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INTRODUCTION: Innovative smoking cessation approaches that overcome barriers such as traveling to program site or that require the staff and infrastructure for sustaining are likely needed to improve smoking quit rates among American Indian (AI) peoples in the United States. In this study, qualitative methods identified recommendations from AI peoples to guide alignment of an evidence-based smoking cessation smartphone app (i.e., QuitGuide) to the culture and needs of AI persons. METHODS: Semi-structured interviews were conducted with AI adults who smoke (n = 40) and with public health professionals (n = 6). Questions included: "The app asks if something triggered you to slip and lists several options. What options were you expecting to see on this list?" as well as how to make the app more engaging such as "What would make the app more helpful for AI peoples, like you, who want to quit smoking?." Constant comparative techniques were used to develop codes and themes. RESULTS: Loss, grief, and not accessing traditional tobacco were put forward as smoking triggers to be addressed in the app. Features that help users connect with and learn about AI cultures and promote healing, such as encouraging traditional tobacco use, being in community, embracing Native spirituality, and participating in cultural crafting were recommended. Some noted the need to motivate AI peoples to think about legacy and ability to care for younger generations and Indigenizing the app with Native imagery. CONCLUSIONS: Themes pointed towards promotion of strengths-based factors, such as healing, cultural connectedness and traditional tobacco use, in the app. IMPLICATIONS: Results will be used to culturally align a smartphone app for smoking cessation among AI peoples and may be insightful for other tribal, federal, and state public health efforts aimed at advancing health equity for AI peoples.
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Indígenas Norte-Americanos , Aplicativos Móveis , Abandono do Hábito de Fumar , Adulto , Humanos , Abandono do Hábito de Fumar/métodos , Uso de TabacoRESUMO
BACKGROUND: As few anaesthetists provide lumbar erector spinae block for disc surgery, there is a need to provide training to enable a randomised controlled trial investigating analgesia after painful spinal surgery (NIHR153170). The primary objective of the study was to develop and measure the construct validity of a checklist for assessment of skills in performing lumbar and thoracic erector spinae fascial plane injection using soft-embalmed Thiel cadavers. METHODS: Twenty-four UK consultant regional anaesthetists completed two iterations of a Delphi questionnaire. The final checklist consisted of 11 steps conducive to best practice. Thereafter, we validated the checklist by comparing the performance of 12 experts with 12 novices, each performing lumbar and thoracic erector spinae plane injections or fascia iliaca, serrato-pectoral (PEC II) and serratus injections, randomly allocated to the left and right sides of six soft-embalmed Thiel cadavers. Six expert, trained raters blinded to operator and site of block examined 120 videos each. RESULTS: The mean (95% confidence interval) internal consistency of the 11-item checklist for erector spinae plane injection was 0.72 (0.63-0.79) and interclass correlation was 0.88 (0.82-0.93). The checklist showed construct validity for lumbar and thoracic erector spinae injection, experts vs novices {median (interquartile range [range]) 8.0 (7.0-10.0 [1-11]) vs 7.0 (5.0-9.0 [4-11]), difference 1.5 (1.0-2.5), P<0.001}. Global rating scales showed construct validity for lumbar and thoracic erector spinae injection, 28.0 (24.0-31.0 [7-35]) vs 21.0 (17.0-24.0 [7-35]), difference 7.5 (6.0-8.5), P<0.001. The most difficult items to perform were identifying the needle tip before advancing and always visualising the needle tip. Instrument handling and flow of procedure were the areas of greatest difficulty on the global rating scale (GRS). Checklists and GRS scores correlated. There was homogeneity of regression slopes controlling for status, type of injection, and rater. Generalisability analysis showed a high reliability using the checklist and GRS for all fascial plane blocks (Rho [ρ2] 0.93-0.96: Phi [Ï] 0.84-0.87). CONCLUSIONS: An 11-point checklist developed through a modified Delphi process to provide best practice guidance for fascial plane injection showed construct validity in performing lumbar and thoracic erector spinae fascial plane injection in soft-embalmed Thiel cadavers.
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PURPOSE: Lumbar spinal fusion surgery (LSFS) is common for lumbar degenerative disorders. The objective was to develop clinical prediction rules to identify which patients are likely to have a favourable outcome to inform decisions regarding surgery and rehabilitation. METHODS: A prospective observational study recruited 600 (derivation) and 600 (internal validation) consecutive adult patients undergoing LSFS for degenerative lumbar disorder through the British Spine Registry. Definition of good outcome (6 weeks, 12 months) was reduction in pain intensity (Numerical Rating Scale, 0-10) and disability (Oswestry Disability Index, ODI 0-50) > 1.7 and 14.3, respectively. Linear and logistic regression models were fitted and regression coefficients, Odds ratios and 95% CIs reported. RESULTS: Lower BMI, higher ODI and higher leg pain pre-operatively were predictive of good disability outcome, higher back pain was predictive of good back pain outcome, and no previous surgery and higher leg pain were predictive of good leg pain outcome; all at 6 weeks. Working and higher leg pain were predictive of good ODI and leg pain outcomes, higher back pain was predictive of good back pain outcome, and higher leg pain was predictive of good leg pain outcome at 12 months. Model performance demonstrated reasonable to good calibration and adequate/very good discrimination. CONCLUSIONS: BMI, ODI, leg and back pain and previous surgery are important considerations pre-operatively to inform decisions for surgery. Pre-operative leg and back pain and work status are important considerations to inform decisions for management following surgery. Findings may inform clinical decision making regarding LSFS and associated rehabilitation.
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Fusão Vertebral , Adulto , Humanos , Fusão Vertebral/efeitos adversos , Resultado do Tratamento , Regras de Decisão Clínica , Dados de Saúde Coletados Rotineiramente , Vértebras Lombares/cirurgia , Dor nas Costas/etiologiaRESUMO
OBJECTIVE: To investigate the changes in asthma exacerbation, as well as in oral corticosteroid (OCS) use, exacerbation-related healthcare resource utilization (HRU), and healthcare costs before and after mepolizumab treatment initiation in patients with severe asthma who started treatment with mepolizumab in a real-world clinical setting in Japan. METHODS: A retrospective, observational, self-controlled study was conducted in Japan using a hospital-based administrative claims database. Patients who were diagnosed with asthma and who were new users of mepolizumab were included in the study. The primary outcome was the incidence rate of any asthma exacerbation/patient-year during the 12-month period before (baseline period) and after (follow-up period) the first mepolizumab prescription. Secondary outcome measures included the proportion of patients with ≥1 any asthma exacerbation, patients with exacerbation requiring hospitalization, the incidence rate of exacerbations requiring hospitalization/patient-year, the median daily OCS dose (OCS sparing effect), exacerbation-related HRU (hospitalization length, the proportion of patients with emergency visits, and the number of emergency/outpatient visits), and associated costs. RESULTS: Of the 377 patients included, 56.2% were ≥65 years of age. Following the first mepolizumab prescription, incidence rates for any asthma exacerbation were reduced by 40.6% (4.00/patient-year to 2.38/patient-year; the incidence rate ratio [95% confidence interval]: 0.60 [0.53-0.67]; p < 0.0001) from the baseline to follow-up periods. The incidence rate of exacerbations requiring hospitalization was reduced by 55.8% (0.37/patient-year to 0.16/patient-year) from the baseline to follow-up periods. The proportion of patients experiencing any exacerbation decreased from 84.4% to 57.8% and those requiring hospitalization decreased from 23.9% to 10.3% both from the baseline to follow-up periods. The median daily OCS dose decreased by 44.6% (median [interquartile range]: 6.7 [4.7-9.9] mg/day to 3.3 [0.9-5.6] mg/day) from the last baseline quarter to the 4th quarter of the follow-up period. All exacerbation-related HRUs decreased from the baseline to follow-up periods. Inpatient cost reduced by >50% (123,279 Japanese Yen [JPY]/patient-year vs. 57,283 JPY/patient-year), reducing the total cost by 80,716 JPY from the baseline to follow-up periods. CONCLUSION: Mepolizumab was effective in treating patients with severe asthma by reducing the incidence rates of exacerbations and exacerbation requiring hospitalization, OCS dose, exacerbation-related HRU, and cost in routine clinical practice in Japan.
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Antiasmáticos , Asma , Corticosteroides/uso terapêutico , Antiasmáticos/uso terapêutico , Anticorpos Monoclonais Humanizados , Asma/diagnóstico , Humanos , Japão , Estudos RetrospectivosRESUMO
BACKGROUND: Research on associations between social integration and wellbeing holds promise to inform policy and practice targets for health promotion. Yet, studies of social connection too frequently rely on overly simplistic measures and give inadequate attention to manifestation and meanings of social integration across diverse groups. We use the term socio-cultural integration to describe expanded assessment of both social and cultural aspects of belonging and connection. METHODS: We examined 7 distinct indicators of socio-cultural integration, identified heterogeneous patterns of responses across these indicators using latent profile analysis, and determined their relevance for wellbeing using survey data from a study with Indigenous communities in the U.S. and Canada. Wellbeing was measured using holistic ratings of self-rated physical, emotional, and spiritual health. RESULTS: Latent profile analysis (LPA) of responses to the 7 socio-cultural integration variables yielded a 3-class model, which we labeled low, moderate, and high integration. Mean scores on self-rated physical, mental and spiritual health were significantly associated with LPA profiles, such that those in the low integration group had the lowest self-rated health scores and those in the high integration group had the highest health scores. With the exception of similar ratings of cultural identification between low and moderate integration profiles, patterns of responses to the diverse socio-cultural integration measures varied significantly across the 3 latent profiles. CONCLUSIONS: Results underscore the importance of expanding our assessment of social integration with attention to the interrelationships of family, community, culture, and our environment. Such concepts align with Indigenous conceptions of wellbeing, and have relevance for health across cultures. More concretely, the indicators of socio-cultural integration used in this study (e.g., cultural identity, having a sense of connectedness to nature or family, giving or receiving social support) represent malleable targets for inclusion in health promotion initiatives.
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Saúde Holística , Apoio Social , Canadá , Promoção da Saúde , Humanos , Inquéritos e Questionários , Adulto JovemRESUMO
PURPOSE: To understand the patient journey to Lumbar Spinal Fusion Surgery (LSFS) and patients' experiences of surgery. METHODS: Qualitative study using interpretive phenomenological analysis. Adult participants following LSFS were recruited from 4 UK clinical sites using purposive sampling to ensure representation of key features (e.g. age). Semi-structured interviews informed by a piloted topic guide developed from the literature were audio-recorded and transcribed verbatim. Framework analysis for individual interviews and then across participants (deductive and inductive) identified emerging themes. Trustworthiness of data analyses was enhanced using multiple strategies (e.g. attention to negative cases). RESULTS: Four emerging themes from n = 31 patients' narratives were identified: decision for surgery, coping strategies, barriers to recovery and recovery after surgery. Decision for surgery and recovery after surgery themes are distinguished by the point of surgery. However, barriers to recovery and coping strategies are key to the whole patient journey encompassing long journeys to surgery and their initial journey after surgery. The themes of coping strategies and barriers to recovery were inter-related and perceived by participants as parallel concepts. The 4 multifactorial themes interacted with each other and shaped the process of an individual patient's recovery. Factors such as sporadic interventions prior to surgery, time-consuming wait for diagnosis and surgery and lack of information regarding recovery strongly influenced perceptions of outcome. CONCLUSION: Patient driven data enables insights to inform research regarding surgery/rehabilitation through depth of understanding of the patient journey. Awareness of factors important to patients is important; ensuring that patient-driven data informs research and patient care.
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Fusão Vertebral , Adulto , Humanos , Região Lombossacral , Pesquisa Qualitativa , Projetos de PesquisaRESUMO
BACKGROUND: Smoking-related disparities exist among racial/ethnic minoritized groups. OBJECTIVE: We compared quit ratios and smoking cessation-related protective and risk factors by race/ethnicity to inform approaches to reduce disparities. METHODS: Among adults who smoke with a quit attempt from Wave 4 (2016-2017) Population Assessment of Tobacco Use and Health Study, the following factors were examined by racial/ethnic group (American Indians/Alaska Native [AI/AN;n = 165], Black/African American [AA;n = 526], Asian [n = 38], Hispanic/Latino/Latina/Spanish [n = 475], or White [n = 1,960]), wherein each were nearly gender-balanced: cessation medications, counseling/self-help materials, home smoking ban, social support, e-cigarette use, sleep, and mental health. RESULTS: Quit ratio was lower for AI/AN (adjusted odds ratio[aOR]:0.61) and Black/AA (aOR:0.49) and higher for Asian (aOR:1.90) and Hispanic/Latino/Latina/Spanish (aOR:1.30) than White adults. Medication use was low among all and lower among Black/AA (aOR:0.70) and Hispanic/Latino/Latina/Spanish (aOR:0.56) than White adults. Use of counseling/self-help materials were low among all and higher in AI/AN (aOR:1.85), Black/AA (aOR:1.87), and Hispanic/Latino/Latina/Spanish (aOR:1.49) than White adults. Presence of a smoking ban was lower among Black/AA (aOR:0.40) and higher in Hispanic/Latino/Latina/Spanish (aOR:1.59) than White adults. E-cigarette use was lower in Black/AA (aOR:0.53) and Hispanic/Latino/Latina/Spanish (aOR:0.43) than White adults. Sadness, anxiety, and sleep difficulties were higher in AI/AN (aORs:1.57, 1.50, 1.64) than White adults. CONCLUSIONS: All racial/ethnic groups would benefit from policies and programs that increase cessation medications and counseling. Quit ratios were particularly low among Black/AA and AI/AN adults. Black/AA adults may benefit from efforts to increase smoking bans, while AI/AN adults may benefit from cessation approaches that simultaneously target sleep and mental health.
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Sistemas Eletrônicos de Liberação de Nicotina , Etnicidade , Adulto , Humanos , Prevalência , Grupos Raciais , Fumar , Estados UnidosRESUMO
This study identified contributing factors for tobacco-related inequities among parents (N = 331) during COVID-19. Compared to non-Hispanic White parents, Asian, Black, and multiracial parents experienced greater discrimination. Parents with a nicotine use history experienced greater discrimination and substance use coping relative to tobacco abstainers. Among parents who used nicotine during the pandemic (n = 45), experiencing financial loss, having COVID-19, and greater worries were positively associated with nicotine reductions during COVID-19. Being female, increased family members with COVID-19, discrimination, and substance use coping were negatively associated with nicotine reductions. Tobacco interventions that reduce substance use coping and increase alternative coping are needed.
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OBJECTIVE: This cross-sectional study quantified differences in (a) social determinants of health (SDOH) and perceived changes in SDOH during the 2019 novel coronavirus (COVID-19) pandemic and (b) COVID-19 psychosocial impacts across four groups: (a) non-Hispanic White (NHW) parents of children with asthma, (b) Black, Indigenous, or other People of Color (BIPOC) parents of healthy children, (c) BIPOC parents of children with asthma, and (d) NHW parents of healthy children (referent). The NIMHD Framework was used to identify SDOHs that may change for families during COVID-19. METHODS: Parents were recruited via Prolific (N = 321) and completed questions about COVID-19 family impacts on employment, income, access to food and healthcare, and psychosocial functioning, including discrimination. It was hypothesized that NHW families of children with asthma and BIPOC families would endorse greater negative outcomes relative to NHW parents of healthy children. RESULTS: BIPOC families experienced greater food insecurity and discrimination relative to NHW parents of healthy children. When compared with the NHW healthy group, COVID-19 resulted in greater parent-reported resource losses for both BIPOC groups and greater reductions in healthcare access for both asthma groups. Children with asthma and BIPOC children had greater distress surrounding COVID-19. BIPOC and NHW parents of children with asthma reported greater worries about resource losses due to COVID-19. CONCLUSIONS: The pandemic is widening inequities for BIPOC families, especially for families of children with asthma. These results highlight the need for interventions that address the needs of underserved communities, providing the infrastructure, policies, and supports needed to reduce health inequities during and after COVID-19.
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Asma , COVID-19 , Criança , Estudos Transversais , Humanos , Pandemias , SARS-CoV-2RESUMO
BACKGROUND: Objectives: Pancreatic cancer (PC) is a costly disease with a limited life-expectancy as it generally presents as an advanced, metastatic disease. Though current literature suggests cost varies by first line treatment, there is limited real-world knowledge about the economic burden of pancreatic cancer. This study describes the economic burden of pancreatic cancer patients overall and by observed first line treatments. METHODS: The IBM MarketScan databases were used to identify adult metastatic PC patients from January 1, 2010 through 3/31/2017. Those without other primary cancers, pregnancy, or prior PC treatment, and with 6 months of continuous enrollment prior to PC were included. Treatment patterns and healthcare utilization and expenditures were measured during the variable-length follow-up period. Continuous measures were presented as per patient per month (PPPM). RESULTS: A total of 6,360 patients met all inclusion criteria. Almost half (46.8%) of patients were untreated. Gemcitabine alone (15.6%) and FOLFIRINOX (11.4%) were the most commonly observed first line regimens. Treated patients incurred $17,513 PPPM (Gemcitabine alone) to $27,889 PPPM (FOLFIRINOX) during follow-up. Untreated patients incurred the highest unadjusted ($30,777 PPPM) and adjusted ($20,392 PPPM) cost. CONCLUSIONS: Metastatic PC patients incur a high economic burden driven by high utilization of healthcare resources, which varies by first line treatment. Also, the high proportion of untreated patients is alarming as these patients may be the most expensive of all patients. There is an unmet need in these patients for effective treatments that also reduce their economic burden.
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Efeitos Psicossociais da Doença , Neoplasias Pancreáticas/economia , Idoso , Antimetabólitos Antineoplásicos/economia , Antimetabólitos Antineoplásicos/uso terapêutico , Protocolos de Quimioterapia Combinada Antineoplásica/economia , Protocolos de Quimioterapia Combinada Antineoplásica/uso terapêutico , Custos e Análise de Custo , Bases de Dados Factuais , Desoxicitidina/análogos & derivados , Desoxicitidina/economia , Desoxicitidina/uso terapêutico , Feminino , Fluoruracila/economia , Fluoruracila/uso terapêutico , Seguimentos , Custos de Cuidados de Saúde , Recursos em Saúde , Humanos , Irinotecano/economia , Irinotecano/uso terapêutico , Leucovorina/economia , Leucovorina/uso terapêutico , Masculino , Pessoa de Meia-Idade , Avaliação das Necessidades , Metástase Neoplásica , Oxaliplatina/economia , Oxaliplatina/uso terapêutico , Neoplasias Pancreáticas/tratamento farmacológico , Estudos Retrospectivos , GencitabinaRESUMO
OBJECTIVES: Overall survival in chronic myeloid leukemia (CML) in chronic phase is not significantly different by treatment with first-line tyrosine kinase inhibitors (TKIs), but emerging evidence reveals differences in costs and safety profiles. We evaluated the 1-year cost-effectiveness of TKI initiation with imatinib, dasatinib, or nilotinib among a hypothetical cohort of incident patients with CML from a US payer's perspective. METHODS: We constructed a decision analytic model to assess quality-adjusted life years (QALYs), healthcare costs, net monetary benefit, and incremental cost-effectiveness of treatment strategies. We used published studies and data from the IBM Watson Health MarketScan database for model parameters. To calculate TKI costs, we used the 2018 Federal Supply Schedule estimates for generic imatinib and branded second-generation TKIs. We evaluated cost-effectiveness under various willingness-to-pay thresholds. We accounted for uncertainty with deterministic and probabilistic sensitivity analyses. RESULTS: In the base-case analysis, imatinib was favored over dasatinib and nilotinib at a lower cost per QALY gained. Imatinib remained the favored strategy after 1-way variations in TKI costs, TKI switching, QALYs, adverse event risk, and CML progression. When we assessed model uncertainty with prespecified parameter distributions, imatinib was cost-saving compared with dasatinib in 40% of 100 0000 simulations and was favored over all simulations compared with nilotinib. First-line treatment with second-generation TKIs was cost-effective in 50% of simulations at a $200 000/QALY willingness-to-pay threshold. CONCLUSIONS: Generic availability of imatinib provides a more cost-effective treatment approach in the first year compared with other available TKIs for newly diagnosed patients with CML.
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Antineoplásicos/uso terapêutico , Dasatinibe/uso terapêutico , Mesilato de Imatinib/uso terapêutico , Leucemia Mielogênica Crônica BCR-ABL Positiva/tratamento farmacológico , Proteínas Tirosina Quinases/antagonistas & inibidores , Pirimidinas/uso terapêutico , Antineoplásicos/economia , Análise Custo-Benefício , Dasatinibe/economia , Técnicas de Apoio para a Decisão , Custos de Medicamentos , Custos de Cuidados de Saúde , Humanos , Mesilato de Imatinib/economia , Leucemia Mielogênica Crônica BCR-ABL Positiva/economia , Pirimidinas/economia , Anos de Vida Ajustados por Qualidade de VidaRESUMO
Suicide is the second leading cause of death for American Indian (AI) young adults. Alcohol use is a well-established risk factor for suicide. On average, AIs ages 12 to 20 exhibit the second-highest rate of binge drinking compared to all other ethnic groups. The current study investigated the relation between alcohol use and suicide ideation in an AI sample and examined these relations in the context of the interpersonal theory of suicide (ITS). It was hypothesized that perceived burdensomeness and thwarted belongingness would each significantly moderate the relations between alcohol use and suicide ideation in an AI sample. College students who self-identified as American Indian (N = 84) completed measures of alcohol use and associated problems, perceived burdensomeness and thwarted belongingness, and suicidality. Results indicated that perceived burdensomeness significantly moderated the relation between alcohol use and suicide ideation, and this interaction was significant at high levels of perceived burdensomeness. However, thwarted belongingness was not a significant moderator of the relation between alcohol use and suicide ideation. Findings suggest that AI young adults who engage in increased alcohol use may be at increased risk for suicide, especially if they also experience stronger perceptions of being a burden on others. The current study provides support for continued examinations of the relationship between alcohol use and suicide to inform culturally appropriate interventions for AI young adults.
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Consumo de Bebidas Alcoólicas/psicologia , Transtornos Relacionados ao Uso de Álcool/psicologia , Indígena Americano ou Nativo do Alasca/psicologia , Relações Interpessoais , Suicídio/psicologia , Adolescente , Criança , Feminino , Humanos , Masculino , Distância Psicológica , Fatores de Risco , Ideação Suicida , Adulto JovemRESUMO
PURPOSE: To compare adherence to tyrosine kinase inhibitors (TKIs) between patients with chronic myeloid leukemia (CML) who initiated branded or generic imatinib. METHODS: We used MarketScan commercial claims data (January 2011-June 2018) to identify patients with CML who newly initiated branded imatinib before 1 August 2015 or generic imatinib on or after 2 February 2016, and were continuously enrolled in health plans for 6 months before through 6 months following their initial fill. After inverse probability of treatment weighting, we compared adherence (proportion of days covered [PDC]) and persistence (no gaps ≥30 and ≥60 consecutive days in therapy) to TKI therapy. RESULTS: Patients initiating generic imatinib consistently had higher average PDC per month and over the 6-month follow-up period than initiators of branded imatinib. Average 6-month PDC was 92% (95%CI:89%-94%) for generic initiators and 85% (95%CI:83%-86%) for brand initiators. Compared with branded imatinib initiators, a larger proportion of generic imatinib initiators were adherent and persistent to TKI therapy (PDC ≥ 90%:78% versus 64%; no≥60-day gap:94% versus 86%). CONCLUSIONS: Patients initiating generic imatinib achieved clinically significant improvements in adherence to TKI therapy relative to branded drug users, presumably due to lower out-of-pocket costs. Given the importance of optimal adherence in CML, considering barriers to adherence (eg, patient-cost sharing and health benefit design) when selecting initial treatment may improve long-term medication adherence. Pharmacoepidemiologic studies should consider how best to account for expected cost-sharing and its impact on adherence and subsequent clinical outcomes.
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Medicamentos Genéricos/administração & dosagem , Mesilato de Imatinib/administração & dosagem , Leucemia Mielogênica Crônica BCR-ABL Positiva/tratamento farmacológico , Adesão à Medicação/estatística & dados numéricos , Inibidores de Proteínas Quinases/administração & dosagem , Adulto , Estudos de Coortes , Bases de Dados Factuais , Custos de Medicamentos , Medicamentos Genéricos/economia , Feminino , Seguimentos , Humanos , Mesilato de Imatinib/economia , Masculino , Pessoa de Meia-Idade , Inibidores de Proteínas Quinases/economiaRESUMO
Escherichia coli Δglk ΔmanZ ΔptsG glucose- strains that lack the glucose phosphotransferase system (PTS) and the mannose PTS as well as glucokinase have been widely used by researchers studying the PTS. In this study we show that both fast- and slow-growing spontaneous glucose+ revertants can be readily obtained from Δglk ΔmanZ ΔptsG glucose- strains. All of the fast-growing revertants either altered the N-acetylglucosamine PTS or caused its overproduction by inactivating the NagC repressor protein, which regulates the N-acetylglucosamine PTS, and these revertants could utilize either glucose or N-acetylglucosamine as a sole carbon source. When a ΔnagE deletion, which abolishes the N-acetylglucosamine PTS, was introduced into the Δglk ΔmanZ ΔptsG glucose- strains, fast-growing revertants could no longer be isolated. Based on our results and other studies, it is clear that the N-acetylglucosamine PTS is the most easily adaptable PTS for transporting and phosphorylating glucose, other than the glucose PTS and mannose PTS, which are the primary glucose transport systems. While the slow-growing glucose+revertants were not characterized, they were likely mutations that other researchers have observed before and affect other PTSs or sugar kinases.
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Acetilglucosamina/metabolismo , Proteínas de Escherichia coli/genética , Escherichia coli/metabolismo , Glucose/metabolismo , Sistema Fosfotransferase de Açúcar do Fosfoenolpiruvato/genética , Transporte Biológico/genética , Escherichia coli/enzimologia , Escherichia coli/genética , Escherichia coli/crescimento & desenvolvimento , Proteínas de Escherichia coli/metabolismo , Deleção de Genes , Expressão Gênica , Genes Bacterianos/genética , Glucoquinase/genética , Manose/metabolismo , Sistema Fosfotransferase de Açúcar do Fosfoenolpiruvato/metabolismo , Proteínas Repressoras/genética , Especificidade por SubstratoRESUMO
OBJECTIVE: Advanced stage epithelial ovarian cancer (AEOC) can be treated with either neoadjuvant chemotherapy (NACT) or primary cytoreductive surgery (PCS). Although randomized controlled trials show that NACT is non-inferior in overall survival compared to PCS, there may be improvement in short-term morbidity. We sought to investigate the cost-effectiveness of NACT relative to PCS for AEOC from the US Medicare perspective. METHODS: A cost-effectiveness analysis using a Markov model with a 7-month time horizon comparing (1) 3cycles of NACT with carboplatin and paclitaxel (CT), followed by interval cytoreductive surgery, then 3 additional cycles of CT, or (2) PCS followed by 6cycles of CT. Input parameters included probability of chemotherapy complications, surgical complications, treatment completion, treatment costs, and utilities. Model outcomes included costs, life-years gained, quality-adjusted life-years (QALYs) gained, and incremental cost-effectiveness ratios (ICER), in terms of cost per life-year gained and cost per QALY gained. We accounted for differences in surgical complexity by incorporating the cost of additional procedures and the probability of undergoing those procedures. Probabilistic sensitivity analysis (PSA) was performed via Monte Carlo simulations. RESULTS: NACT resulted in a savings of $7034 per patient with a 0.035 QALY increase compared to PCS; therefore, NACT dominated PCS in the base case analysis. With PSA, NACT was the dominant strategy more than 99% of the time. CONCLUSIONS: In the short-term, NACT is a cost-effective alternative compared to PCS in women with AEOC. These results may translate to longer term cost-effectiveness; however, data from randomized control trials continues to mature.
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Procedimentos Cirúrgicos de Citorredução/economia , Neoplasias Epiteliais e Glandulares/economia , Neoplasias Ovarianas/economia , Idoso , Carcinoma Epitelial do Ovário , Quimioterapia Adjuvante/economia , Análise Custo-Benefício , Feminino , Humanos , Cadeias de Markov , Terapia Neoadjuvante/economia , Neoplasias Epiteliais e Glandulares/tratamento farmacológico , Neoplasias Epiteliais e Glandulares/cirurgia , Neoplasias Ovarianas/tratamento farmacológico , Neoplasias Ovarianas/cirurgia , Anos de Vida Ajustados por Qualidade de VidaRESUMO
OBJECTIVES: Neoadjuvant chemotherapy (NACT) versus primary debulking surgery (PDS) for advanced epithelial ovarian cancer (AEOC) remains controversial in the United States. Generalizability of existing trial results has been criticized because of less aggressive debulking procedures than commonly used in the United States. As a result, economic evaluations using input data from these trials may not accurately reflect costs and outcomes associated with more aggressive primary surgery. Using data from an ongoing trial performing aggressive debulking, we investigated the cost-effectiveness and cost-utility of NACT versus PDS for AEOC. METHODS: A decision tree model was constructed to estimate differences in short-term outcomes and costs for a hypothetical cohort of 15,000 AEOC patients (US annual incidence of AEOC) treated with NACT versus PDS over a 1-year time horizon from a Medicare payer perspective. Outcomes included costs per cancer-related death averted, life-years and quality-adjusted life-years (QALYs) gained. Base-case probabilities, costs, and utilities were based on the Surgical Complications Related to Primary or Interval Debulking in Ovarian Neoplasms trial. Base-case analyses assumed equivalent survival; threshold analysis estimated the maximum survival difference that would result in NACT being cost-effective at $50,000/QALY and $100,000/QALY willingness-to-pay thresholds. Probabilistic sensitivity analysis was used to characterize model uncertainty. RESULTS: Compared with PDS, NACT was associated with $142 million in cost savings, 1098 fewer cancer-related deaths, and 1355 life-years and 1715 QALYs gained, making it the dominant treatment strategy for all outcomes. In sensitivity analysis, NACT remained dominant in 99.3% of simulations. Neoadjuvant chemotherapy remained cost-effective at $50,000/QALY and $100,000/QALY willingness-to-pay thresholds if survival differences were less than 2.7 and 1.4 months, respectively. CONCLUSIONS: In the short term, NACT is cost-saving with improved outcomes. However, if PDS provides a longer-term survival advantage, it may be cost-effective. Research is needed on the role of patient preferences in tradeoffs between survival and quality of life.
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Carcinoma Epitelial do Ovário/economia , Carcinoma Epitelial do Ovário/terapia , Carcinoma Epitelial do Ovário/tratamento farmacológico , Carcinoma Epitelial do Ovário/cirurgia , Quimioterapia Adjuvante/economia , Análise Custo-Benefício , Procedimentos Cirúrgicos de Citorredução/economia , Procedimentos Cirúrgicos de Citorredução/métodos , Árvores de Decisões , Feminino , Custos de Cuidados de Saúde , Humanos , Terapia Neoadjuvante/economia , Qualidade de Vida , Resultado do Tratamento , Estados UnidosRESUMO
PURPOSE: The objective of this article is to report a case of type V osteogenesis imperfecta (OI) undergoing posterior instrumented fusion for scoliosis. Type V OI is a moderately severe dysplasia causing primary defects in endochondral bone ossification or mineralisation. It is characterised by hyperplastic callus (HPC) formation, interosseous membrane calcifications, poor bone quality and spinal deformities including scoliosis. Data on the surgical management of spinal deformities in this patient group are lacking. CASE REPORT: A 16-year-old patient with a confirmed diagnosis of type V OI presented with a progressive scoliosis. The patient underwent a T3-L4 posterior instrumented correction and fusion utilising pedicle screws, pedicle hooks and sub-laminar wiring. At 4 months after surgery, the pedicle hooks pulled out and required partial metalwork removal after CT scanning confirmed bony union and no evidence of HPC formation. The patient was successfully discharged with satisfactory correction, confirmed bony union, no neurologic complication and absence of any hyperplastic callus formation. CONCLUSION: Type V OI patients requiring surgical intervention for scoliosis correction can safely undergo posterior instrumented fusion using sublaminar wiring and pedicle hook/screw constructs without apparent risk of HPC formation around neural elements. Surgery in this patient group remains challenging due to the associated poor bone quality. LEVEL OF EVIDENCE: V.
RESUMO
BACKGROUND: We aimed to analyse the rates of early and causes of death in patients aged over 65 years with a type II odontoid fracture. METHODS: A consecutive series of 93 patients with a type II fracture of the odontoid process was retrospectively identified. Data collected included patient demographics, co-morbidities, associated injuries, neurological injury, date of death and cause of death. Mean patient age was 81. Five patients (5%) were treated operatively while the rest were treated in a hard cervical collar. Five patients (5%) had an incomplete cervical cord injury secondary to the fracture. RESULTS: The rate of mortality at 30 days was 10% (9 patients) and at 90 days it was 16% (15 patients). Following multivariate analysis, the factors found to significantly increase the risk of 30-day mortality included increasing age, increasing injury severity score and leukaemia. Following univariate analysis the only factor found to increase the risk of 90-day mortality was advancing age. The commonest causes of death were pneumonia and ischaemic coronary disease. CONCLUSION: Our results suggest that this patient cohort is frail and at risk of early mortality. We suggest that their inpatient care be provided in close conjunction with elderly care physicians.
Assuntos
Fraturas Ósseas/epidemiologia , Fragilidade/epidemiologia , Processo Odontoide/lesões , Idoso , Idoso de 80 Anos ou mais , Comorbidade , Fraturas Ósseas/mortalidade , Fraturas Ósseas/terapia , Fragilidade/mortalidade , Hospitalização/estatística & dados numéricos , Humanos , Morbidade , Estudos RetrospectivosRESUMO
Racial microaggressions are a contemporary form of subtle discrimination that occur in everyday exchanges, and are associated with a variety of negative mental health outcomes, including suicide ideation. Previous work (e.g., Torres-Harding, Andrade, & Romero Diaz, 2012) has identified 6 dimensions of racial microaggressions: invisibility, criminality, low-achieving/undesirable culture, sexualization, foreigner/not belonging, and environmental invalidations. The current study examined whether the 6 dimensions of racial microaggressions were associated with increased suicide ideation through perceived burdensomeness and thwarted belongingness among 135 African American young adults. Results indicated that perceived burdensomeness, but not thwarted belongingness, mediated the relationship between 3 racial microaggression dimensions (i.e., invisibility, low-achievement/undesirable culture, and environmental invalidations) and suicide ideation. These results imply that for African American college students, experiencing certain dimensions of racial microaggressions was associated with higher levels of perceived burdensomeness, which in turn was related to increased levels of suicide ideation. Clinical and societal implications are discussed. This study found that specific types of racial microaggressions were associated with higher levels of perceptions of being a burden on others, which in turn was associated with higher levels of suicide ideation in a sample of African Americans. These findings are important as they demonstrate 1 possible avenue through which racial microaggressions can negatively impact mental health. (PsycINFO Database Record