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1.
BMJ ; 368: l7078, 2020 Feb 05.
Artigo em Inglês | MEDLINE | ID: mdl-32024657

RESUMO

OBJECTIVES: To conduct a systematic review and meta-analysis of the effects of rosiglitazone treatment on cardiovascular risk and mortality using multiple data sources and varying analytical approaches with three aims in mind: to clarify uncertainties about the cardiovascular risk of rosiglitazone; to determine whether different analytical approaches are likely to alter the conclusions of adverse event meta-analyses; and to inform efforts to promote clinical trial transparency and data sharing. DESIGN: Systematic review and meta-analysis of randomized controlled trials. DATA SOURCES: GlaxoSmithKline's (GSK's) ClinicalStudyDataRequest.com for individual patient level data (IPD) and GSK's Study Register platforms, MEDLINE, PubMed, Embase, Web of Science, Cochrane Central Registry of Controlled Trials, Scopus, and ClinicalTrials.gov from inception to January 2019 for summary level data. ELIGIBILITY CRITERIA FOR SELECTING STUDIES: Randomized, controlled, phase II-IV clinical trials that compared rosiglitazone with any control for at least 24 weeks in adults. DATA EXTRACTION AND SYNTHESIS: For analyses of trials for which IPD were available, a composite outcome of acute myocardial infarction, heart failure, cardiovascular related death, and non-cardiovascular related death was examined. These four events were examined independently as secondary analyses. For analyses including trials for which IPD were not available, myocardial infarction and cardiovascular related death were examined, which were determined from summary level data. Multiple meta-analyses were conducted that accounted for trials with zero events in one or both arms with two different continuity corrections (0.5 constant and treatment arm) to calculate odds ratios and risk ratios with 95% confidence intervals. RESULTS: 33 eligible trials were identified from ClinicalStudyDataRequest.com for which IPD were available (21 156 patients). Additionally, 103 trials for which IPD were not available were included in the meta-analyses for myocardial infarction (23 683 patients), and 103 trials for which IPD were not available contributed to the meta-analyses for cardiovascular related death (22 772 patients). Among 29 trials for which IPD were available and that were included in previous meta-analyses using GSK's summary level data, more myocardial infarction events were identified by using IPD instead of summary level data for 26 trials, and fewer cardiovascular related deaths for five trials. When analyses were limited to trials for which IPD were available, and a constant continuity correction of 0.5 and a random effects model were used to account for trials with zero events in only one arm, patients treated with rosiglitazone had a 33% increased risk of a composite event compared with controls (odds ratio 1.33, 95% confidence interval 1.09 to 1.61; rosiglitazone population: 274 events among 11 837 patients; control population: 219 events among 9319 patients). The odds ratios for myocardial infarction, heart failure, cardiovascular related death, and non-cardiovascular related death were 1.17 (0.92 to 1.51), 1.54 (1.14 to 2.09), 1.15 (0.55 to 2.41), and 1.18 (0.60 to 2.30), respectively. For analyses including trials for which IPD were not available, odds ratios for myocardial infarction and cardiovascular related death were attenuated (1.09, 0.88 to 1.35, and 1.12, 0.72 to 1.74, respectively). Results were broadly consistent when analyses were repeated using trials with zero events across both arms and either of the two continuity corrections was used. CONCLUSIONS: The results suggest that rosiglitazone is associated with an increased cardiovascular risk, especially for heart failure events. Although increased risk of myocardial infarction was observed across analyses, the strength of the evidence varied and effect estimates were attenuated when summary level data were used in addition to IPD. Because more myocardial infarctions and fewer cardiovascular related deaths were reported in the IPD than in the summary level data, sharing IPD might be necessary when performing meta-analyses focused on safety. SYSTEMATIC REVIEW REGISTRATION: OSF Home https://osf.io/4yvp2/.


Assuntos
Doenças Cardiovasculares/induzido quimicamente , Hipoglicemiantes/efeitos adversos , Rosiglitazona/efeitos adversos , Doenças Cardiovasculares/mortalidade , Humanos , Hipoglicemiantes/farmacologia , Disseminação de Informação , Ensaios Clínicos Controlados Aleatórios como Assunto , Fatores de Risco , Rosiglitazona/farmacologia
2.
JAMA Intern Med ; 2020 Feb 24.
Artigo em Inglês | MEDLINE | ID: mdl-32091540

RESUMO

Importance: Previous studies have shown that medical student mistreatment is common. However, few data exist to date describing how the prevalence of medical student mistreatment varies by student sex, race/ethnicity, and sexual orientation. Objective: To examine the association between mistreatment and medical student sex, race/ethnicity, and sexual orientation. Design, Setting, and Participants: This cohort study analyzed data from the 2016 and 2017 Association of American Medical Colleges Graduation Questionnaire. The questionnaire annually surveys graduating students at all 140 accredited allopathic US medical schools. Participants were graduates from allopathic US medical schools in 2016 and 2017. Data were analyzed between April 1 and December 31, 2019. Main Outcomes and Measures: Prevalence of self-reported medical student mistreatment by sex, race/ethnicity, and sexual orientation. Results: A total of 27 504 unique student surveys were analyzed, representing 72.1% of graduating US medical students in 2016 and 2017. The sample included the following: 13 351 female respondents (48.5%), 16 521 white (60.1%), 5641 Asian (20.5%), 2433 underrepresented minority (URM) (8.8%), and 2376 multiracial respondents (8.6%); and 25 763 heterosexual (93.7%) and 1463 lesbian, gay, or bisexual (LGB) respondents (5.3%). At least 1 episode of mistreatment was reported by a greater proportion of female students compared with male students (40.9% vs 25.2%, P < .001); Asian, URM, and multiracial students compared with white students (31.9%, 38.0%, 32.9%, and 24.0%, respectively; P < .001); and LGB students compared with heterosexual students (43.5% vs 23.6%, P < .001). A higher percentage of female students compared with male students reported discrimination based on gender (28.2% vs 9.4%, P < .001); a greater proportion of Asian, URM, and multiracial students compared with white students reported discrimination based on race/ethnicity (15.7%, 23.3%, 11.8%, and 3.8%, respectively; P < .001), and LGB students reported a higher prevalence of discrimination based on sexual orientation than heterosexual students (23.1% vs 1.0%, P < .001). Moreover, higher proportions of female (17.8% vs 7.0%), URM, Asian, and multiracial (4.9% white, 10.7% Asian, 16.3% URM, and 11.3% multiracial), and LGB (16.4% vs 3.6%) students reported 2 or more types of mistreatment compared with their male, white, and heterosexual counterparts (P < .001). Conclusions and Relevance: Female, URM, Asian, multiracial, and LGB students seem to bear a disproportionate burden of the mistreatment reported in medical schools. It appears that addressing the disparate mistreatment reported will be an important step to promote diversity, equity, and inclusion in medical education.

4.
Pediatr Obes ; 15(4): e12603, 2020 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-31925928

RESUMO

BACKGROUND: Overweight/obesity is prevalent among children in the Pacific Islands, but its aetiology is poorly understood. Few studies have considered body composition in addition to body mass index-based measures. OBJECTIVES: To describe body composition among Samoan children and determine sex-specific associations among dietary intake, physical activity, and body composition. METHODS: Body composition (percent body fat [%BF], lean mass, and trunk-to-peripheral fat ratio) of n = 83 Samoan children (3-7 y) was assessed using dual-energy X-ray absorptiometry. Children completed 7 days of objective physical activity monitoring. Mothers reported child nutritional intake using a 115-item food frequency questionnaire. Stepwise generalized linear regression was used to determine independent associations of nutritional intake and physical activity with body composition. RESULTS: Samoan children had higher average %BF than reported among other ethnic groups but lower trunk-to-peripheral fat ratios. In sex-stratified analyses, quartile of carbohydrate intake was negatively associated with %BF (ß = -2.02 SE = 0.58; P < .001) in girls only. Among boys, physical activity (quartile of accelerometer counts per minute) was negatively associated with %BF (ß = -1.66 SE = 0.55; P < .01). CONCLUSIONS: Sex differences in the associations among nutritional intake, physical activity, and body composition may be important to consider as interventions are developed to address overweight/obesity among Samoan children.

5.
J Aging Soc Policy ; : 1-16, 2019 Jul 02.
Artigo em Inglês | MEDLINE | ID: mdl-31266436

RESUMO

Approximately 25% of US older adults live with a mental health disorder. The mental health needs of this population are chiefly met by primary care providers. Primary care practices may have inadequate strategies to provide satisfactory care to mentally ill older adults. This study used Centers for Medicare and Medicaid Services data to identify factors, including racial/ethnic differences, associated with dissatisfaction with medical care quality among older adults diagnosed with a mental health disorder. Our findings suggest factors that can be addressed to improve satisfaction with medical care quality and potentially promote adherence and follow-up for mentally ill older adults.

6.
Am J Trop Med Hyg ; 100(2): 306-310, 2019 02.
Artigo em Inglês | MEDLINE | ID: mdl-30628567

RESUMO

Local therapies have been proposed as safe and effective alternatives to systemic drugs in cutaneous leishmaniasis (CL), especially among less severe cases. However, they are not widely available and used in endemic places, including Colombia, which has a high burden of disease. Further complicating the uptake of local therapies is that different treatment guidelines have been established by the World Health Organization (WHO) and Pan American Health Organization (PAHO). Using data from a large referral center in Colombia, we determined the proportion of patients who would be eligible for and potentially benefit from local therapies according to both international guidelines. The sample included 1,891 confirmed cases of CL aged ≥ 12 years, mostly infected with Leishmania Viannia panamensis (91%, n = 601/660), between 2004 and 2014. Overall, 57% of the sample had one lesion, whereas another 31% had two to three lesions. For 74% of patients, all lesions were in an area other than head or neck. The maximum lesion size was ≤ 3 cm for 58% and < 5 cm for 88% of the sample. Based on our data, up to 56% of patients could have been eligible for local therapies according to the WHO criteria. By contrast, only 23% were eligible according to the more restrictive PAHO criteria. Regardless, these data suggest that a substantial proportion of CL patients in Colombia may benefit from local therapies given their relatively mild presentation of disease and low risk of complications. Individualized risk-benefit assessment and guideline adjustments may increase local therapy eligibility and benefit a large number of patients.


Assuntos
Antimônio/uso terapêutico , Antiprotozoários/uso terapêutico , Leishmania braziliensis/efeitos dos fármacos , Leishmania guyanensis/efeitos dos fármacos , Leishmaniose Cutânea/terapia , Paromomicina/uso terapêutico , Pentamidina/uso terapêutico , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Criança , Colômbia/epidemiologia , Estudos Transversais , Crioterapia/métodos , Feminino , Humanos , Hipertermia Induzida/métodos , Leishmania braziliensis/crescimento & desenvolvimento , Leishmania braziliensis/patogenicidade , Leishmania guyanensis/crescimento & desenvolvimento , Leishmania guyanensis/patogenicidade , Leishmaniose Cutânea/epidemiologia , Leishmaniose Cutânea/parasitologia , Masculino , Pessoa de Meia-Idade , Guias de Prática Clínica como Assunto , Índice de Gravidade de Doença
7.
J Aging Health ; 31(10): 1739-1747, 2019 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-30041558

RESUMO

Objective: Much of the literature on aging cognitive health has focused on individual determinants, rather than societal ones; in contrast, this study examined whether country-level age status predicts cognitive performance of older individuals over time. Method: Eight countries were examined using a novel combination of country-level age status data from the European Social Survey and individual-level data from the Survey on Health, Ageing, and Retirement in Europe, between 2004 and 2013. Results: We found that more positive age status significantly predicted better performance on three cognitive measures over a 10-year period, after adjusting for relevant covariates. The generalized-linear model nested individuals within countries to account for the multilevel data. Discussion: To our knowledge, this is the first study to report an association between country-level age status and cognitive performance over time. The results suggest that a small change in the perception of old age at the population level could have a significant effect on the cognitive health of older individuals.

8.
PLoS Negl Trop Dis ; 12(12): e0006986, 2018 12.
Artigo em Inglês | MEDLINE | ID: mdl-30550538

RESUMO

BACKGROUND: Case management in children with cutaneous leishmaniasis (CL) is mainly based on studies performed in adults. We aimed to determine the efficacy and harms of interventions to treat CL in children. METHODS: We conducted a systematic review of clinical trials and cohort studies, assessing treatments of CL in children (≤12 years old). We performed structured searches in PubMed, CENTRAL, LILACS, SciELO, Scopus, the International Clinical Trials Registry Platform (ICTRP), clinicaltrials.gov and Google Scholar. No restrictions regarding ethnicity, country, sex or year of publication were applied. Languages were limited to English, Spanish and Portuguese. Two reviewers screened articles, completed the data extraction and assessment of risk of bias. A qualitative summary of the included studies was performed. RESULTS: We identified 1092 records, and included 8 manuscripts (6 Randomized Clinical Trials [RCT] and 2 non-randomized studies). Most of the articles excluded in full-text review did not report outcomes separately for children. In American CL (ACL), 5 studies evaluated miltefosine and/or meglumine antimoniate (MA). Their efficacy varied from 68-83% and 17-69%, respectively. In Old-World CL (OWCL), two studies evaluated systemic therapies: rifampicin and MA; and one study assessed efficacy of cryotherapy (42%, Per Protocol [PP]) vs intralesional MA (72%, PP). Few studies (4) provided information on adverse events (AEs) for children, and no serious AEs were reported in participants. Risk of bias was generally low to unclear in ACL studies, and unclear to high in OWCL studies. CONCLUSION: Information on efficacy of treatment for CL in children is scarce. There is an unmet need to develop specific formulations, surveillance of AEs, and guidelines both for the management of CL and clinical trials involving the pediatric population. REGISTRATION: The protocol of this review was registered in the PROSPERO International register of systematic reviews, number CRD42017062164.


Assuntos
Antiprotozoários/uso terapêutico , Leishmaniose Cutânea/tratamento farmacológico , Ensaios Clínicos como Assunto , Humanos , Leishmania/genética , Leishmania/fisiologia , Leishmaniose Cutânea/parasitologia , Antimoniato de Meglumina/uso terapêutico , Fosforilcolina/análogos & derivados , Fosforilcolina/uso terapêutico , Rifampina/uso terapêutico
10.
PLoS Med ; 15(10): e1002667, 2018 10.
Artigo em Inglês | MEDLINE | ID: mdl-30300351

RESUMO

BACKGROUND: Sustained retention in HIV care (RIC) and viral suppression (VS) are central to US national HIV prevention strategies, but have not been comprehensively assessed in criminal justice (CJ) populations with known health disparities. The purpose of this study is to identify predictors of RIC and VS following release from prison or jail. METHODS AND FINDINGS: This is a retrospective cohort study of all adult people living with HIV (PLWH) incarcerated in Connecticut, US, during the period January 1, 2007, to December 31, 2011, and observed through December 31, 2014 (n = 1,094). Most cohort participants were unmarried (83.7%) men (77.0%) who were black or Hispanic (78.1%) and acquired HIV from injection drug use (72.6%). Prison-based pharmacy and custody databases were linked with community HIV surveillance monitoring and case management databases. Post-release RIC declined steadily over 3 years of follow-up (67.2% retained for year 1, 51.3% retained for years 1-2, and 42.5% retained for years 1-3). Compared with individuals who were not re-incarcerated, individuals who were re-incarcerated were more likely to meet RIC criteria (48% versus 34%; p < 0.001) but less likely to have VS (72% versus 81%; p = 0.048). Using multivariable logistic regression models (individual-level analysis for 1,001 individuals after excluding 93 deaths), both sustained RIC and VS at 3 years post-release were independently associated with older age (RIC: adjusted odds ratio [AOR] = 1.61, 95% CI = 1.22-2.12; VS: AOR = 1.37, 95% CI = 1.06-1.78), having health insurance (RIC: AOR = 2.15, 95% CI = 1.60-2.89; VS: AOR = 2.01, 95% CI = 1.53-2.64), and receiving an increased number of transitional case management visits. The same factors were significant when we assessed RIC and VS outcomes in each 6-month period using generalized estimating equations (for 1,094 individuals contributing 6,227 6-month periods prior to death or censoring). Additionally, receipt of antiretroviral therapy during incarceration (RIC: AOR = 1.33, 95% CI 1.07-1.65; VS: AOR = 1.91, 95% CI = 1.56-2.34), early linkage to care post-release (RIC: AOR = 2.64, 95% CI = 2.03-3.43; VS: AOR = 1.79; 95% CI = 1.45-2.21), and absolute time and proportion of follow-up time spent re-incarcerated were highly correlated with better treatment outcomes. Limited data were available on changes over time in injection drug use or other substance use disorders, psychiatric disorders, or housing status. CONCLUSIONS: In a large cohort of CJ-involved PLWH with a 3-year post-release evaluation, RIC diminished significantly over time, but was associated with HIV care during incarceration, health insurance, case management services, and early linkage to care post-release. While re-incarceration and conditional release provide opportunities to engage in care, reducing recidivism and supporting community-based RIC efforts are key to improving longitudinal treatment outcomes among CJ-involved PLWH.


Assuntos
Fármacos Anti-HIV/uso terapêutico , Infecções por HIV/tratamento farmacológico , Adesão à Medicação/estatística & dados numéricos , Pacientes Desistentes do Tratamento/estatística & dados numéricos , Prisioneiros/estatística & dados numéricos , Adulto , Fatores Etários , Administração de Caso/estatística & dados numéricos , Connecticut , Feminino , Humanos , Seguro Saúde/estatística & dados numéricos , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Resposta Viral Sustentada
11.
Int J Prison Health ; 14(3): 197-209, 2018 09 10.
Artigo em Inglês | MEDLINE | ID: mdl-30274560

RESUMO

Purpose Little is known about the health status of prisoners in low-income countries. In Haiti, prisons typically lack adequate medical care, clean water and food, though some prisoners receive additional food from visitors. The purpose of this paper is to characterize the physical and mental health of Haitian prisoners in three select prisons and examine the effects of having visitors and length of detention on health status. The authors hypothesized that prisoners with more visitors and shorter detention times would have better overall health status. Design/methodology/approach The authors conducted a cross-sectional study of 290 male inmates in three regional prisons in Haiti. Data were collected on prisoners' sociodemographic characteristics, number of visitors, length of detention, body mass index (BMI), self-reported physical and mental health status, and food insecurity. Findings Overall, prisoners at all three prisons had poor health outcomes. Prisoners with more visitors were significantly less likely to be underweight and more likely to have a higher BMI, better self-reported physical function and lower levels of food insecurity. The length of incarceration was negatively associated with physical function and self-rated health, but positively associated with BMI. These results suggest that prisoners who do not receive supplemental food from visitors are at increased risk for food insecurity and poor nutritional and physical health status. Originality/value These findings demonstrate the importance of supplemental food from visitors in stabilizing prisoner health in Haiti and emphasize the need for the provision of adequate nutrition to all prisoners. This study also suggests that policies that reduce incarceration times could improve health status among prisoners.


Assuntos
Nível de Saúde , Saúde Mental/estatística & dados numéricos , Prisioneiros/estatística & dados numéricos , Prisões/estatística & dados numéricos , População Rural/estatística & dados numéricos , Apoio Social , Adulto , Índice de Massa Corporal , Estudos Transversais , Países em Desenvolvimento , Abastecimento de Alimentos/normas , Haiti , Acesso aos Serviços de Saúde , Inquéritos Epidemiológicos , Humanos , Masculino , Prisioneiros/psicologia , Fatores Socioeconômicos , Fatores de Tempo
12.
Lancet HIV ; 5(11): e617-e628, 2018 11.
Artigo em Inglês | MEDLINE | ID: mdl-30197101

RESUMO

BACKGROUND: People transitioning from prisons or jails have high mortality, but data are scarce for people with HIV and no studies have integrated data from both criminal justice and community settings. We aimed to assess all-cause mortality in people with HIV released from an integrated system of prisons and jails in Connecticut, USA. METHODS: We linked pharmacy, custodial, death, case management, and HIV surveillance data from Connecticut Departments of Correction and Public Health to create a retrospective cohort of all adults with HIV released from jails and prisons in Connecticut between 2007 and 2014. We compared the mortality rate of adults with HIV released from incarceration with the general US and Connecticut populations, and modelled time-to-death from any cause after prison release with Cox proportional hazard models. FINDINGS: We identified 1350 people with HIV who were released after 24 h or more of incarceration between 2007 and 2014, of whom 184 (14%) died after index release; median age was 45 years (IQR 39-50) and median follow-up was 5·2 years (IQR 3·0-6·7) after index release. The crude mortality rate for people with HIV released from incarceration was 2868 deaths per 100 000 person-years, and the standardised mortality ratio showed that mortality was higher for this cohort than the general US population (6·97, 95% CI 5·96-7·97) and population of Connecticut (8·47, 7·25-9·69). Primary cause of death was reported for 170 individuals; the most common causes were HIV/AIDS (78 [46%]), drug overdose (26 [15%]), liver disease (17 [10%]), cardiovascular disease (16 [9%]), and accidental injury or suicide (13 [8%]). Black race (adjusted hazard ratio [HR] 0·52, 95% CI 0·34-0·80), having health insurance (0·09, 0·05-0·17), being re-incarcerated at least once for 365 days or longer (0·41, 0·22-0·76), and having a high percentage of re-incarcerations in which antiretroviral therapy was prescribed (0·08, 0·03-0·21) were protective against mortality. Positive predictors of time-to-death were age (≥50 years; adjusted HR 3·65, 95% CI 1·21-11·08), lower CD4 count (200-499 cells per µL, 2·54, 1·50-4·31; <200 cells per µL, 3·44, 1·90-6·20), a high number of comorbidities (1·86, 95% CI 1·23-2·82), virological failure (2·76, 1·94-3·92), and unmonitored viral load (2·13, 1·09-4·18). INTERPRETATION: To reduce mortality after release from incarceration in people with HIV, resources are needed to identify and treat HIV, in addition to medical comorbidities, psychiatric disorders, and substance use disorders, during and following incarceration. Policies that reduce incarceration and support integrated systems of care between prisons and communities could have a substantial effect on the survival of people with HIV. FUNDING: US National Institutes of Health.


Assuntos
Infecções por HIV/mortalidade , Prisioneiros/estatística & dados numéricos , Prisões , Adulto , Causas de Morte , Connecticut , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Prisioneiros/psicologia , Modelos de Riscos Proporcionais , Estudos Retrospectivos , Fatores de Risco
13.
Lancet HIV ; 5(2): e96-e106, 2018 02.
Artigo em Inglês | MEDLINE | ID: mdl-29191440

RESUMO

BACKGROUND: Incarceration provides an opportunity for engagement in HIV care but is associated with poor HIV treatment outcomes after release. We aimed to assess post-release linkage to HIV care (LTC) and the effect of transitional case management services. METHODS: To create a retrospective cohort of all adults with HIV released from jails and prisons in Connecticut, USA (2007-14), we linked administrative custody and pharmacy databases with mandatory HIV/AIDS surveillance monitoring and case management data. We examined time to LTC (defined as first viral load measurement after release) and viral suppression at LTC. We used generalised estimating equations to show predictors of LTC within 14 days and 30 days of release. FINDINGS: Among 3302 incarceration periods for 1350 individuals between 2007 and 2014, 672 (21%) of 3181 periods had LTC within 14 days of release, 1042 (34%) of 3064 had LTC within 30 days of release, and 301 (29%) of 1042 had detectable viral loads at LTC. Factors positively associated with LTC within 14 days of release are intermediate (31-364 days) incarceration duration (adjusted odds ratio 1·52; 95% CI 1·19-1·95), and transitional case management (1·65; 1·36-1·99), receipt of antiretroviral therapy during incarceration (1·39; 1·11-1·74), and two or more medical comorbidities (1·86; 1·48-2·36). Reincarceration (0·70; 0·56-0·88) and conditional release (0·62; 0·50-0·78) were negatively associated with LTC within 14 days. Hispanic ethnicity, bonded release, and psychiatric comorbidity were also associated with LTC within 30 days but reincarceration was not. INTERPRETATION: LTC after release is suboptimal but improves when inmates' medical, psychiatric, and case management needs are identified and addressed before release. People who are rapidly cycling through jail facilities are particularly vulnerable to missed linkage opportunities. The use of integrated programmes to align justice and health-care goals has great potential to improve long-term HIV treatment outcomes. FUNDING: US National Institutes of Health.


Assuntos
Fármacos Anti-HIV/uso terapêutico , Continuidade da Assistência ao Paciente , Infecções por HIV/tratamento farmacológico , Terapia Antirretroviral de Alta Atividade/métodos , Feminino , Infecções por HIV/virologia , Humanos , Masculino , Vigilância da População , Prisioneiros/estatística & dados numéricos , Prisões , Estudos Retrospectivos , Resultado do Tratamento , Carga Viral
14.
BMC Public Health ; 17(1): 947, 2017 Dec 12.
Artigo em Inglês | MEDLINE | ID: mdl-29233114

RESUMO

BACKGROUND: Community health workers are essential personnel in resource-limited settings. In Uganda, they are organized into Village Health Teams (VHTs) and are focused on infectious diseases and maternal-child health; however, their skills could potentially be utilized in national efforts to reduce the growing burden of non-communicable diseases (NCDs). We sought to assess the knowledge of, and attitudes toward NCDs and NCD care among VHTs in Uganda as a step toward identifying their potential role in community NCD prevention and management. METHODS: We administered a knowledge, attitudes and practices questionnaire to 68 VHT members from Iganga and Mayuge districts in Eastern Uganda. In addition, we conducted four focus group discussions with 33 VHT members. Discussions focused on NCD knowledge and facilitators of and barriers to incorporating NCD prevention and care into their role. A thematic qualitative analysis was conducted to identify salient themes in the data. RESULTS: VHT members possessed some knowledge and awareness of NCDs but identified a lack of knowledge about NCDs in the communities they served. They were enthusiastic about incorporating NCD care into their role and thought that they could serve as effective conduits of knowledge about NCDs to their communities if empowered through NCD education, the availability of proper reporting and referral tools, and visible collaborations with medical personnel. The lack of financial remuneration for their role did not emerge as a major barrier to providing NCD services. CONCLUSIONS: Ugandan VHTs saw themselves as having the potential to play an important role in improving community awareness of NCDs as well as monitoring and referral of community members for NCD-related health issues. In order to accomplish this, they anticipated requiring context-specific and culturally adapted training as well as strong partnerships with facility-based medical personnel. A lack of financial incentivization was not identified to be a major barrier to such role expansion. Developing a role for VHTs in NCD prevention and management should be a key consideration as local and national NCD initiatives are developed.


Assuntos
Agentes Comunitários de Saúde/psicologia , Conhecimentos, Atitudes e Prática em Saúde , Doenças não Transmissíveis/psicologia , Adulto , Idoso , Agentes Comunitários de Saúde/estatística & dados numéricos , Estudos Transversais , Feminino , Grupos Focais , Humanos , Masculino , Pessoa de Meia-Idade , Uganda
15.
J Am Coll Cardiol ; 70(13): 1587-1597, 2017 Sep 26.
Artigo em Inglês | MEDLINE | ID: mdl-28935036

RESUMO

BACKGROUND: Inferior vena cava (IVC) filters are widely used for prevention of pulmonary embolism (PE). However, uncertainty persists about their efficacy and safety. OBJECTIVES: The authors conducted a systematic review and meta-analysis of the published reports on the efficacy and safety of IVC filters. METHODS: The authors searched PubMed, the Cochrane Central Register of Controlled Trials, and ClinicalTrials.gov through October 3, 2016, for randomized controlled trials (RCTs) or prospective controlled observational studies of IVC filters versus none in patients at risk of PE. Inverse variance fixed-effects models with odds ratio (OR) as the effect measure were used for primary analyses. Main outcomes included subsequent PE, PE-related mortality, all-cause mortality, and subsequent deep vein thrombosis (DVT). RESULTS: The authors' search retrieved 1,986 studies, of which 11 met criteria for inclusion (6 RCTs and 5 prospective observational studies). Quality of evidence for RCTs was low to moderate. Overall, patients receiving IVC filters had lower risk for subsequent PE (OR: 0.50; 95% confidence interval [CI]: 0.33 to 0.75); increased risk for DVT (OR: 1.70; 95% CI: 1.17 to 2.48); nonsignificantly lower PE-related mortality (OR: 0.51; 95% CI: 0.25 to 1.05); and no change in all-cause mortality (OR: 0.91; 95% CI: 0.70 to 1.19). Limiting the results to RCTs showed similar results. Findings were substantively similar across a wide range of sensitivity analyses. CONCLUSIONS: Very few prospective controlled studies, with limited quality of evidence, exist regarding the efficacy and safety of IVC filters. Overall, filters appear to reduce the risk of subsequent PE, increase the risk for DVT, and have no significant effect on overall mortality.


Assuntos
Embolia Pulmonar/prevenção & controle , Filtros de Veia Cava , Tromboembolia Venosa/complicações , Humanos , Embolia Pulmonar/etiologia , Veia Cava Inferior
16.
PLoS Negl Trop Dis ; 11(7): e0005713, 2017 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-28704369

RESUMO

BACKGROUND: The determinants of parasite persistence or elimination after treatment and clinical resolution of cutaneous leishmaniasis (CL) are unknown. We investigated clinical and parasitological parameters associated with the presence and viability of Leishmania after treatment and resolution of CL caused by L. Viannia. METHODS: Seventy patients who were treated with meglumine antimoniate (n = 38) or miltefosine (n = 32) and cured, were included in this study. Leishmania persistence and viability were determined by detection of kDNA and 7SLRNA transcripts, respectively, before, at the end of treatment (EoT), and 13 weeks after initiation of treatment in lesions and swabs of nasal and tonsillar mucosa. RESULTS: Sixty percent of patients (42/70) had evidence of Leishmania persistence at EoT and 30% (9/30) 13 weeks after treatment initiation. A previous episode of CL was found to be a protective factor for detectable Leishmania persistence (OR: 0.16, 95%CI: 0.03-0.92). kDNA genotyping could not discern differences between parasite populations that persisted and those isolated at diagnosis. CONCLUSIONS: Leishmania persist in skin and mucosal tissues in a high proportion of patients who achieved therapeutic cure of CL. This finding prompts assessment of the contribution of persistent infection in transmission and endemicity of CL, and in disease reactivation and protective immunity.


Assuntos
Leishmania/isolamento & purificação , Leishmaniose Cutânea/tratamento farmacológico , Leishmaniose Cutânea/parasitologia , Adolescente , Adulto , Idoso , DNA de Cinetoplasto/análise , DNA de Protozoário/análise , Feminino , Seguimentos , Humanos , Leishmania/fisiologia , Masculino , Pessoa de Meia-Idade , Membrana Mucosa/parasitologia , Estudos Prospectivos , RNA de Protozoário/análise , RNA Citoplasmático Pequeno/análise , Partícula de Reconhecimento de Sinal/análise , Pele/parasitologia , Análise de Sobrevida , Fatores de Tempo , Resultado do Tratamento , Adulto Jovem
17.
Public Health Nutr ; 20(7): 1235-1247, 2017 May.
Artigo em Inglês | MEDLINE | ID: mdl-28162141

RESUMO

OBJECTIVE: Young children are particularly vulnerable to malnutrition as nutrition transition progresses. The present study aimed to document the prevalence, coexistence and correlates of nutritional status (stunting, overweight/obesity and anaemia) in Samoan children aged 24-59 months. DESIGN: A cross-sectional community-based survey. Height and weight were used to determine prevalence of stunting (height-for-age Z-score +2) based on WHO growth standards. Anaemia was determined using an AimStrip Hemoglobin test system (Hb <110 g/l). SETTING: Ten villages on the Samoan island of Upolu. SUBJECTS: Mother-child pairs (n 305) recruited using convenience sampling. RESULTS: Moderate or severe stunting was apparent in 20·3 % of children, 16·1 % were overweight/obese and 34·1 % were anaemic. Among the overweight/obese children, 28·6 % were also stunted and 42·9 % anaemic, indicating dual burden of malnutrition. Stunting was significantly less likely among girls (OR=0·41; 95 % CI 0·21, 0·79, P<0·01) than boys. Overweight/obesity was associated with higher family socio-economic status and decreased sugar intake (OR per 10 g/d=0·89, 95 % CI 0·80, 0·99, P=0·032). The odds of anaemia decreased with age and anaemia was more likely in children with an anaemic mother (OR=2·20; 95 % CI 1·22, 3·98, P=0·007). No child, maternal or household characteristic was associated with more than one of the nutritional status outcomes, highlighting the need for condition-specific interventions in this age group. CONCLUSIONS: The observed prevalences of stunting, overweight/obesity and anaemia suggest that it is critical to invest in nutrition and develop health programmes targeting early childhood growth and development in Samoa.


Assuntos
Anemia Ferropriva/epidemiologia , Transtornos do Crescimento/epidemiologia , Desnutrição/epidemiologia , Estado Nutricional , Sobrepeso/epidemiologia , Obesidade Pediátrica/epidemiologia , Estatura , Peso Corporal , Pré-Escolar , Estudos Transversais , Dieta , Exercício Físico , Características da Família , Feminino , Humanos , Masculino , Mães , Avaliação Nutricional , Prevalência , Samoa , Fatores Socioeconômicos
18.
Drug Alcohol Depend ; 164: 120-127, 2016 Jul 01.
Artigo em Inglês | MEDLINE | ID: mdl-27207155

RESUMO

INTRODUCTION: Methadone maintenance therapy (MMT) is crucial for HIV prevention and treatment in people who inject opioids. In Malaysia, a large proportion of the prison population is affected by both HIV and opioid use disorders. This study assessed individual preferences and factors associated with interest in receiving MMT among male prisoners meeting criteria for opioid dependence in Malaysia. METHODS: A convenience sample of 96 HIV-positive and 104 HIV-negative incarcerated men who met pre-incarceration criteria for opioid dependence was interviewed using a structured questionnaire to examine participant characteristics and attitudes toward MMT. Factors associated with interest in prison-based MMT initiation were identified using logistic regression analysis. RESULTS: Among all participants, 85 (42.5%) were interested in receiving MMT within prison. Independent correlates of interest in prison-based MMT were being previously married (AOR=4.15, 95% CI: 1.15, 15.02), previously incarcerated (AOR=5.68, 95% CI: 1.54, 21.02), depression (AOR=3.66, 95% CI: 1.68, 7.98), daily heroin use in the 30days prior to incarceration (AOR=5.53, 95% CI: 1.65, 18.58), and more favorable attitudes toward MMT (AOR=19.82, 95% CI: 6.07, 64.74). CONCLUSIONS: Overall, interest in receiving prison-based MMT was low, and was associated with adverse social, mental health, and drug use consequences. Incarceration provides a unique opportunity to initiate MMT for those who need it, however, optimal scale-up efforts must be systemic and address modifiable factors like improving attitudes toward and motivation for MMT. Informed or shared decision-making tools may be useful in improving expectations and acceptability of MMT.


Assuntos
Metadona/uso terapêutico , Tratamento de Substituição de Opiáceos/métodos , Tratamento de Substituição de Opiáceos/psicologia , Transtornos Relacionados ao Uso de Opioides/psicologia , Transtornos Relacionados ao Uso de Opioides/reabilitação , Aceitação pelo Paciente de Cuidados de Saúde/psicologia , Prisioneiros/psicologia , Adulto , Humanos , Malásia/epidemiologia , Masculino , Pessoa de Meia-Idade , Adulto Jovem
19.
J Am Coll Cardiol ; 67(9): 1027-1035, 2016 Mar 08.
Artigo em Inglês | MEDLINE | ID: mdl-26940921

RESUMO

BACKGROUND: Inferior vena caval filters (IVCFs) may prevent recurrent pulmonary embolism (PE). Despite uncertainty about their net benefit, patterns of use and outcomes of these devices in contemporary practice are unknown. OBJECTIVES: The authors determined the trends in utilization rates and outcomes of IVCF placement in patients with PE and explored regional variations in use in the United States. METHODS: In a national cohort study of all Medicare fee-for-service beneficiaries ≥65 years of age with principal discharge diagnoses of PE between 1999 and 2010, rates of IVCF placement per 100,000 beneficiary-years and per 1,000 patients with PE were determined. The 30-day and 1-year mortality rates after IVCF placement were also investigated. RESULTS: Among 556,658 patients hospitalized with PE, 94,427 underwent IVCF placement. Between 1999 and 2010, the number of PE hospitalizations with IVCF placement increased from 5,003 to 8,928, representing an increase in the rate per 100,000 beneficiary-years from 19.0 to 32.5 (p < 0.001 for both). As the total number of PE hospitalizations increased (from 31,746 in 1999 to 54,392 in 2010), the rate of IVCF placement per 1,000 PE hospitalizations did not change significantly (from 157.6 to 164.1, p = 0.11). Results were consistent across demographic subgroups, although IVCF use was higher in blacks and patients ≥85 years of age. IVCF utilization varied widely across regions, with the highest rate in the South Atlantic region and the lowest rate in the Mountain region. CONCLUSIONS: In a period of increasing PE hospitalizations among Medicare fee-for-service beneficiaries, IVCF placement increased as utilization rates in patients with PE remained greater than 15%. Mortality associated with PE hospitalizations is declining, regardless of IVCF use.


Assuntos
Planos de Pagamento por Serviço Prestado/economia , Hospitalização/estatística & dados numéricos , Embolia Pulmonar/prevenção & controle , Filtros de Veia Cava/estatística & dados numéricos , Idoso , Idoso de 80 Anos ou mais , Feminino , Humanos , Incidência , Masculino , Medicare , Embolia Pulmonar/economia , Embolia Pulmonar/epidemiologia , Estudos Retrospectivos , Taxa de Sobrevida/tendências , Estados Unidos/epidemiologia
20.
J Interprof Care ; 30(2): 191-200, 2016.
Artigo em Inglês | MEDLINE | ID: mdl-27026189

RESUMO

Efforts to improve interprofessional education (IPE) are informed by attitudes of health professional students, yet there are limited US data on student characteristics and experiences associated with positive attitudes towards IPE. A cohort of US medical, nursing, and physician associate students was surveyed in their first and third years, using the Readiness for Interprofessional Learning Scale and Interdisciplinary Education Perception Scale. Information was also collected on demographics and experiences during training. Health professional students differed in their attitudes towards IPE; characteristics associated with having more positive attitudes at both time points included being a nursing student, female, older, and having more previous healthcare experience. Students who participated in interprofessional extracurricular activities (particularly patient-based activities) during training reported more positive attitudes in the third year than those who did not participate in such activities. Based on these findings, schools may consider how student characteristics and participation in interprofessional extracurricular activities can affect attitudes regarding IPE. Building on the positive elements of this interprofessional extracurricular experience, schools may also want to consider service-learning models of IPE where students work together on shared goals.


Assuntos
Atitude do Pessoal de Saúde , Pessoal de Saúde/educação , Relações Interprofissionais , Estudantes de Ciências da Saúde/psicologia , Adulto , Fatores Etários , Competência Clínica , Serviços de Saúde Comunitária/organização & administração , Comportamento Cooperativo , Feminino , Humanos , Estudos Longitudinais , Masculino , Equipe de Assistência ao Paciente/organização & administração , Fatores Sexuais , Fatores de Tempo , Estados Unidos , Universidades
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