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INTRODUCTION: Tenecteplase has been compared to alteplase in acute stroke randomized trials, with similar outcomes and safety measures, but higher doses of tenecteplase have been associated with higher hemorrhage rates in some studies. Limited data are available on the safety of tenecteplase outside of clinical trials. METHODS: We examined the safety measures of intracranial hemorrhage, angioedema, and serious extracranial adverse events in a 21-hospital integrated healthcare system that switched from alteplase (0.9 mg/kg, maximum dose 90 mg) to tenecteplase (0.25 mg/kg, maximum dose 25 mg) for acute ischemic stroke. RESULTS: Among 3,689 subjects, no significant differences were seen between tenecteplase and alteplase in the rate of intracranial hemorrhage (ICH), parenchymal hemorrhage, or volume of parenchymal hemorrhage. Symptomatic hemorrhage (sICH) was not different between the two agents: sICH by NINDS criteria was 2.0 % for alteplase vs 2.3 % for tenecteplase (P = 0.57), and sICH by SITS criteria was 0.8 % vs 1.1 % (P = 0.39). Adjusted logistic regression models also showed no differences between tenecteplase and alteplase: the odds ratio for tenecteplase (vs alteplase) modeling sICH by NINDS criteria was 0.9 (95 % CI 0.33 - 2.46, P = 0.83) and the odds ratio for tenecteplase modeling sICH by SITS criteria was 1.12 (95 % CI 0.25 - 5.07, P = 0.89). Rates of angioedema and serious extracranial adverse events were low and did not differ between tenecteplase and alteplase. Elapsed door-to-needle times showed a small improvement after the switch to tenecteplase (51.8 % treated in under 30 min with tenecteplase vs 43.5 % with alteplase, P < 0.001). CONCLUSION: In use outside of clinical trials, complication rates are similar between tenecteplase and alteplase. In the context of a stroke telemedicine program, the rates of hemorrhage observed with either agent were lower than expected based on prior trials and registry data. The more easily prepared tenecteplase was associated with a lower door-to-needle time.
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Angioedema , Isquemia Encefálica , Accidente Cerebrovascular Isquémico , Accidente Cerebrovascular , Humanos , Activador de Tejido Plasminógeno/efectos adversos , Tenecteplasa/efectos adversos , Fibrinolíticos/efectos adversos , Accidente Cerebrovascular Isquémico/diagnóstico , Accidente Cerebrovascular Isquémico/tratamiento farmacológico , Accidente Cerebrovascular Isquémico/inducido químicamente , Accidente Cerebrovascular/diagnóstico , Accidente Cerebrovascular/tratamiento farmacológico , Accidente Cerebrovascular/inducido químicamente , Hemorragias Intracraneales/inducido químicamente , Hemorragias Intracraneales/tratamiento farmacológico , Angioedema/inducido químicamente , Resultado del Tratamiento , Isquemia Encefálica/diagnóstico , Isquemia Encefálica/tratamiento farmacológico , Isquemia Encefálica/inducido químicamenteRESUMEN
BACKGROUND AND PURPOSE: In large artery occlusion stroke, both intravenous (IV) tPA (tissue-type plasminogen activator) and endovascular stroke treatment (EST) are standard-of-care. It is unknown how often tPA causes distal embolization, in which a procedurally accessible large artery occlusion is converted to a more distal and potentially inaccessible occlusion. METHODS: We analyzed data from a decentralized stroke telemedicine program in an integrated healthcare delivery system covering 21 hospitals, with 2 high-volume EST centers. We captured all cases sent for EST and examined the relationship between IV tPA administration and the rate of distal embolization, the rate of target recanalization (modified Treatment in Cerebral Infarction scale 2b/3), clinical improvement before EST, and short-term and long-term clinical outcomes. RESULTS: Distal embolization before EST was quite common (63/314 [20.1%]) and occurred more often after IV tPA before EST (57/229 [24.9%]) than among those not receiving IV tPA (6/85 [7.1%]; P<0.001). Distal embolization was associated with an inability to attempt EST: after distal embolization, 26/63 (41.3%) could not have attempted EST because of the new clot location, while in cases without distal embolization, only 8/249 (3.2%) were unable to have attempted EST (P<0.001). Among patients who received IV tPA, 13/242 (5.4%) had sufficient symptom improvement that a catheter angiogram was not performed; 6/342 (2.5%) had improvement to within 2 points of their baseline NIHSS. At catheter angiogram, 2/229 (0.9%) of patients who had received tPA had complete recanalization without distal embolization. Both IV tPA and EST recanalization were associated with improved long-term outcome. CONCLUSIONS: IV tPA administration before EST for large artery occlusion is associated with distal embolization, which in turn may reduce the chance that EST can be attempted and recanalization achieved. At the same time, some IV tPA-treated patients show symptomatic improvement and complete recanalization. Because IV tPA is associated with both distal embolization and improved long-term clinical outcome, there is a need for prospective clinical trials testing the net benefit or harm of IV tPA before EST.
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Embolización Terapéutica/efectos adversos , Procedimientos Endovasculares/métodos , Fibrinolíticos/efectos adversos , Accidente Cerebrovascular/cirugía , Activador de Tejido Plasminógeno/efectos adversos , Anciano , Anciano de 80 o más Años , Angiografía , Arteriopatías Oclusivas/complicaciones , Infarto Cerebral/cirugía , Femenino , Fibrinolíticos/uso terapéutico , Humanos , Masculino , Persona de Mediana Edad , Estudios Prospectivos , Medición de Riesgo , Activador de Tejido Plasminógeno/uso terapéutico , Tomografía Computarizada por Rayos X , Resultado del TratamientoRESUMEN
BACKGROUND AND PURPOSE: Faster treatment with intravenous alteplase in acute ischemic stroke is associated with better outcomes. Starting in 2015, Kaiser Permanente Northern California redesigned its acute stroke workflow across all 21 Kaiser Permanente Northern California stroke centers to (1) follow a single standardized version of a modified Helsinki model and (2) have all emergency stroke cases managed by a dedicated telestroke neurologist. We examined the effect of Kaiser Permanente Northern California's Stroke EXpediting the PRrocess of Evaluating and Stopping Stroke program on door-to-needle (DTN) time, alteplase use, and symptomatic intracranial hemorrhage rates. METHODS: The program was introduced in a staggered fashion from September 2015 to January 2016. We compared DTN times for a seasonally adjusted 9-month period at each center before implementation to the corresponding 9-month calendar period from the start of implementation. The primary outcome was the DTN time for alteplase administration. Secondary outcomes included rate of alteplase administrations per month, symptomatic intracranial hemorrhage, and disposition at time of discharge. RESULTS: This study included 310 patients treated with alteplase in the pre-EXpediting the PRrocess of Evaluating and Stopping Stroke period and 557 patients treated with alteplase in the EXpediting the PRrocess of Evaluating and Stopping Stroke period. After implementation, alteplase administrations increased to 62/mo from 34/mo at baseline (P<0.001). Median DTN time decreased to 34 minutes after implementation from 53.5 minutes prior (P<0.001), and DTN time of <60 minutes was achieved in 87.1% versus 61.0% (P<0.001) of patients. DTN times <30 minutes were much more common in the Stroke EXpediting the PRrocess of Evaluating and Stopping Stroke period (40.8% versus 4.2% before implementation). There was no significant difference in symptomatic intracranial hemorrhage rates in the 2 periods (3.8% versus 2.2% before implementation; P=0.29). CONCLUSIONS: Introduction of a standardized modified Helsinki protocol across 21 hospitals using telestroke management was associated with increased alteplase administrations, significantly shorter DTN times, and no increase in adverse outcomes.
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Prestación Integrada de Atención de Salud/métodos , Accidente Cerebrovascular , Telemedicina/métodos , Terapia Trombolítica/métodos , Activador de Tejido Plasminógeno/uso terapéutico , Anciano , Anciano de 80 o más Años , California , Prestación Integrada de Atención de Salud/organización & administración , Prestación Integrada de Atención de Salud/normas , Femenino , Humanos , Masculino , Persona de Mediana Edad , Accidente Cerebrovascular/diagnóstico , Accidente Cerebrovascular/tratamiento farmacológico , Telemedicina/organización & administración , Telemedicina/normas , Terapia Trombolítica/normas , Factores de TiempoAsunto(s)
Analgésicos Opioides/uso terapéutico , Procedimientos Quirúrgicos del Sistema Digestivo/efectos adversos , Recuperación Mejorada Después de la Cirugía , Procedimientos Ortopédicos/efectos adversos , Dolor Postoperatorio/tratamiento farmacológico , Cuidados Posoperatorios , Adulto , Anciano , Anciano de 80 o más Años , Femenino , Humanos , Masculino , Persona de Mediana Edad , Dolor Postoperatorio/etiología , Estudios RetrospectivosRESUMEN
This was a retrospective cohort study of pregnant individuals in the Kaiser Permanente Northern California system who were screened for adverse childhood experiences and resilience as part of standard prenatal care at about 16 weeks of gestation. Overall, 14,625 pregnancies were included; 17.0% had newly identified depression; 9.8% had newly identified depression symptoms; and 8.9% had newly identified anxiety during the pregnancy with no known preexisting diagnosis. We found that adverse childhood experiences and low resilience were independently associated with newly identified depressive disorders, depression symptoms, and anxiety disorders during pregnancy. When adverse childhood experiences and resilience were modeled in combination, the greatest odds of each outcome occurred in individuals with a combination of four or more adverse childhood experiences and low resilience (vs no adverse childhood experiences and high resilience): depression adjusted odds ratio (aOR) 6.43 (95% CI, 5.23-7.90), depression symptoms aOR 9.49 (95% CI, 7.50-12.0), and anxiety disorder aOR 4.79 (95% CI, 3.81-6.02). Routine screening for adverse childhood experiences and resilience may identify individuals at risk of developing prenatal depression and anxiety, allowing faster resource linkage and potentially improved maternal and child outcomes.
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Experiencias Adversas de la Infancia , Resiliencia Psicológica , Femenino , Embarazo , Niño , Humanos , Depresión/epidemiología , Depresión/diagnóstico , Estudios Retrospectivos , Ansiedad/epidemiología , Trastornos de Ansiedad/epidemiologíaRESUMEN
INTRODUCTION Immunization rates against the human papillomavirus (HPV) remain suboptimal in the young adult population. Little is known about the most effective means for encouraging vaccination in this population. METHODS The authors conducted a clinical trial of 3 methods to encourage HPV vaccination in a large Northern California integrated Health Plan. Young adults aged 18-26 with evidence of insufficient HPV vaccination were sent a bulk secure message from the Health Plan (standard outreach); those who did not respond were randomized to no further outreach, a second, personalized secure message from a specific practitioner, or a letter mailed to their home. The primary outcome was receipt of at least 1 HPV vaccine within 3 months following the initial bulk secure message. RESULTS In total, 7718 young adults were randomized. After 3 months, 86 patients (3.5%) who received no additional outreach obtained an immunization, compared with 114 (4.6%) who received the second secure message (p = 0.05) and 126 (5.1%) who received the mailed letter (p = 0.006). DISCUSSION Supplemental mailed or personalized electronic messages increased vaccination beyond no additional intervention, although gains were not clinically meaningful. These findings highlight the need for more successful alternatives to encourage uptake of such preventive health interventions among young adults. The successful conduct of this rapid-cycle, randomized trial showed that such evaluations are feasible, providing actionable data to inform implementation strategies. CONCLUSIONS Further study is needed to identify effective strategies for improving preventive health uptake in this important and underserved population. Rapid-cycle randomized evaluation strategies can provide critical information to focus efforts for achieving this goal.
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Aprendizaje del Sistema de Salud , Infecciones por Papillomavirus , Vacunas contra Papillomavirus , Humanos , Adulto Joven , Virus del Papiloma Humano , Infecciones por Papillomavirus/prevención & control , Vacunación , Inmunización/métodos , Vacunas contra Papillomavirus/uso terapéuticoRESUMEN
Background: Treatment of latent tuberculosis infection (LTBI) is highly effective at preventing active tuberculosis (TB) disease. Understanding LTBI treatment practices in US health system settings is critical to identify opportunities to improve treatment prescription, initiation, and completion, and thus to prevent TB disease. Methods: We assessed LTBI treatment practices among a cohort of adults after their first positive LTBI test (tuberculin skin test [TST] or interferon gamma release assay [IGRA]) between 2009 and 2018 at 2 large integrated health systems in California. We described the prescription, initiation, and completion of LTBI treatment (isoniazid [INH], rifampin, and rifamycin-INH short-course combinations) by demographic and clinical characteristics. We used multivariable robust Poisson regression to examine factors that were independently associated with treatment prescription and completion. Results: Among 79 302 individuals with a positive LTBI test, 33.0% were prescribed LTBI treatment, 28.3% initiated treatment, and 18.5% completed treatment. Most individuals were prescribed INH (82.0%), but treatment completion was higher among those prescribed rifamycin-INH short-course combinations (69.6% for INH + rifapentine and 70.3% for INH + rifampin) compared with those prescribed INH (56.3%) or rifampin (56.6%). In adjusted analyses, treatment prescription and completion were associated with older age, female sex, more comorbidities, immunosuppression, not being born in a high-TB incidence country, and testing positive with IGRA vs TST. Conclusions: LTBI treatment is underutilized, requiring tailored interventions to support treatment prescription and completion for patients with LTBI.
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OBJECTIVES: The opioid abuse epidemic has focused attention on efforts to decrease opioid prescribing. Although education and feedback interventions are potential levers to affect opioid prescribing, their incremental contribution against a background of declining opioid prescriptions is unclear. STUDY DESIGN: We retrospectively evaluated opioid prescribing frequencies after an emergency physician-specific education and feedback initiative in an integrated health care system. METHODS: We evaluated opioid prescriptions for adult patients discharged from 21 emergency departments (EDs) between January 1, 2014, and December 31, 2018. Applying interrupted time series methodology to account for time trends, we analyzed pre- to postintervention changes in prescribing of any opioid and in opioid prescriptions for greater than 20 tablets. We studied all ED visits, visits for back pain and acute extremity fracture, and visits stratified by physicians with high vs low frequency of opioid prescribing. We identified patient, physician, and visit characteristics associated with postintervention ED opioid prescriptions (2018). RESULTS: Of 1.01 million preintervention and 1.59 million postintervention ED visits, after adjusting for the background trend over time, the intervention was associated with a 3.4% decrease in frequency of opioid prescriptions post intervention (95% CI, -4% to -2.8%), with similar decreases in high-quantity prescriptions (> 20 tablets) and back pain- and acute extremity fracture-related ED visits. Postintervention adjusted analyses indicated no significant association between opioid prescription and race/ethnicity or prior history of opioid abuse. CONCLUSIONS: The ED Opioid Safety Initiative was associated with a near-term decrease in multiple categories of opioid prescribing, including for selected subgroups of common painful conditions.
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Analgésicos Opioides , Trastornos Relacionados con Opioides , Adulto , Analgésicos Opioides/uso terapéutico , Dolor de Espalda , Servicio de Urgencia en Hospital , Humanos , Trastornos Relacionados con Opioides/tratamiento farmacológico , Trastornos Relacionados con Opioides/epidemiología , Trastornos Relacionados con Opioides/prevención & control , Pautas de la Práctica en Medicina , Estudios RetrospectivosRESUMEN
Objective Eating disorders typically onset in preadolescence and adolescence and cause negative mental and physical health sequelae over the life span. This study examined the incidence and medical hospitalization rates of pediatric eating disorders in an integrated health system in the United States. Methods This retrospective cohort study examined 4883 Kaiser Permanente Northern California members 8-18 years of age with an eating disorder diagnosis from January 2015 to June 2019. Medical hospitalizations include admissions at any of the 13 Kaiser Permanente Northern California hospitals with a primary or secondary eating disorder diagnosis. Results Incidence rates ranged between 177 and 205 per 100,000 adolescents per year. More than half the adolescents were non-White: 10.8% Asian, 4.3% Black, 26.7% Hispanic/Latinx, 8.4% multiracial, 0.3% Native American/Alaskan Native, and 0.5% Native Hawaiian/Pacific Islander. Thirteen percent had a body mass index (BMI) below the 5th percentile, 61.8% had a BMI between the 5th and the 84th percentiles, 19.7% had a BMI above the 85th percentile, and 5.6% had an unknown BMI. During the 12-month follow-up period, 5.4% of adolescents had medical hospitalizations. Conclusions This study adds to the evidence that eating disorders affect children/adolescents across all weight/BMI ranges and racial/ethnic backgrounds. Future studies call for exploration on treatment strategies that tailor to the diverse populations.
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Trastornos de Alimentación y de la Ingestión de Alimentos , Grupos Raciales , Adolescente , Niño , Humanos , Estados Unidos , Incidencia , Estudios Retrospectivos , Trastornos de Alimentación y de la Ingestión de Alimentos/epidemiología , Trastornos de Alimentación y de la Ingestión de Alimentos/terapia , HospitalizaciónRESUMEN
OBJECTIVE: Though targeted testing for latent tuberculosis infection ("LTBI") for persons born in countries with high tuberculosis incidence ("HTBIC") is recommended in health care settings, this information is not routinely recorded in the electronic health record ("EHR"). We develop and validate a prediction model for birth in a HTBIC using EHR data. MATERIALS AND METHODS: In a cohort of patients within Kaiser Permanente Southern California ("KPSC") and Kaiser Permanent Northern California ("KPNC") between January 1, 2008 and December 31, 2019, KPSC was used as the development dataset and KPNC was used for external validation using logistic regression. Model performance was evaluated using area under the receiver operator curve ("AUCROC") and area under the precision and recall curve ("AUPRC"). We explored various cut-points to improve screening for LTBI. RESULTS: KPSC had 73% and KPNC had 54% of patients missing country-of-birth information in the EHR, leaving 2,036,400 and 2,880,570 patients with EHR-documented country-of-birth at KPSC and KPNC, respectively. The final model had an AUCROC of 0.85 and 0.87 on internal and external validation datasets, respectively. It had an AUPRC of 0.69 and 0.64 (compared to a baseline HTBIC-birth prevalence of 0.24 at KPSC and 0.19 at KPNC) on internal and external validation datasets, respectively. The cut-points explored resulted in a number needed to screen from 7.1-8.5 persons/positive LTBI diagnosis, compared to 4.2 and 16.8 persons/positive LTBI diagnosis from EHR-documented birth in a HTBIC and current screening criteria, respectively. DISCUSSION: Using logistic regression with EHR data, we developed a simple yet useful model to predict birth in a HTBIC which decreased the number needed to screen compared to current LTBI screening criteria. CONCLUSION: Our model improves the ability to screen for LTBI in health care settings based on birth in a HTBIC.
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Tuberculosis Latente , Tuberculosis , Algoritmos , California/epidemiología , Humanos , Incidencia , Tuberculosis Latente/diagnóstico , Tuberculosis Latente/epidemiología , Tuberculosis/diagnóstico , Tuberculosis/epidemiologíaRESUMEN
BACKGROUND: Following the H1N1 influenza pandemic in 2009, pregnant women were recommended to receive both seasonal (TIV) and H1N1 influenza vaccines. This study presents incidence of adverse birth and pregnancy outcomes among a population of pregnant women immunized with TIV and H1N1 vaccines at Kaiser Permanente Northern California during 2009-2010. METHODS: We telephone surveyed pregnant Kaiser Permanente Northern California members to assess non-medically-attended reactions following H1N1, TIV or both vaccines during 2009-2010 (n=5365) in a separate study. Here we assessed preterm birth (<37weeks), very preterm birth (<32weeks), low birth weight (<2500 g, LBW), very low birth weight (<1500g), small for gestational age, spontaneous abortions, stillbirths and congenital anomalies among this cohort by comparing incidence and 95% confidence intervals between the following immunization groups: TIV only, H1N1 only, H1N1 prior to TIV immunization, TIV prior to H1N1 and both immunizations given at the same time. RESULTS: Results did not vary significantly between groups. Comparing H1N1 with TIV, incidence were similar for preterm births (6.37vs 6.28/100 births), very preterm births (5.30vs 8.29/1000 births), LBW (4.19vs 2.90/100 births), very LBW (4.54vs 5.52/1000 births), small for gestational age (9.99vs 9.24/1000 births), spontaneous abortion (7.10vs 6.83/1000 pregnancies), stillbirths (7.10vs 4.57/1000 pregnancies), and congenital anomalies (2.66vs 2.43/100 births). CONCLUSIONS: Although constrained by small sample size, complex vaccine groups, and differential vaccine availability during 2009-2010, this study found no difference in adverse birth outcomes between H1N1 vaccine and TIV.
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Vacunas contra la Influenza/uso terapéutico , Gripe Humana/prevención & control , Resultado del Embarazo/epidemiología , Aborto Espontáneo/epidemiología , Adulto , Estudios de Cohortes , Femenino , Humanos , Recién Nacido , Recién Nacido Pequeño para la Edad Gestacional , Recién Nacido de muy Bajo Peso , Subtipo H1N1 del Virus de la Influenza A/inmunología , Subtipo H1N1 del Virus de la Influenza A/patogenicidad , Embarazo , Complicaciones Infecciosas del Embarazo/prevención & control , Nacimiento Prematuro/epidemiología , Mortinato/epidemiologíaRESUMEN
BACKGROUND: Quadrivalent live attenuated influenza vaccine (Q/LAIV) was licensed in 2012 and replaced trivalent live attenuated influenza vaccine in the United States during the 2013-2014 influenza season. This study assessed the safety of Q/LAIV in children and adults aged 2-49years. METHODS: This was a prospective observational cohort study using data collected from Kaiser Permanente Northern California. Post-vaccination events of interest were any hospitalization, hospitalization for lower respiratory tract infection, and the following medically attended events: hypersensitivity, seizures/convulsions, lower respiratory tract infection, wheezing, Guillain-Barré syndrome, Bell's palsy, encephalitis, neuritis, vasculitis, and narcolepsy/cataplexy. The rates of these events during the risk interval post-vaccination were compared with rates observed during reference periods later in the follow-up (within-cohort analysis) and with rates observed in frequency-matched unvaccinated controls and inactivated influenza vaccine (IIV) recipients. RESULTS: A total of 62,040 eligible Q/LAIV recipients were identified during the 2013-2014 influenza season. Within-cohort comparisons of all Q/LAIV recipients as well as comparisons between Q/LAIV recipients and unvaccinated controls or IIV recipients did not show any significantly higher risk of hospitalizations or medically attended events following administration of Q/LAIV. Additional analyses by setting (clinic visits, emergency department visits, and hospital admissions) and age group (2-4, 5-8, 9-17, and 18-49years) also did not reveal clinically consistent findings that suggested any increased risk after administration of Q/LAIV. CONCLUSION: In this large population study of individuals aged 2-49years, no safety signals associated with the administration of Q/LAIV were observed. A much larger study population would be needed to confidently reject any association between Q/LAIV and very rare events, specifically those with an incidence of <1 event/10,000 person-years. TRIAL REGISTRATION: ClinicalTrials.gov NCT01985997.
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Vacunas contra la Influenza/efectos adversos , Gripe Humana/prevención & control , Adolescente , Adulto , California/epidemiología , Niño , Preescolar , Estudios de Cohortes , Femenino , Síndrome de Guillain-Barré/etiología , Hospitalización , Humanos , Vacunas contra la Influenza/administración & dosificación , Gripe Humana/epidemiología , Masculino , Persona de Mediana Edad , Estudios Prospectivos , Ruidos Respiratorios/etiología , Vacunación/efectos adversos , Vacunas Atenuadas/administración & dosificación , Vacunas Atenuadas/efectos adversos , Adulto JovenRESUMEN
BACKGROUND: Intimate partner violence (IPV) is an important health problem affecting women of all ages, but is often not addressed during healthcare visits. PURPOSE: To use electronic records of diagnoses and telephone advice calls to describe the clinical patterns of midlife women experiencing IPV. MATERIALS AND METHODS: Using case-control methodology, women with an ICD9 diagnosis of IPV were chosen from those enrolled in 2005-2006 in Kaiser Permanente Northern California (KPNC) and matched on visit date, age, and facility with women without such a diagnosis. The study population was divided into subsets: ages 45-53 years (318 cases, 1588 controls); ages 54-64 years (200 cases, 1000 controls). Diagnoses and symptoms reported by phone that were significantly related to the cases compared with the controls were identified using multivariate logistic regression. RESULTS: Among women aged 45-53 years, diagnoses of anxiety (odds ratio [OR] = 2.05) and of psychiatric problems (OR = 1.65) and calls for head injury (OR = 3.17), mental health problems (OR = 2.46), and sexually transmitted diseases (OR = 2.40) were associated with IPV. Among women aged 54-64 years, diagnoses of anxiety (OR = 1.74) and other psychiatric problems (OR = 1.76), injuries (other than head and neck) (OR = 1.57), urinary tract infection (UTI; OR = 2.31), headache (OR = 2.06), and calls for mental health problems (OR = 4.16) were associated with IPV. Among all women aged 45-64 years, history of prior IPV was strongly associated with subsequent diagnosis of IPV. CONCLUSIONS: Information available in the electronic health record of women who have been identified as experiencing IPV can be used to identify patterns of symptoms and diagnosis among midlife women. These patterns can potentially be used to improve identification of IPV in this age group. In addition to screening of all women for IPV, the presence of psychiatric problems, injuries, headache, and UTI and prior experience of IPV should prompt additional focused clinical inquiry about IPV in midlife women.
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Ansiedad/psicología , Depresión/psicología , Registros Electrónicos de Salud/estadística & datos numéricos , Violencia de Pareja/estadística & datos numéricos , Teléfono , Salud de la Mujer , Ansiedad/diagnóstico , California , Estudios de Casos y Controles , Depresión/diagnóstico , Femenino , Humanos , Violencia de Pareja/psicología , Modelos Logísticos , Persona de Mediana Edad , Oportunidad Relativa , Prevalencia , Encuestas y CuestionariosRESUMEN
BACKGROUND: In the United States, live attenuated influenza vaccine (LAIV) was initially approved for use in individuals aged 5-49 years in 2003, which was extended to individuals aged 2-49 years in 2007. At that time, a postlicensure commitment was made to describe the safety of LAIV within a cohort of eligible children aged 2-5 years. METHODS: A prospective observational postmarketing study was conducted to evaluate the safety of LAIV. Rates of medically attended events (MAEs) and serious adverse events (SAEs) in eligible children aged 24-59 months receiving LAIV as part of routine care from October 2007 to March 2010 were compared with rates in a within-cohort self-control, as well as matched unvaccinated and matched trivalent inactivated influenza vaccine (TIV)-vaccinated controls. Children with asthma and other high-risk medical conditions before vaccination were excluded. All MAEs and SAEs through 42 days postvaccination and all hospitalizations and deaths through 6 months postvaccination were analyzed. Statistical significance was declared without multiplicity adjustment. RESULTS: A total of 28,226 unique LAIV recipients were matched with similar numbers of TIV-vaccinated and unvaccinated children. Of 4696 MAE incidence rate comparisons, 83 (1.8%) were statistically significantly higher and 221 (4.7%) were statistically significantly lower in LAIV recipients versus controls. No pattern of MAE rate differences suggested a safety signal with LAIV. Asthma/wheezing MAEs were not statistically increased in LAIV recipients. No anaphylaxis events occurred within 3 days postvaccination. Rates of SAEs were similar between LAIV and control groups. CONCLUSIONS: Results of this postlicensure evaluation of LAIV safety in US children are consistent with preapproval clinical studies and Vaccine Adverse Event Reporting System reports, both of which demonstrated no significant increase in asthma/wheezing events or other adverse outcomes among eligible children aged 24-59 months who received LAIV.
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Vacunas contra la Influenza/efectos adversos , Preescolar , Efectos Colaterales y Reacciones Adversas Relacionados con Medicamentos/inmunología , Femenino , Humanos , Vacunas contra la Influenza/inmunología , Gripe Humana/inmunología , Gripe Humana/prevención & control , Masculino , Estudios Prospectivos , Estados Unidos , Vacunación/efectos adversos , Vacunas Atenuadas/efectos adversos , Vacunas Atenuadas/inmunologíaRESUMEN
BACKGROUND: Intimate partner violence (IPV) is a significant health problem but goes largely undiagnosed, undisclosed, and clinically undocumented. PURPOSE: To use historical data on diagnoses and telephone advice calls to develop a predictive model that identifies clinical profiles of women at high risk for undisclosed IPV. METHODS: A case-control study was conducted in women aged 18-44 years enrolled at Kaiser Permanente Northern California (KPNC) in 2005-2006 using symptoms reported by telephone and clinical diagnosis from electronic medical records. Analysis was conducted in 2007-2010. Overall, 1276 cases were identified using ICD-9 codes for IPV and were matched with 5 controls each. A full multivariate model was developed to identify those with IPV, as well as a reduced model and a summed-score model whose performance characteristics were assessed. RESULTS: Predictors most highly associated with IPV were history of remote IPV (OR=7.8); calls or diagnoses for psychiatric problems (OR=2.4); calls for HIV concerns (OR=2.4); and clinical diagnoses of prenatal complications (OR=2.1). Using the summed-score model for a population with IPV prevalence of 7%, and using a threshold score of 3 for predicting IPV with a sensitivity of 75%, 9.7 women would need to be assessed to diagnose one case of IPV. CONCLUSIONS: Diagnosed IPV was associated with a clinical profile based on both telephone call data and clinical diagnoses. The simple predictive model can prompt focused clinical inquiry and improve diagnosis of IPV in any clinical setting.