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1.
Subst Abus ; : 1-11, 2019 Aug 12.
Artículo en Inglés | MEDLINE | ID: mdl-31403914

RESUMEN

Background: Despite substantial benefits associated with opioid agonist treatment (OAT) with buprenorphine and methadone for opioid use disorder (OUD), only a small proportion of patients with OUD initiate OAT. There is a lack of studies addressing the correlates of OAT initiation among patients with OUD. Methods: Using Veterans Health Administration (VHA) national administrative data, we identified veterans with OUD who started OAT with either buprenorphine or methadone maintenance treatment (MMT) in fiscal year (FY) 2012 (first prescription of buprenorphine or first methadone clinic visit after the first 60 days of FY) and those who received no OAT that year. Multivariate logistic regression models including sociodemographic characteristics, diagnoses, and service and psychotropic drug use variables were used to identify independent predictors of OAT initiation. Results: Greater age (10-year increments; odds ratio [OR]: 0.96, 95% confidence interval [CI]: 0.0.9-0.97) and black race (OR: 0.46, 95% CI: 0.38-0.55) were associated with lower odds of being started on buprenorphine compared with no OAT, but not with MMT initiation. Veterans with cocaine and anxiolytic-sedative hypnotic use disorders had higher odds of being started on both buprenorphine and methadone compared with no OAT. Receipt of any mental health inpatient treatment was associated with higher odds of being started on buprenorphine but not methadone. Overall, we were unable to identify a robust set of patient characteristics associated with initiation of OAT. Conclusion: This study points out the stark reality that in the middle of an opioid crisis, we have very little insight into which patients with OUD initiate OAT.

2.
Pain ; 160(9): 2126-2135, 2019 Sep.
Artículo en Inglés | MEDLINE | ID: mdl-31145217

RESUMEN

Despite evidence linking increased risk of opioid use disorder with specific opioid-prescribing patterns, the relationship between these patterns and heroin use is less understood. This study aimed to determine whether dose and duration of opioid prescriptions predict subsequent heroin use in United States veterans. We analyzed data from 2002 to 2012 from the Veterans Aging Cohort Study, a prospective cohort study. We used inverse probability of censoring weighted Cox regression to examine the relationship between self-reported past year heroin use and 2 primary predictors: (1) prior receipt of a high-dose opioid prescription (≥90 mg morphine equivalent daily dose), and (2) prior receipt of a long-term opioid prescription (≥90 days). Heroin use was ascertained using most recent value of time-updated self-reported past year heroin use. Models were adjusted for HIV and hepatitis C virus infection status, sociodemographics, pain interference, posttraumatic stress disorder, depression, and use of marijuana, cocaine, methamphetamines, and unhealthy alcohol use. In the final model, prior receipt of a high-dose opioid prescription was associated with past year heroin use (adjusted hazard ratio use = 2.54, 95% confidence interval: 1.26-5.10), whereas long-term opioid receipt was not (adjusted hazard ratio = 1.09, 95% confidence interval: 0.75-1.57). Patients receiving high-dose opioid prescriptions should be monitored for heroin use. These findings support current national guidelines recommending against prescribing high-dose opioids for treating pain.

3.
Drug Alcohol Depend ; 198: 70-75, 2019 05 01.
Artículo en Inglés | MEDLINE | ID: mdl-30878769

RESUMEN

BACKGROUND: Opioid use disorder (OUD) is prevalent among people with HIV (PWH). Opioid agonist therapy (OAT) is the most effective treatment for OUD and is associated with improved health outcomes, but is often not initiated. To inform clinical practice, we identified factors predictive of OAT initiation among patients with and without HIV. METHODS: We identified 19,698 new clinical encounters of OUD between 2000 and 2012 in the Veterans Aging Cohort Study (VACS), a national observational cohort of PWH and matched uninfected controls. Mixed effects models examined factors predictive of OAT initiation within 30-days of a new OUD clinical encounter. RESULTS: 4.9% of both PWH and uninfected patients initiated OAT within 30 days of a new OUD clinical encounter. In adjusted models, participants with a psychiatric diagnosis (aOR = 0.54, 95% CI 0.47 - 0.62), PWH (aOR = 0.79, 95% CI 0.68-0.92), and rural residence (aOR = 0.56, 95% CI 0.39-0.78) had a lower likelihood of any OAT initiation, while African-American patients (aOR = 1.60, 95% CI 1.34-1.92), those with an alcohol related diagnosis (aOR = 1.76, 95% CI 1.48-2.08), diagnosis year 2005-2008 relative to 2000-2004 (aOR = 1.24, 95% CI 1.05-1.45), and patients with HCV (aOR = 1.50, 95% CI 1.27-1.77) had a greater likelihood of initiating any OAT within 30 days. Predictive factors were similar in the total sample and PWH only models. CONCLUSIONS: PWH were less likely to receive timely OAT initiation than demographically similar uninfected patients. Given the health benefits of such treatment, the low rate of OAT initiation warrants focused efforts in both PWH and uninfected populations.

5.
Pain Med ; 19(suppl_1): S38-S45, 2018 Sep 01.
Artículo en Inglés | MEDLINE | ID: mdl-30203007

RESUMEN

Objectives: We aimed to evaluate a novel clinical program designed to address unsafe use of opioids prescribed for pain-the Opioid Reassessment Clinic (ORC)-to inform practice and health system improvement. Design: Controlled, retrospective cohort study. Setting: The ORC is a multidisciplinary clinic in a primary care setting in a Veterans Health Administration hospital designed to perform longitudinal treatment of patients with unsafe use of opioids prescribed for pain, including tapering or rotating to the partial opioid agonist buprenorphine. Subjects: We included patients referred to the ORC from March 1, 2016, to March 1, 2017, who had an intake appointment (intervention group) and who did not (control group). Methods: We compared a priori-defined metrics at the patient, clinic process, and health system levels and compared metrics between groups. Results: During the study period, 114 veterans were referred to the ORC, and 71 (62%) of these had an intake appointment. Those in the intervention group were more likely to trial buprenorphine (N = 41, 62% vs N = 1, 2%, P < 0.01) and had greater reductions in their full agonist morphine equivalent daily dose than those in the control group (30 mg [interquartile range {IQR} = 0-120] vs 0 mg [IQR = 0-20] decrease, P < 0.01). Of those engaging in the ORC, 20 (30%) had not transitioned chronic pain management back to their primary care providers (PCPs) by the end of follow-up. Only one patient transitioned the management of buprenorphine to the PCP. Conclusions: Results suggest the ORC was effective in reducing total prescribed opioid doses and in transitioning patients to partial-agonist therapy, but PCP adoption strategies are needed.

6.
Artículo en Inglés | MEDLINE | ID: mdl-30083393

RESUMEN

The high prevalence of pain in patients with spinal cord injury, coupled with a national recalibration of opioid prescribing, presents a challenge. Prescribers may attempt to taper opioids, where observable harms from the prescribed opioid appear to outweigh benefits, a stance endorsed by the 2016 Guideline for Prescribing Opioids for Chronic Pain, issued by the Centers for Disease Control and Prevention. Different considerations apply when clinicians wish to reduce doses in adherent and stable patients, absent their consent. In this perspective piece, we acknowledge the problematic nature of opioids as a treatment. However, forced tapers may destabilize patients and clinical evidence to support forced tapers is lacking. We favor an ethic of informed consent when proposing changes to care involve meaningful risk, and suggest alternative approaches to optimizing safety.

8.
J Addict Med ; 2018 Aug 09.
Artículo en Inglés | MEDLINE | ID: mdl-30096077

RESUMEN

: Topiramate is a non-benzodiazepine anticonvulsant medication with multi-faceted pharmacologic action. It has emerged as an efficacious pharmacotherapeutic option for the treatment of addiction, especially alcohol use disorder (AUD). We present a broad narrative review of the putative mechanism of action and clinical utility of topiramate with regard to AUD and other substance use disorders. Collective evidence suggests topiramate is an effective treatment option in AUD, with notable efficacy in reducing harmful drinking patterns in AUD. Though not currently approved by the United States Food and Drug Administration for the indication of AUD, topiramate should be considered as a pharmacological treatment option with high utility among AUD patients. Early pharmacogenetic studies raise the intriguing possibility of identifying patients likely to respond to topiramate using genetic testing, and initial studies show that topiramate may also be useful in treating cocaine use disorder, smoking cessation and behavioral addictions. However, further research is needed in all these areas.

9.
Med Clin North Am ; 102(4): 745-763, 2018 Jul.
Artículo en Inglés | MEDLINE | ID: mdl-29933827

RESUMEN

The current opioid crisis highlights an urgent need for better paradigms for prevention and treatment of chronic pain and addiction. Although many approach this complex clinical condition with the question, "Is this pain or is this addiction?," it is more than the sum of its parts. Chronic pain among those with dependence and addiction often evolves into a complex disabling condition with pain at multiple sites, psychosocial dysfunctions, medical and psychiatric disorders, polypharmacy, and polysubstance use, all interacting with each other in complex ways (multimorbidity). The authors offer an integrative therapeutic approach to manage this complex clinical scenario.


Asunto(s)
Analgésicos Opioides/uso terapéutico , Dolor Crónico/tratamiento farmacológico , Dolor Crónico/epidemiología , Trastornos Mentales/epidemiología , Trastornos Relacionados con Opioides/epidemiología , Factores de Edad , Analgésicos Opioides/administración & dosificación , Analgésicos Opioides/efectos adversos , Conducta Adictiva/epidemiología , Conducta Adictiva/psicología , Dolor Crónico/psicología , Estado de Salud , Humanos , Trastornos Mentales/psicología , Multimorbilidad , Trastornos Relacionados con Opioides/diagnóstico , Trastornos Relacionados con Opioides/psicología , Autoeficacia , Factores Sexuales , Factores Socioeconómicos , Trastornos Relacionados con Sustancias/epidemiología , Trastornos Relacionados con Sustancias/psicología
10.
Psychiatr Serv ; 69(7): 768-776, 2018 Jul 01.
Artículo en Inglés | MEDLINE | ID: mdl-29656707

RESUMEN

OBJECTIVE: This study examined factors related to retention in buprenorphine treatment for opioid use disorder (OUD) among privately insured patients. METHODS: Patients with OUD who were newly started on buprenorphine during federal fiscal year (FY) 2011 were identified in a national private insurance claims database (MarketScan), and treatment retention (filled buprenorphine prescriptions) was evaluated through FY 2014. Proportional hazards models were used to examine demographic, clinical, and service use characteristics in FY 2011, including ongoing insurance coverage, associated with discontinuation of treatment. RESULTS: Of 16,190 patients with OUD newly started on buprenorphine in FY 2011, 45.0% were retained in treatment for more than one year, and 13.7% for more than three years (mean±SD duration of retention=1.23±1.16 years). During the first three years after buprenorphine initiation, 49.3% (N=7,988) disenrolled from their insurance plan. Cox proportional hazards models showed that for every 30 days of enrollment, the risk of discontinuation declined by 10% (hazard ratio [HR]=.90, 95% confidence interval [CI]=.90-.91). FY 2011 factors reducing discontinuation risk were age greater than the median (HR=.90, CI=.87-.93) and receipt of outpatient psychotherapy (HR=.90, CI=.86-.92); increased risk was associated with psychiatric hospitalization (HR=1.30, CI=1.24-1.36), emergency department visits (HR=1.07, CI=1.04-1.14), and additional substance use disorders (HR=1.05, CI=1.01-1.10). CONCLUSIONS: Buprenorphine treatment retention declined markedly in the first year and was substantially lower than in comparable studies from publicly funded health care systems, apparently largely due to disenrollment. The association of psychotherapy with greater retention suggests that it may be an important complement to opioid agonist treatment.

11.
Pain Med ; 19(7): 1419-1424, 2018 Jul 01.
Artículo en Inglés | MEDLINE | ID: mdl-28371816

RESUMEN

Objectives: Unsafe use of opioids prescribed for pain is a common challenge in primary care. We aimed to describe a novel clinical program designed to address this issue-the Opioid Reassessment Clinic-and evaluate preliminary efficacy. Methods: The Opioid Reassessment Clinic is a multidisciplinary care team staffed by an internist, addiction psychiatrist, advanced practice nurse, and health psychologist designed to perform enhanced assessment and longitudinal treatment of patients with unsafe use of opioids prescribed for pain. We assessed preliminary efficacy of the clinic using a priori-defined metrics at the patient, provider, clinic process, and health system levels. Results: Of referred patients (N = 87), 84% had a history of substance abuse/dependence and 70% had current misuse of prescribed opioids; 22% received a new substance use disorder diagnosis, each of whom engaged in addiction treatment. Among primary care physicians, 48% referred a patient to the clinic. In terms of process metrics, high fidelity to structured clinical assessments was assisted by templated electronic progress notes. Wait time averaged 22.1 days while length of treatment averaged 137 days. Urine drug testing was performed on 91% of patients an average of 6.4 times, while assessing out-of-system opioid receipt occurred universally. Systems-level findings included evidence of institutional support: hiring a nurse case manager to help with care coordination. Conclusions: Results suggest the Opioid Reassessment Clinic was effective in the management of a small group of high-complexity patients. Wide-scale dissemination may require adapted care models.

12.
Subst Abus ; : 1-10, 2017 Sep 20.
Artículo en Inglés | MEDLINE | ID: mdl-28929914

RESUMEN

BACKGROUND: In response to the opioid epidemic and new guidelines, many patients on high-dose long-term opioid therapy (LTOT) for chronic pain are getting tapered off opioids. As a result, a unique clinical challenge is emerging: although many on LTOT have poor pain control, functional decline, psychiatric instability, aberrancies, and misuse, these issues may often worsen with opioid tapering. Currently, a clear explanation and practical guidance on how to manage this perplexing clinical scenario is lacking. METHODS: The authors offer a commentary with their perspective on possible mechanisms involved in this clinical phenomenon and offer practical management guidance, supported by available evidence. RESULTS: It is not well recognized that allostatic opponent process involved in development of opioid dependence can cause worsening pain, functional status, sleep, and psychiatric symptoms over time, and significant fluctuation of pain and other affective symptoms due to their bidirectional dynamic interaction with opioid dependence ("affective dynamism"). These elements of complex persistent dependence (CPD), the gray area between simple dependence and addiction, can lead to escalating and labile opioid need, often generating aberrant behaviors. Opioid tapering, a seemingly logical intervention in this situation, may lead to worsening of pain, function, and psychiatric symptoms due to development of protracted abstinence syndrome. The authors offer practicing clinicians management principles and practical guidance focused on management of CPD in addition to chronic pain in these difficult clinical scenarios. CONCLUSION: Awareness of the science of the neuroplasticity effects of repeated use of opioids is necessary to better manage these patients with complex challenges.

13.
Am J Addict ; 26(6): 572-580, 2017 Sep.
Artículo en Inglés | MEDLINE | ID: mdl-28472543

RESUMEN

BACKGROUND: Buprenorphine has become the major treatment for opioid use disorder (OUD) but data on long treatment term retention and its correlates are sparse. METHODS: All veterans with OUD treated in Veterans Health Administration (VHA) facilities nationally in fiscal year (FY) 2012, and who began treatment with buprenorphine as indicated by a first prescription after the first 60 days of the year were identified with the date of and their last prescription from FY 2012-2015. Veterans were classified into four groups based on time from first to last prescription: (0-30 days, 31-365 days; 1-3 years; and more than 3 years). These groups were compared on socio-demographic, diagnoses and service, and psychotropic drug use. Kaplan-Meier curves and Cox proportional hazards models were used to identify variables independently associated with retention in buprenorphine treatment. RESULTS: Veterans newly started on buprenorphine (n = 3,151) were retained in treatment for a mean duration of 1.68 years (standard deviation [SD] 1.23), with 61.60% (n = 1,941) retained for more than a year and 31.83% (n = 1,003) for more than 3 years. Cox proportion hazards model showed that only black race (Hazards ratio [HR] 1.26; standard error [SE] .06; p.0003), the Charlson index (HR 1.03; SE .01; p.0132) and emergency room visits during FY 2012 (HR 1.03; SE .01; p < .0001) were the only available variables independently associated higher odds of buprenorphine discontinuation. CONCLUSIONS: Buprenorphine retention was substantial among veterans treated in VHA, but few individual characteristics correlated with retention. SCIENTIFIC SIGNIFICANCE: Future research focused on identifying further correlates of treatment retention is required to help devise interventions to improve treatment continuation. (Am J Addict 2017;26:572-580).


Asunto(s)
Buprenorfina/administración & dosificación , Cumplimiento de la Medicación , Trastornos Relacionados con Opioides/tratamiento farmacológico , Veteranos/psicología , Adulto , Buprenorfina/uso terapéutico , Demografía , Femenino , Humanos , Cuidados a Largo Plazo/psicología , Cuidados a Largo Plazo/estadística & datos numéricos , Masculino , Cumplimiento de la Medicación/psicología , Cumplimiento de la Medicación/estadística & datos numéricos , Antagonistas de Narcóticos/uso terapéutico , Tratamiento de Sustitución de Opiáceos/métodos , Tratamiento de Sustitución de Opiáceos/psicología , Tratamiento de Sustitución de Opiáceos/estadística & datos numéricos , Trastornos Relacionados con Opioides/epidemiología , Trastornos Relacionados con Opioides/psicología , Modelos de Riesgos Proporcionales , Factores Socioeconómicos , Estados Unidos/epidemiología , United States Department of Veterans Affairs/estadística & datos numéricos , Salud de los Veteranos/estadística & datos numéricos
14.
J Addict Med ; 11(4): 293-299, 2017 Jul/Aug.
Artículo en Inglés | MEDLINE | ID: mdl-28368906

RESUMEN

INTRODUCTION: Very little is known of the behavioral vulnerabilities of patients diagnosed with smoking-related chronic medical illness who continue to smoke, potentially worsening morbidity and mortality risks. This study explores the association of tobacco use disorder (TUD) among those with smoking-related chronic medical illnesses with other substance use disorders (SUDs) and risk factors. METHODS: Among veterans with smoking-related chronic medical illnesses identified from the National Veterans Health Administration administrative records from fiscal year 2012, we compared the characteristics of those with a diagnosis of TUD (International Classification of Diseases, 9th edition code 305.xx; n = 519,918), and those without such a diagnosis (n = 2,691,840). Using multiple logistic regression, we further explored the independent association of factors associated with TUD. RESULTS: SUD prevalence was markedly higher among those with TUD (24.9% vs 5.44%), including alcohol use disorder (20.4% vs 4.3%) and drug use disorder (13.5% vs 2.6%), compared with nonsmokers. On multiple logistic regression analyses, alcohol use disorder (odds ratio [OR] 2.94, 95% confidence interval [CI] 2.90-2.97) and drug use disorder (OR 1.97, 95% CI 1.94-1.99) were independently associated with current TUD diagnosis. Having any single SUD was associated with considerably high odds of having TUD (OR 3.32, 95% CI 3.29-2.36), and having multiple SUDs with even further increased risk (OR 4.09, 95% CI 4.02-4.16). CONCLUSIONS: A substantial proportion of people with TUD diagnosis despite concurrent smoking-related medical illnesses are also likely to have other comorbid SUDs, complicating efforts at smoking cessation, and requiring a broader approach than standard nicotine-dependence interventions.

16.
Drug Alcohol Depend ; 160: 82-9, 2016 Mar 01.
Artículo en Inglés | MEDLINE | ID: mdl-26804898

RESUMEN

BACKGROUND: The advent of buprenorphine as an alternative to methadone has dramatically shifted the landscape of opioid agonist therapy (OAT) for opioid use disorder (OUD). However, there is limited US national level data describing thedifferences between patients who are prescribed these two OAT options. METHODS: From veterans with OUD diagnosis who used Veterans Health Administration services in 2012, we identified 3 mutually exclusive groups: those who received (1) buprenorphine only (n=5,670); (2) methadone only (n=6,252); or (3) both buprenorphine and methadone in the same year (n=2513). We calculated the bi-varate effect size differences (risk ratios and Cohen's d) forcharacteristics that differentiated these groups. Logistic regression analysis was then used to identify factors independently differentiating the groups. RESULTS: Ten year increment in age (OR 0.67; 95% CI 0.64-0.70), urban residence (OR 0.26; 95% CI 0.25-0.33), and black race (OR 0.39; 95% CI 0.35-0.43) were strongly and negatively associated with odds of receiving buprenorphine compared to methadone, while medical and psychiatric comorbidities or receipt of other psychiatric medications did not demonstrate substantial differences between groups. CONCLUSIONS: Differences between veterans receiving buprenorphine or methadone based OAT seems to be largely shaped by demographic characteristics rather than medical or psychiatric or service use characteristics. A clearer understanding of the reasons for racial differences could be helpful in assuring that black OUD patients are not denied the opportunity to receive buprenorphine if that is their preference.


Asunto(s)
Buprenorfina/uso terapéutico , Metadona/uso terapéutico , Trastornos Relacionados con Opioides/tratamiento farmacológico , Trastornos Relacionados con Opioides/epidemiología , Veteranos/estadística & datos numéricos , Adulto , Comorbilidad , Demografía/estadística & datos numéricos , Femenino , Estado de Salud , Humanos , Masculino , Persona de Mediana Edad , Tratamiento de Sustitución de Opiáceos , Aceptación de la Atención de Salud/estadística & datos numéricos , Estados Unidos/epidemiología , United States Department of Veterans Affairs , Veteranos/psicología
17.
Addict Sci Clin Pract ; 11(1): 3, 2016 Jan 28.
Artículo en Inglés | MEDLINE | ID: mdl-26818474

RESUMEN

BACKGROUND: Patients, providers, communities and health systems have struggled to achieve balance between access to opioid treatment for chronic pain and its potential harmful consequences: especially misuse, addiction and overdose. We developed an interdisciplinary clinic embedded within primary care (the Opioid Reassessment Clinic-ORC) with the goal of improving the quality of care of patients with co-occurring chronic pain and issues related to opioid safety, efficacy and/or misuse. CASE DESCRIPTIONS: We present three cases referred to the ORC that highlight complex clinical scenarios related to assessment and treatment of patients with chronic pain and issues related to opioid safety, efficacy and misuse. DISCUSSION AND EVALUATION: In the context of the three cases, with respect to assessment, we discuss: making the diagnosis of opioid use disorder; allowing the patient space to endorse lack of efficacy; identification of co-occurring hazardous alcohol use; and recognizing barriers to multimodal pain care. With respect to treatment, we discuss: making a change in treatment with which the patient may not agree; effectiveness of buprenorphine/naloxone for the treatment of chronic pain; responding to low efficacy; and making continued opioid therapy contingent on engagement with substance abuse treatment. CONCLUSIONS: The core components of our approach-biopsychosocial assessment and multimodal treatment planning with an emphasis on promoting functional goals and safety using clear communication and a patient-centered stance-should guide providers in the management of similar clinical scenarios. More evidence is needed to definitively guide specific interventions and points of clinical equipoise.


Asunto(s)
Analgésicos Opioides/uso terapéutico , Dolor Crónico/tratamiento farmacológico , Trastornos Relacionados con Opioides/diagnóstico , Manejo del Dolor/métodos , Alcoholismo/diagnóstico , Alcoholismo/epidemiología , Analgésicos Opioides/administración & dosificación , Combinación Buprenorfina y Naloxona/uso terapéutico , Humanos , Trastornos Relacionados con Opioides/epidemiología , Trastornos Relacionados con Opioides/terapia , Atención Primaria de Salud , Mejoramiento de la Calidad
18.
Circ Cardiovasc Qual Outcomes ; 9(6): 629-640, 2016 11.
Artículo en Inglés | MEDLINE | ID: mdl-28263938

RESUMEN

BACKGROUND: The current ability to predict readmissions in patients with heart failure is modest at best. It is unclear whether machine learning techniques that address higher dimensional, nonlinear relationships among variables would enhance prediction. We sought to compare the effectiveness of several machine learning algorithms for predicting readmissions. METHODS AND RESULTS: Using data from the Telemonitoring to Improve Heart Failure Outcomes trial, we compared the effectiveness of random forests, boosting, random forests combined hierarchically with support vector machines or logistic regression (LR), and Poisson regression against traditional LR to predict 30- and 180-day all-cause readmissions and readmissions because of heart failure. We randomly selected 50% of patients for a derivation set, and a validation set comprised the remaining patients, validated using 100 bootstrapped iterations. We compared C statistics for discrimination and distributions of observed outcomes in risk deciles for predictive range. In 30-day all-cause readmission prediction, the best performing machine learning model, random forests, provided a 17.8% improvement over LR (mean C statistics, 0.628 and 0.533, respectively). For readmissions because of heart failure, boosting improved the C statistic by 24.9% over LR (mean C statistic 0.678 and 0.543, respectively). For 30-day all-cause readmission, the observed readmission rates in the lowest and highest deciles of predicted risk with random forests (7.8% and 26.2%, respectively) showed a much wider separation than LR (14.2% and 16.4%, respectively). CONCLUSIONS: Machine learning methods improved the prediction of readmission after hospitalization for heart failure compared with LR and provided the greatest predictive range in observed readmission rates.


Asunto(s)
Algoritmos , Minería de Datos/métodos , Insuficiencia Cardíaca/terapia , Readmisión del Paciente , Máquina de Vectores de Soporte , Telemedicina , Anciano , Bases de Datos Factuales , Femenino , Insuficiencia Cardíaca/diagnóstico , Humanos , Modelos Logísticos , Masculino , Persona de Mediana Edad , Dinámicas no Lineales , Ensayos Clínicos Controlados Aleatorios como Asunto , Reproducibilidad de los Resultados , Medición de Riesgo , Factores de Riesgo , Factores de Tiempo
19.
Drug Alcohol Depend ; 156: 70-77, 2015 Nov 01.
Artículo en Inglés | MEDLINE | ID: mdl-26429726

RESUMEN

BACKGROUND: Scant longitudinal data exists about the interplay between specific substances of abuse, the achievement of abstinence, and clinical outcomes in the treatment of dually diagnosed Veterans with post-traumatic stress disorder (PTSD). METHODS: As part of a national program evaluation, Veterans admitted from the community to specialized intensive PTSD programs were assessed at intake and 4 months after discharge. Seven mutually exclusive groups were identified from admission self-report data (N=22,948): no substance use, exclusive use of alcohol, opiates, sedatives, cocaine, marijuana, and use of three or more substances. Analysis of covariance, adjusting for potentially confounding baseline variables was used to compare change among these seven groups in non-substance use outcomes (PTSD symptoms, violent behavior, suicidality, medical problems, and employment). The effect of abstinence on specific groups was evaluated as the interaction of group membership by abstinence. RESULTS: All outcome measures except for employment showed significant improvement, with few differences between the groups. Although rate of abstinence differed markedly between the groups, abstinence achievement was associated with greater improvement on all the outcomes except employment in every group. No significant differences in the effect of abstinence across the substance abuse groups were observed. CONCLUSION: The specific type of substance used prior to entry into treatment among dually diagnosed PTSD patients seems to have limited effect on treatment outcomes. However, attainment of abstinence at 4 months after treatment, irrespective of the substances abused, was strongly associated with improvement in PTSD symptoms, violence, suicidality and medical problems.


Asunto(s)
Trastornos por Estrés Postraumático/rehabilitación , Trastornos Relacionados con Sustancias/rehabilitación , Veteranos/psicología , Adulto , Anciano , Diagnóstico Dual (Psiquiatría) , Empleo/estadística & datos numéricos , Grupos Étnicos , Femenino , Humanos , Estudios Longitudinales , Masculino , Persona de Mediana Edad , Factores Socioeconómicos , Ideación Suicida , Resultado del Tratamiento , Estados Unidos , Violencia/psicología
20.
BMC Cardiovasc Disord ; 13: 104, 2013 Nov 19.
Artículo en Inglés | MEDLINE | ID: mdl-24245738

RESUMEN

BACKGROUND: The decreased number and senescence of circulating endothelial progenitor cells (EPCs) are considered markers of vascular senescence associated with aging, atherosclerosis, and coronary artery disease (CAD) in elderly. In this study, we explore the role of vascular senescence in premature CAD (PCAD) in a developing country by comparing the numerical status and senescence of circulating EPCs in PCAD patients to controls. METHODS: EPCs were measured by flow cytometry in 57 patients with angiographically documented CAD, and 57 controls without evidence of CAD, recruited from random patients ≤ 50 years of age at All India Institute of Medical Sciences. EPC senescence as determined by telomere length (EPC-TL) and telomerase activity (EPC-TA) was studied by real time polymerase chain reaction (q PCR) and PCR- ELISA respectively. RESULT: The number of EPCs (0.18% Vs. 0.039% of total WBCs, p < 0.0001), and EPC-TL (3.83 Vs. 5.10 kb/genome, p = 0.009) were markedly lower in PCAD patients compared to controls. These differences persisted after adjustment for age, sex, BMI, smoking and medications. EPC-TA was reduced in PCAD patients, but was statistically significant only after adjustment for confounding factors (1.81 Vs. 2.20 IU/cell, unadjusted p = 0.057, adjusted p = 0.044). CONCLUSIONS: We observed an association between increased vascular cell senescence with PCAD in a sample of young patients from India. This suggests that early accelerated vascular cell senescence may play an important mechanistic role in CAD epidemic in developing countries like India where PCAD burden is markedly higher compared to developed countries.


Asunto(s)
Senescencia Celular/fisiología , Enfermedad de la Arteria Coronaria/diagnóstico , Enfermedad de la Arteria Coronaria/epidemiología , Países en Desarrollo , Células Endoteliales/patología , Células Madre/patología , Adulto , Estudios de Casos y Controles , Enfermedad de la Arteria Coronaria/fisiopatología , Células Endoteliales/metabolismo , Endotelio Vascular/citología , Endotelio Vascular/patología , Femenino , Humanos , Masculino , Persona de Mediana Edad , Células Madre/metabolismo , Factores de Tiempo
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