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1.
J Am Med Dir Assoc ; 21(7): 895-899.e1, 2020 07.
Artigo em Inglês | MEDLINE | ID: mdl-32674815

RESUMO

OBJECTIVES: Many nursing home residents infected with SARS-CoV-2 fail to be identified with standard screening for the associated COVID-19 syndrome. Current nursing home COVID-19 screening guidance includes assessment for fever, defined as a temperature of at least 38.0°C. The objective of this study was to describe the temperature changes before and after universal testing for SARS-CoV-2 in nursing home residents. DESIGN: Cohort study. SETTING AND PARTICIPANTS: The Veterans Administration (VA) operates 134 Community Living Centers (CLC), similar to nursing homes, that house residents who cannot live independently. VA guidance to CLCs directed daily clinical screening for COVID-19 that included temperature assessment. MEASURES: All CLC residents (n = 7325) underwent SARS-CoV-2 testing. We report the temperature in the window of 14 days before and after universal SARS-CoV-2 testing among CLC residents. Baseline temperature was calculated for 5 days before the study window. RESULTS: SARS-CoV-2 was identified in 443 (6.0%) residents. The average maximum temperature in SARS-CoV-2-positive residents was 37.66 (0.69) compared with 37.11 (0.36) (P = .001) in SARS-CoV-2-negative residents. Temperatures in those with SARS-CoV-2 began rising 7 days before testing and remained elevated during the 14-day follow-up. Among SARS-CoV-2-positive residents, only 26.6% (n = 118) met the fever threshold of 38.0°C during the survey period. Most residents (62.5%, n = 277) with confirmed SARS-CoV-2 did experience 2 or more 0.5°C elevations above their baseline values. One cohort of SARS-CoV-2 residents' (20.3%, n = 90) temperatures never deviated >0.5°C from baseline. CONCLUSIONS AND IMPLICATIONS: A single screening for temperature is unlikely to detect nursing home residents with SARS-CoV-2. Repeated temperature measurement with a patient-derived baseline can increase sensitivity. The current fever threshold as a screening criteria for SARS-CoV-2 infection should be reconsidered.


Assuntos
Infecções por Coronavirus/diagnóstico , Febre/diagnóstico , Programas de Rastreamento/métodos , Casas de Saúde/organização & administração , Pneumonia Viral/diagnóstico , Instituições de Cuidados Especializados de Enfermagem/organização & administração , Idoso , Idoso de 80 Anos ou mais , Temperatura Corporal/fisiologia , Técnicas de Laboratório Clínico/métodos , Estudos de Coortes , Infecções por Coronavirus/prevenção & controle , Surtos de Doenças/prevenção & controle , Diagnóstico Precoce , Feminino , Febre/epidemiologia , Humanos , Controle de Infecções , Masculino , Pandemias/prevenção & controle , Pneumonia Viral/prevenção & controle , Termômetros/estatística & dados numéricos , Estados Unidos , Veteranos
4.
JAMA ; 324(3): 301-302, 2020 07 21.
Artigo em Inglês | MEDLINE | ID: mdl-32692384
5.
JAMA ; 324(1): 68-78, 2020 07 07.
Artigo em Inglês | MEDLINE | ID: mdl-32633800

RESUMO

Importance: Data are limited regarding statin therapy for primary prevention of atherosclerotic cardiovascular disease (ASCVD) in adults 75 years and older. Objective: To evaluate the role of statin use for mortality and primary prevention of ASCVD in veterans 75 years and older. Design, Setting, and Participants: Retrospective cohort study that used Veterans Health Administration (VHA) data on adults 75 years and older, free of ASCVD, and with a clinical visit in 2002-2012. Follow-up continued through December 31, 2016. All data were linked to Medicare and Medicaid claims and pharmaceutical data. A new-user design was used, excluding those with any prior statin use. Cox proportional hazards models were fit to evaluate the association of statin use with outcomes. Analyses were conducted using propensity score overlap weighting to balance baseline characteristics. Exposures: Any new statin prescription. Main Outcomes and Measures: The primary outcomes were all-cause and cardiovascular mortality. Secondary outcomes included a composite of ASCVD events (myocardial infarction, ischemic stroke, and revascularization with coronary artery bypass graft surgery or percutaneous coronary intervention). Results: Of 326 981 eligible veterans (mean [SD] age, 81.1 [4.1] years; 97% men; 91% white), 57 178 (17.5%) newly initiated statins during the study period. During a mean follow-up of 6.8 (SD, 3.9) years, a total 206 902 deaths occurred including 53 296 cardiovascular deaths, with 78.7 and 98.2 total deaths/1000 person-years among statin users and nonusers, respectively (weighted incidence rate difference [IRD]/1000 person-years, -19.5 [95% CI, -20.4 to -18.5]). There were 22.6 and 25.7 cardiovascular deaths per 1000 person-years among statin users and nonusers, respectively (weighted IRD/1000 person-years, -3.1 [95 CI, -3.6 to -2.6]). For the composite ASCVD outcome there were 123 379 events, with 66.3 and 70.4 events/1000 person-years among statin users and nonusers, respectively (weighted IRD/1000 person-years, -4.1 [95% CI, -5.1 to -3.0]). After propensity score overlap weighting was applied, the hazard ratio was 0.75 (95% CI, 0.74-0.76) for all-cause mortality, 0.80 (95% CI, 0.78-0.81) for cardiovascular mortality, and 0.92 (95% CI, 0.91-0.94) for a composite of ASCVD events when comparing statin users with nonusers. Conclusions and Relevance: Among US veterans 75 years and older and free of ASCVD at baseline, new statin use was significantly associated with a lower risk of all-cause and cardiovascular mortality. Further research, including from randomized clinical trials, is needed to more definitively determine the role of statin therapy in older adults for primary prevention of ASCVD.


Assuntos
Aterosclerose/prevenção & controle , Doenças Cardiovasculares/mortalidade , Inibidores de Hidroximetilglutaril-CoA Redutases/uso terapêutico , Veteranos , Idoso , Idoso de 80 Anos ou mais , Doenças Cardiovasculares/prevenção & controle , Causas de Morte , Fatores de Confusão Epidemiológicos , Feminino , Humanos , Masculino , Mortalidade , Pontuação de Propensão , Estudos Retrospectivos , Estados Unidos/epidemiologia , Serviços de Saúde para Veteranos Militares
7.
Psychol Trauma ; 12(S1): S217-S219, 2020 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-32525383

RESUMO

Prior wartime trauma likely acts as a double-edged sword that promotes both aging veterans' vulnerability and resilience in the context of the current COVID-19 pandemic. During this stressful time, aging veterans may benefit from having an array of socially supportive network ties. We therefore suggest that clinicians working with veterans encourage veterans to (a) create or sustain positive social connections while maintaining physical distance and (b) call upon coping strategies that helped them manage past difficulties. (PsycInfo Database Record (c) 2020 APA, all rights reserved).


Assuntos
Adaptação Psicológica , Envelhecimento/psicologia , Infecções por Coronavirus , Pandemias , Pneumonia Viral , Trauma Psicológico/psicologia , Rede Social , Apoio Social , Transtornos de Estresse Pós-Traumáticos/psicologia , Veteranos/psicologia , Idoso , Humanos
10.
N Z Med J ; 133(1515): 70-78, 2020 05 22.
Artigo em Inglês | MEDLINE | ID: mdl-32438378

RESUMO

AIMS: To describe health conditions in New Zealand nuclear veterans and their offspring, and examine the utility of tests to assess their heritability. METHOD: An online survey, open to all veterans and offspring, with questions on health conditions, the GHQ12 to measure psychological distress, the Euroquol-5D visual analogue scale (EQ5D VAS) to measure health state, and free text items on veteran support. RESULTS: Eighty-three responses (56%) were from veterans, 65 (44%) from offspring. Anxiety and depression were prevalent in both groups, with cancers (n=31, 37%) and joint conditions common in veterans (n=26, 31%). Few offspring reported cancer, rather problems with fertility (n=18, 40%). The free text themes fell into four domains, official commitment, health, emotional and information support; however, little support had been sought. CONCLUSION: Cancers have utility in assessing heritability, but a low prevalence and lack of diagnostic data rules this out. Psychological conditions may be heritable, but the techniques to assess this are still developing. Chromosomal damage in veterans and offspring can be detected, but with present knowledge cannot explain health outcomes. Future work should assemble a veteran and family register with linkage to routine data-sets. Veterans and offspring should be encouraged to seek support.


Assuntos
Ansiedade/epidemiologia , Depressão/epidemiologia , Neoplasias/epidemiologia , Armas Nucleares , Exposição Ocupacional , Veteranos/estatística & dados numéricos , Adolescente , Adulto , Idoso , Ansiedade/genética , Depressão/genética , Família , Testes Genéticos , Inquéritos Epidemiológicos , Humanos , Infertilidade/epidemiologia , Infertilidade/genética , Artropatias/epidemiologia , Artropatias/genética , Pessoa de Meia-Idade , Neoplasias/genética , Nova Zelândia/epidemiologia , Exposição Ocupacional/efeitos adversos , Prevalência , Radiação Ionizante , Apoio Social , Adulto Jovem
11.
MMWR Morb Mortal Wkly Rep ; 69(21): 651-655, 2020 May 29.
Artigo em Inglês | MEDLINE | ID: mdl-32463809

RESUMO

On March 28, 2020, two residents of a long-term care skilled nursing facility (SNF) at the Veterans Affairs Greater Los Angeles Healthcare System (VAGLAHS) had positive test results for SARS-CoV-2, the cause of coronavirus disease 2019 (COVID-19), by reverse transcription-polymerase chain reaction (RT-PCR) testing of nasopharyngeal specimens collected on March 26 and March 27. During March 29-April 23, all SNF residents, regardless of symptoms, underwent serial (approximately weekly) nasopharyngeal SARS-CoV-2 RT-PCR testing, and positive results were communicated to the county health department. All SNF clinical and nonclinical staff members were also screened for SARS-CoV-2 by RT-PCR during March 29-April 10. Nineteen of 99 (19%) residents and eight of 136 (6%) staff members had positive test results for SARS-CoV-2 during March 28-April 10; no further resident cases were identified on subsequent testing on April 13, April 22, and April 23. Fourteen of the 19 residents with COVID-19 were asymptomatic at the time of testing. Among these residents, eight developed symptoms 1-5 days after specimen collection and were later classified as presymptomatic; one of these patients died. This report describes an outbreak of COVID-19 in an SNF, with case identification accomplished by implementing several rounds of RT-PCR testing, permitting rapid isolation of both symptomatic and asymptomatic residents with COVID-19. The outbreak was successfully contained following implementation of this strategy.


Assuntos
Betacoronavirus/isolamento & purificação , Técnicas de Laboratório Clínico/métodos , Infecções por Coronavirus/diagnóstico , Infecções por Coronavirus/prevenção & controle , Surtos de Doenças/prevenção & controle , Pandemias/prevenção & controle , Pneumonia Viral/diagnóstico , Pneumonia Viral/prevenção & controle , Instituições de Cuidados Especializados de Enfermagem , Serviços de Saúde para Veteranos Militares , Idoso , Idoso de 80 Anos ou mais , Infecções por Coronavirus/epidemiologia , Feminino , Humanos , Assistência de Longa Duração , Los Angeles/epidemiologia , Masculino , Pneumonia Viral/epidemiologia , Reação em Cadeia da Polimerase Via Transcriptase Reversa , Veteranos/estatística & dados numéricos
12.
Psychol Trauma ; 12(S1): S69-S70, 2020 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-32463289

RESUMO

The COVID-19 pandemic has caused many Veterans Healthcare Administration providers working with veterans diagnosed with posttraumatic stress disorder to question the feasibility and appropriateness of continuing to provide trauma-focused treatment during this crisis. The Veterans Healthcare Administration is in a unique position to continue to provide trauma-informed care because of its capacity to offer telemental health services. Data from a Veterans Affairs medical center's posttraumatic stress disorder clinical team suggest that not only are veterans interested in continuing with treatment but also that the treatments can be modified to accommodate the current climate. (PsycInfo Database Record (c) 2020 APA, all rights reserved).


Assuntos
Infecções por Coronavirus , Serviços de Saúde Mental , Pandemias , Pneumonia Viral , Trauma Psicológico/terapia , Transtornos de Estresse Pós-Traumáticos/terapia , Telemedicina , Veteranos , Adulto , Humanos , Masculino , Pessoa de Meia-Idade , Estados Unidos , United States Department of Veterans Affairs
13.
N Engl J Med ; 382(15): 1420-1429, 2020 04 09.
Artigo em Inglês | MEDLINE | ID: mdl-32268027

RESUMO

BACKGROUND: Both physical therapy and intraarticular injections of glucocorticoids have been shown to confer clinical benefit with respect to osteoarthritis of the knee. Whether the short-term and long-term effectiveness for relieving pain and improving physical function differ between these two therapies is uncertain. METHODS: We conducted a randomized trial to compare physical therapy with glucocorticoid injection in the primary care setting in the U.S. Military Health System. Patients with osteoarthritis in one or both knees were randomly assigned in a 1:1 ratio to receive a glucocorticoid injection or to undergo physical therapy. The primary outcome was the total score on the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) at 1 year (scores range from 0 to 240, with higher scores indicating worse pain, function, and stiffness). The secondary outcomes were the time needed to complete the Alternate Step Test, the time needed to complete the Timed Up and Go test, and the score on the Global Rating of Change scale, all assessed at 1 year. RESULTS: We enrolled 156 patients with a mean age of 56 years; 78 patients were assigned to each group. Baseline characteristics, including severity of pain and level of disability, were similar in the two groups. The mean (±SD) baseline WOMAC scores were 108.8±47.1 in the glucocorticoid injection group and 107.1±42.4 in the physical therapy group. At 1 year, the mean scores were 55.8±53.8 and 37.0±30.7, respectively (mean between-group difference, 18.8 points; 95% confidence interval, 5.0 to 32.6), a finding favoring physical therapy. Changes in secondary outcomes were in the same direction as those of the primary outcome. One patient fainted while receiving a glucocorticoid injection. CONCLUSIONS: Patients with osteoarthritis of the knee who underwent physical therapy had less pain and functional disability at 1 year than patients who received an intraarticular glucocorticoid injection. (ClinicalTrials.gov number, NCT01427153.).


Assuntos
Glucocorticoides/administração & dosagem , Osteoartrite do Joelho/tratamento farmacológico , Osteoartrite do Joelho/reabilitação , Modalidades de Fisioterapia , Feminino , Hospitais Militares , Humanos , Injeções Intra-Articulares , Masculino , Pessoa de Meia-Idade , Militares , Osteoartrite do Joelho/fisiopatologia , Manejo da Dor/métodos , Medição da Dor , Índice de Gravidade de Doença , Resultado do Tratamento , Estados Unidos , Veteranos
14.
J Frailty Aging ; 9(2): 94-100, 2020.
Artigo em Inglês | MEDLINE | ID: mdl-32259183

RESUMO

BACKGROUND: Diabetes (DM) is associated with an accelerated aging that promotes frailty, a state of vulnerability to stressors, characterized by multisystem decline that results in diminished intrinsic reserve and is associated with morbidity, mortality and utilization. Research suggests a bidirectional relationship between frailty and diabetes. Frailty is associated with mortality in patients with diabetes, but its prevalence and impact on hospitalizations are not well known. OBJECTIVES: Determine the association of frailty with all-cause hospitalizations and mortality in older Veterans with diabetes. DESIGN: Retrospective cohort. SETTING: Outpatient. PARTICIPANTS: Veterans 65 years and older with diabetes who were identified as frail through calculation of a 44-item frailty index. MEASUREMENTS: The FI was constructed as a proportion of healthcare variables (demographics, comorbidities, medications, laboratory tests, and ADLs) at the time of the screening. At the end of follow up, data was aggregated on all-cause hospitalizations and mortality and compared non-frail (robust, FI≤ .10 and prefrail FI=>.10, <.21) and frail (FI≥.21) patients. After adjusting for age, race, ethnicity, median income, history of hospitalizations, comorbidities, duration of DM and glycemic control, the association of frailty with all-cause hospitalizations was carried out according to the Andersen-Gill model, accounting for repeated hospitalizations and the association with all-cause mortality using a multivariate Cox proportional hazards regression model. RESULTS: We identified 763 patients with diabetes, mean age 72.9 (SD=6.8) years, 50.5% were frail. After a median follow-up of 561 days (IQR=172), 37.0% they had 673 hospitalizations. After adjustment for covariates, frailty was associated with higher all-cause hospitalizations, hazard ratio (HR)=1.71 (95%CI:1.31-2.24), p<.0001, and greater mortality, HR=2.05 (95%CI:1.16-3.64), p=.014. CONCLUSIONS: Frailty was independently associated with all-cause hospitalizations and mortality in older Veterans with diabetes. Interventions to reduce the burden of frailty may be helpful to improve outcomes in older patients with diabetes.


Assuntos
Diabetes Mellitus/mortalidade , Diabetes Mellitus/terapia , Fragilidade/epidemiologia , Hospitalização/estatística & dados numéricos , Vida Independente , Idoso , Idoso Fragilizado/estatística & dados numéricos , Humanos , Estudos Retrospectivos , Veteranos/estatística & dados numéricos
15.
PLoS One ; 15(4): e0230751, 2020.
Artigo em Inglês | MEDLINE | ID: mdl-32320421

RESUMO

In the United States (US), long-term opioid therapy has been commonly prescribed for chronic pain. Since recognition of the opioid overdose epidemic, clinical practice guidelines have recommended tapering long-term opioids to reduced doses or discontinuation. The Effects of Prescription Opioid Changes for veterans (EPOCH) study is a national population-based prospective observational study of US Veterans Health Administration primary care patients designed to assess effects of evolving opioid prescribing practice on patients treated with long-term opioids for chronic pain. A stratified random sampling design was used to identify a survey sample from the target population of patients treated with opioid analgesics for ≥ 6 months. Demographic, diagnostic, visit, and pharmacy dispensing data were extracted from existing datasets. A 2016 mixed-mode mail and telephone survey collected patient-reported data, including the main patient-reported outcomes of pain-related function (Brief Pain Inventory interference; BPI-I scores 0-10, higher scores = worse) and health-related quality of life. Data on survey participants and non-participants were analyzed to assess potential nonresponse bias. Weights were used to account for design. Linear regression models were used to assess cross-sectional associations of opioid treatment with patient-reported measures. Of 14,160 patients contacted, 9253 (65.4%) completed the survey. Participants were older than non-participants (63.9 ± 10.6 vs. 59.6 ± 13.0 years). The mean number of bothersome pain locations was 6.8 (SE 0.04). Effectiveness of pain treatment and quality of pain care were rated fair or poor by 56.1% and 45.3%, respectively. The opioid daily dosage range was 1.6 to 1038.2 mg, with mean = 50.6 mg (SE 1.1) and median = 30.9 mg (IQR 40.7). Among the 73.2% of patients who did not receive long-acting opioids, the mean daily dosage was 30.4 mg (SE 0.6) and mean BPI-I was 6.4 (SE 00.4). Among patients who received long-acting opioids, the mean daily dosage was 106.2 mg (SE 2.8) and mean BPI-I was 6.8 (SE 0.07). Higher daily dosage was associated with worse pain-related function and quality of life among patients without long-acting opioids, but not among patients with long-acting opioids. Future analyses will use follow-up data to examine effects of opioid dose reduction and discontinuation on patient outcomes.


Assuntos
Analgésicos Opioides , Prescrições de Medicamentos/estatística & dados numéricos , Inquéritos e Questionários , Veteranos/estatística & dados numéricos , Estudos de Coortes , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Autorrelato
16.
Am J Hum Genet ; 106(4): 535-548, 2020 04 02.
Artigo em Inglês | MEDLINE | ID: mdl-32243820

RESUMO

The Million Veteran Program (MVP), initiated by the Department of Veterans Affairs (VA), aims to collect biosamples with consent from at least one million veterans. Presently, blood samples have been collected from over 800,000 enrolled participants. The size and diversity of the MVP cohort, as well as the availability of extensive VA electronic health records, make it a promising resource for precision medicine. MVP is conducting array-based genotyping to provide a genome-wide scan of the entire cohort, in parallel with whole-genome sequencing, methylation, and other 'omics assays. Here, we present the design and performance of the MVP 1.0 custom Axiom array, which was designed and developed as a single assay to be used across the multi-ethnic MVP cohort. A unified genetic quality-control analysis was developed and conducted on an initial tranche of 485,856 individuals, leading to a high-quality dataset of 459,777 unique individuals. 668,418 genetic markers passed quality control and showed high-quality genotypes not only on common variants but also on rare variants. We confirmed that, with non-European individuals making up nearly 30%, MVP's substantial ancestral diversity surpasses that of other large biobanks. We also demonstrated the quality of the MVP dataset by replicating established genetic associations with height in European Americans and African Americans ancestries. This current dataset has been made available to approved MVP researchers for genome-wide association studies and other downstream analyses. Further data releases will be available for analysis as recruitment at the VA continues and the cohort expands both in size and diversity.


Assuntos
Grupos Étnicos/genética , Idoso , Idoso de 80 Anos ou mais , Estudos de Coortes , Feminino , Marcadores Genéticos/genética , Estudo de Associação Genômica Ampla/métodos , Genótipo , Humanos , Masculino , Pessoa de Meia-Idade , Polimorfismo de Nucleotídeo Único/genética , Medicina de Precisão/métodos , Controle de Qualidade , Veteranos , Sequenciamento Completo do Genoma/métodos
17.
Environ Sci Pollut Res Int ; 27(18): 22451-22460, 2020 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-32314290

RESUMO

The effect of Zataria multiflora (Z. multiflora) on serum cytokine, chemokines, and respiratory symptoms in the veterans exposed to sulfur mustard (SM) more than two decades (27-30 years) ago was conducted in 2018. Thirty-four patients were randomly assigned to the placebo group (P, mean age (54.40 ± 5.51)) and two treated groups with Z. multiflora extract 5 and 10 mg/kg/day (Z5 and 10; mean age, 58.50 ± 3.60 and 55.18 ± 4.11, respectively). Serum levels of tumor necrosis factor (TNF-α), monocyte chemotactic protein 1 (MCP-1), vascular endothelial growth factor (VEGF), epidermal growth factor (EGF), forced expiratory volume-one second (FEV1), and respiratory symptoms including chest wheeze (CW), night wheeze (NW), night cough (NC), and cough and wheeze during exercise (ECW) were assessed at the baseline (phase 0), 1 and 2 months after starting treatment (phase I and II, respectively). The value of FEV1 was significantly increased in Z10 in phase I and II compared with that in phase 0 (p < 0.01 for both) and in Z5 in phase II compared with phase I and 0 (p < 0.001for both). All respiratory symptoms significantly decreased in Z5 and 10 in phase I and II compared with those in phase 0 (p < 0.05 to p < 0.001). Serum levels of TNF-α and VEGF were decreased in Z5 and 10 in phase I and II compared with those in phase 0 (p < 0.05 to p < 0.001). Serum levels of MCP-1 and EGF were decreased in Z10 in phase I and II compared with those in phase 0 (p < 0.05 to p < 0.001). The percent change of respiratory symptoms, serum levels of cytokines during the treatment period, was significantly improved in the treated groups compared with that in the placebo group. Two months' of treatment with Z. multiflora improved cytokine levels, respiratory symptom, and FEV1 values in SM-exposed patients.


Assuntos
Citocinas , Pulmão , Gás de Mostarda , Veteranos , Humanos , Pulmão/efeitos dos fármacos , Pulmão/fisiopatologia , Pessoa de Meia-Idade , Extratos Vegetais , Testes de Função Respiratória , Fator A de Crescimento do Endotélio Vascular
18.
Am J Psychiatry ; 177(3): 190-194, 2020 03 01.
Artigo em Inglês | MEDLINE | ID: mdl-32114786
19.
BMJ ; 368: m283, 2020 03 04.
Artigo em Inglês | MEDLINE | ID: mdl-32131996

RESUMO

OBJECTIVE: To examine the associations between stopping treatment with opioids, length of treatment, and death from overdose or suicide in the Veterans Health Administration. DESIGN: Observational evaluation. SETTING: Veterans Health Administration. PARTICIPANTS: 1 394 102 patients in the Veterans Health Administration with an outpatient prescription for an opioid analgesic from fiscal year 2013 to the end of fiscal year 2014 (1 October 2012 to 30 September 2014). MAIN OUTCOME MEASURES: A multivariable Cox non-proportional hazards regression model examined death from overdose or suicide, with the interaction of time varying opioid cessation by length of treatment (≤30, 31-90, 91-400, and >400 days) as the main covariates. Stopping treatment with opioids was measured as the time when a patient was estimated to have no prescription for opioids, up to the end of the next fiscal year (2014) or the patient's death. RESULTS: 2887 deaths from overdose or suicide were found. The incidence of stopping opioid treatment was 57.4% (n=799 668) overall, and based on length of opioid treatment was 32.0% (≤30 days), 8.7% (31-90 days), 22.7% (91-400 days), and 36.6% (>400 days). The interaction between stopping treatment with opioids and length of treatment was significant (P<0.001); stopping treatment was associated with an increased risk of death from overdose or suicide regardless of the length of treatment, with the risk increasing the longer patients were treated. Hazard ratios for patients who stopped opioid treatment (with reference values for all other covariates) were 1.67 (≤30 days), 2.80 (31-90 days), 3.95 (91-400 days), and 6.77 (>400 days). Descriptive life table data suggested that death rates for overdose or suicide increased immediately after starting or stopping treatment with opioids, with the incidence decreasing over about three to 12 months. CONCLUSIONS: Patients were at greater risk of death from overdose or suicide after stopping opioid treatment, with an increase in the risk the longer patients had been treated before stopping. Descriptive data suggested that starting treatment with opioids was also a risk period. Strategies to mitigate the risk in these periods are not currently a focus of guidelines for long term use of opioids. The associations observed cannot be assumed to be causal; the context in which opioid prescriptions were started and stopped might contribute to risk and was not investigated. Safer prescribing of opioids should take a broader view on patient safety and mitigate the risk from the patient's perspective. Factors to address are those that place patients at risk for overdose or suicide after beginning and stopping opioid treatment, especially in the first three months.


Assuntos
Analgésicos Opioides/uso terapêutico , Overdose de Drogas/epidemiologia , Suicídio/estatística & dados numéricos , Veteranos/estatística & dados numéricos , Suspensão de Tratamento/estatística & dados numéricos , Adulto , Idoso , Prescrições de Medicamentos , Humanos , Pessoa de Meia-Idade , Padrões de Prática Médica , Modelos de Riscos Proporcionais , Estados Unidos/epidemiologia
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