (e.g., health-related quality of life) differed across studies. We standardized results presentation such that a negative value indicates a greater intervention effect. We present summary estimates, standard errors, and confidence intervals in our data synthesis.
We organized our analyses by KQ. When a single study reported outcomes relevant to multiple KQs, it was included in the analyses for each question. For example, a study evaluating a weight-loss intervention that specified weight as the primary outcome—but also reported effects on glucose and lipid parameters—was described in each relevant KQ. When a study was designed to intervene on more than one CVD risk factor (e.g., metabolic syndrome), it was summarized in KQ 4. We specified, a priori, weight control as measured by change in kilograms (or pounds), hemoglobin A1c (HbA1c) as the preferred measure of glucose control since it reflects average glucose values over a 3-month interval, and total and LDL cholesterol as measures of lipid control. For adverse effects, we report significant worsening of psychiatric status and discontinuations due to adverse effects. Interventions were categorized as: behavioral, pharmacological, peer or family support, or multicondition (e.g., specifically targeting more than one condition such as smoking cessation and weight loss). Drug classes were psychotropics, neurologics, metformin, antihistamines, nutritionals (i.e., carnitine), and switching between antipsychotic medications.
We tested for heterogeneity using graphical displays and test statistics (Q statistic), while recognizing that the ability of statistical methods to detect heterogeneity may be limited.37 The I2 describes the percentage of total variation across studies due to heterogeneity rather than to chance. Heterogeneity was categorized as low, moderate, or high based on I2 values of 25 percent, 50 percent, and 75 percent respectively.37 All analyses were conducted using Comprehensive Meta-Analysis software (Version 2; Biostat, Englewood, NJ).
Strength of the Body of Evidence
The strength of evidence for each KQ and outcome was assessed using the approach described in the Methods Guide.35,38 In brief, the approach requires assessment of four domains: risk of bias, consistency, directness, and precision. Additional domains were used when appropriate: coherence, and publication bias. These domains were considered qualitatively, and a summary rating of high, moderate, or low strength of evidence was assigned after discussion by two reviewers. In some cases, high, moderate, or low ratings were impossible or imprudent to make; for example, when no evidence was available or when evidence on the outcome was too weak, sparse, or inconsistent to permit any conclusion to be drawn. In these situations, a grade of insufficient was assigned.
We assessed applicability across our KQs using the method described in the Methods Guide.35,39 In brief, this method uses the PICOTS format as a way to organize information relevant to applicability. The most important issue with respect to applicability is whether the outcomes are different across studies that recruit different populations (e.g., age groups, exclusions for comorbidities) or use different methods to implement the interventions of interest; that is, important characteristics are those that affect baseline (control-group) rates of events, intervention-group rates of events, or both. We used a checklist to guide the assessment of applicability. We used these data to evaluate the applicability to clinical practice, paying special attention to study eligibility criteria, demographic features of the enrolled population in comparison with the target population, characteristics of the intervention used in comparison with care models currently in use, and clinical relevance and timing of the outcome measures. We summarized issues of applicability qualitatively.
Figure B depicts the flow of articles through the literature search and screening process. Searches of PubMed®, Embase®, and the Cochrane Database of Systematic Reviews yielded 5,769 citations, 756 of which were duplicate citations. Manual searching identified 213 additional citations, for a total of 5,226 citations. After applying inclusion/exclusion criteria at the title-and-abstract level, 179 full-text articles were retrieved and screened. Of these, 139 were excluded at the full-text screening stage, leaving 40 articles (representing 35 unique studies) for data abstraction. No additional information was found through our gray literature search.
Overall, we included 35 studies, some of which were relevant to more than one KQ: 32 studies were relevant to KQ 1, 7 to KQ 2, 15 to KQ 3, and 3 to KQ 4. Studies were conducted in Europe (23%); Asia (14%); the United States (37%); Australia/New Zealand (6%); and South America (6%); or multiple continents (14%). Sixty-three percent of included studies enrolled individuals with schizophrenia or schizoaffective disorder, 11 percent recruited individuals with schizophrenia, schizoaffective disorder, or bipolar disorder, 20 percent recruited patients either taking antipsychotics or with an unspecified SMI diagnosis, and only 6 percent recruited individuals with bipolar disorder. The vast majority of studies were specifically designed to control weight (80%); only one study was designed to target diabetes management, and no studies were designed to target dyslipidemia.
The most common comparisons were between behavioral interventions and control (26% of comparisons), followed by neurologics (13%), and psychotropics or antihistamines compared with control (10% for each comparison). Relatively few studies compared two active interventions. No studies evaluated standard medications for hyperlipidemia (e.g., HMG-CoA reductase inhibitors) or orlistat (a Food and Drug Administration [FDA]-approved medication for weight control), and only a few studies evaluated hypoglycemic medication.
Key Question 1. Effectiveness of Weight-Management Interventions
Key points are:
- Of the 32 studies identified, most were specifically designed to control weight gain for individuals with SMI.
- Behavioral interventions were found in a meta-analysis to have a significant advantage over control conditions. We found moderate strength of evidence (SOE) that behavioral interventions are associated with small decreases in weight (about 3 kg) compared with controls.
- Switching to or adding adjunctive aripiprazole, adding the anticonvulsant medications topiramate and zonisamide, or adding metformin yielded small to moderate weight loss (low SOE).
- There was no advantage in favor of nizatidine compared with placebo for the management of weight gain among patients with SMI (low SOE).
- No studies evaluated the weight loss medication orlistat in this population.
- Few studies reported effects on physical functioning or health-related quality of life, and no studies reported all-cause mortality.
We identified 32 RCTs encompassing 3,473 participants that assessed the effects of weight-management strategies among adults with SMI. Most studies (n=19) were rated fair quality, with 9 studies rated good quality and 4 poor quality. In total, 22 studies targeted weight control, 6 obesity prevention, 3 antipsychotic metabolic effects, and 1 diabetes management. Of the 3,473 participants across the 32 included studies, most were male and white.
We had sufficient studies to perform three meta-analyses: behavioral interventions, the anticonvulsant medications topiramate and zonisamide, and the antihistamine nizatidine compared with placebo control. Other comparisons were synthesized qualitatively. We found moderate SOE that behavioral interventions are associated with small decreases in weight compared with controls (mean difference, -3.13 kg; 95% CI, -4.21 to -2.05). We found low SOE that switching to or adding adjunctive aripiprazole, adding the anticonvulsant medications topiramate and zonisamide (mean difference, -5.11 kg; CI, -9.48 to -0.74), or adding metformin (mean difference, -4.13 kg; 95% CI, ?6.58 to -1.68) yield small to moderate weight loss. Nizatidine, an antihistamine, did not show any consistent effect on weight (mean difference, -0.496 kg; CI, -1.256 to 0.266) with a low SOE. The SOE was insufficient for all other interventions. No studies evaluated orlistat, an FDA-approved medication for the treatment of obesity that is also available without prescription at a lower dose.
Key Question 2. Effectiveness of Diabetes-Management Interventions
Key points are:
- Overall, we found insufficient evidence to support any strategy to control glucose. Of the seven studies identified, only one evaluated an intervention specifically designed to target glucose control in individuals with SMI who have diabetes. Two additional studies evaluated interventions targeting nondiabetic individuals who had or were at risk for poor glycemic control. Four studies evaluated interventions targeting weight, with glycemic control as a secondary outcome.
- The interventions represented in these seven studies were ramelteon, antipsychotic switching, metformin, amantadine, and behavioral interventions.
- Just two of the trials found significant advantages for the intervention in controlling HbA1c, with both of these studies involving the use of metformin. Improvements in HbA1c were small.
- Health-related quality of life and serious adverse events were inconsistently reported in the seven trials. Only one study reported effects on physical functioning or health-related quality of life, and no studies reported CVD mortality.
We identified 7 RCTs encompassing 681 participants that assessed the effects of diabetes-management strategies among adults with SMI. Of these studies, one was rated good quality, five fair quality, and one poor quality. Only one study enrolled patients with diabetes and addressed glucose control directly; the other six studies assessed HbA1c as a secondary outcome.
There was an insufficient number of studies to conduct meta-analyses on the effects of any of the intervention classes by HbA1c. Just two of the trials found significant advantages for the intervention in controlling HbA1c, with both of these studies involving the use of metformin, an FDA-approved drug for the treatment of type 2 diabetes.
Key Question 3. Effectiveness of Dyslipidemia-Management Interventions
Key points are:
- Lipid levels have not been a primary target for interventions studied in individuals with SMI. While 15 RCTs reported lipid levels as a secondary outcome (the studies included in this section), no studies evaluated an intervention specifically designed to target lipid levels in individuals with SMI who have or are at risk for dyslipidemia. Hence, the strength of evidence for this KQ 3 is insufficient.
- Interventions known to be effective for managing dyslipidemia, such as medications (e.g., HMG-CoA reductase inhibitors) or dietary interventions, have not been studied in SMI populations. It seems that such interventions should be considered for clinical use, but direct evidence in SMI populations is lacking.
- Behavioral interventions were found in a meta-analysis to have no advantage over usual care for managing low-density lipoprotein (LDL) levels, but this analysis consisted of three small, 3- to 12-month studies aimed primarily at either weight or diabetes management.
- Small improvements in lipids were seen in one study of ramelteon, one study of topiramate, and one study that used a sequenced medication algorithm of amantadine, metformin, and zonisamide.
- Lipid levels improved modestly in two studies of aripiprazole—one that added aripiprazole to chronic clozapine and one that switched patients from olanzapine to aripiprazole. Switching from oral to injectable olanzapine increased LDL cholesterol.
We identified no articles reporting on trials in which the intervention was designed to target lipid levels. Specifically, no study evaluated HMG-CoA reductase inhibitors (statins), niacin, fibrates, or low-fat diets. However, 15 of the eligible studies, involving 2,322 patients, reported on total cholesterol (n=12) or LDL cholesterol (n=14) as a secondary outcome. Most studies (n=8) were rated fair quality, with four studies rated good quality, and three poor quality. The experimental intervention was psychotropic medication in three trials, antipsychotic switching in four trials, behavioral interventions in three trials, neurological agents in three trials, an antihistamine in one trial, and a neurological agent or a biguanide in one trial (this trial was the only one with three arms instead of two). The majority of patients were male, white, and middle-aged.
We had sufficient studies with cohesive intervention strategies to conduct a meta-analysis only for the effect of behavioral interventions on lipid levels. Behavioral interventions focusing on weight loss or diabetes management have no substantial effects on lipids (LDL levels mean difference, 1.91 mg/dl; 95% CI, -6.06 to 9.88). Small benefits were seen when aripiprazole was used as an adjunct or as an antipsychotic-switching strategy, and single studies suggested possible benefit with ramelteon or topiramate. However, SOE was insufficient for all interventions; no strategies were designed to target lipid levels.
Key Question 4. Effectiveness of Multicondition Lifestyle Interventions
Key points are:
- Only three studies evaluated lifestyle interventions. Lifestyle interventions consisted primarily of dietary and exercise components. One study offered additional provisions such as heart rate monitors and financial subsidies to support the exercise component.
- One study reported small to moderate beneficial effects on body mass index (BMI), weight, and cholesterol.
- This good-quality study showed benefit in switching from olanzapine, quetiapine, or risperidone to aripiprazole in the context of a manualized, behaviorally oriented diet and exercise program.
- The effects of the behavioral component of the lifestyle intervention in this study are unknown, since both the intervention and comparison arm received the behavioral component.
- Two studies reported significant benefits of multicondition lifestyle interventions for self-reported health-related quality of life.
- Studies included in KQ 4 varied substantially on methodological rigor and quality variables.
- Overall, the evidence is insufficient to estimate the effects of multicondition lifestyle interventions.
We identified 1 good and 2 fair-quality studies involving 286 patients that assessed the effects of lifestyle interventions on CVD risk factors and related physical health outcomes among adults with SMI. Most participants were male and white. There was an insufficient number of studies with cohesive intervention strategies to conduct a meta-analysis; results are summarized qualitatively. Two studies evaluated multicomponent lifestyle interventions alone, and one evaluated switching from one of three second-generation antipsychotic medications to aripiprazole in combination with a structured diet and exercise program. None of these studies evaluated lifestyle interventions in combination with medications that directly address weight (e.g., orlistat), glucose (e.g., metformin), or lipids (e.g., statins). Studies reported each outcome separately; only one reported an overall CVD risk score, which was unaffected by the intervention. Adding or switching to aripiprazole results in a small benefit on weight (low SOE), but the evidence is insufficient for overall CVD risk. The two multicomponent behavioral interventions did not have a positive effect on the individual CVD risk factors, although one of the two studies showed a large positive effect on health-related quality of life.
Figure B. Literature flow diagram
KQ = Key Question
Key Findings and Strength of Evidence
We identified 35 trials that tested a wide array of pharmacological and behavioral interventions to address one or more CVD risk factors in adults with SMI who have elevated risk for CVD. Given that CVD is the most prevalent cause of death in this population, this is a surprisingly small number of studies. Further, we identified no peer and family support interventions to address elevated CVD risk, nor did we find any interventions designed specifically to address lipids. No interventions targeted individuals with psychotic depression specifically. Outcomes reported were primarily metabolic outcomes such as glucose control or weight; effects on physical function and overall CVD risk (e.g., Framingham Risk Score) were reported infrequently, and all-cause mortality was not reported.
Table A presents a brief overview of key findings by intervention as well as the strength of evidence (SOE) by KQ for major outcomes. The drug classes in our review sometimes included drugs with diverse mechanisms of action. When results varied by drug, we assigned separate SOE. Publication bias was difficult to assess because only a few comparisons had sufficient studies for statistical analysis. For adverse effects, we considered discontinuation due to adverse effects and worsening of psychiatric status as the key outcomes when rating SOE. When the majority of studies reported only one of these outcomes, we considered the evidence for adverse effects incomplete and rated the limited evidence as indirect. In brief, evidence was insufficient for most intervention strategies, and there were too few studies to conduct quantitative synthesis for all outcomes of interest, except for weight.
Prior reviews have identified effective treatments for CVD risk factors such as obesity, tobacco use, and hyperlipidemia in general populations or in adults at increased risk for CVD.40-42 We specifically excluded from our review evaluations of general health advice, smoking cessation interventions, and models that provide integrated mental health–general medical care because these topics had been the subject of recent high-quality reviews in patients with SMI.30-34 Tsoi et al.30,31 found that bupropion more than doubled the rate of smoking abstinence in smokers with schizophrenia without jeopardizing their mental state. There were few studies of other smoking cessation treatments (including nicotine replacement therapy) and no evidence of benefit for these other treatments. In contrast, Tosh et al.32 found a small number of RCTs evaluating general physical health advice for patients with SMI, and no clear benefit on health outcomes. Bradford et al.34 found moderately strong evidence that integrated mental health–general medical care improves preventive services, including CVD screening, but limited and inconsistent effects on physical functioning and CVD risk factors.
Our results complement prior reports by examining a broad array of interventions for patients at increased risk for worsening health outcomes due to CVD risk factors such as obesity, hyperlipidemia, diabetes mellitus, or chronic administration of antipsychotic medication that negatively impacts metabolic parameters. Earlier narrative and systematic reviews have focused primarily on behavioral interventions for weight control in patients with schizophrenia or who were on antipsychotic medications.43-49 These reviews used differing eligibility criteria, with some including observational designs. Despite the differences in methods, the conclusions of these reviews are largely consistent with our findings that behavioral interventions are associated with small improvements in weight. Our review builds on these findings by identifying clear omissions in treatments that are known to be effective in non-SMI populations, including guideline-concordant care, and promising treatment strategies such as aripiprazole, metformin, and topiramate, which deserve further investigation.
In our review, only 15 of 35 trials were conducted in the United States, and most studies (n=21) were classified as efficacy studies and were relatively short in duration.
Studies typically enrolled midlife adults; none specifically enrolled older adults. Women, as well as racial minorities, were well represented overall but underrepresented for some specific comparisons. Most studies were conducted in mental health outpatient settings, typical of the principal locus of medical care for patients with SMI; none were conducted in patient-centered medical homes or in settings that integrated mental health with general medical services. None were classified as effectiveness studies, but for many interventions, initial studies are justifiably designed to answer the question "Can it work under ideal conditions?" before moving to a test of effectiveness. Probably the most important constraint on applicability is the inconsistent reporting of the CVD-related outcomes of interest and the nearly total lack of reporting (only reported in one study) for overall CVD risk indices (e.g., Framingham Risk Score).
Implications for Clinical and Policy Decisionmaking
The U.S. Preventive Services Task Force makes recommendations for CVD screening in adults, including blood pressure50 and tobacco use,51 screening for diabetes in patients with elevated blood pressure,52 and lipid screening in midlife adults or young adults at increased risk for CVD.53 Increasing guideline-concordant care for individuals with SMI—given the current lack of evidence for SMI-specific interventions—could be considered a starting point for minimizing CVD risk in patients with SMI. These guidelines for the general population should then be modified to consider the special risks for patients with SMI.
Our review, together with other reviews on interventions to decrease CVD risk in patients with or without SMI, suggests a few actionable strategies and others requiring further study. For weight control, moderate evidence supports behavioral interventions, and more limited evidence supports metformin, topiramate, or aripiprazole as an adjunctive or antipsychotic-switching strategy. All of these interventions yield small to moderate effects, and the benefits must be weighed against the potential harms. Because only limited data on harms were reported in the trials examined, data from non-SMI populations should be incorporated into decisionmaking. Data are much more limited for effects on average glucose control or lipid levels in patients at increased risk. The antihistamine nizatidine was not effective for any CVD risk factor and is unlikely to be a useful treatment. Other reviews identify bupropion as the best-supported treatment for smoking cessation;30,31 nicotine replacement therapy is effective in non-SMI populations but has not been adequately studied in patients with schizophrenia, bipolar disorder, or psychotic depression. Other reviews identified tailored mood management in patients with depressive symptoms54,55 and behavioral support interventions in individuals with mental illness as potentially effective.56 Although the evidence is limited, the meta-finding is that, of the interventions tested in SMI populations to date, effects on intermediate outcomes (e.g., weight) are similar to the effects found in the general population.
Studies of guideline adherence show significant gaps between current practice and recommendations for CVD risk screening and followup.57 Studies show screening rates ranging from about 10 to 26 percent for lipids and 22 to 52 percent for glucose.58-61 Data on monitoring of these risk factors in patients treated with second-generation antipsychotics are more limited but also show gaps between guidelines and practice. Assessment and monitoring is only a first step. When abnormalities are detected, they must be addressed, either by the mental health professional or by a general medicine clinician. Integrated mental health–general medical care has shown promise as the optimal way to deliver this care, and the current move to medical homes has the potential to make this type of care more readily available. Unfortunately, few medical home models to date have explicitly included mental health care.62 Until integrated care is better established and more readily available, there are a number of implementation strategies to consider when a change to a metabolically more neutral antipsychotic is not sufficient to address elevated CVD risk factors. When patients have access to both mental health specialty care and general medical care, it is important that these clinicians coordinate care across issues that may impact both physical and mental health. For example, general medical providers may be aware of the adverse metabolic effects of some psychotropics but are appropriately hesitant to adjust these medications. Coordinating care with the mental health professional about roles and specific strategies for addressing CVD risk factors has the potential to improve care and clinical outcomes.
Research Gaps
We considered PICOTS (population, intervention, comparator, outcomes, timing, and setting) to identify gaps and classifies gaps as due to: (1) insufficient or imprecise information, (2) biased information; (3) inconsistency or unknown consistency, and (4) not the right information.63 Gaps and recommendations are presented in Table B.
Because the list of gaps in evidence is extensive, we suggest general principles for prioritizing research as applied to the population of adults with SMI. Most groups64 advocate input from multiple stakeholders and consideration of issues such as the burden of disease, the availability of existing treatment options, the likelihood that the new intervention will substantially improve outcomes, practice variation and health disparities, and the feasibility of implementing effective interventions with existing resources. Specific research questions can be evaluated quantitatively, using value-of-information analysis, which employs Bayesian methods to estimate the potential benefits of gathering more information through research.65 A recent AHRQ white paper used a multiple-stakeholder consensus process to identify patient-centered outcomes research priorities for serious mental illness,66 and prioritized comparative effectiveness studies of interventions targeting modifiable risk factors such as tobacco abuse, physical exercise, and nutrition.
We also considered the most appropriate research designs for the research gaps. We suggest that observational designs may be particularly appropriate for these applications: (1) evaluating interventions proven effective in non-SMI populations, (2) testing the effectiveness of interventions demonstrated efficacious in tightly controlled trials, and (3) formulating hypotheses to be tested in RCTs. RCTs may be particularly useful for interventions specifically tailored for SMI populations and for drugs, or drug strategies (e.g., antipsychotic switching), that are used primarily in this population. Although we recommend multicenter RCTs to address some evidence gaps, we are aware that there are particular challenges to conducting RCTs in this population. For example, individuals with SMI have been routinely excluded from large cardiovascular trials—limiting opportunities to participate in research. Also, behavioral interventions may be affected by limited access to healthy foods or opportunities for exercise because many individuals with SMI are in lower socioeconomic status groups. Some important outcomes, such as cardiovascular events, may take large sample sizes and long followup periods to evaluate.
|KQ 1: Weight
|KQ 2:Diabetes (HbA1c)
|KQ 3: Lipidsb
|Overall CVD Risk and Other Outcomes
|CVD = cardiovascular disease; KQ = Key Question; SOE = strength of evidence
aSOE ratings are above insufficient.
bNo studies of lipid-focused interventions.
|Small benefit (-3.1 kg)a Moderate SOEa
|Insufficient SOE
|No important effect from weight control interventions
Insufficient SOE
|1 study assessed health-related quality of life and found no differences
Only 2 studies reported discontinuation due to adverse effects Insufficient SOE
|Peer or family support
|No studies
Insufficient SOE
|No studies
Insufficient SOE
|No studies
Insufficient SOE
|No studies
Insufficient SOE
|Small benefit (-4.1 kg)a
Low SOEa
|Insufficient SOE
|No studies
Insufficient SOE
|Insufficient SOE for CVD risk
|Topiramate, zonisamide
|Small to moderate benefit (-5.1 kg)a
Low SOEa
|Insufficient SOE
|Possible benefit with topiramate
Insufficient SOE
|Insufficient SOE for CVD risk
|No benefita
Low SOEa
|Insufficient SOE
|Single study did not suggest benefit
Insufficient SOE
|Insufficient SOE for CVD risk
|Other medications
|Insufficient SOE
|Insufficient SOE
|No study suggested possible benefit
Insufficient SOE
|Insufficient SOE for CVD risk
|Antipsychotic switching or adjunctive use
|Low SOE for small benefit (-2 to -3 kg) with switching to aripiprazole or adjunctive aripiprazolea
Insufficient SOE from single studies that found no effect with switching to quetiapine or parenteral olanzapine
|Insufficient SOE
|Possible benefit with adjunctive or switching to aripiprazolea
Low SOEa
|Insufficient SOE for CVD risk
Low SOE for possible higher rate of mental health worsening with switchinga
|Multicomponent lifestyle
|Insufficient SOE
|Insufficient SOE
|Insufficient SOE
|2 studies suggested benefit for health-related quality of life
1 study reported no benefit on CVD risk score
Insufficient SOE
|Evidence Gap
|Type of Studies To Consider
CATIE = Clinical Antipsychotic Trials in Intervention Effectiveness; CVD = cardiovascular disease; PICOTS = patients, interventions, comparators, outcomes, timing, setting; RCT = randomized controlled trial; SMI = serious mental illness.
aResearch gaps from prior high-quality systematic reviews that were identified during the topic refinement phase of this review and are described briefly in this report.
|Limited data for patients with conditions other than schizophrenia
|Insufficient information
|Single and multisite RCTs
Quasi-experimental or clinical records-based observational studies
|No data in older adults who have more comorbid medical illness
|Insufficient information
|Single and multisite RCTs
Quasi-experimental or clinical records-based observational studies
|Few studies of ethnic and racial minorities
|Insufficient information
|Single and multisite RCTs
Quasi-experimental or clinical records-based observational studies
|No interventions evaluating peer and family support interventions
|Insufficient information
|Single and multisite RCTs
|No studies on the effects of the most recently approved second-generation antipsychotics such as paliperidone, iloperidone, asenapine, and lurasidone
|Insufficient information
|Single and multisite RCTs
Quasi-experimental or clinical records-based observational studies
|Limited evidence about the benefits and harms of switching from one antipsychotic to another on metabolic parameters
|Insufficient information
|Secondary analyses of existing studies such as the CATIE trial or large observational datasets
|No studies comparing optimized antipsychotic management (e.g., start with or switch to drugs with more favorable metabolic profiles) with continuing current antipsychotics in responders and treating adverse metabolic effects directly using treatments (e.g., statins) with known efficacy
|Insufficient information
|Single and multisite RCTs
Quasi-experimental studies
|Few multimodal interventions (e.g., robust behavioral and pharmacological treatments) and few multicondition interventions (interventions that address multiple CVD risk factors)
|Insufficient information
|Single and multisite RCTs
|Few evaluations of smoking cessation interventions other than bupropiona
|Insufficient information
|Single and multisite RCTs
Quasi-experimental or clinical records-based observational studies
|Few studies evaluating integrated mental health and general medical carea
|Insufficient information
|Single and multisite RCTs
Quasi-experimental or clinical records-based observational studies
|Uncertainty about the key characteristics of successful behavioral interventions (e.g., tailoring, dose, duration, delivery mode, individual vs. group)
Insufficient information
Not the right information
|Improved intervention reporting
Single and multisite RCTs
Systematic reviews
|Uncertainty about the details of the intervention
|Not the right information
|Manuals provided to promote replication/implementation of successful interventions
|Interventions to improve guideline concordant care
|Insufficient information
|Single and multisite RCTs
Quasi-experimental studies
|Few studies comparing two active interventions
|Insufficient information
|Single and multisite RCTs comparing effective treatments
Quasi-experimental or clinical records-based observational studies
|Uncertain effects on overall CVD risk or cardiovascular events
|Insufficient information
|Risk indices (e.g., Framingham Risk Score) and/or cardiovascular events used as outcome measures
|Intervention adherence
|Insufficient information
|Improved study reporting
|Uncertainty about adverse effects on mental health status and other serious adverse effects, specifically in individuals with SMI
|Insufficient information
|Studies that define and report the proportion of patients for whom mental health status worsens Improved reporting of adverse effects
|Few studies with outcomes measured beyond 6 months
|Insufficient information
|RCTs with longer term followup
Quasi-experimental or observational studies
|Lack of studies designed to evaluate "real world" effects of the intervention (effectiveness studies)
|Insufficient information
|RCTs or quasi-experimental studies with broad inclusion criteria, conducted in community practices, with long-term followup and which include clinically important outcomes such as physical functioning, cardiovascular events, and adverse eventsImproved reporting of efficacy–effectiveness characteristics
In summary, individuals with SMI are at risk for increased CVD—in part due to health behaviors, direct effects of the illness, and adverse effects from some treatments. Prior reviews identified bupropion as effective for smoking cessation, and integrated general medical and mental health care as effective for CVD screening. In our review, surprisingly few studies addressed one or more CVD risk factors in patients with SMI, and most studies were skewed toward efficacy trials. Behavioral interventions, switching to or adding adjunctive aripiprazole, adding anticonvulsant medications topiramate and zonisamide, or adding metformin yield small to moderate weight loss compared with controls. We found insufficient evidence to support any strategy to control glucose. We found limited support of behavioral interventions focusing on weight loss or diabetes management or lipid control; SOE was insufficient for all other interventions. We found no studies testing a number of important interventions (e.g., orlistat, statins) known to be effective in non-SMI populations. Comparative effectiveness trials are needed that test multimodal strategies, known effective agents in non-SMI population (e.g., statins), and antipsychotic management strategies. However, in the absence of evidence for SMI-specific interventions, guideline-concordant care for individuals with SMI may help mitigate the unequal burden of CVD that SMI populations sustain.
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- Williams JW, Jackson GL, Powers BJ, et al. Closing the Quality Gap Series: Revisiting the State of the Science. The Patient-Centered Medical Home. (Prepared by the Duke Evidence-based Practice Center under Contract No. 290-2007-10066-I.) Rockville, MD. Agency for Healthcare Research and Quality. [in press].
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- Myers E, McBroom AJ, Shen L, et al. Value-of-Information Analysis for Patient-Centered Outcomes Research Prioritization. Report prepared by the Duke Evidence-based Practice Center. Patient-Centered Outcomes Research Institute. March 2012.
- Jonas D, Mansfield AJ, Curtis P, et al. Identifying Priorities for Patient-Centered Outcomes Research for Serious Mental Illness. Research White Paper. (Prepared by the RTI-UNC Institute Evidence-based Practice Center under Contract No. 290-2007-10056-I.) AHRQ Publication No. 11-EHC066-EF. Rockville, MD: Agency for Healthcare Research and Quality. September 2011. www.effectivehealthcare.ahrq.gov/reports/final.cfm.
AHRQ—Agency for Healthcare Research and Quality
CI—confidence interval
CVD—cardiovascular disease
df—degrees of freedom
HR—hazard ratio
HRQOL—health-related quality of life
KQ—Key Question
MI—myocardial infarction
NA—not available
NR—not reported
OR—odds ratio
PICOTS—population,intervention, comparator, outcomes, timing, setting
QOL—quality of life
RCT—randomized controlled trial
ROB—risk of bias
RR—risk ratio
SMI—serious mental illness
SOE—strength of evidence
TEP—Technical Expert Panel
Full Report
This executive summary is part of the following document: Gierisch JM, Nieuwsma JA, Bradford DW, Wilder CM, Mann-Wrobel MC, McBroom AJ, Wing L, Musty MD, Chobot MM, Hasselblad V, Williams JW Jr. Interventions To Improve Cardiovascular Risk Factors in People With Serious Mental Illness. Comparative Effectiveness Review No. 105. (Prepared by the Duke Evidence-based Practice Center under Contract No. 290-2007-10066-I.) AHRQ Publication No. 13-EHC063-EF. Rockville, MD: Agency for Healthcare Research and Quality; April 2013.


text:
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And I dont see how you can say that about Jurgensen...he had a longer career than Namath, and led the league in multiple passing categories for numerous years....but whatever....I wasn't there, right?
My favorite band in the world is playing 15 miles from here and I can't go tonight.
My new favorite band is "Chester Copperpot and the Booty Traps", lol
ok, not really, but i have friends from these 2 bands who do strictly 90s covers at bars, and they are awesome, and hilarious
Matchbook Romance had tracks on Madden and Guitar hero awhile back.

subset: commoncrawl


text:
Big and bold, tender and juicy, these pork tenderloins get a dose of sultry Southwestern flavor from smoky adobo sauce and canned chipotle chiles.
Pork tenderloin is a lean piece of pork cut from the loin. Because this cut contains little fat to moisten it during cooking, pork tenderloin benefits from a glaze or marinade.
To reduce spiciness, use only 1 chipotle chile and omit the adobo sauce.
To broil pork tenderloins, place on broiler pan; broil 4 to 6 inches from heat using times above as a guide, turning occasionally and brushing with taco sauce mixture during last 10 minutes of cooking time.
© 2017 ®/TM General Mills All Rights Reserved


text:
The Florida Bar
NEW APPLICATIONS SOUGHT FOR ONE VACANCY TO SERVE ON THE 3rd CIRCUIT JUDICIAL NOMINATING COMMISSION
June 11, 2013
CONTACT: Kristen Wilson,
The Florida Bar
TELEPHONE: (850) 561-5757; firstname.lastname@example.com
New applications are sought for one lawyer vacancy on the 3rd Circuit Judicial Nominating Commission. By letter of May 30, 2013, the Governor rejected The Florida Bar's May 31, 2012 list of nominees for the 3rd Circuit Judicial Nominating Commission pursuant to Section 43.29(1)(a), Florida Statutes. Accordingly, The Florida Bar must submit a new list of three different nominees to the Governor.
Applicants must be engaged in the practice of law and a resident of the territorial jurisdiction served by the commission to which the member is applying. Applicants must comply with state financial disclosure laws. Commissioners are not eligible for state judicial office for vacancies filled by the JNC on which they sit for 2 years following completion of their 4-year term.
Applications must be received by mail, e-mail, or fax no later than 5:00 p.m., Friday, June 28, 2013 in the Executive Director's Office of The Florida Bar. Resumes will not be accepted in lieu of an application. The Florida Bar Executive Committee will finalize the list of nominees and send to the Governor.
Persons interested in applying may download the proper application form (there is a specific JNC application) from the Bar's Web site or call Bar headquarters at (850)561-5757, to obtain the application. Completed applications must be received by the Executive Director, The Florida Bar, 651 E. Jefferson St., Tallahassee, FL 32399-2300, by the deadline of June 28, 2013.
EDITORS: Please note The Florida Bar is not an association and "Association" is not part of our name. Proper reference is "The Florida Bar." Local bar organizations are properly termed "associations."
[Revised: 06-16-2013]


text:
-looking for 6 – 8 men or women who would like to hunt with our group for the 2nd shotgun season. We will be hunting a 6 mile radius of Brighton. Both in Washington County and in Jefferson County. We would meet the Thursday before season open to introduce everyone. If interested call 319-694-3074 if no answer please leave a message or call 319-461-1657
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text:
jcayer wrote:Last night, we played again and one of those darn PCs was determined to get killed. At the last second, he backed down, but it was not a pretty scene at the table.
I'm dropping them off in Newport next session to be Hell's distraction. I saw the great model that DG put together, but with 2-3 remote players, maptools is my tool of choice.
How much did you guys build out for this? Did everything happen in the street? Did you rough out several blocks, or just improvise as it came?
I considered Google Earth, but I don't think it's going to work.
All opinions requested.
I used Google Earth and picked Beaufort, NC as my town of choice. Then I used "selective compression" to pick out some buildings I wanted to feature and "scrolled" the active area as the players moved forward. I kept to the main street and no more than one block in either direction (the area I chose was built this way). Almost everything happened in the main street and one back alley.


text: The shocking finale to Season 5 of Star Wars: The Clone Wars has arrived, with major revelations that will leave characters forever changed. Ahsoka is wrongly accused for sedition and murder, and is to be prosecuted in the High Courts of the Galactic Republic by a zealous Admiral Tarkin. Seemingly abandoned, Ahsoka


text:
I grabbed this right away.
"Teach your dog how to control it self in high excitement/high adrenaline situations".
I suspect that being on top of obedience is the answer but there has to be more ideas out there. Hard to get more exposure to the line except at the line and those times are not conducive to training. Many of us don't have bird boys or even spouses that can help out so what really is the answer?


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Gregory P. Pisarski MD
About the Practice
Practice Philosophy
Dr. Pisarski is a board-certified plastic surgeon offering many years of experience. But what truly sets him apart is his attention to his patients' needs. Each patient consultation is a conversation, not a lecture or a sales presentation, because Dr. Pisarski understands the value of clear communication. He knows that an honest exchange of information and expectations is the essential link between your desires and truly beautiful results.
Practice Specialization
As a triple board-certified plastic surgeon with patients in Lake Jackson, Pearland and the Houston area, Dr Pisarski offers a full spectrum of plastic surgery procedures including breast enhancement (breast augmentation, breast lift, and breast reduction), body contouring procedures (tummy tuck, smartlipo, bra line back lift, thigh lift and arm lift); and facial rejuvenation (Quicklift, Precisiontx (Lazerlift), eyelid surgery, browlift, face and neck lift and facial resurfacing.
Gulf Coast Plastic Surgery also offers medical spa services including pulsed light photorejuvenation,1540 fractional resurfacing, injectable fillers, botox, physician-strength skin care products and more.
Additional Information
Dr. Pisarski has been actively involved with the Rotary Club and Knights of Columbus. He has also had the opportunity to travel to the Philippines, Mexico and Nicaragua to treat patients with cleft lip and palate deformities. In his free time, Dr Pisarski enjoys lifting weights and off road motorcycles.
Background & Certification
Board Certification
American Board of Plastic Surgery
American Board of Facial Plastic and Reconstructive Surgery
American Board of Surgery
Professional Background
Undergraduate, BA Chemistry (magna cum laude): Texas Christian University, Fort Worth, Texas
Medical School, MD (with honors): University of Texas Health Science Center, Houston, Texas
Residency, General Surgery: University Cincinnati Hospitals, Department of Surgery, Cincinnati OH
Residency, Plastic Surgery: University Cincinnati Hospitals, Department of Surgery, Cincinnati OH
Fellowship, Shriners Burn Institute: Cincinnati OH
Fellowship, Cosmetic Surgery: Dr Baker, Gordon and Stuzin, Miami, Florida
Affiliations & Memberships
Hospital Affiliations
Dr. Pisarski has surgical privileges at several facilities including: Brazosport Regional Health Systems, in Lake Jackson, TX; Angleton-Danbury Medical Center, in Angleton, TX; Pearland Surgery Center, in Pearland, TX; and the Brazoria County Surgery Center, Angleton, TX
Society Memberships
American Society for Aesthetic Plastic Surgery
American Society of Plastic Surgeons
Fellow, American College of Surgeons
American Academy of Facial Plastic and Reconstructive Surgery
Texas Society of Plastic Surgeons
Brazoria County Medical Society
Offices Held
Dr. Pisarski is a past Chairman of The Department of Surgery at the Brazosport Regional Health Systems. He has also been a member of the Medical Executive Committee, Peer Review Committee, Utilization Review Committee, and Credentialing Committee at Brazosport Regional Health Systems. Association's Advisory Panel on Plastic Surgery.
Staff & Facilities
Skin Care Products
ZO Skin Health Medical
GloTherapeutics / GloMinerals MakeUp
Payment Options
Payment for surgery must be made in advance of surgery. In office procedures are due at the time of service. We accept cash, personal checks and/or most credit cards. Financing through Care Credit is also available. Contact either of Dr Pisarski's office for details.
Gregory P. Pisarski MD
186 Abner Jackson Parkway,
Lake Jackson, TX, 77566, US
10905 Memorial Hermann Drive,
Suite 207, Pearland, TX, 77584,
United States
Request More Information
- Add to "My Doctors"
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View phone number
Phone: 979-297-9289


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NRG Park - Parking Lot
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Vans Warped Tour, Central Florida Fairgrounds, Orlando, Fla.
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When you leave school (either after year 11 or later) you will be strongly advised by your personal adviser and careers teacher to look for opportunities which include training leading to recognised qualifications. This will improve your future prospects.
Apprenticeships are high quality training programmes with local employers. They enable you to obtain formal qualifications through day release, and last for about three years
As an apprentice you would follow a training programme which has been devised by a professional training organisation for that industry.
Apprenticeships are available at two levels:
The Apprenticeship leads to NVQ level 2 and the Advanced Apprenticeship leads to NVQ level 3. You'll also be trained in key skills, such as Team Working, Communication, IT and problem solving.
You can progress from an Apprenticeship to an Advanced Apprenticeship and then continue gaining higher qualifications.
If you are thinking about leaving school to go into a job, you need to consider it carefully. Check out this kind of jobs being advertised, what wages and conditions are they offering, is it what you expected? Is this the best choice for you?


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This is a lesson about water and water-ice. Learners will explore the molecular geometry and mechanics of ice. They will create a model of H2O, investigate its molecular structure and its consistent shape. Faraday's experiment is used as background.... (View More) Activities include small group miming, speaking, drawing, and/or writing. This is lesson 2 of 12 in the unit, Exploring Ice in the Solar System. (View Less)
Audience: Pre-kindergarten, Elementary school
Materials Cost: $1 - $5 per group of students
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Living-Learning Community News
Earth Hour 2009 [March 28, 2009]
Join us and VOTE EARTH in Earth Hour 2009. Turn off your lights on Saturday, March 28, 2009 for just one hour at 8:30 PM and join millions of people across the globe in taking a stand against global warming. Encourage your hallmates to participate in this epic event.
Themed FYE Application Available [March 22, 2009]
Applications are now available for the Citizenship and Living Green FYE Programs. All first-year students are encouraged to apply. Learn more about the program Citizenship or contact Ryan Roche for questions regarding the Citizenship program. Contact Roger Montiel for questions about Living Green. Applications for 2009-10 are due May 29, 2009.


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Perk Up Your Pout! Our 8 Favorite New Spring Lipsticks
There's more than one way to skin a cat—and rock a cat-eye. For the classic '60s version, look no further than Kenzo, Monique Lhullier, and Anna Sui, where CoverGirl makeup artist Pat McGrath layered liquid and pencil liners in a dramatic winged shape, then dotted below the lashline for an avant-garde edge. At Christian Dior (left) and Jason Wu, makeup artists added a flash of color, turning to icy blue and violet, respectively. Meanwhile at Salvatore Ferragamo, Michael Kors, Lanvin and Tracy Reese, liner was nowhere to be found. Instead, diffused almond shapes were blended on with a range of smudgy dark shadows.
Salvatore Ferragamo
Secrets to Thick, Shiny Hair


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John "Jay" Wood
Middleton-John "Jay" Wood, age 59, went home to the lord, to be a soldier for God, on Thursday, November 22, 2012. He was born on January 26, 1953 in Los Angeles, CA, the son of John and Nellie (Stadler) Wood. John had the biggest heart. He was incredibly loving and will be dearly missed.
John is survived by his wife, Gail Wood; his son, Jeff Wood; his stepson, Shane Haddix; brother, George (Jodie) Wood; sister, Cathy Wood; nephews, James Wood and Jesse Wood; and many other loving family members and friends.
A Celebration of Life will be held at the WILLOWS, corner of 5485 Willow Rd and Cnty Rd M, on December 15, 2012 at 2:00pm


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01-07-2010 01:58 AM - edited 01-07-2010 02:11 AM
It's nice to see that Lenovo has finally made the Fix interval time feature available as a selection in the GUI. This should remedy a lot of inaccuracy while driving using the GPS.
However, there seems to be a bug with this feature on a Thinkpad T500 2081-CTO (Ericsson F3507g) Windows 7 where NMEA commands will be sent every 1 "minute" on the destination port when the fix interval time is set to 1 "second" in the GPS Enabler GUI. (Note the different units) This makes the GPS port undiscoverable by most GPS software since the NMEA statements are sent at such a slow rate (1 min/statement).
When the fix interval time is set to "2" sec or above in the GPS Enabler GUI, everything works as expected (except for an additional second of lag for GPS NMEA statements).
I know this is not a hardware limitation since I was able to have the F3507g card manually send NMEA statements every 1 second by doing the following:
1. Close down Thinkvantage GPS
2. Stop the Mobile Broadband Core Service
3. Using HyperTerminal, open COM6, issue the following commands:
4. Using HyperTerminal, open COM4, issue the following command:
5. NMEA statements can be seen refreshed on COM4 every second (instead of 2 sec, or 1 min when using GPS enabler)
Clearly there is some kind of software bug somewhere, either located in the Mobile Broadband Core Service or witin the Thinkvantage GPS software itself.
It would be nice if anyone can confirm this or have this fixed.
P.S. Does anyone know if the GPS enabler enables DGPS by default? This card supports this function, but no such option can be selected in the GUI.
On my T400 gps v 2.50 set at 1 sec never gives me any fix but seems ok otherwise. RBS
Just a little update on the situation.
DId a little research on it today, it does seem to confirm my observations:
See this:
This can be seen under Portmon on COM6 when GPS Fix Interval is set to 1.
Clearly there is some misinterpretation somewhere of this unit "1" and should be fixed.
It also seems that the GPS enabler does not specify the third argument for E2GPSCTL, I assume it's defaulted to off when the argument is not specified - any plans to add it into the GUI as well?
Yea, there is a bug either in the driver or in the GPS enabler itself where it is interpreting 1 sec as 1 min for GPS fix interval time. This makes the GPS location refresh at such a slow rate (1 min per update) that you will never really have a fix.
Nice bit of work. I've been trying to get GPS working on my new W500 (win7-64) for a month with no joy. Seemed as if the GPS function might be working but never got a fix. I didn't get down to the low level analysis. So it feels to me that I could be also suffering from the 60 second bug. Driver = 2.41. I have not yet downoaded 2.50 because TVSU 4.0 is not yet showing it in the download list (along with some pre-reqs) and I don't want to install manually. Hopefully Lenovo will get a move on adding them to the download list. Hint Lenovo !! However it seems that you find 2.50 to be broken also, so I'll report back as and when anything improves ....
Hey guys!
Any luck on getting this fixed. I have 7-64bit on my T500 as well and I can't seem to get my GPS to work. It's been a while now since this post was stared. Are we to expect any updates soon?
Yes! I got it working (W500 + Win7/64) the other day. I manually downloaded and installed V2.50 of the GPS driver from http://www-307.ibm.com/pc/support/site.wss/MIGR-73
2.50 has been working on my win7 t400 for some time but i notice that when i start up the gps it always picks up the sats much faster if i immediately stop and start again. any ideas why?
Hi ,
I own a SL-500 with 3G Ericsson module an win7 pro 32bit (3G card properly installed and TVGPS ) .
I have the problem that GPS doesn't work properly- perhaps you can help me.
I have GPS port on Com4 , Device Management on com6 and the modem port on com 5.
WIn7 recognises also a Localization device on COM4.
Starting TVGPS doenst enable GPS on my Notebook.
I can enable it manually by sending the AT commandy on COM5 - But then I have the NMEA Stream on COm 5 and
as soon as I close the terminal/ GPS prog from which I send the AT commands - the stream ceases( goes off)
COM4 does accept a connection but I cannot send any AT's.
Anyone with an Idea ? I really need the GPS :-(
I also have the same problem. While I am not sure what exactly is causing the issue, it could be that the Ericsson is hiding the satellites until it acquires a fix. Once I acquire a fix, usually many satellites come forward. But you are right though, I find that it takes longer to fix (or very long to fix) if you just go straight from a cold start. It does seem that stopping and restarting it causes it to fix faster (perhaps because it is in a "warm" state). Just my two cents though.
You will have to send your AT commands on COM6. Once you send your AT commands on COM6, the NMEA stream should be sent to your COM4 port and you can close the terminal. What AT commands are you exactly sending by the way? Also, the Lenovo GPS application requires that the Mobile Broadband Core Service be started under System Services. It will give an error if that's not properly started. Good luck.


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Such is the growing reputation of the Toyota Racing Series in some European countries, drivers who have done a championship in the past are recommending their fellow open-wheel pilots head down south.
Young Netherlands driver Steijn Schothorst is one, who, on the recommendation of former TRS competitor and teammate Jordan King, decided to expand his single-seater experience by coming to New Zealand to race.
The 18-year-old is just starting his third year in single seaters, having already competed in the 2012 Formula Renault 2.0-litre Northern European Cup and Formula Ford. He does, however, come from a racing family as his father and cousin compete in the Eurocup Megane Trophy, and he's raced alongside his brother Pieter in Formula Renault.
"I started following the TRS series after Jordan told me about it," says Schothorst. "Halfway through last season we decided to come here and have some fun.
"I really like it a lot and it's very good for learning things that I might not learn in Europe but may need.
"You learn how to drive the car very, very smoothly to get the last few tenths of a second out of it."
Schothorst has steadily improved over the nine races so far in the championship. His worst finish of eighth (other than having to pit for a broken front wing) was in the opening race of the series in Teretonga. Like a number of newcomers to the TRS series, he's not been on any of the tracks but did follow Hannes van Asseldonk, another TRS graduate, on YouTube last year.
Schothorst has steadily moved towards the front of the pack and now has three podium finishes, three fourth places and a sixth. Not too shabby for a young man in a new car on unfamiliar circuits.
"We're close to getting our first win after two thirds and a second. My driving is getting better and who knows, maybe a win is close now.
"I don't have as much experience as some of the guys in single seaters, but if you want to compete you have to adjust quickly," he says.
Natural talent is all well and good, but having a great mentor on hand to help young drivers negotiate their way through a new series and new machinery is a must. With M2 Competition, Schothorst not only has a good crew looking after his car, but his engineer and mentor is none other than Chris van der Drift.
The Kiwi has a growing international reputation as a fast bloke in anything with four wheels and an engine. Van der Drift has either set the fastest time, won, or been on the podium in every category he's competed in from A1GP, GP2 Asia, Formula Renault, Formula BMW, WSR, Italian GT3 and others.
"Chris has been a big help and because he has so much experience in many different cars, you can believe the stuff he tells you. It's really good and I believe most of things he tells me, especially about the racing,"says Schothorst. "Honestly, I do listen to him."
Van der Drift is held in high regard as a driver coach overseas and in New Zealand and is the driver coach for the entire M2 Competition team. He has a quiet, no-nonsense approach and is keen to get the best out of his charges.
"Back in Europe I suggested it would be good for Steijn to come down here and further develop his driver skills," said van der Drift. "I was looking after Tanart [Sathienthirakul] here last year and he improved a lot when he got back to Europe.
"Steijn was in his first European season and he won a couple of races and finished fifth in championship. You could see he has good speed. He's also a very nice kid, which is helpful.
"He's good to work with and after a session we sit down and go through things. When you suggest something to him he'll go and do it and see the benefits.
"The good thing for him is he's able to put the advice into practice and get better gaining more confidence as he goes along. The plan is to keep building on what he's learning and get him his first race win."
This weekend at the fourth round of the TRS season at Hampton Downs may just be the circuit Schothorst gets his first win. He sits fifth on the points table in behind Brit Alex Lynn, with Puerto Rican Felix Serralles, Austrian Lucas Auer and defending champion, New Zealander Nick Cassidy, in the top three spots.
Cassidy has yet to get his first win, but by accumulating points in each race he leads the title race by six points from Auer. Lynn has been in scorching form and if he hadn't crashed heavily at Teretonga, he'd be in command and control of the championship. He's won three of the last four races, however the Hampton Downs track is a different kettle of fish to that of Taupo.
There have been five different winners in nine races and each driver is more than capable of standing on top of the podium - as is Cassidy, Damon Leitch and Schothorst.
The north Waikato is New Zealand's newest international track and with its European influence will suit the wings and slicks of TRS cars. The weekend will be one to watch - and don't be too surprised if there are a few different winners come Sunday afternoon.


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I guess Win/Browning are the same company now.
Anyways last year I wanted a backup turkey/duck gun and wanted it to be a pump. So I bought a Win SXP pump shotgun and called Winchester to make sure I could switch the safety to lefthand. The said yes. I didn't want to switch the safety until I made sure the gun would work for me.
I didn't want to have to put any sights on this gun as it is a backup gun and I don't want to mess with sighting it in every spring.
So I get the gun and pattern it a little and after messing with a few chokes I get a good turkey pattern for what I wanted out of the gun.
But the gun is off a little on POA/POI, probably because of I shoot from the "wrong" side. So I make a shim out of some gasket material I had and was able to move the stock over just enough by putting it in where the stock meets the receiver to have the gun shoot right on for me.
Great! Now I take it to Bass Pro to get the safety switched and have a center bead put on the barrel (the center bead makes for a little better turkey aiming when shooting beads). After several days and a few phone calls I find out the safety CANNOT be switched.
I called Win/Browning and they offered to buy the gun back, they even paid for shipping the gun back to them. I just got the check a couple of days ago.
Bass Pro already put the center bead on my gun but when they found out I was sending the gun back to Win, they said no charge.
So Kudos to both Win/Browning and Bass Pro for their good customer service. I did waste some shells and time, but when you are lefthanded you get use to that.