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1.
BMC Med Educ ; 20(1): 39, 2020 Feb 07.
Artículo en Inglés | MEDLINE | ID: mdl-32033553

RESUMEN

BACKGROUND: Despite a paucity of evidence to support a multitude of educational innovations, curricular leaders are pressured to find innovative solutions to better prepare medical students for an evolving twenty-first century health care system. As part of this effort, this study directly compared student-rated effectiveness scores of six different learning modalities. METHODS: Study participants included 286 medical students enrolled in the second-year rheumatology core at a single academic medical center between 2013 and 2017. Students were surveyed at the end of the core with a 15-item questionnaire, and student perceived effectiveness of six different learning modalities were compared. RESULTS: The modality that outperformed all others was Live Patient Encounters (LPE), with significantly higher student-rated effectiveness scores when compared to the referent modality of Problem-Based Learning (PBL). Using a 5-point Likert scale with responses ranging from "not effective" to "highly effective," LPE received a mean effectiveness score of 4.77 followed by Augenblick (4.21), PBL (4.11), Gout Racer video game (3.49), Rheumatology Remedy e-module (3.49), and simulation knee injection (3.09). CONCLUSIONS: Technologically advanced novel learning strategies were outperformed in this study by the more traditional active learning modality of LPE. This finding highlights the importance of testing innovative learning strategies at the level of the learner. Three additional conclusions can be drawn from this result. First, conflation of technology with innovation may lead to a myopic view of educational reform. Second, human factors seem to be responsible for the success of LPE and may have far-reaching educational rewards. Third, further applications of LPE should be tested in non-rheumatologic curricula. The relevance of this study is innately tied to the humanities-based application. While a formal qualitative analysis was not performed in this study, preliminary results suggest that live, structured patient interactions in the pre-clinical years of medical education may not only promote the learning of important educational objectives but also foster professional development, empathy, reflection, leadership, agency, and interpersonal skills. This "win-win" scenario (if true) would stand out as a rarity among strategic educational initiatives.

2.
Clin Rheumatol ; 2019 Nov 15.
Artículo en Inglés | MEDLINE | ID: mdl-31729679

RESUMEN

OBJECTIVE: To evaluate the relationship between air pollutant (AP) exposure and rheumatoid arthritis (RA) autoantibody status METHODS: We performed a cross sectional study utilizing enrollment data from participants in the Veterans Affairs rheumatoid arthritis registry. HLA-DRB1 shared epitope (SE), smoking, rheumatoid factor (RF), and anti-cyclic citrullinated peptide antibody (ACPA) status were collected. Mean exposure levels were obtained for AP (NO2, SO2, particulate matter [PM2.5, PM10], and ozone) from air quality monitoring stations at patients' residential zip codes in the year prior to enrollment. Multivariable logistic and ordinary least squares regression models were used to determine independent associations of AP with RA seropositivity and autoantibody concentration. RESULTS: The cohort included 557 veterans (90% male, 76% Caucasian), with mean age of 70 years and mean disease duration of 13 years. The majority were HLA-DRB1 SE, RF, and ACPA positive (73%, 79%, and 76%, respectively). In univariate models, PM2.5 exposure was associated with higher ACPA concentration (p = 0.009). Similarly, in multivariable regression models, PM2.5 exposure was independently associated with higher ACPA concentration (p = 0.037). Current smoking independently predicted RF and ACPA positivity and titers, while HLA-DRB1 SE alleles were associated with RF positivity and ACPA positivity and titers. CONCLUSIONS: In an elderly cohort of RA patients, fine particulate matter (PM2.5) exposure independently predicted higher ACPA concentration. Further study of fine particulate matter in the pathogenesis of RA is warranted. Key Points • A study that integrates both genetic and environmental exposure data, relative to RA autoantibody status. • Of different air pollutants measures, exposure to fine particulate matter (PM2.5) appears to be most closely linked to ACPA titers.

3.
Artículo en Inglés | MEDLINE | ID: mdl-31421018

RESUMEN

OBJECTIVE: To determine the performance of administrative-based algorithms for classifying interstitial lung disease (ILD) complicating rheumatoid arthritis (RA). METHODS: Participants in a large, multicenter RA registry were screened for ILD using International Classification of Diseases (ICD) codes. Medical record review confirmed ILD among participants screening positive and a random sample of those screening negative. ICD and procedure codes, provider specialty, and dates were extracted from Veterans Affairs administrative data to construct ILD algorithms. Performance of these algorithms against medical record review was assessed by sensitivity, specificity, positive predictive value (PPV), negative predictive value, and Kappa using inverse probability weighting to account for sampling methods. RESULTS: Medical records of 536 RA patients were reviewed, confirming 182 (stringent definition) and 203 (relaxed definition) ILD cases. Initially, we identified ≥2 ICD codes from inpatient or outpatient encounters as optimal discriminating factors (specificity 96.0%, PPV 65.5%, Kappa 0.70). Subsequently, we constructed a set of ICD-9/10 codes that improved algorithm specificity (specificity 96.8%, PPV 69.5%, Kappa 0.72). Algorithms that included a pulmonologist diagnosis or chest CT plus pulmonary function testing or lung biopsy had improved performance (specificity 98.0%, PPV 77.4%, Kappa 0.75). PPV increased with exclusion of other ILD causes (78.5%), in comparisons with the relaxed ILD definition (82.4%), and in sensitivity analyses (83.4-86.3%). Gains in specificity and PPV with greater algorithm requirements were accompanied by declines in sensitivity. CONCLUSION: Administrative algorithms with optimal combinations of ICD codes, provider specialty, diagnostic testing, and exclusion of other ILD causes accurately classify ILD in RA.

4.
Open Forum Infect Dis ; 6(10)2019 Oct 01.
Artículo en Inglés | MEDLINE | ID: mdl-31412131

RESUMEN

BACKGROUND: HIV pre-exposure prophylaxis (PrEP) substantially reduces the risk of HIV acquisition, yet significant barriers exist to its prescription and use. Incorporating pharmacists in the PrEP care process may help increase access to PrEP services. METHODS: Our pharmacist-led PrEP program (P-PrEP) included pharmacists from a university-based HIV clinic, a community pharmacy, and two community-based clinics. Through a collaborative practice agreement, pharmacists conducted PrEP visits with potential candidates for PrEP, according to the recommended CDC guidelines, and authorized emtricitabine-tenofovir disoproxil fumarate prescriptions. Demographics and retention in care over 12 months were summarized and participant satisfaction and pharmacist acceptability with the P-PrEP program were assessed by Likert-scale questionnaires. RESULTS: Sixty patients enrolled in the P-PrEP program between January and June 2017 completing 139 visits. The mean age was 34 years (range 20-61 years) and 88% identified as men who have sex with men, 91.7% were men, 83.3% were white, 80% were commercially insured, and 89.8% had completed some college education or higher. Participant retention at 3, 6, 9, and 12 months was 73%, 58%, 43%, and 28%, respectively. To date, no participant has seroconverted. One hundred percent of the participants who completed the patient satisfaction questionnaire would recommend the P-PrEP program. Pharmacists reported feeling comfortable performing point-of-care testing and rarely reported feeling uncomfortable during PrEP visits (3 occasions - 2.2%) or experiencing workflow disruption (1 occasion - 0.7%). CONCLUSIONS: Implementation of a pharmacist-led PrEP program is feasible and associated with high rates of patient satisfaction and pharmacist acceptability.

5.
Indian J Surg Oncol ; 10(2): 237-244, 2019 Jun.
Artículo en Inglés | MEDLINE | ID: mdl-31168242

RESUMEN

While mortality is low, morbidity remains high for patients undergoing pancreas resections, especially for those who return to the operating room (RTOR). The aim of this study is to identify risk factors for RTOR following pancreaticoduodenectomy (PD) for ductal adenocarcinoma. Logistic regression models were constructed using the 2014 and 2015 National Surgical Quality Improvement Program (NSQIP) Pancreas Targeted database. Preoperative and procedure-related risk factors predictive of RTOR for patients undergoing either classic or pylorus-preserving pancreaticoduodenectomy for pancreatic ductal adenocarcinoma (PDAC) were identified. A total of 1736 patients were included. Multivariable analysis of patients undergoing classic PD demonstrated that an abnormally low preoperative WBC count was significantly associated with RTOR (OR 2.78, 95% CI 1.27-6.06, p = 0.010). For patients who underwent pylorus-preserving PD, the wound classification (OR 3.99, 95% CI 1.75-9.11, p = 0.001) and arterial resection (OR 26.3, 95% CI 7.96-87.20, p < 0.001) were associated with a higher rate of RTOR. When analyzing both approaches (classic and pylorus-preserving PD) together, only isolated arterial (OR 9.98, 95% CI 3.81-26.18, p < 0.001) and isolated venous (OR 1.79, 95% CI 1.05-3.05, p = 0.032) resections were independently associated with RTOR. The results of our study demonstrate that few factors are predictive of RTOR. Knowledge of these few variables in combination with a focus on the components of medical care in the immediate postoperative period may help identify individuals at risk for RTOR and improve patient care.

6.
Artículo en Inglés | MEDLINE | ID: mdl-31074584

RESUMEN

OBJECTIVE: Although hyperuricemia and gout can complicate the course of rheumatoid arthritis (RA), the impact of these factors on outcomes in RA is unclear. We examined associations of coexistent hyperuricemia and gout with RA disease measures, RA treatments, and survival. METHODS: Participants from a longitudinal RA study were categorized by the presence of gout and serum urate (sUA) status. Groups were compared by baseline patient characteristics, RA disease activity, treatments, and comorbidities. Associations of baseline sUA levels with all-cause and cardiovascular disease (CVD)-related mortality were examined in multivariable survival analyses. RESULTS: Of 1,999 participants with RA, 341 (17%) had sUA concentrations >6.8 mg/dl and 121 (6.1%) were diagnosed with gout. There were no significant associations of enrollment sUA or gout with RA disease activity or treatment with the exception that those with gout were more likely to be receiving sulfasalazine and less likely to be receiving NSAIDs. After age- and sex-adjustment, moderate hyperuricemia (sUA >6.8-8 mg/dl) was associated with an increased risk of CVD-related mortality (HR 1.56; 95% CI 1.11-2.21). This association was attenuated and not significant following additional adjustment for comorbidities that more commonly accompanied hyperuricemia. Results corresponding with sUA >8.0 mg/dl were similar, although not reaching statistical significance in any model. There were no associations of baseline sUA with all-cause mortality. CONCLUSION: Our study reports the frequency of hyperuricemia and gout in patients with RA. These results demonstrate strong associations of hyperuricemia with CVD mortality in this population, a risk that appears to be driven by excess comorbidity. This article is protected by copyright. All rights reserved.

7.
Open Forum Infect Dis ; 6(3): ofz082, 2019 Mar.
Artículo en Inglés | MEDLINE | ID: mdl-30895208

RESUMEN

Background: We sought to characterize human immunodeficiency virus (HIV) practitioners' recommendations to patients regarding treatment as prevention, pre-exposure prophylaxis (PrEP) and condom use among persons with HIV (PWH) with viral suppression and individuals receiving PrEP. Methods: A brief survey about counseling practices was distributed electronically to previous attendees of an International Antiviral Society-USA continuing medical education activity. Descriptive analyses were performed for all questions. Pearson χ2 tests were used to identify potential differences in counseling practices based on sex, degree/license, years in practice, number of PWH cared for in the past year, and practice location. Results: Of the 3238 persons surveyed, 478 (15%) responded. 65% were female, 47% were physicians, 78% had been in practice ≥6 years, and 52% had cared for >100 PWH in the last year. Of the respondents, 51% (95% confidence interval, 46.8%-56.0%) agreed that the evidence "supports, strongly supports or proves" that condomless sex with a PWH with viral suppression does not lead to HIV transmission, and 76% (72.2%-80.0%) commonly or always recommend condoms for such patients. Although 42% (95% confidence interval, 37.0%-46.0%) of respondents said the evidence "supports, strongly supports or proves" that condomless sex involving a person at risk for HIV infection receiving PrEP does not lead to HIV transmission, 81% (77.3%-84.5%) commonly or always recommend condom use for such patients. Responses differed significantly by practitioner experience, region, sex and degree. Conclusions: Although many practitioners caring for individuals with and at risk for HIV infection acknowledge that successful treatment or PrEP prevents transmission, the majority of practitioners commonly or always recommend condom use.

8.
Artículo en Inglés | MEDLINE | ID: mdl-30891938

RESUMEN

BACKGROUND/PURPOSE: Better disease activity and quality of life have been observed among patients with rheumatoid arthritis (RA) who drink alcohol. This association might be explained by reverse causality. We identified predictors of changes in alcohol use and evaluated independent associations between alcohol use and RA activity and mortality. METHODS: Participants in Forward, The National Databank for Rheumatic Diseases, were asked about alcohol use (any v. none), and disease activity was collected through the Patient Activity Scale-II (PAS-II) on semi-annual surveys. We identified factors associated with changes in alcohol use and determined associations between alcohol use and disease activity and mortality using linear and logistic regression models, Cox proportional hazards models, and marginal structural models. RESULTS: A total of 121,280 observations were studied among 16,762 unique participants. Discontinuation and initiation of alcohol were common among drinkers and abstainers (8.2% and 8.4% of observations, respectively). Greater discontinuation and less initiation were observed with greater disease activity, older age, female sex, non-white race, obesity, greater comorbidity, low quality of life, low educational level, low income, and work disability. While alcohol users had lower PAS-II [ß: -0.15 (-0.18,-0.11) p<0.001], and a lower mortality [OR 0.87 (0.76,0.98) p=0.03] in traditional models, associations were not seen in marginal structural models. CONCLUSIONS: Higher disease activity, disability, comorbidity, and poor quality of life contribute to reductions in alcohol use. Active use and changes in use were not associated with disease activity or mortality when adjusting for confounding, suggesting no clear benefit of alcohol consumption in RA. This article is protected by copyright. All rights reserved.

9.
J Rheumatol ; 46(7): 685-693, 2019 Jul.
Artículo en Inglés | MEDLINE | ID: mdl-30824656

RESUMEN

OBJECTIVE: To evaluate associations of HLA-DRB1 haplotypes and shared epitope (SE) with rheumatoid arthritis (RA) severity and all-cause mortality in RA. METHODS: Patients with RA from the Veterans Affairs Rheumatoid Arthritis (VARA) registry were followed from enrollment until death or December 31, 2013. Clinical characteristics, DNA, and serum were collected at enrollment. Radiographic damage, the presence or absence of subcutaneous nodules, disease activity measures, and functional status were assessed at enrollment and updated during followup. Sixteen HLA-DRB1 haplotypes and SE status were determined from banked DNA. Associations between HLA-DRB1 haplotypes, RA disease characteristics, and mortality were assessed in multivariable regression models. RESULTS: Within VARA, 1443 participants had genotyping and accrued 6150 patient-years of followup. Haplotypes VKA, VRA, LRA, SRA, SRE, SKR, and SEA, and SE alleles were significantly associated with seropositivity for rheumatoid factor (RF) and/or anticyclic citrullinated peptide (anti-CCP). Haplotypes VKA and SKR were associated with higher RF concentrations, while VRA, DRE, and GRQ were associated with lower RF concentrations. Haplotypes VKA, VRA, and LRA were associated with higher concentrations of anti-CCP antibody, while haplotypes SRA, SRE, LEA, SKR, and SEA were significantly associated with lower anti-CCP concentrations. Haplotype VKA (OR 1.39, 95% CI 1.08-1.80) was associated with increased frequency of radiographic damage at enrollment but none of the haplotypes were associated with the presence of subcutaneous nodules. Haplotypes SKA (HR 1.52, 95% CI 1.26-1.83) was associated with higher mortality. CONCLUSION: HLA-DRB1 haplotypes are independently and variably associated with seropositivity, autoantibody concentrations, and outcomes in RA.

10.
Clin Exp Rheumatol ; 37(5): 768-773, 2019.
Artículo en Inglés | MEDLINE | ID: mdl-30719967

RESUMEN

OBJECTIVES: Obesity is paradoxically associated with a lower risk of mortality in chronic illnesses including rheumatoid arthritis (RA). Weight loss in patients with poor health, however, may in part explain this observation. This study evaluated the impact of weight early in life and weight loss on mortality in patients with RA. METHODS: Patients with RA (age >40 years) were active participants in a prospective clinical registry with up to 17 years of follow-up. Current and age-30 body mass index (BMI) were determined from self-report of height and weight from semi-annual questionnaires. Mortality was assessed from National Death Index. Risks of obesity reported from both early in life and at enrolment in the registry were evaluated using Cox proportional hazards models. RESULTS: Among 12,679 participants (80% female), there were 1,520 deaths in 80,502 person-years. Obesity at enrolment (BMI >30 kg/m2) was modestly associated with greater mortality [HR: 1.34 (1.18,1.53) p=0.001]. Adjusting for disability and comorbidities hypothesised to be mediators in the causal pathway between obesity and mortality further attenuated this association [HR: 0.92 (0.80,1.06) p=0.24]. In contrast, obesity at age 30 was strongly associated with mortality [HR: 2.00 (1.65,2.42) p<0.001]. Additionally, weight loss since age-30 was a strong, dose-dependent predictor of mortality independent of enrolment BMI. CONCLUSIONS: The risk of obesity is substantially underestimated when epidemiologic methods do not account for long-term weight changes. Both obesity and weight loss are strongly associated with mortality risk in patients with RA.


Asunto(s)
Artritis Reumatoide , Obesidad/fisiopatología , Pérdida de Peso , Adulto , Artritis Reumatoide/mortalidad , Artritis Reumatoide/fisiopatología , Índice de Masa Corporal , Femenino , Humanos , Masculino , Modelos de Riesgos Proporcionales , Estudios Prospectivos , Factores de Riesgo , Pérdida de Peso/fisiología
11.
Clin Rheumatol ; 38(4): 1075-1081, 2019 Apr.
Artículo en Inglés | MEDLINE | ID: mdl-30506404

RESUMEN

OBJECTIVE: To assess the potential utility of a cytokine measurement in rheumatoid arthritis (RA) patients with active joint disease but normal acute phase reactants (APR). METHODS: RA patients in a longitudinal observational registry with available cytokine array data were included. Patients were categorized based on agreement/disagreement of physical examination and APR measurements: concordant high (CH) [high tender and/or swollen joint counts (TJC + SJC > 3) and APR (ESR ≥ 28 mm/h + CRP ≥ 1.5 mg/L)]; concordant low (CL) [TJC + SJC ≤ 3 and normal APR]. Discordant (D) [TJC + SJC > 3 and normal APR] patients were stratified into low, medium, and high-disease activity (DL, DM, DH). Weighted-average and log-transformed cytokine scores were calculated based on results of a cytokine array. Chi-square tests compared categorical variables by concordance status; t tests, Wilcoxon rank-sum tests, ANOVA models, and ordinary least squares (OLS) regressions were used to compare continuous measures. RESULTS: RA patients (n = 1467) were predominantly male (91%). Compared to CH patients (n = 174), D (n = 434) were younger, less frequently seropositive, with lower TJC, SJC, and DAS28-3v scores (p < 0.001). Cytokine scores for DL, DM, and DH groups were lower than CH patients (p < 0.001) and did not differ between DL, DM, and DH subgroups and were similar to CL (n = 356) patients. In multivariable analyses including CH and D patients, log-cytokine score was associated with higher DAS28-3v scores (p = 0.029). In multivariable analyses including CL patients, concordance status (p = 0.011) and ACPA (p = 0.013) were predictors of higher log cytokine score. CONCLUSION: In this study, cytokine scores did not identify active joint disease in RA patients with normal APR.


Asunto(s)
Artritis Reumatoide/sangre , Citocinas/sangre , Factores de Edad , Anciano , Antirreumáticos/uso terapéutico , Artritis Reumatoide/diagnóstico , Artritis Reumatoide/tratamiento farmacológico , Evaluación de la Discapacidad , Femenino , Humanos , Masculino , Persona de Mediana Edad , Sistema de Registros , Índice de Severidad de la Enfermedad
12.
J Pharm Biomed Anal ; 164: 460-466, 2019 Feb 05.
Artículo en Inglés | MEDLINE | ID: mdl-30447534

RESUMEN

BACKGROUND: Circulating uric acid (UA) is an important biomarker, not only in the detection and management of gout, but also in assessing the risk of related comorbidity. The impact of collection methods on clinical UA measurements has been the subject of limited study. After observing significant differences between UA concentrations of blood samples obtained by different collection tubes, we began examining the effects of exogenous tube components on measured UA concentrations. We aimed to: (1) demonstrate the variability in uricase-based UA measurements attributable to different collection methods and (2) identify factors influencing this variability. METHODS: Blood samples from human subjects were collected using Serum Separator Tubes (SST tubes), Acid Citrate Dextrose (ACD) tubes, and Sodium Citrate (SC) tubes. Circulating UA concentrations were measured by chemistry analyzers utilizing the uricase method. Absorbance assays were run in order to determine the effects of citric acid, sodium citrate, and dextrose on measured absorbance in the presence of leuco crystal violet dye, hydrogen peroxide, and peroxidase. Statistical analyses-including Student's T tests and ANOVA-were used to compare results. RESULTS: UA concentrations of blood samples collected in ACD tubes were significantly lower than those collected in SST tubes (P < 0.01). Samples collected in SC tubes trended towards lower UA measurements than samples collected in SST tubes, although this difference did not reach statistical significance (P = 0.06). Blood samples spiked with separate concentrations of sodium citrate (3.2 and 22.0 g/L), citric acid (8.0 g/L), and dextrose (24.5 g/L) demonstrated significantly lower UA measurements compared to controls (P < 0.01). Absorbance assays demonstrated that increasing concentrations of citric acid and sodium citrate-in the presence of leuco crystal violet, hydrogen peroxide, and peroxidase-decreased the amount of oxidized dye in the uricase method of UA measurement in a dose-dependent manner (P < 0.01). In contrast, dextrose did not significantly alter the amount of oxidized dye available. DISCUSSION: Our results indicate that citric acid obstructs accurate uricase-based UA measurement, providing falsely low values. Citric acid, a known antioxidant, scavenges hydrogen peroxide, a key intermediate using the uricase method. By scavenging hydrogen peroxide, citric acid decreases the amount of oxidized leuco dye leading to falsely low UA measurements. Therefore, collection tubes, like ACD and SC tubes, which contain concentrations of citric acid or its conjugate base sodium citrate should not be used to measure circulating UA levels when utilizing uricase-based measurement methods.


Asunto(s)
Antioxidantes/química , Recolección de Muestras de Sangre/métodos , Ácido Cítrico/química , Urato Oxidasa/química , Ácido Úrico/sangre , Anciano , Anticoagulantes/química , Biomarcadores/sangre , Estudios de Cohortes , Glucosa/análogos & derivados , Glucosa/química , Gota/sangre , Gota/diagnóstico , Voluntarios Sanos , Humanos , Masculino , Persona de Mediana Edad , Citrato de Sodio/química
14.
J Ren Nutr ; 29(6): 490-497, 2019 11.
Artículo en Inglés | MEDLINE | ID: mdl-30581062

RESUMEN

OBJECTIVE: The purpose of this study was to determine the prevalence of vitamin D (25(OH)D) and balance deficits in persons with chronic kidney disease (CKD) and the likelihood of self-reporting balance and falling problems, measured gait speed in persons with kidney disease, and low levels of vitamin D and albumin. DESIGN: Analysis of the National Health and Nutrition Examination Survey 1999-2004 data set. SUBJECTS: The study included 8,554 subjects aged >40 years who were categorized into CKD stages based on the glomerular filtration rate (normal kidney function and stages 1 and 2 served as the control group, and stages 3 and 4/5 served as the CKD groups). MAIN OUTCOME MEASURES: Measured 25(OH)D levels, timed 20-feet walk, Romberg standing balance task, and self-reported balance and falling issues. RESULTS: The prevalence of balance deficits was found to be high in this CKD sample, with fail rates increasing with kidney disease severity. Similarly, when examining the relationship between CKD stage and the measurement of balance, fail rates (impaired balance) increased and gait speed decreased with kidney disease severity. In addition, the likelihood of self-reporting a balance and falling problem in the past year was higher in persons who had advanced CKD, were of older age, were of female sex, were with former or current smoking status, had lower 25(OH)D levels, and had lower albumin levels. Similarly, the likelihood of having a 20-feet walk time of more than 8 seconds was associated with those who were older, had higher body mass index, and had lower levels of 25(OH)D and albumin. CONCLUSION: The unique finding of this study is that increased reporting of balance and falling issues (both perceived and measured) and slower gait were found in persons with increased CKD severity and lower 25(OH)D status.

15.
PLoS One ; 13(11): e0207372, 2018.
Artículo en Inglés | MEDLINE | ID: mdl-30427912

RESUMEN

INTRODUCTION: Pharmacist provision of pre-exposure prophylaxis (PrEP) through collaborative practice agreements with physicians could expand access to people at risk for HIV. We characterized pharmacists' familiarity with and willingness to provide PrEP services in Nebraska and Iowa. METHODS: An invitation to complete an 18-question survey was emailed to 1,140 pharmacists in Nebraska and Iowa in June and July of 2016. Descriptive analyses and Pearson chi-square tests were used to determine to what extent demographics, familiarity and experience were associated with respondent willingness to provide PrEP. Wilcoxon rank-sum tests compared ages and years of experience between groups of respondents. RESULTS: One hundred forty pharmacists (12.3%) responded. Less than half were familiar with the use of PrEP (42%) or the CDC guidelines for its use (25%). Respondents who were older (p = .015) and in practice longer (p = .005) were less likely to be familiar with PrEP. Overall, 54% indicated they were fairly or very likely to provide PrEP services as part of a collaborative practice agreement and after additional training. While familiarity with PrEP use or guidelines did not affect respondents' willingness to provide PrEP, respondents were more likely to provide PrEP with prior experience counseling HIV-infected patients on antiretroviral therapy (OR 2.43; p = 0.023) or PrEP (OR 4.67; p = 0.013), and with prior HIV-related continuing education (OR 2.77; p = 0.032). CONCLUSIONS: Pharmacist respondents in Nebraska and Iowa had limited familiarity and experience with PrEP, but most indicated willingness to provide PrEP through collaborative practice agreements after additional training. Provision of PrEP-focused continuing education may lead to increased willingness to participate in PrEP programs.


Asunto(s)
Infecciones por VIH/prevención & control , Profilaxis Pre-Exposición , Adulto , Anciano , Educación Continua en Farmacia , Femenino , Infecciones por VIH/epidemiología , Conocimientos, Actitudes y Práctica en Salud , Humanos , Iowa/epidemiología , Masculino , Persona de Mediana Edad , Nebraska/epidemiología , Farmacéuticos , Profilaxis Pre-Exposición/métodos
16.
World J Gastrointest Endosc ; 10(11): 354-366, 2018 Nov 16.
Artículo en Inglés | MEDLINE | ID: mdl-30487946

RESUMEN

AIM: To investigate indications and outcomes of endoscopic retrograde cholangiopancreatography (ERCP) in cirrhotics, especially adverse events. Patients with cirrhosis undergoing ERCP are believed to have increased risk. However, there is a paucity of literature describing the indications and outcomes of ERCP procedures in patients with cirrhosis, especially focusing on adverse events. METHODS: We performed a systematic appraisal of major literature databases, including PubMed and EMBASE, with a manual search of literature from their inception until April 2017. RESULTS: A total of 6,505 patients from 15 studies were analyzed (male ratio 59%, mean age 59 years), 11% with alcoholic and 89% with non-alcoholic cirrhosis, with 56.2% Child-Pugh class A, and 43.8% class B or C. Indications for ERCP included choledocholithiasis 60.9%, biliary strictures 26.2%, gallstone pancreatitis 21.1% and cholangitis 15.5%. Types of interventions included endoscopic sphincterotomy 52.7%, biliary stenting 16.7% and biliary dilation 4.6%. Individual adverse events included hemorrhage in 4.58% (95%CI: 2.77-6.75%, I 2 = 85.9%), post-ERCP pancreatitis (PEP) in 3.68% (95%CI: 1.83-6.00%, I 2 = 89.5%), cholangitis in 1.93% (95%CI: 0.63-3.71%, I 2 = 87.1%) and perforation in 0.00% (95%CI: 0.00-0.23%, I 2 = 37.8%). Six studies were used for comparison of ERCP-related complications in cirrhosis vs non-cirrhosis, which showed higher overall rates of complications in cirrhosis patients with pooled OR of 1.63 (95%CI: 1.27-2.09, I 2 = 65%): higher rates of hemorrhage with OR of 2.05 (95%CI: 1.62-2.58, I 2 = 2.1%) and PEP with OR of 1.33 (95%CI: 1.04-1.70, I 2=65%), but similar cholangitis rates with OR of 1.23 (95%CI: 0.67-2.26, I 2 = 44.3%). CONCLUSION: There is an overall higher rate of adverse events related to ERCP in patients with cirrhosis, especially hemorrhage and PEP. A thorough risk/benefit assessment should be performed prior to undertaking ERCP in patients with cirrhosis.

17.
Clin Rheumatol ; 37(11): 2907-2915, 2018 Nov.
Artículo en Inglés | MEDLINE | ID: mdl-30280369

RESUMEN

Assess the impact of chronic lung diseases (CLD) on survival in rheumatoid arthritis (RA). Among participants in the Veterans Affairs Rheumatoid Arthritis (VARA) Registry, a prospective cohort of U.S. Veterans with RA, we identified CLD and cardiovascular disease (CVD) using administrative and registry data. Demographics, smoking status, RA characteristics including Disease Activity Score in 28 joints (DAS28), and disease-modifying anti-rheumatic drug (DMARD) use were obtained from registry data, which were linked to the National Death Index to obtain vital status. We evaluated associations of CLD with survival using the multivariable Cox regression models. Among a large (n = 2053), male-predominant (91%) RA cohort, 554 (27%) had CLD at enrollment. Mortality risk was increased 1.51-fold (95% CI 1.26-1.81) in RA patients with CLD after multivariable adjustment, a risk that was similar to that observed with CVD (HR CLD alone 1.46 [1.03-2.06]; CVD alone 1.62 [1.35-1.94]). Survival was significantly reduced in those with interstitial lung disease (ILD) as well as other forms of CLD. Mortality risk with methotrexate and biologic use was not different in those with CLD compared to those without (p interaction ≥ 0.15) using multiple exposure definitions and propensity score adjustment. Mortality risk is significantly increased in RA patients with CLD. This risk is attributable not only to ILD but also to other chronic lung conditions and does not appear to be substantially greater in those receiving methotrexate or biologic therapies. Comorbid lung disease should be targeted as a means of improving long-term outcomes in RA.


Asunto(s)
Antirreumáticos/uso terapéutico , Artritis Reumatoide/mortalidad , Enfermedades Pulmonares/complicaciones , Veteranos/estadística & datos numéricos , Anciano , Artritis Reumatoide/complicaciones , Artritis Reumatoide/tratamiento farmacológico , Enfermedades Cardiovasculares/complicaciones , Enfermedad Crónica , Femenino , Humanos , Estudios Longitudinales , Masculino , Metotrexato/uso terapéutico , Persona de Mediana Edad , Análisis Multivariante , Sistema de Registros , Factores de Riesgo , Índice de Severidad de la Enfermedad , Análisis de Supervivencia , Estados Unidos
18.
JAMA Otolaryngol Head Neck Surg ; 144(11): 1004-1010, 2018 11 01.
Artículo en Inglés | MEDLINE | ID: mdl-30286230

RESUMEN

Importance: Patients with head and neck cancer (HNC) experience increased risk of depression and compromised quality of life. Identifying patients with HNC at risk of depression can help establish targeted interventions. Objective: To identify factors that may be associated with the development of moderate or severe depression during treatment of HNC. Design, Setting, and Participants: This is a retrospective, ad hoc, secondary analysis of prospectively collected data from a randomized, double-blind, placebo-controlled clinical trial. Patients were screened at academic- and community-based tertiary care HNC centers from January 2008 to December 2011. Of the 125 evaluable patients with stages II through IV HNC but without baseline depression, 60 were randomized to prophylactic antidepressant escitalopram oxalate and 65 to placebo at the time of the initial diagnosis. Data analyses were conducted from May 2016 to April 2017. Main Outcomes and Measures: Depression outcomes were measured using Quick Inventory of Depressive Symptomatology-Self Report (QIDS-SR) scores (range, 0-27 with a score of 11 or higher indicative of moderate or greater depression). Factors that may be associated with development of moderate or severe depression were assessed, including patient demographics; cancer site and stage; primary treatment modality (surgery or radiotherapy); history of depression or other psychiatric diagnosis; previous treatment of depression or suicide attempt, family history of depression, suicide, or suicide attempt; and baseline score on the QIDS-SR and clinician-rated QIDS instruments. Participants were stratified by study site, sex, cancer stage (early [stage II] vs advanced [stage III or IV]), primary modality of treatment (radiotherapy with or without chemotherapy vs surgery with or without radiotherapy), and randomization to placebo or escitalopram and balanced within these strata. Results: The mean (SD) age of the 148 patients in the study population was 63.0 (11.9) years; 118 (79.7%) were men, and 143 (96.6%) were white. In the evaluable population of 125 patients, receiver operating characteristic analyses assessing the area under the curve for baseline QIDS-SR score (0.816; 95% CI, 0.696-0.935) and for initial radiotherapy-based treatment (0.681, 95% CI, 0.552-0.811) suggested that these 2 variables were associated with the likelihood of developing moderate or greater depression during the study period among patients who did not receive prophylactic antidepressants. The diagnostic sensitivity for identifying patients at risk of depression using the baseline QIDS-SR score improved to 100% at a threshold of 2 from 94% at a threshold of 4. Conclusions and Relevance: Baseline symptoms and initial radiotherapy-based treatment may be associated with development of moderate or greater depression in patients with HNC. Patients with QIDS-SR baseline scores of 2 or higher may benefit the most from pharmacologic prophylaxis of depression.


Asunto(s)
Depresión/psicología , Neoplasias de Cabeza y Cuello/psicología , Antidepresivos de Segunda Generación/uso terapéutico , Citalopram/uso terapéutico , Depresión/prevención & control , Método Doble Ciego , Femenino , Neoplasias de Cabeza y Cuello/patología , Neoplasias de Cabeza y Cuello/radioterapia , Humanos , Masculino , Persona de Mediana Edad , Recurrencia Local de Neoplasia/psicología , Estadificación de Neoplasias , Calidad de Vida , Estudios Retrospectivos , Factores de Riesgo
19.
Otolaryngol Head Neck Surg ; 159(6): 1006-1011, 2018 12.
Artículo en Inglés | MEDLINE | ID: mdl-30126321

RESUMEN

OBJECTIVE: To identify factors that may predict discharge to intermediate-care facilities following total laryngectomy and may promote earlier discharge planning and optimize resource utilization. STUDY DESIGN: Retrospective review of large national data set. SETTING: Academic and nonacademic health care facilities in United States, contributing deidentified, risk-adjusted clinical data to the American College of Surgeons' National Surgical Quality Improvement Program (ACS-NSQIP). SUBJECTS AND METHODS: Retrospective evaluation of the NSQIP database (2011-2014) identified 487 patients who underwent total laryngectomy without free tissue transfer. Risk of discharge to intermediate-care facilities was evaluated. Role of preoperative and postoperative factors and their association with discharge disposition were assessed using multivariable regression analysis. RESULTS: Compared to reference groups, advanced age (61-70 years: odds ratio [OR], 3.16; 95% confidence interval [CI], 1.12-8.89; >70 years: OR, 3.77; 95% CI, 1.33-10.65), baseline functional dependence (OR, 5.61; 95% CI, 2.62-12.02), cardiac failure (OR, 3.80; 95% CI, 1.08-13.42), and steroid dependence (OR, 3.30; 95% CI, 1.36-8.0) independently predicted discharge to intermediate-care facilities. CONCLUSION: Patients with advanced age, functional dependence, cardiac failure, and steroid dependence may benefit from preemptive counseling and discharge planning in anticipation of postlaryngectomy discharge to intermediate-care facilities.


Asunto(s)
Instituciones de Cuidados Intermedios , Laringectomía , Alta del Paciente , Transferencia de Pacientes , Anciano , Femenino , Predicción , Humanos , Masculino , Persona de Mediana Edad , Estudios Retrospectivos
20.
BMC Infect Dis ; 18(1): 310, 2018 07 06.
Artículo en Inglés | MEDLINE | ID: mdl-29980192

RESUMEN

BACKGROUND: Tenofovir alafenamide (TAF) is associated with less renal and bone toxicity compared with tenofovir disoproxil (TDF). TAF's recent FDA approval has spurred HIV providers to consider switching antiretroviral therapy (ART) regimens containing TDF to TAF to minimize long term risks. Patient views on the process of such medication switches have not been explored. METHODS: Patients taking elvitegravir/cobicistat/emtricitabine/tenofovir disoproxil fumarate (E/C/F/TDF) following the Food and Drug Administration's (FDA) approval of elvitegravir/cobicistat/emtricitabine/tenofovir alafenamide (E/C/F/TAF) received medication education from an HIV pharmacist prior to switching to the tenofovir alafenamide (TAF) formulation. Patients were asked to complete a cross-sectional survey assessing satisfaction with the switch process and knowledge about the new medication 4 to 8 weeks post-switch. RESULTS: Sixty five patients completed the switch and 57 (88%) completed a follow-up survey. Most (86%) reported understanding why the switch was made, while 91% correctly identified that TAF is associated with reduced renal toxicity, and 73% correctly identified that TAF is associated with reduced bone toxicity. No statistically significant difference was found in satisfaction with or understanding of why the medication switch was made when assessed by sex, age, race, or education, but there was a trend toward significance in the distribution of answers based on education level with those with a high school diploma, General Educational Development (GED) or less being more likely to be satisfied with the medication switch (p = 0.074). CONCLUSIONS: Education from an ambulatory clinic-based HIV pharmacist resulted in high rates of patient satisfaction and understanding of the switch from TDF to TAF-containing ART.


Asunto(s)
Adenina/análogos & derivados , Infecciones por VIH/tratamiento farmacológico , Satisfacción del Paciente , Farmacéuticos , Tenofovir/uso terapéutico , Adenina/uso terapéutico , Adulto , Fármacos Anti-VIH/uso terapéutico , Estudios Transversales , Combinación Elvitegravir, Cobicistat, Emtricitabina y Fumarato de Tenofovir Disoproxil/uso terapéutico , Femenino , Conocimientos, Actitudes y Práctica en Salud , Encuestas Epidemiológicas , Humanos , Masculino , Persona de Mediana Edad
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