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1.
Pharmacol Res Perspect ; 8(6): e00664, 2020 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-33047487

RESUMO

The objective of this study was to evaluate the association between fluoroquinolone (FQ) use and the occurrence of aortic aneurysm/dissection (AA/AD), acute myocardial infarction (AMI), ventricular arrhythmias (VenA), and all-cause mortality vs other commonly used antibiotics. We conducted a self-controlled case series analysis of patients who experienced the outcomes of AA/AD, AMI, and VenA, based on diagnosis codes from emergency department visits and hospitalizations within Veterans Health Administration, and death in FY2014-FY2018. These Veterans also received outpatient prescriptions for FQs. Conditional Poisson regression models were used to estimate the association between FQs and each of the outcomes vs antibiotics of interest (ie amoxicillin or amoxicillin/clavulanate, azithromycin, doxycycline, cefuroxime or cephalexin, or sulfamethoxazole-trimethoprim), adjusted for time-varying covariates. Using a 30-day risk period after each antibiotic prescription, adjusted incidence rate ratios (aIRRs) for FQs vs each comparator antibiotic were not statistically different for outcomes of VenA or AMI. For AA/AD, incidence was higher during FQ risk periods vs amoxicillin [aIRR 1.50 (95% CI 1.01, 2.25)] and azithromycin [aIRR 2.15 (95% CI 1.27, 3.64)] risk periods. A significantly increased risk of mortality was observed with FQs vs each antibiotic of interest. FQs were associated with an increased risk of AA/AD vs amoxicillin and azithromycin and an increased risk of all-cause mortality vs multiple antibiotics commonly used for outpatient infections. Although the differences in event rates are small, FQ use should be limited to serious infections without appropriate alternatives.

2.
Artigo em Inglês | MEDLINE | ID: mdl-33012670

RESUMO

OBJECTIVES: The use of e-cigarettes is becoming more common in the United States. E-cigarettes are often refilled with nicotine-containing solutions of various concentrations purchased in local shops or on the Internet. There is evidence that the nicotine content in these solutions is often mislabeled; thus, we reviewed the available literature on this topic. DATA SOURCES: We conducted a systematic review of peer-reviewed articles published worldwide on e-liquid nicotine content accuracy using the databases CAB Direct, Cochrane Central Register of Controlled Trials, PubMed, and SPORTDiscus (EBSCO). STUDY SELECTION: Initial screening of titles and abstracts was conducted to determine relevancy for inclusion. Full-article reviews of studies involving the purchase and chemical analysis of nicotine content in refillable e-liquids were conducted for final inclusion. DATA EXTRACTION: Data extraction included e-liquid sample size, whether the samples were labeled to contain nicotine, whether the samples were purchased in retail shops or online, and the number and percentage of samples where the analyzed nicotine content fell outside 10% of the labeled nicotine content. RESULTS: Twenty articles described cross-sectional studies of purchased samples containing nicotine. The number of nicotine-containing e-liquid samples obtained in each study varied from 2 to 71. The percentage of samples with an analyzed nicotine concentration of more than 10% above or below the labeled nicotine concentration ranged from 0% to 100% (277/574 or 48.3%; median 46.85%). A large percentage of the samples deviated by 10% from the labeled nicotine concentrations in both U.S. and non-U.S. samples, with U.S. samples having a higher percentage. CONCLUSION: Our review shows that actual nicotine concentrations in e-liquids may vary considerably from labeled concentrations. Pharmacists should warn patients to be wary of the contents of e-cigarettes, and explain the dangers of using these products.

3.
J Gen Intern Med ; 2020 Sep 15.
Artigo em Inglês | MEDLINE | ID: mdl-32930938

RESUMO

BACKGROUND: Lean management has been successfully employed in healthcare to improve outcomes and efficiencies. Facilitation is increasingly being used to support evidence-based practice uptake in healthcare. However, while both Lean and Facilitation are used in healthcare quality improvement, limited research has explored their integration and the sustainability of their combined effects. OBJECTIVE: To improve hepatitis C virus (HCV) screening rates among persons born between 1945 and 1965 through the design and evaluation of a multi-modal Lean-Facilitation intervention (LFI) for Department of Veterans Affairs primary care community clinics. DESIGN: We conducted a mixed methods quasi-experimental evaluation in eight clinics, guided by the integrated Promoting Action on Research Implementation in Health Services framework. PARTICIPANTS: We engaged regional and local leadership (N = 9), implemented our LFI with clinicians and staff (N = 68), and conducted summative interviews with participants (N = 13). INTERVENTION: The LFI included six implementation strategies: (1) external facilitation, (2) stakeholder engagement, (3) champion activation, (4) rapid process improvement sessions, (5) Plan-Do-Study-Act cycles, and (6) audit-feedback. MEASURES: The primary outcome was rate of new HCV screening among previously untested patients with a primary care visit. Using interrupted time series, we analyzed intervention and time effects on HCV testing rates, and administered organizational readiness surveys, conducted summative qualitative interviews, and tracked facilitation events. RESULTS: The LFI was associated with significant, immediate, and sustained increases in HCV testing. No change was detected at matched comparison clinics. Staff accepted the LFI and the philosophy of "bottom-up" solution development yet had mixed feedback on its appropriateness and feasibility. Enablers of implementation and early sustainment included lower satisfaction with baseline HCV testing processes and staff culture, while later sustainment was related to implementation climate support, measurement, and evaluation. CONCLUSIONS: High-reach and relatively low effort, but persistent intervention led to significant improvement in guideline-concordant HCV testing rates which were sustained. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT02936648.

4.
PLoS One ; 15(8): e0237430, 2020.
Artigo em Inglês | MEDLINE | ID: mdl-32841307

RESUMO

BACKGROUND & AIMS: Given ongoing challenges in non-invasive non-alcoholic liver disease (NAFLD) diagnosis, we sought to validate an ALT-based NAFLD phenotype using measures readily available in electronic health records (EHRs) and population-based studies by leveraging the clinical and genetic data in the Million Veteran Program (MVP), a multi-ethnic mega-biobank of US Veterans. METHODS: MVP participants with alanine aminotransferases (ALT) >40 units/L for men and >30 units/L for women without other causes of liver disease were compared to controls with normal ALT. Genetic variants spanning eight NAFLD risk or ALT-associated loci (LYPLAL1, GCKR, HSD17B13, TRIB1, PPP1R3B, ERLIN1, TM6SF2, PNPLA3) were tested for NAFLD associations with sensitivity analyses adjusting for metabolic risk factors and alcohol consumption. A manual EHR review assessed performance characteristics of the NAFLD phenotype with imaging and biopsy data as gold standards. Genetic associations with advanced fibrosis were explored using FIB4, NAFLD Fibrosis Score and platelet counts. RESULTS: Among 322,259 MVP participants, 19% met non-invasive criteria for NAFLD. Trans-ethnic meta-analysis replicated associations with previously reported genetic variants in all but LYPLAL1 and GCKR loci (P<6x10-3), without attenuation when adjusted for metabolic risk factors and alcohol consumption. At the previously reported LYPLAL1 locus, the established genetic variant did not appear to be associated with NAFLD, however the regional association plot showed a significant association with NAFLD 279kb downstream. In the EHR validation, the ALT-based NAFLD phenotype yielded a positive predictive value 0.89 and 0.84 for liver biopsy and abdominal imaging, respectively (inter-rater reliability (Cohen's kappa = 0.98)). HSD17B13 and PNPLA3 loci were associated with advanced fibrosis. CONCLUSIONS: We validate a simple, non-invasive ALT-based NAFLD phenotype using EHR data by leveraging previously established NAFLD risk-associated genetic polymorphisms.


Assuntos
Alanina Transaminase/metabolismo , Hepatopatia Gordurosa não Alcoólica/patologia , 17-Hidroxiesteroide Desidrogenases/genética , Abdome/diagnóstico por imagem , Proteínas Adaptadoras de Transdução de Sinal/genética , Idoso , Alanina Transaminase/genética , Registros Eletrônicos de Saúde , Feminino , Loci Gênicos , Predisposição Genética para Doença , Variação Genética , Humanos , Lipase/genética , Fígado/patologia , Lisofosfolipase/genética , Masculino , Proteínas de Membrana/genética , Pessoa de Meia-Idade , Hepatopatia Gordurosa não Alcoólica/etnologia , Hepatopatia Gordurosa não Alcoólica/genética , Fenótipo , Fatores de Risco , Veteranos
5.
Nat Genet ; 52(7): 680-691, 2020 07.
Artigo em Inglês | MEDLINE | ID: mdl-32541925

RESUMO

We investigated type 2 diabetes (T2D) genetic susceptibility via multi-ancestry meta-analysis of 228,499 cases and 1,178,783 controls in the Million Veteran Program (MVP), DIAMANTE, Biobank Japan and other studies. We report 568 associations, including 286 autosomal, 7 X-chromosomal and 25 identified in ancestry-specific analyses that were previously unreported. Transcriptome-wide association analysis detected 3,568 T2D associations with genetically predicted gene expression in 687 novel genes; of these, 54 are known to interact with FDA-approved drugs. A polygenic risk score (PRS) was strongly associated with increased risk of T2D-related retinopathy and modestly associated with chronic kidney disease (CKD), peripheral artery disease (PAD) and neuropathy. We investigated the genetic etiology of T2D-related vascular outcomes in the MVP and observed statistical SNP-T2D interactions at 13 variants, including coronary heart disease (CHD), CKD, PAD and neuropathy. These findings may help to identify potential therapeutic targets for T2D and genomic pathways that link T2D to vascular outcomes.


Assuntos
Complicações do Diabetes/genética , Diabetes Mellitus Tipo 2/genética , Predisposição Genética para Doença , Afro-Americanos , Cromossomos Humanos X , Diabetes Mellitus Tipo 2/complicações , Diabetes Mellitus Tipo 2/tratamento farmacológico , Diabetes Mellitus Tipo 2/etnologia , Angiopatias Diabéticas/genética , Europa (Continente) , Feminino , Estudos de Associação Genética , Humanos , Hipoglicemiantes/uso terapêutico , Masculino , Polimorfismo de Nucleotídeo Único , Medição de Risco
6.
Circ Cardiovasc Qual Outcomes ; 13(5): e005993, 2020 05.
Artigo em Inglês | MEDLINE | ID: mdl-32393128

RESUMO

BACKGROUND: Use of phosphodiesterase-5 inhibitors (PDE5i) for groups 2 and 3 pulmonary hypertension (PH) is rising nationally, despite guidelines recommending against this low-value practice. Although receiving care across healthcare systems is encouraged to increase veterans' access to specialists critical for PH management, receiving care in 2 systems may increase risk of guideline-discordant prescribing. We sought to identify factors associated with prescribing of PDE5i for group 2/3 PH, particularly, to test the hypothesis that veterans prescribed PDE5i for PH in the community (through Medicare) will have increased risk of subsequently receiving potentially inappropriate treatment in Veterans Health Administration (VA). METHODS AND RESULTS: We constructed a retrospective cohort of 34 775 Medicare-eligible veterans with group 2/3 PH by linking national patient-level data from VA and Medicare from 2006 to 2015. We calculated adjusted odds ratios (ORs) of receiving daily PDE5i treatment for PH in VA using multivariable models with facility-specific random effects. In this cohort, 1556 veterans received VA prescriptions for PDE5i treatment for group 2/3 PH. Supporting our primary hypothesis, the variable most strongly associated with PDE5i treatment in VA for group 2/3 PH was prior treatment through Medicare (OR, 6.5 [95% CI, 4.9-8.7]). Other variables strongly associated with increased likelihood of VA treatment included more severe disease as indicated by recent right heart failure (OR, 3.3 [95% CI, 2.8-3.9]) or respiratory failure (OR, 3.7 [95% CI, 3.1-4.4]) and prior right heart catheterization (OR, 3.8 [95% CI, 3.4-4.3]). CONCLUSIONS: Our data suggest a missed opportunity to reassess treatment appropriateness when pulmonary hypertension patients seek prescriptions from VA-a relevant finding given policies promoting shared care across VA and community settings. Interventions are needed to reinforce awareness that pulmonary vasodilators are unlikely to benefit group 2/3 pulmonary hypertension patients and may cause harm.


Assuntos
Anti-Hipertensivos/uso terapêutico , Hipertensão Pulmonar/tratamento farmacológico , Prescrição Inadequada , Inibidores da Fosfodiesterase 5/uso terapêutico , Padrões de Prática Médica , Vasodilatadores/uso terapêutico , Idoso , Idoso de 80 Anos ou mais , Anti-Hipertensivos/efeitos adversos , Bases de Dados Factuais , Feminino , Fidelidade a Diretrizes , Humanos , Hipertensão Pulmonar/diagnóstico , Hipertensão Pulmonar/epidemiologia , Masculino , Medicare , Pessoa de Meia-Idade , Inibidores da Fosfodiesterase 5/efeitos adversos , Guias de Prática Clínica como Assunto , Estudos Retrospectivos , Medição de Risco , Fatores de Risco , Fatores de Tempo , Resultado do Tratamento , Estados Unidos/epidemiologia , Vasodilatadores/efeitos adversos , Serviços de Saúde para Veteranos Militares
8.
JAMA Netw Open ; 2(12): e1917141, 2019 12 02.
Artigo em Inglês | MEDLINE | ID: mdl-31825502

RESUMO

Importance: Androgen deficiency is common among male opioid users, and opioid use has emerged as a common antecedent of testosterone treatment. The long-term health outcomes associated with testosterone therapy remain unknown, however. Objective: To compare health outcomes between long-term opioid users with testosterone deficiency who filled testosterone prescriptions and those with the same condition but who did not receive testosterone treatment. Design, Setting, and Participants: This cohort study focused on men in the care of the Veterans Health Administration (VHA) facilities throughout the United States from October 1, 2008, to September 30, 2014. It included male veterans who were long-term opioid users, had low testosterone levels (<300 ng/dL), and received either a testosterone prescription or any other prescription. It excluded male patients with HIV infection, gender dysphoria, or prostate cancer and those who received testosterone in fiscal year 2008. Data were analyzed from April 1, 2017, to April 30, 2019. Exposure: Prescription for testosterone. Main Outcomes and Measures: All-cause mortality and incidence of major adverse cardiovascular events (MACE), vertebral or femoral fractures, and anemia during the 6-year follow-up through September 30, 2015. Results: After exclusions, 21 272 long-term opioid users (mean [SD] age, 53 [10] years; n = 16 689 [78.5%] white) with low total or free testosterone levels were included for analysis, of whom 14 121 (66.4%) received testosterone and 7151 (33.6%) did not. At baseline, compared with opioid users who did not receive testosterone, long-term opioid users who received testosterone treatment were more likely to have obesity (43.7% vs 49.0%; P < .001), hyperlipidemia (43.0% vs 48.8%; P < .001), and hypertension (53.9% vs 55.2%; P = .07) but had lower prevalence of coronary artery disease (15.9% vs 12.9%; P < .001) and stroke (2.4% vs 1.3%; P < .001). After adjusting for covariates, opioid users who received testosterone had significantly lower all-cause mortality (hazard ratio [HR] = 0.51; 95% CI, 0.42-0.61) and lower incidence of MACE (HR = 0.58; 95% CI, 0.51-0.67), femoral or hip fractures (HR = 0.68; 95% CI, 0.48-0.96), and anemia (HR = 0.73; 95% CI, 0.68-0.79) during the follow-up period of up to 6 years, compared with their counterparts without a testosterone prescription. In covariate-adjusted models, men who received opioids plus testosterone were more likely to have resolved anemia compared with those who received opioids only during the 6-year follow-up (HR = 1.16; 95% CI, 1.02-1.31). Similar results were obtained in propensity score-matched models and when analyses were restricted to opioid users with noncancer pain or those who did not receive glucocorticoids. Conclusions and Relevance: This study found that, in the VHA system, male long-term opioid users with testosterone deficiency who were treated with opioid and testosterone medications had significantly lower all-cause mortality and significantly lower incidence of MACE, femoral or hip fractures, and anemia after a multiyear follow-up. These results warrant confirmation through a randomized clinical trial to ascertain the efficacy of testosterone in improving health outcomes for opioid users with androgen deficiency.


Assuntos
Androgênios/deficiência , Androgênios/uso terapêutico , Doenças do Sistema Endócrino/tratamento farmacológico , Transtornos Relacionados ao Uso de Opioides/complicações , Testosterona/deficiência , Testosterona/uso terapêutico , Saúde dos Veteranos , Adulto , Idoso , Idoso de 80 Anos ou mais , Doenças Cardiovasculares/epidemiologia , Doenças Cardiovasculares/etiologia , Causas de Morte , Doenças do Sistema Endócrino/etiologia , Doenças do Sistema Endócrino/mortalidade , Fraturas do Fêmur/epidemiologia , Fraturas do Fêmur/etiologia , Seguimentos , Humanos , Incidência , Masculino , Pessoa de Meia-Idade , Transtornos Relacionados ao Uso de Opioides/mortalidade , Fraturas da Coluna Vertebral/epidemiologia , Fraturas da Coluna Vertebral/etiologia , Resultado do Tratamento , Estados Unidos
9.
Nat Genet ; 51(11): 1574-1579, 2019 11.
Artigo em Inglês | MEDLINE | ID: mdl-31676865

RESUMO

Venous thromboembolism is a significant cause of mortality1, yet its genetic determinants are incompletely defined. We performed a discovery genome-wide association study in the Million Veteran Program and UK Biobank, with testing of approximately 13 million DNA sequence variants for association with venous thromboembolism (26,066 cases and 624,053 controls) and meta-analyzed both studies, followed by independent replication with up to 17,672 venous thromboembolism cases and 167,295 controls. We identified 22 previously unknown loci, bringing the total number of venous thromboembolism-associated loci to 33, and subsequently fine-mapped these associations. We developed a genome-wide polygenic risk score for venous thromboembolism that identifies 5% of the population at an equivalent incident venous thromboembolism risk to carriers of the established factor V Leiden p.R506Q and prothrombin G20210A mutations. Our data provide mechanistic insights into the genetic epidemiology of venous thromboembolism and suggest a greater overlap among venous and arterial cardiovascular disease than previously thought.


Assuntos
Loci Gênicos , Predisposição Genética para Doença , Estudo de Associação Genômica Ampla , Inibidor 1 de Ativador de Plasminogênio/metabolismo , Doenças Vasculares/genética , Tromboembolia Venosa/genética , Idoso , Animais , Estudos de Casos e Controles , Feminino , Humanos , Masculino , Camundongos , Camundongos Endogâmicos C57BL , Pessoa de Meia-Idade , Inibidor 1 de Ativador de Plasminogênio/genética , Fatores de Risco , Reino Unido/epidemiologia , Doenças Vasculares/epidemiologia , Doenças Vasculares/patologia , Tromboembolia Venosa/epidemiologia , Tromboembolia Venosa/patologia
10.
Am J Pharm Educ ; 83(5): 6754, 2019 06.
Artigo em Inglês | MEDLINE | ID: mdl-31333252

RESUMO

Objective. To determine whether pharmacy students' prior beliefs and attitudes about drug products and dietary supplements affected their ability to analyze the quality of research study abstracts and use them in making drug recommendations to patients. Methods. Fifty-nine Doctor of Pharmacy (PharmD) students in a drug literature course were randomly assigned to receive one of two forms to evaluate four drug literature abstracts of varying quality and study design. On each form, there were two abstracts that had been taken directly from published research studies and two abstracts in which a different product had been substituted for the actual product studied. Pharmacy students completed a questionnaire about the studies to determine whether their evaluation of quality was affected by their prior opinions about the products. Results. Students correctly recognized the relative quality of the studies. However, after reading abstracts of research articles that were identical except for the product named, students were still more likely to recommend drugs approved by the Food and Drug Administration than dietary supplements. Conclusion. Pharmacy students' evaluation of clinical research studies was mildly influenced by confirmation bias but more so by the quality of the research.


Assuntos
Educação em Farmácia/métodos , Conhecimentos, Atitudes e Prática em Saúde , Estudantes de Farmácia/psicologia , Atitude , Viés , Suplementos Nutricionais , Humanos , Percepção , Publicações , Inquéritos e Questionários
11.
Circulation ; 140(12): 1031-1040, 2019 09 17.
Artigo em Inglês | MEDLINE | ID: mdl-31337231

RESUMO

BACKGROUND: Approximately 13% of black individuals carry 2 copies of the apolipoprotein L1 (APOL1) risk alleles G1 or G2, which are associated with 1.5- to 2.5-fold increased risk of chronic kidney disease. There have been conflicting reports as to whether an association exists between APOL1 risk alleles and cardiovascular disease (CVD) that is independent of the effects of APOL1 on kidney disease. We sought to test the association of APOL1 G1/G2 alleles with coronary artery disease, peripheral artery disease, and stroke among black individuals in the Million Veteran Program. METHODS: We performed a time-to-event analysis of retrospective electronic health record data using Cox proportional hazard and competing-risks Fine and Gray subdistribution hazard models. The primary exposure was APOL1 risk allele status. The primary outcome was incident coronary artery disease among individuals without chronic kidney disease during the 12.5-year follow-up period. We separately analyzed the cross-sectional association of APOL1 risk allele status with lipid traits and 115 cardiovascular diseases using phenome-wide association. RESULTS: Among 30 903 black Million Veteran Program participants, 3941 (13%) carried the 2 APOL1 risk allele high-risk genotype. Individuals with normal kidney function at baseline with 2 risk alleles had slightly higher risk of developing coronary artery disease compared with those with no risk alleles (hazard ratio, 1.11 [95% CI, 1.01-1.21]; P=0.039). Similarly, modest associations were identified with incident stroke (hazard ratio, 1.20 [95% CI, 1.05-1.36; P=0.007) and peripheral artery disease (hazard ratio, 1.15 [95% CI, 1.01-1.29l; P=0.031). When both cardiovascular and renal outcomes were modeled, APOL1 was strongly associated with incident renal disease, whereas no significant association with the CVD end points could be detected. Cardiovascular phenome-wide association analyses did not identify additional significant associations with CVD subsets. CONCLUSIONS: APOL1 risk variants display a modest association with CVD, and this association is likely mediated by the known APOL1 association with chronic kidney disease.


Assuntos
Afro-Americanos , Apolipoproteína L1/genética , Doença da Artéria Coronariana/genética , Genótipo , Infarto do Miocárdio/genética , Doença Arterial Periférica/genética , Adulto , Alelos , Doença da Artéria Coronariana/epidemiologia , Registros Eletrônicos de Saúde , Feminino , Predisposição Genética para Doença , Humanos , Incidência , Masculino , Pessoa de Meia-Idade , Infarto do Miocárdio/epidemiologia , Doença Arterial Periférica/epidemiologia , Polimorfismo Genético , Estudos Retrospectivos , Risco , Estados Unidos/epidemiologia , Veteranos
12.
Nat Med ; 25(8): 1274-1279, 2019 08.
Artigo em Inglês | MEDLINE | ID: mdl-31285632

RESUMO

Peripheral artery disease (PAD) is a leading cause of cardiovascular morbidity and mortality; however, the extent to which genetic factors increase risk for PAD is largely unknown. Using electronic health record data, we performed a genome-wide association study in the Million Veteran Program testing ~32 million DNA sequence variants with PAD (31,307 cases and 211,753 controls) across veterans of European, African and Hispanic ancestry. The results were replicated in an independent sample of 5,117 PAD cases and 389,291 controls from the UK Biobank. We identified 19 PAD loci, 18 of which have not been previously reported. Eleven of the 19 loci were associated with disease in three vascular beds (coronary, cerebral, peripheral), including LDLR, LPL and LPA, suggesting that therapeutic modulation of low-density lipoprotein cholesterol, the lipoprotein lipase pathway or circulating lipoprotein(a) may be efficacious for multiple atherosclerotic disease phenotypes. Conversely, four of the variants appeared to be specific for PAD, including F5 p.R506Q, highlighting the pathogenic role of thrombosis in the peripheral vascular bed and providing genetic support for Factor Xa inhibition as a therapeutic strategy for PAD. Our results highlight mechanistic similarities and differences among coronary, cerebral and peripheral atherosclerosis and provide therapeutic insights.


Assuntos
Estudo de Associação Genômica Ampla , Doença Arterial Periférica/genética , Idoso , LDL-Colesterol/genética , Fator V/genética , Inibidores do Fator Xa/uso terapêutico , Predisposição Genética para Doença , Humanos , Pessoa de Meia-Idade , Receptores de LDL/genética , Veteranos
14.
West J Nurs Res ; 41(8): 1184-1202, 2019 08.
Artigo em Inglês | MEDLINE | ID: mdl-30774036

RESUMO

Tobacco use and exposure to secondhand smoke (SHS) remain leading causes of preventable disease, disability, and mortality in the United States. Rural populations are among those being left behind in the recent declining smoking rates and have become a focus of discussions on tobacco-related disparities. This article describes tobacco-related disparities in rural populations including tobacco use, exposure to SHS, smoke-free policies, and tobacco taxes. Nurses, as social justice and tobacco control policy advocates, are needed especially at the local level, where much of the policy work occurs and where nursing's voice is respected and can be powerful.


Assuntos
Disparidades em Assistência à Saúde , População Rural , Política Antifumo , Impostos/economia , Uso de Tabaco/efeitos adversos , Doença Crônica/prevenção & controle , Humanos , Papel do Profissional de Enfermagem/psicologia , Justiça Social , Inquéritos e Questionários , Poluição por Fumaça de Tabaco/efeitos adversos , Estados Unidos
16.
Chiropr Man Therap ; 26: 45, 2018.
Artigo em Inglês | MEDLINE | ID: mdl-30534361

RESUMO

Background: Tobacco use remains a leading cause of death and disability in the United States. Health professionals need to address the use of tobacco products by their patients, but chiropractic clinical systems often remain unsupported and underappreciated in their role to facilitate tobacco use cessation. Methods: This pilot study tested an intervention to assist a chiropractic community to implement sustainable health systems changes for tobacco use based on U.S. Public Health Service guidelines. Chiropractors were educated on the Ask, Advise, Refer (AAR) approach, provided with ongoing guidance, and followed for six months to assess systems change. The study was conducted from March 2016 to July 2017. Results: Evidence of a systematic process in place to conduct AAR was present in all clinics by the end of the fourth month of the intervention period. Although no clinic had sustained health system change for full AAR, all six of the clinics made progress in the individual AAR components. Furthermore, five clinics achieved sustained system change for the Ask component, as after systems change was achieved, the rate of tobacco user identifications did not drop below 50%. For the Advise component, five clinics succeeded in having individual months of ≥50% of tobacco users being advised, and three clinics achieved the formal definition of systems change. For the Refer component, no clinic achieved system change, although four had individual months of ≥50% of tobacco users being referred. The patient quit rate was 13.3% (n = 15) for the 30-day follow-up and 16.7% (n = 6) for the three-month follow-up. Conclusions: This study demonstrates the feasibility of implementing a health systems change in the chiropractic setting to identify tobacco users, to advise them to quit, and to refer users for cessation services.


Assuntos
Quiroprática , Aconselhamento , Pessoal de Saúde/educação , Encaminhamento e Consulta , Abandono do Hábito de Fumar/métodos , Fumar , Uso de Tabaco , Adulto , Instituições de Assistência Ambulatorial , Terapias Complementares , Estudos de Viabilidade , Feminino , Fidelidade a Diretrizes , Comportamentos Relacionados com a Saúde , Promoção da Saúde , Humanos , Masculino , Pessoa de Meia-Idade , Projetos Piloto , Abandono do Uso de Tabaco/métodos , Tabagismo/prevenção & controle , Estados Unidos
17.
Am J Manag Care ; 24(11): 536-540, 2018 11.
Artigo em Inglês | MEDLINE | ID: mdl-30452210

RESUMO

OBJECTIVES: The aim of this study was to evaluate whether veterans in Massachusetts receiving opioids and/or benzodiazepines from both Veterans Health Administration (VHA) and non-VHA pharmacies are at higher risk of adverse events compared with those receiving opioids at VHA pharmacies only. STUDY DESIGN: A cohort study of veterans who filled a prescription for any Schedule II through V substance at a Massachusetts VHA pharmacy. Prescriptions were recorded in the Massachusetts Department of Public Health Chapter 55 data set. METHODS: The study sample included 16,866 veterans residing in Massachusetts, of whom 9238 (54.8%) received controlled substances from VHA pharmacies only and 7628 (45.2%) had filled prescriptions at both VHA and non-VHA pharmacies ("dual care users") between October 1, 2013, and December 31, 2015. Our primary outcomes were nonfatal opioid overdose, fatal opioid overdose, and all-cause mortality. RESULTS: Compared with VHA-only users, more dual care users resided in rural areas (12.6% vs 10.6%), received high-dose opioid therapy (26.3% vs 7.3%), had concurrent prescriptions of opioids and benzodiazepines (34.8% vs 8.2%), and had opioid use disorder (6.8% vs 1.6%) (P <.0001 for all). In adjusted models, dual care users had higher odds of nonfatal opioid overdose (odds ratio [OR], 1.29; 95% CI, 0.98-1.71) and all-cause mortality (OR, 1.66; 95% CI, 1.43-1.93) compared with VHA-only users. Dual care use was not associated with fatal opioid overdoses. CONCLUSIONS: Among veterans in Massachusetts, receipt of opioids from multiple sources was associated with worse outcomes, specifically nonfatal opioid overdose and mortality. Better information sharing between VHA and non-VHA pharmacies and prescribers has the potential to improve patient safety.


Assuntos
Analgésicos Opioides/envenenamento , Benzodiazepinas/envenenamento , Overdose de Drogas/epidemiologia , Transtornos Relacionados ao Uso de Opioides/epidemiologia , Farmácias/estatística & dados numéricos , Veteranos/estatística & dados numéricos , Adulto , Fatores Etários , Idoso , Idoso de 80 Anos ou mais , Comorbidade , Overdose de Drogas/mortalidade , Feminino , Humanos , Masculino , Massachusetts , Transtornos Mentais/epidemiologia , Saúde Mental , Pessoa de Meia-Idade , Transtornos Relacionados ao Uso de Opioides/mortalidade , Características de Residência , Fatores Sexuais , Fatores Socioeconômicos , Estados Unidos , United States Department of Veterans Affairs/estatística & dados numéricos
18.
Diabetes Ther ; 9(4): 1431-1440, 2018 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-29808360

RESUMO

INTRODUCTION: Among the most pressing clinical decisions in type 2 diabetes treatments are which drugs should be used after metformin is no longer sufficient, and whether sulfonylureas (SUs) should remain as a suitable second-line treatment. In this article we summarize current evidence on the long-term safety risks associated with SU therapy relative to other oral glucose-lowering therapies. METHODS: The MEDLINE database and Clinicaltrials.gov were searched for observational and experimental studies comparing the safety of SUs to that of other diabetes medications in people with type 2 diabetes mellitus through December 15, 2015. Studies with at least 1 year of follow-up, which explicitly examined major cardiovascular events or death in patients who showed no evidence of serious conditions at baseline, were selected for inclusion in meta-analyses. RESULTS: SU treatment was associated with an elevated risk relative to treatment with metformin (METF), thiazolidinedione (TZD), dipeptidyl peptidase-4 inhibitor (DPP-4), and glucagon-like peptide-1 (GLP-1) agonist classes, either when compared alone (as a monotherapy) or when used in combination with METF. Significant findings were almost entirely derived from nontrial data and not confirmed by smaller, efficacy designed randomized controlled trials whose effects were in the same direction but much more imprecise. CONCLUSION: Although much of the evidence is derived and will continue to come from observational studies, the methodological rigor of such studies is questionable. A key challenge for evaluators is the extent to which they should incorporate evidence from study designs that are quasi-experimental.

19.
Am J Manag Care ; 24(3): e61-e72, 2018 03 01.
Artigo em Inglês | MEDLINE | ID: mdl-29553279

RESUMO

OBJECTIVES: To describe the prevalence and incidence of opioid and nonsteroidal anti-inflammatory drug (NSAID) use before and since the start of the Veterans Health Administration (VHA) Opioid Safety Initiative (OSI) and to assess rates of adverse events (AEs). STUDY DESIGN: Historical cohort study. METHODS: The OSI began in August 2012 and was fully implemented by the end of fiscal year (FY) 2013. The study timeframe was categorized into baseline (FY 2011-2012), transition (FY 2013), and postimplementation (FY 2014-2015) phases. Prevalence and incidence rates were calculated for opioid and NSAID users by quarter between FY 2011 and FY 2015. For AEs among new users of an NSAID or opioid, Cox proportional hazards models with inverse probability weighting were used to adjust for potential confounding. RESULTS: There were 3,315,846 regular users of VHA care with at least 1 opioid and/or NSAID outpatient prescription between FYs 2011 and 2015. The quarterly opioid prevalence rate was approximately 21% during the baseline and transition phases, then decreased to 17.3% in the postimplementation phase. NSAID prevalence remained constant at about 16%. Opioid incidence rates gradually decreased (2.7% to 2.2%) during the study, whereas NSAID incidence rates remained about 2.2%. After inverse probability weighting, patients receiving opioids had a greater risk of cardiovascular events (hazard ratio [HR], 1.41; 95% CI, 1.36-1.47), acute kidney injury (HR, 2.60; 95% CI, 2.51-2.68), gastrointestinal bleeding (HR, 1.68; 95% CI, 1.56-1.81), and all-cause mortality (HR, 3.73; 95% CI, 3.60-3.87) than NSAID users. CONCLUSIONS: Opioid use declined following implementation of the OSI, whereas NSAID use remained constant. Rates of AEs were higher among opioid users, which provides additional rationale for efforts to use NSAIDs for pain management when appropriate.


Assuntos
Analgésicos Opioides/efeitos adversos , Anti-Inflamatórios não Esteroides/efeitos adversos , United States Department of Veterans Affairs/estatística & dados numéricos , Adolescente , Adulto , Idoso , Uso de Medicamentos/estatística & dados numéricos , Feminino , Humanos , Incidência , Masculino , Pessoa de Meia-Idade , Prevalência , Modelos de Riscos Proporcionais , Estados Unidos , Adulto Jovem
20.
Ann Am Thorac Soc ; 15(6): 693-701, 2018 06.
Artigo em Inglês | MEDLINE | ID: mdl-29485908

RESUMO

RATIONALE: Care of patients with pulmonary hypertension is complex. Although pulmonary vasodilators are effective for Group 1 pulmonary hypertension, clinical guidelines and the Choosing Wisely Campaign recommend against routine use for Groups 2 and 3 pulmonary hypertension (the most common types of pulmonary hypertension) because of a lack of benefit, potential for harm, and high cost ($10,000-$13,000 per patient per year treated). Little is known about how these medications are used in practice. OBJECTIVES: To determine national patterns of phosphodiesterase-5 inhibitor prescribing for pulmonary hypertension in the Veterans Health Administration. METHODS: Retrospective analysis of Veterans prescribed phosphodiesterase-5 inhibitor for pulmonary hypertension between 2005 and 2012 at any Veterans Health Administration site. Patients were identified by presence of an International Classification of Diseases, Ninth Revision, Clinical Modification diagnosis code for pulmonary hypertension and one or more outpatient prescriptions for daily phosphodiesterase-5 inhibitor therapy. We developed and validated, using gold-standard chart abstraction, an International Classification of Diseases, Ninth Revision, Clinical Modification-based algorithm to assign pulmonary hypertension group. Our primary outcome was the proportion of patients who received potentially inappropriate phosphodiesterase-5 inhibitor, as determined by guideline recommendations (Group 1 pulmonary hypertension: appropriate; Groups 2/3: potentially inappropriate; Groups 4/5: uncertain value), among all patients prescribed phosphodiesterase-5 inhibitor for pulmonary hypertension. Secondary outcomes included proportion of treated patients who received guideline-recommended right heart catheterization. RESULTS: Among 108,777 Veterans with pulmonary hypertension, 2,790 (2.6% [95% confidence interval, 2.5-2.7%]) received daily phosphodiesterase-5 inhibitor therapy. Among treated patients, 541 (19.4% [95% confidence interval, 18.0-20.9%]) received appropriate treatment, 1,711 (61.3% [95% confidence interval, 59.5-63.1%]) potentially inappropriate treatment, and 358 (12.8% [95% confidence interval, 11.6-14.1%]) treatment of uncertain value. The number of potentially inappropriately treated patients per year increased substantially over the study period (53 in 2005, 748 in 2012). On the basis of chart abstraction in a randomly selected subset of patients treated with phosphodiesterase-5 inhibitor, half (110 of 230, 47.8% [95% confidence interval, 41.3-54.5%]) had documented right heart catheterization to confirm presence or type of pulmonary hypertension. After factoring presence of and data from right heart catheterization into our treatment appropriateness algorithm, only 11.7% (95% confidence interval, 8.0-16.8%) received clearly appropriate treatment. CONCLUSIONS: Most Veterans with pulmonary hypertension do not receive phosphodiesterase-5 inhibitor therapy. However, among treated Veterans, almost two-thirds of phosphodiesterase-5 inhibitor prescriptions are inconsistent with pulmonary hypertension guidelines, exposing patients to potential harm and creating a financial burden on the healthcare system. Further study is warranted to clarify the effects of these prescription patterns on pulmonary hypertension outcomes.


Assuntos
Prescrições de Medicamentos/estatística & dados numéricos , Hipertensão Pulmonar/tratamento farmacológico , Inibidores da Fosfodiesterase 5/uso terapêutico , Guias de Prática Clínica como Assunto , Idoso , Feminino , Seguimentos , Humanos , Hipertensão Pulmonar/fisiopatologia , Masculino , Pessoa de Meia-Idade , Pressão Propulsora Pulmonar/fisiologia , Estudos Retrospectivos , Resultado do Tratamento , Estados Unidos , Veteranos
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