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Can Fam Physician ; 65(9): 625-633, 2019 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-31515311


OBJECTIVE: To describe the burden of pneumococcal disease and associated risk factors in the Canadian adult population, delineate available pneumococcal vaccines and associated efficacy and effectiveness data, and review current pneumococcal vaccine recommendations and community-acquired pneumonia (CAP) prevention strategies in Canada. QUALITY OF EVIDENCE: Pneumococcal vaccination guidelines from the Canadian National Advisory Committee on Immunization in 2013 and 2016 constitute level III evidence for CAP prevention in the Canadian adult population. MAIN MESSAGE: It is recommended that immunosuppressed adults of all ages receive the 13-valent pneumococcal conjugate vaccine (PCV13) (grades A and B recommendations). In 2016, the National Advisory Committee on Immunization also recommended that all adults aged 65 years and older receive PCV13 (grade A recommendation) on an individual basis, followed by the 23-valent pneumococcal polysaccharide vaccine (grade B recommendation). This update is based on a large clinical study that demonstrated PCV13 efficacy against vaccine-type CAP in this population. CONCLUSION: Physicians should focus on improving pneumococcal vaccination rates among adults, which remain low. Vaccination with PCV13 should also be considered for adults with chronic conditions, whose baseline risk is often higher than that for healthy individuals aged 65 years and older.

Mayo Clin Proc ; 94(5): 842-856, 2019 05.
Artigo em Inglês | MEDLINE | ID: mdl-30954288


Sexual problems are common in women of all ages. Despite their frequency and impact, female sexual dysfunctions (FSDs) are often unrecognized and untreated in clinical settings. In response, the International Society for the Study of Women's Sexual Health convened a multidisciplinary, international expert panel to develop a process of care (POC) that outlines recommendations for identification of sexual problems in women. This POC describes core and advanced competencies in FSD for clinicians who are not sexual medicine specialists and serve as caregivers of women and, therefore, is useful for clinicians with any level of competence in sexual medicine. The POC begins with the expectation of universal screening for sexual concerns, proceeds with a 4-step model (eliciting the story, naming/reframing attention to the problem, empathic witnessing of the patient's distress and the problem's impact, and referral or assessment and treatment) that accommodates all levels of engagement, and delineates a process for referral when patients' needs exceed clinician expertise. Distressing problems related to desire, arousal, and orgasm affect 12% of women across the lifespan. Low desire is the most common sexual problem, but sexual pain and other less common disorders of arousal and orgasm are also seen in clinical practice. Screening is best initiated by a ubiquity statement that assures the patient that sexual concerns are common and can be revealed. Patient-centered communication skills facilitate and optimize the discussion. The goal of the POC is to provide guidance to clinicians regarding screening, education, management, and referral for women with sexual problems.

Disfunções Sexuais Fisiológicas , Disfunções Sexuais Psicogênicas , Saúde Sexual/normas , Saúde da Mulher/normas , Competência Clínica , Empatia , Feminino , Humanos , Assistência Centrada no Paciente/métodos , Relações Médico-Paciente , Guias de Prática Clínica como Assunto , Encaminhamento e Consulta/normas , Disfunções Sexuais Fisiológicas/diagnóstico , Disfunções Sexuais Fisiológicas/terapia , Disfunções Sexuais Psicogênicas/diagnóstico , Disfunções Sexuais Psicogênicas/terapia , Sociedades Médicas
Diabetes Care ; 39(10): 1711-7, 2016 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-27515966


OBJECTIVE: To highlight the utility of a large patient registry to identify functionally refractory patients (persistent HbA1c ≥75 mmol/mol [9.0%]) with type 2 diabetes, identify their barriers to glycemic control, and implement barrier-specific care path strategies to improve glycemic control. RESEARCH DESIGN AND METHODS: A working group developed a structured tool to optimize the collection of information on barriers to glycemic control and designed structured care paths to address each barrier. Participants were identified from a large Canadian registry and were assigned to a certified diabetes educator (CDE) as their case manager for a 12-month period to coordinate assessment of their barriers and to implement appropriate care path strategies. The primary outcome measure was the mean change in HbA1c from baseline at 12 months. RESULTS: Overall, 3,662 refractory patients were initially identified of whom 1,379 were eligible for inclusion and 155 enrolled. The most common barrier categories participants identified were psychological/support (93%), socioeconomic (87%), and accessibility (82%), with high concordance (75-94%) between participant and CDE. No specific barriers were predictive of hyperglycemia. After implementation of barrier-specific care paths, the mean reduction in HbA1c at 12 months was 17 mmol/mol (1.5%; P < 0.01 vs. baseline) versus only 5 mmol/mol (0.5%) in the source cohort (n = 966) who continued with standard care. The incidence of severe hypoglycemia did not change significantly during the study. CONCLUSIONS: In registry-identified hyperglycemic patients with type 2 diabetes, the use of barrier-specific care paths significantly improved glycemic control in otherwise refractory patients with persistently elevated HbA1c. Further studies using this strategy in other practice settings are warranted.

Diabetes Mellitus Tipo 2/epidemiologia , Hiperglicemia/epidemiologia , Sistema de Registros , Idoso , Glicemia/análise , Canadá , Diabetes Mellitus Tipo 2/sangue , Feminino , Hemoglobina A Glicada/análise , Humanos , Hiperglicemia/sangue , Masculino , Pessoa de Meia-Idade , Prevalência
J Diabetes ; 8(1): 76-85, 2016 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-25565383


BACKGROUND: The aim of the present study was to explore features associated with glycemic control in type 2 diabetes (T2D) patients undergoing care by specialist clinics. METHODS: Literature searches identified diabetes registries whose databases recorded outcomes of specialist care. The LMC Diabetes Registry database (n = 58 280; LMC) was queried to identify patients with T2D who had been seen in a defined 14-month period. Logistic regression modeling was used to identify predictors of glycemic control in these patients. Poor glycemic control was defined as HbA1c ≥9.0% (75 mmol/mol) despite specialist care for ≥1 year. RESULTS: Few published registry-based studies have discussed glycemic control and outcomes of specialist care for T2D. Among 10 590 LMC patients with T2D, mean HbA1c was 7.6% (60 mmol/mol), with 38% of patients meeting the Canadian Diabetes Association target of ≤7.0% (53 mmol/mol). Overall, 15% showed poor glycemic control with persistent HbA1c ≥9.0% (75 mmol/mol); among insulin-treated patients (n = 3856), 28% met this criterion. Patient characteristics independently associated with poor glycemic control included early age of onset, the number of diabetes education program visits, the number of oral therapies, and insulin use. CONCLUSIONS: Type 2 diabetes patients with poor glycemic control are found disproportionately in referral specialist care clinics. These functionally refractory patients demonstrate features that may assist in predicting their potential outcome, and may represent a group with specific barriers to care. Specialist patient registries, such as the LMC Diabetes Registry, may provide critical information regarding this cohort.

Glicemia/metabolismo , Diabetes Mellitus Tipo 2/sangue , Hemoglobina A Glicada/metabolismo , Índice Glicêmico , Hiperglicemia/sangue , Hipoglicemia/sangue , Sistema de Registros , Adolescente , Adulto , Idoso , Estudos Transversais , Diabetes Mellitus Tipo 2/tratamento farmacológico , Feminino , Humanos , Hiperglicemia/diagnóstico , Hiperglicemia/etiologia , Hipoglicemia/etiologia , Hipoglicemiantes/uso terapêutico , Hipolipemiantes/uso terapêutico , Masculino , Pessoa de Meia-Idade , Atenção Primária à Saúde , Resultado do Tratamento , Adulto Jovem
Curr Med Res Opin ; 31(10): 1941-8, 2015.
Artigo em Inglês | MEDLINE | ID: mdl-26390802


BACKGROUND: The dosing, schedules, and other aspects of combined oral contraceptive (COC) design have evolved in recent years to address a variety of issues including short- and long-term safety, bleeding profiles, and contraceptive efficacy. In particular, several newer formulations have altered the length of the hormone-free interval (HFI), in order to minimize two key undesired effects that occur during this time: hormone-withdrawal-associated symptoms (HWaS) and follicular development. OBJECTIVE: This primer reviews our current understanding of the key biological processes that occur during the HFI and how this understanding has led to changes in the dosing and schedule of newer COC formulations. MAIN MESSAGE: In brief, HWaS are common, underappreciated, and a likely contributor to COC discontinuation; because of this, shortening the HFI and/or supplementing with estrogen during the progestin-free interval may provide relief from these symptoms and improve adherence. A short HFI (with or without estrogen supplementation) may also help maintain effective follicular suppression and contraceptive efficacy, even when the overall dose of estrogen throughout the cycle is low. CONCLUSIONS: Taken together, the available data about HWaS and follicular activity during the HFI support the rationale for recent COC designs that use a low estrogen dose and a short HFI. The availability of a variety of COC regimens gives physicians a range of choices when selecting the most appropriate COC for each woman's particular priorities and needs.

Anticoncepcionais Orais Combinados/administração & dosagem , Estrogênios/administração & dosagem , Hemorragia Uterina , Feminino , Humanos
CMAJ ; 186(17): 1322, 2014 Nov 18.
Artigo em Inglês | MEDLINE | ID: mdl-25404655
Menopause ; 21(2): 137-42, 2014 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-23736862


OBJECTIVE: This study aims to determine the emotional and physical impact of vaginal atrophy on North American postmenopausal women and their male partners. METHODS: A weighted sample of 1,000 married or cohabiting North American postmenopausal women aged 55 to 65 years with vaginal discomfort and 1,000 male partners of postmenopausal women aged 55 to 65 years who experienced vaginal discomfort participated in the Clarifying Vaginal Atrophy's Impact on Sex and Relationships (CLOSER) online survey to determine the impact of vaginal discomfort and local estrogen therapy on intimacy, relationships, and women's self-esteem. RESULTS: Vaginal discomfort caused most surveyed North American women to avoid intimacy (58%), experience loss of libido (64%), and experience pain associated with sex (64%). Most surveyed North American men also believed that vaginal discomfort caused their partners to avoid intimacy (78%), experience loss of libido (52%), and find sex painful (59%). Approximately 30% of North American women and men cited vaginal discomfort as the reason they ceased having sex altogether. North American women who used local estrogen therapy to treat their vaginal discomfort reported less painful sex (56%), more satisfying sex (41%), and improved sex life (29%). Most men reported looking forward to having sex (57%) because of their partner's use of local estrogen therapy. CONCLUSIONS: Local estrogen therapy ameliorates the negative impact of vaginal atrophy on the intimate relationships of North American postmenopausal women and their male partners. Additional education and awareness efforts about the symptoms of and available treatments for vaginal atrophy may be of further benefit to North American partners.

Dispareunia/etiologia , Dispareunia/psicologia , Pós-Menopausa , Parceiros Sexuais , Vagina/patologia , Idoso , Atrofia , Coito/fisiologia , Coito/psicologia , Dispareunia/tratamento farmacológico , Estrogênios/administração & dosagem , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Disfunções Sexuais Fisiológicas/tratamento farmacológico , Vagina/efeitos dos fármacos , Doenças Vaginais/tratamento farmacológico