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1.
PLoS Med ; 17(3): e1003058, 2020 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-32231363

RESUMO

BACKGROUND: Evidence and guidelines do not support use of systemic steroids for acute respiratory tract infections (ARTIs), but such practice appears common. We aim to quantify such use and determine its predictors. METHODS AND FINDINGS: We conducted a cohort study based on a large United States national commercial claims database, the IBM MarketScan, to identify patients aged 18-64 years with an ARTI diagnosis (acute bronchitis, sinusitis, pharyngitis, otitis media, allergic rhinitis, influenza, pneumonia, and unspecified upper respiratory infections) recorded in ambulatory visits from 2007 to 2016. We excluded those with systemic steroid use in the prior year and an extensive list of steroid-indicated conditions, including asthma, chronic obstructive pulmonary disease, and various autoimmune diseases. We calculated the proportion receiving systemic steroids within 7 days of the ARTI diagnosis and determined its significant predictors. We identified 9,763,710 patients with an eligible ARTI encounter (mean age 39.6, female 56.0%) and found 11.8% were prescribed systemic steroids (46.1% parenteral, 47.3% oral, 6.6% both). All ARTI diagnoses but influenza predicted receiving systemic steroids. There was high geographical variability: the adjusted odds ratio (aOR) of receiving parenteral steroids was 14.48 (95% confidence interval [CI] 14.23-14.72, p < 0.001) comparing southern versus northeastern US. The corresponding aOR was 1.68 (95% CI 1.66-1.69, p < 0.001) for oral steroids. Other positive predictors for prescribing included emergency department (ED) or urgent care settings (versus regular office), otolaryngologist/ED doctors (versus primary care), fewer comorbidities, and older patient age. There was an increasing trend from 2007 to 2016 (aOR 1.93 [95% CI 1.91-1.95] comparing 2016 to 2007, p < 0.001). Our findings are based on patients between 18 and 64 years old with commercial medical insurance and may not be generalizable to older or uninsured populations. CONCLUSIONS: In this study, we found that systemic steroid use in ARTI is common with a great geographical variability. These findings call for an effective education program about this practice, which does not have a clear clinical net benefit.

2.
Ann Intern Med ; 172(7): 463-473, 2020 Apr 07.
Artigo em Inglês | MEDLINE | ID: mdl-32150751

RESUMO

Background: Apixaban and rivaroxaban are the most commonly prescribed direct oral anticoagulants for adults with atrial fibrillation, but head-to-head data comparing their safety and effectiveness are lacking. Objective: To compare the safety and effectiveness of apixaban versus rivaroxaban for patients with nonvalvular atrial fibrillation. Design: New-user, active-comparator, retrospective cohort study. Setting: A U.S. nationwide commercial health care claims database from 28 December 2012 to 1 January 2019. Patients: Adults newly prescribed apixaban (n = 59 172) or rivaroxaban (n = 40 706). Measurements: The primary effectiveness outcome was a composite of ischemic stroke or systemic embolism. The primary safety outcome was a composite of intracranial hemorrhage or gastrointestinal bleeding. Results: 39 351 patients newly prescribed apixaban were propensity score matched to 39 351 patients newly prescribed rivaroxaban. Mean age was 69 years, 40% of patients were women, and mean follow-up was 288 days for new apixaban users and 291 days for new rivaroxaban users. The incidence rate of ischemic stroke or systemic embolism was 6.6 per 1000 person-years for adults prescribed apixaban compared with 8.0 per 1000 person-years for those prescribed rivaroxaban (hazard ratio [HR], 0.82 [95% CI, 0.68 to 0.98]; rate difference, 1.4 fewer events per 1000 person-years [CI, 0.0 to 2.7]). Adults prescribed apixaban also had a lower rate of gastrointestinal bleeding or intracranial hemorrhage (12.9 per 1000 person-years) compared with those prescribed rivaroxaban (21.9 per 1000 person-years), corresponding to an HR of 0.58 (CI, 0.52 to 0.66) and a rate difference of 9.0 fewer events per 1000 person-years (CI, 6.9 to 11.1). Limitation: Unmeasured confounding, incomplete laboratory data. Conclusion: In routine care, adults with atrial fibrillation prescribed apixaban had a lower rate of both ischemic stroke or systemic embolism and bleeding compared with those prescribed rivaroxaban. Primary Funding Source: Division of Pharmacoepidemiology and Pharmacoeconomics, Brigham and Women's Hospital.

4.
Circ Cardiovasc Qual Outcomes ; 11(12): e004700, 2018 12.
Artigo em Inglês | MEDLINE | ID: mdl-30562067

RESUMO

BACKGROUND: Ejection fraction (EF) class is an important predictor of treatment response in heart failure (HF); however, administrative claims databases lack information on EF, limiting their usefulness in clinical and health services research of HF. METHODS AND RESULTS: We linked Medicare claims data to electronic medical records containing EF measurements for a cohort of 11 073 patients with HF from 2 academic medical centers. A a claims-based model predicting EF class was constructed using data from center 1 ("training sample") and validated using data from center 2 ("testing sample). Linear and logistic regression models with least absolute square shrinkage operator and Bayesian information criteria were developed to select the relevant predictor variables out of the total 57 candidate variables in the training sample. Higher accuracy was noted in the testing sample with models classifying patients into 2 EF classes (reduced EF <0.45) versus preserved EF (≥0.45) when compared with classifying patients into 3 EF classes (reduced, <0.40, moderately reduced, 0.40-0.49, or preserved, ≥0.50). In the testing sample, the most efficient model had 35 predictors and resulted in 83% of patients being correctly classified (95% CI, 82%-84%). The model had positive predictive value of 0.73 (95% CI, 0.68-0.78) and 0.84 (95% CI, 0.83-0.86) and sensitivity of 0.29 (95% CI, 0.25-0.32) and 0.97 (95% CI, 0.97-0.98) for reduced and preserved EF, respectively. In addition to HF-specific diagnosis codes, other factors including age, sex, medication use, and comorbidities, such as myocardial infarction and valve disorders, were important discriminators between EF classes. CONCLUSIONS: The claims-based model developed in this study may be used to identify patient subgroups with specific EF class in studies evaluating the health outcomes, utilization patterns, and cost, of HF patients in routine care when EF measurements are not available.


Assuntos
Mineração de Dados/métodos , Insuficiência Cardíaca/diagnóstico , Insuficiência Cardíaca/fisiopatologia , Volume Sistólico , Função Ventricular Esquerda , Centros Médicos Acadêmicos , Demandas Administrativas em Assistência à Saúde , Idoso , Idoso de 80 Anos ou mais , Teorema de Bayes , Bases de Dados Factuais , Registros Eletrônicos de Saúde , Feminino , Insuficiência Cardíaca/classificação , Insuficiência Cardíaca/terapia , Humanos , Classificação Internacional de Doenças , Masculino , Registro Médico Coordenado , Medicare , Valor Preditivo dos Testes , Prognóstico , Reprodutibilidade dos Testes , Medição de Risco , Fatores de Risco , Estados Unidos
5.
Epidemiology ; 29(3): 356-363, 2018 05.
Artigo em Inglês | MEDLINE | ID: mdl-29283893

RESUMO

BACKGROUND: It is unclear how out-of-system care or electronic health record (EHR) discontinuity (i.e., receiving care outside of an EHR system) may affect validity of comparative effectiveness research using these data. We aimed to compare the misclassification of key variables in patients with high versus low EHR continuity. METHODS: The study cohort comprised patients ages ≥65 identified in electronic health records from two US provider networks linked with Medicare insurance claims data from 2007 to 2014. By comparing electronic health records and claims data, we quantified EHR continuity by the proportion of encounters captured by the EHRs (i.e., "capture proportion"). Within levels of EHR continuity, for 40 key variables, we quantified misclassification by mean standardized differences between coding based on EHRs alone versus linked claims and EHR data. RESULTS: Based on 183,739 patients, we found that mean capture proportion in a single electronic health record system was 16%-27% across two provider networks. Patients with highest level of EHR continuity (capture proportion ≥ 80%) had 11.4- to 17.4-fold less variable misclassification, when compared with those with lowest level of EHR continuity (capture proportion< 10%). Capturing at least 60% of the encounters in an EHR system was required to have reasonable variable classification (mean standardized difference <0.1). We found modest differences in comorbidity profiles between patients with high and low EHR continuity. CONCLUSIONS: EHR discontinuity may lead to substantial misclassification in key variables. Restricting comparative effectiveness research to patients with high EHR continuity may confer a favorable benefit (reducing information bias) to risk (losing generalizability) ratio.


Assuntos
Pesquisa Comparativa da Efetividade , Continuidade da Assistência ao Paciente , Registros Eletrônicos de Saúde/normas , Acesso aos Serviços de Saúde , Idoso , Comorbidade , Feminino , Humanos , Masculino , Estados Unidos
6.
Clin Pharmacol Ther ; 103(5): 899-905, 2018 05.
Artigo em Inglês | MEDLINE | ID: mdl-28865143

RESUMO

Electronic health record (EHR)-discontinuity, i.e., having medical information recorded outside of the study EHR system, is associated with substantial information bias in EHR-based comparative effectiveness research (CER). We aimed to develop and validate a prediction model identifying patients with high EHR-continuity to reduce this bias. Based on 183,739 patients aged ≥65 in EHRs from two US provider networks linked with Medicare claims data from 2007-2014, we quantified EHR-continuity by mean proportion of encounters captured (MPEC) by the EHR system. We built a prediction model for MPEC using one EHR system as training and the other as the validation set. Patients with top 20% predicted EHR-continuity had 3.5-5.8-fold smaller misclassification of 40 CER-relevant variables, compared to the remaining study population. The comorbidity profiles did not differ substantially by predicted EHR-continuity. These findings suggest that restriction of CER to patients with high predicted EHR-continuity may confer a favorable validity to generalizability trade-off.


Assuntos
Pesquisa Comparativa da Efetividade/estatística & dados numéricos , Registros Eletrônicos de Saúde/estatística & dados numéricos , Idoso , Comorbidade , Humanos
7.
J Am Heart Assoc ; 6(10)2017 Oct 05.
Artigo em Inglês | MEDLINE | ID: mdl-28982676

RESUMO

BACKGROUND: Time in the therapeutic range (TTR) is associated with the effectiveness and safety of vitamin K antagonist (VKA) therapy. To optimize prescribing of VKA, we aimed to develop and validate a prediction model for TTR in older adults taking VKA for nonvalvular atrial fibrillation and venous thromboembolism. METHODS AND RESULTS: The study cohort comprised patients aged ≥65 years who were taking VKA for atrial fibrillation or venous thromboembolism and who were identified in the 2 US electronic health record databases linked with Medicare claims data from 2007 through 2014. With the predictors identified from a systematic review and clinical knowledge, we built a prediction model for TTR, using one electronic health record system as the training set and the other as the validation set. We compared the performance of the new models to that of a published prediction score for TTR, SAMe-TT2R2. Based on 1663 patients in the training set and 1181 in the validation set, our optimized score included 42 variables and the simplified model included 7 variables, abbreviated as PROSPER (Pneumonia, Renal dysfunction, Oozing blood [prior bleeding], Staying in hospital ≥7 days, Pain medication use, no Enhanced [structured] anticoagulation services, Rx for antibiotics). The PROSPER score outperformed SAMe-TT2R2 when predicting both TTR ≥70% (area under the receiver operating characteristic curve 0.67 versus 0.55) and the thromboembolic and bleeding outcomes (area under the receiver operating characteristic curve 0.62 versus 0.52). CONCLUSIONS: Our geriatric TTR score can be used as a clinical decision aid to select appropriate candidates to receive VKA therapy and as a research tool to address confounding and treatment effect heterogeneity by anticoagulation quality.


Assuntos
Anticoagulantes/uso terapêutico , Fibrilação Atrial/tratamento farmacológico , Coagulação Sanguínea/efeitos dos fármacos , Técnicas de Apoio para a Decisão , Monitoramento de Medicamentos/métodos , Coeficiente Internacional Normatizado , Tromboembolia Venosa/tratamento farmacológico , Fatores Etários , Idoso , Analgésicos/uso terapêutico , Antibacterianos/uso terapêutico , Anticoagulantes/efeitos adversos , Área Sob a Curva , Fibrilação Atrial/sangue , Fibrilação Atrial/diagnóstico , Tomada de Decisão Clínica , Bases de Dados Factuais , Monitoramento de Medicamentos/normas , Registros Eletrônicos de Saúde , Feminino , Hemorragia/induzido quimicamente , Humanos , Coeficiente Internacional Normatizado/normas , Tempo de Internação , Masculino , Seleção de Pacientes , Valor Preditivo dos Testes , Controle de Qualidade , Indicadores de Qualidade em Assistência à Saúde , Curva ROC , Reprodutibilidade dos Testes , Fatores de Risco , Fatores de Tempo , Resultado do Tratamento , Tromboembolia Venosa/sangue , Tromboembolia Venosa/diagnóstico
8.
Circ Cardiovasc Qual Outcomes ; 7(1): 70-7, 2014 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-24254886

RESUMO

BACKGROUND: The benefit-risk profile of low-dose aspirin in primary prevention of cardiovascular disease is unclear. We sought to quantify upper gastrointestinal bleeding (UGIB) risk associated with low-dose aspirin in secondary versus primary prevention patients. METHODS AND RESULTS: We performed a population-based nested case-control study using The Health Improvement Network (THIN) Database between 2000 and 2007. We identified 2049 cases of UGIB and 20,000 controls, frequency-matched to the cases on age, sex, and calendar year, who were subdivided into primary (without previous cardiovascular disease) and secondary (with previous cardiovascular disease) prevention populations. We estimated the relative risk of UGIB associated with the use of low-dose aspirin by multivariate logistic regression. The UGIB risk in patients taking low-dose aspirin relative to nonusers was significantly higher in the primary (adjusted relative risk, 1.90; 95% confidence interval, 1.59-2.26) than in the secondary (relative risk, 1.40; 95% confidence interval, 1.14-1.72; P value for the difference=0.0014) prevention cohort. However, as the baseline risk of UGIB was lower in the primary than in the secondary prevention cohort, numbers needed to harm per 1 year of low-dose aspirin use were 601 and 391 for primary and secondary prevention, respectively. CONCLUSIONS: The relative risk of UGIB in patients taking low-dose aspirin is higher when used for primary than for secondary cardiovascular disease prevention, but this difference is more than compensated by the lower baseline risk in the primary prevention population. Such estimates are important for an assessment of the net clinical benefit in primary prevention.


Assuntos
Aspirina/efeitos adversos , Aspirina/uso terapêutico , Doenças Cardiovasculares/prevenção & controle , Hemorragia Gastrointestinal/epidemiologia , Prevenção Primária , Prevenção Secundária , Adulto , Idoso , Idoso de 80 Anos ou mais , Doenças Cardiovasculares/epidemiologia , Estudos de Casos e Controles , Relação Dose-Resposta a Droga , Feminino , Hemorragia Gastrointestinal/etiologia , Humanos , Incidência , Modelos Logísticos , Masculino , Pessoa de Meia-Idade , Inibidores da Agregação de Plaquetas/efeitos adversos , Inibidores da Agregação de Plaquetas/uso terapêutico , Estudos Retrospectivos , Medição de Risco , Fatores de Risco , Resultado do Tratamento
9.
J Interv Card Electrophysiol ; 39(3): 211-23, 2014 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-24346619

RESUMO

PURPOSE: The impact of metabolic syndrome (MetS) on recurrence of atrial fibrillation (AF) after catheter ablation remains uncertain. We conducted a meta-analysis to summarize the relative risks (RR) of AF recurrence after catheter ablation in patients with vs. without MetS and its components. METHODS: Among 839 articles identified from PubMed, EMBASE, and the Cochrane Central Register of Controlled Trials, we included 23 studies with a total of 12,924 patients (7,594 with paroxysmal AF and 5,330 with nonparoxysmal AF) for analysis. Five of these had complete information on MetS components. Variables assessed comprised study design and population characteristics, AF ablation methods, use of anti-arrhythmic drugs, AF recurrence ascertainment methods, adjustment variables, and other quality indicators. RESULTS: Our meta-analysis found an elevated risk of AF recurrence after ablation in patients with vs. without MetS (pooled RR, 1.63; 95 % confidence interval (CI), 1.25-2.12). Among components of MetS, hypertension was a predictor of AF post-ablation recurrence in studies without adjustment for other MetS components (RR, 1.62; 95 % CI, 1.23-2.13) but not in those adjusting for two or more additional MetS components (RR, 1.03; 95 % CI, 0.88-1.20). There was a borderline association between overweight/obesity and AF recurrence after ablation (RR, 1.27; 95 % CI, 0.99-1.64). CONCLUSIONS: MetS is associated with an increased risk of AF recurrence after catheter ablation. Further study of the MetS and its components as determinants of AF risk could help refine patient selection and improve procedural outcomes.


Assuntos
Fibrilação Atrial/fisiopatologia , Fibrilação Atrial/cirurgia , Ablação por Cateter , Síndrome Metabólica/fisiopatologia , Humanos , Recidiva , Risco , Fatores de Risco
10.
Am J Epidemiol ; 178(2): 198-208, 2013 Jul 15.
Artigo em Inglês | MEDLINE | ID: mdl-23825167

RESUMO

Previous studies suggested that early pregnancy exposure to specific oral decongestants increases the risks of several birth defects. Using January 1993-January 2010 data from the Slone Epidemiology Center Birth Defects Study, we tested those hypotheses among 12,734 infants with malformations (cases) and 7,606 nonmalformed control infants in the United States and Canada. Adjusted odds ratios and 95% confidence intervals were estimated for specific birth defects, with controlling for potential confounders. Findings did not replicate several hypotheses but did support 3 previously reported associations: phenylephrine and endocardial cushion defect (odds ratio = 8.0; 95% confidence interval: 2.5, 25.3; 4 exposed cases), phenylpropanolamine and ear defects (odds ratio = 7.8; 95% confidence interval: 2.2, 27.2; 4 exposed cases), and phenylpropanolamine and pyloric stenosis (odds ratio = 3.2; 95% confidence interval: 1.1, 8.8; 6 exposed cases). Hypothesis-generating analyses involving multiple comparisons identified a small number of associations with oral and intranasal decongestants. Accumulating evidence supports associations between first-trimester use of specific oral and possibly intranasal decongestants and the risk of some infrequent specific birth defects.


Assuntos
Anormalidades Induzidas por Medicamentos , Descongestionantes Nasais/efeitos adversos , Medicamentos sem Prescrição/efeitos adversos , Administração Intranasal , Administração Oral , Adulto , Canadá , Estudos de Casos e Controles , Feminino , Humanos , Recém-Nascido , Modelos Logísticos , Descongestionantes Nasais/administração & dosagem , Medicamentos sem Prescrição/administração & dosagem , Razão de Chances , Gravidez , Primeiro Trimestre da Gravidez , Autorrelato , Estados Unidos
11.
Am J Obstet Gynecol ; 208(3): 221.e1-8, 2013 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-23254249

RESUMO

OBJECTIVE: Prior studies have reported increased risks of congenital heart defects (CHD) and pyloric stenosis (PS) after prenatal exposure to macrolide antibiotics. We sought to assess the association between maternal use of erythromycin and nonerythromycin macrolides and the risks of CHD and PS. STUDY DESIGN: Among participants in the Slone Epidemiology Center Birth Defects Study from 1994 through 2008, we identified 4132 infants with CHD and 735 with PS as cases, and 6952 infants without any malformation as controls. We estimated odds ratios (ORs) and 95% confidence intervals (CIs) associated with use of erythromycin or nonerythromycin macrolides in each trimester using conditional logistic regression and adjusting for risk factors for CHD and PS, fever, specific types of infections, and their associated treatments. RESULTS: During the first trimester, 0.4% and 0.7% of control women had used erythromycin and nonerythromycin macrolides, respectively. Compared to non-use during pregnancy, first-trimester exposure to erythromycin was not associated with an increased risk of CHD (OR, 1.3; 95% CI, 0.6-2.6) or PS (OR, 0.9; 95% CI, 0.3-3.0). The corresponding ORs for nonerythromycin macrolides were 0.7 (95% CI, 0.4-1.3) for CHD and 1.7 (95% CI, 0.6-4.6) for PS. We found no association between third-trimester exposure to erythromycin or nonerythromycin macrolides and the risk of PS. Hypothesis generation analyses did not identify appreciable associations between maternal use of macrolides and other common specific birth defects. CONCLUSION: We found no meaningful associations between the risks of CHD, PS, and other common malformations in relation to use of macrolides in pregnancy.


Assuntos
Antibacterianos/efeitos adversos , Cardiopatias Congênitas/induzido quimicamente , Macrolídeos/efeitos adversos , Efeitos Tardios da Exposição Pré-Natal/etiologia , Estenose Pilórica/induzido quimicamente , Adulto , Azitromicina/efeitos adversos , Claritromicina/efeitos adversos , Eritromicina/efeitos adversos , Feminino , Humanos , Modelos Logísticos , Gravidez , Risco
12.
Epidemiology ; 23(5): 699-705, 2012 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-22766750

RESUMO

BACKGROUND: Prior studies have suggested an increased risk of oral clefts after exposure to amoxicillin in early pregnancy, but findings have been inconsistent. METHODS: Among participants in the Slone Epidemiology Center Birth Defects Study from 1994 to 2008, we identified 877 infants with cleft lip with/without cleft palate and 471 with cleft palate alone. Controls included 6952 nonmalformed infants. Mothers were interviewed about demographic, reproductive and medical factors, and details of medication use. We estimated odds ratios (ORs) and 95% confidence intervals (CIs) associated with use of amoxicillin in the first trimester using conditional logistic regression and adjusting for known risk factors for oral clefts, as well as for infections, fever, and concomitant treatments. RESULTS: In the control group, 2.1% of women had used amoxicillin in the first trimester. Maternal use of amoxicillin was associated with an increased risk of cleft lip with/without cleft palate (adjusted OR = 2.0 [95% confidence interval = 1.0-4.1]), with an OR of 4.3 (1.4-13.0) for third-gestational-month use. Risks were not elevated for use of other penicillins or cephalosporins. For cleft palate, the OR for first-trimester amoxicillin was 1.0 (0.4-2.3) with an OR of 7.1 (1.4-36) for third-gestational month use. CONCLUSIONS: Amoxicillin use in early pregnancy may be associated with an increased risk of oral clefts.


Assuntos
Amoxicilina/efeitos adversos , Antibacterianos/efeitos adversos , Fenda Labial/induzido quimicamente , Fissura Palatina/induzido quimicamente , Efeitos Tardios da Exposição Pré-Natal/induzido quimicamente , Adulto , Algoritmos , Estudos de Casos e Controles , Feminino , Humanos , Recém-Nascido , Entrevistas como Assunto , Modelos Logísticos , Análise Multivariada , Razão de Chances , Vigilância da População , Gravidez , Primeiro Trimestre da Gravidez , Fatores de Risco , Autorrelato
13.
Int J Cancer ; 130(2): 419-30, 2012 Jan 15.
Artigo em Inglês | MEDLINE | ID: mdl-21365647

RESUMO

Studies suggest that estrogen therapy (ET) and combined estrogen-progestogen therapy (EPT) may have different associations with colorectal cancer (CRC) risk, but data are conflicting. Prior meta-analyses did not distinguish between ET and EPT. We conducted a meta-analysis to summarize the relative risks (RR) of CRC due to ET versus EPT among peri- or postmenopausal women. From a total of 2,661 articles, four randomized controlled trials, eight cohort and eight case-control studies were included. Variables assessed included study characteristics, duration and recency of menopausal hormone therapy (HT) use, method of assessment of HT use, outcome definition and its ascertainment method. RRs were synthesized by random-effects models. We found that EPT ever use was associated with a decreased risk of CRC (RR 0.74, 95% CI 0.68-0.81), and so was ET ever use (RR 0.79, 95% CI 0.69-0.91). While current use of ET was associated with a significantly reduced risk of CRC (RR 0.70, 95% CI 0.57-0.85), former use was not (RR 0.86, 95%CI 0.67-1.11). Recency did not significantly modify the association between EPT and CRC risk. EPT former use was associated with a lower RR of CRC compared to ET former use (p = 0.008) but no such difference was observed between EPT and ET current use (p = 0.12). Overall, we found consistent evidence supporting the association between EPT and CRC risk reduction, regardless of recency. While literature for the association between ET and CRC risk is heterogeneous, our analyses suggest only current use of ET is associated with a decreased CRC risk.


Assuntos
Neoplasias Colorretais/epidemiologia , Estrogênios/administração & dosagem , Terapia de Reposição Hormonal/estatística & dados numéricos , Progesterona/administração & dosagem , Feminino , Humanos , Fatores de Risco
14.
Pharmacoepidemiol Drug Saf ; 20(11): 1210-6, 2011 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-21913281

RESUMO

PURPOSE: Imperfect recall of exposure timing challenges the ascertainment of medications in interview-based studies. METHODS: We propose an algorithm to classify medication exposure, taking into account recall certainty. The availability of medication use details, including duration of use, start and stop dates, and maternal estimates of how certain they were about these dates, allowed classification of subjects as either likely or possibly exposed in the first trimester of pregnancy. We applied the algorithm to study an association between prenatal tetracycline exposure and risk of congenital heart defects previously reported by the National Birth Defects Prevention Study, using 1993-2008 data from 11,517 subjects in the Slone Epidemiology Center Birth Defects Study. RESULTS: Among women exposed to tetracyclines during pregnancy (n = 58), 50% and 19% were likely and possibly exposed, respectively, in the first trimester, and 31% were exposed outside the first trimester. Compared with non-use during pregnancy, the crude OR for exposure outside the first trimester was 1.0 (95%CI 0.4-2.5), and that for exposed (likely or possibly, combined) in the first trimester was 1.7 (95%CI 0.9-3.2); however, the ORs based on the algorithms were 0.9 (95%CI 0.3-3.0) for possibly exposed and 2.2 (95%CI 1.0-4.6) for likely exposed. CONCLUSIONS: A "certainty-response" (stronger association with higher level of certainty) was found within exposures in the window of etiological interest. Algorithms for exposure classification that incorporate recall certainty may be useful in interview-based studies.


Assuntos
Anormalidades Induzidas por Medicamentos/epidemiologia , Anormalidades Induzidas por Medicamentos/etiologia , Algoritmos , Entrevistas como Assunto , Modelos Estatísticos , Resultado da Gravidez/epidemiologia , Tetraciclinas/efeitos adversos , Antibacterianos , Intervalos de Confiança , Feminino , Cardiopatias Congênitas/complicações , Cardiopatias Congênitas/epidemiologia , Humanos , Exposição Materna/estatística & dados numéricos , Rememoração Mental , Gravidez , Primeiro Trimestre da Gravidez/efeitos dos fármacos , Efeitos Tardios da Exposição Pré-Natal/epidemiologia , Reprodutibilidade dos Testes , Estudos Retrospectivos , Risco , Inquéritos e Questionários , Tetraciclinas/uso terapêutico , Fatores de Tempo
15.
Eur J Anaesthesiol ; 28(11): 788-95, 2011 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-21897263

RESUMO

BACKGROUND: Video laryngoscopes have been introduced in recent years as an alternative choice to facilitate tracheal intubation. We conducted a meta-analysis to assess their value when compared with direct laryngoscopy. METHODS: PubMed and EMBASE were searched up until 24 September 2010. Randomised trials that reported data on the comparison of video laryngoscopes with direct laryngoscopy for tracheal intubation were included. RESULTS: Eleven trials with a total of 1196 participants were identified. During tracheal intubation, video laryngoscopes can achieve a better view of the glottis and have a similar success rate [rate ratio 1.0; 95% confidence interval (CI) 0.99-1.01]. Overall, the time to tracheal intubation was not different between the video laryngoscopes and direct laryngoscopy (standardised mean difference 0.19; 95% CI -0.37-0.75). However, in a subgroup analysis, video laryngoscopes shortened the time taken for difficult intubation (standardised mean difference, -0.75; 95% CI -1.24 to -0.25). CONCLUSION: Video laryngoscopes are a good alternative to direct laryngoscopy during tracheal intubation. The advantage seems to be more prominent when difficult intubation is encountered.


Assuntos
Intubação Intratraqueal/instrumentação , Intubação Intratraqueal/métodos , Laringoscópios , Laringoscopia/instrumentação , Laringoscopia/métodos , Ensaios Clínicos Controlados Aleatórios como Assunto , Gravação em Vídeo , Adulto , Criança , Pré-Escolar , Desenho de Equipamento , Medicina Baseada em Evidências , Feminino , Glote/anatomia & histologia , Humanos , Intubação Intratraqueal/efeitos adversos , Laringoscópios/efeitos adversos , Laringoscopia/efeitos adversos , Masculino , Pessoa de Meia-Idade , Fatores de Tempo
16.
Pharmacoepidemiol Drug Saf ; 20(7): 718-28, 2011 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-21626606

RESUMO

PURPOSE: Incidence rate (IR) estimates for peptic ulcer disease (PUD) vary widely among studies. We conducted a systematic review to quantify and examine the discrepancies. METHODS: Of 4780 articles identified from PubMed and EMBASE databases, 31 published in the last three decades that had reported IRs of PUD in the general population were included. Random effects meta-analysis and meta-regression were performed to calculate pooled estimates and to identify sources of heterogeneity. RESULTS: The pooled IR estimate per 1000 person-years was 0.90 (95% confidence interval: 0.78-1.04) for uncomplicated PUD, 0.57 (0.49-0.65) for peptic ulcer bleeding, 0.10 (0.08-0.13) for gastrointestinal perforations, and 3.18 (2.05-4.92) for nonspecific PUD. Within specific outcomes definitions, IR estimates were significantly lower in studies with restriction to hospitalized cases, case validation, and case ascertainment directly from hospital or clinical sources versus computerized health care databases. Younger age, female sex, and later calendar time were also associated with lower PUD incidence. CONCLUSIONS: We found that the IR of uncomplicated PUD was in the order of one case per 1000 person-years in the general population, and that the IR of peptic ulcer complications was around 0.7 cases per 1000 person-years. Comparisons of IR estimates among studies need to take into account disease definition and other study characteristics, particularly whether outcome validation was performed in computerized claims. The use of claims to identify PUD cases might overestimate the IR by around 45%.


Assuntos
Métodos Epidemiológicos , Úlcera Péptica/epidemiologia , Adulto , Fatores Etários , Idoso , Bases de Dados Factuais/estatística & dados numéricos , Feminino , Humanos , Incidência , Masculino , Pessoa de Meia-Idade , Úlcera Péptica/patologia , Análise de Regressão , Fatores de Risco , Fatores Sexuais , Estudos de Validação como Assunto
17.
Gastroenterology ; 141(1): 71-9, 2011 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-21458456

RESUMO

BACKGROUND & AIMS: We investigated the effect of different prevention strategies against upper gastrointestinal bleeding (UGIB) in the general population and in patients on antithrombotic or anti-inflammatory treatments. METHODS: We performed a population-based, nested, case-control study using The Health Improvement Network UK primary care database. From 2000 to 2007, we identified 2049 cases of UGIB and 20,000 controls. The relative risk (RR) of UGIB associated with various gastroprotective agents was estimated by comparing current use (defined as use within 30 days of the index date) with nonuse in the previous year, using multivariate logistic regression. RESULTS: The adjusted RR of UGIB associated with current use of proton pump inhibitors (PPIs) for more than 1 month was 0.58 (95% confidence interval [CI], 0.42-0.79) among patients who received low-dose acetylsalicylic acid (ASA), 0.18 (95% CI, 0.04-0.79) for clopidogrel, 0.17 (95% CI, 0.04-0.76) for dual antiplatelet therapy, 0.48 (95% CI, 0.22-1.04) for warfarin, and 0.51 (95% CI, 0.34-0.78) for nonsteroidal anti-inflammatory drugs. The corresponding estimates for therapy with histamine-2-receptor antagonists (H2RAs) were more unstable, but tended to be of a smaller magnitude. In the general population, PPI use was associated with a reduced risk of UGIB compared with nonuse (RR, 0.80; 95% CI, 0.68-0.94); no such reduction was observed for H2RAs or nitrates. CONCLUSIONS: PPI use was associated with a lower risk of UGIB in the general population and in patients on antithrombotic or anti-inflammatory therapy compared with nonuse of PPIs. The reduction in risks of UGIB was smaller in H2RA than in PPI users.


Assuntos
Anti-Inflamatórios/efeitos adversos , Fibrinolíticos/efeitos adversos , Hemorragia Gastrointestinal/prevenção & controle , Antagonistas dos Receptores Histamínicos H2/uso terapêutico , Inibidores da Bomba de Prótons/uso terapêutico , Adulto , Idoso , Idoso de 80 Anos ou mais , Estudos de Casos e Controles , Feminino , Hemorragia Gastrointestinal/induzido quimicamente , Humanos , Modelos Logísticos , Masculino , Pessoa de Meia-Idade , Nitratos/efeitos adversos , Medição de Risco , Fatores de Risco , Medicina Estatal , Resultado do Tratamento , Reino Unido
18.
Circulation ; 123(10): 1108-15, 2011 Mar 15.
Artigo em Inglês | MEDLINE | ID: mdl-21357821

RESUMO

BACKGROUND: This study evaluated the risk of upper gastrointestinal bleeding (UGIB) associated with use of low-dose acetylsalicylic acid (ASA) alone and in combination with other gastrotoxic medications. METHODS AND RESULTS: The Health Improvement Network UK primary care database was used to identify individuals 40 to 84 years of age with a UGIB diagnosis in 2000 to 2007 (n = 2049). An age-, sex-, and calendar year-matched control group (n = 20,000) was identified from the same source population. The relative risk (RR) of UGIB associated with use of low-dose ASA (75 to 300 mg/d), clopidogrel, and other commonly coadministered medications was estimated by multivariate logistic regression. The risk of UGIB was increased in current users of low-dose ASA (RR, 1.80; 95% confidence interval [CI], 1.59 to 2.03) or clopidogrel (RR, 1.67; 95% CI, 1.24 to 2.24) compared with nonusers. Compared with low-dose ASA monotherapy, the risk of UGIB was significantly increased when low-dose ASA was coadministered with clopidogrel (RR, 2.08; 95% CI, 1.34 to 3.21), oral anticoagulants (RR, 2.00; 95% CI, 1.15 to 3.45), low-/medium-dose nonsteroidal antiinflammatory drugs (RR, 2.63; 95% CI, 1.93 to 3.60), high-dose nonsteroidal antiinflammatory drugs (RR, 2.66; 95% CI, 1.88 to 3.76), or high-dose oral corticosteroids (RR, 4.43; 95% CI, 2.10 to 9.34); this was not apparent with coadministration of statins (RR, 0.99; 95% CI, 0.81 to 1.21) or low-dose oral corticosteroids (RR, 1.01; 95% CI, 0.58 to 1.77). CONCLUSIONS: Use of low-dose ASA is associated with an almost 2-fold increase in the risk of UGIB compared with nonuse. This risk is increased further in individuals taking low-dose ASA along with clopidogrel, oral anticoagulants, nonsteroidal antiinflammatory drugs, or high-dose oral corticosteroids.


Assuntos
Aspirina/efeitos adversos , Hemorragia Gastrointestinal/induzido quimicamente , Inibidores da Agregação de Plaquetas/efeitos adversos , Ticlopidina/análogos & derivados , Corticosteroides/efeitos adversos , Adulto , Idoso , Idoso de 80 Anos ou mais , Anti-Inflamatórios não Esteroides/administração & dosagem , Anti-Inflamatórios não Esteroides/efeitos adversos , Anticoagulantes/administração & dosagem , Anticoagulantes/efeitos adversos , Aspirina/administração & dosagem , Estudos de Casos e Controles , Clopidogrel , Estudos de Coortes , Quimioterapia Combinada , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Inibidores da Agregação de Plaquetas/administração & dosagem , Risco , Ticlopidina/administração & dosagem , Ticlopidina/efeitos adversos , Reino Unido
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