Your browser doesn't support javascript.
loading
Mostrar: 20 | 50 | 100
Resultados 1 - 20 de 109
Filtrar
1.
J Gen Intern Med ; 2021 Jun 07.
Artigo em Inglês | MEDLINE | ID: mdl-34100230

RESUMO

BACKGROUND: Cigarette smoking is a risk factor for severe COVID-19 disease. Understanding smokers' responses to the pandemic will help assess its public health impact and inform future public health and provider messages to smokers. OBJECTIVE: To assess risk perceptions and change in tobacco use among current and former smokers during the COVID-19 pandemic. DESIGN: Cross-sectional survey conducted in May-July 2020 (55% response rate) PARTICIPANTS: 694 current and former daily smokers (mean age 53, 40% male, 78% white) who had been hospitalized pre-COVID-19 and enrolled into a smoking cessation clinical trial at hospitals in Massachusetts, Pennsylvania, and Tennessee. MAIN MEASURES: Perceived risk of COVID-19 due to tobacco use; changes in tobacco consumption and interest in quitting tobacco use; self-reported quitting and relapse since January 2020. KEY RESULTS: 68% (95% CI, 65-72%) of respondents believed that smoking increases the risk of contracting COVID-19 or having a more severe case. In adjusted analyses, perceived risk was higher in Massachusetts where COVID-19 had already surged than in Pennsylvania and Tennessee which were pre-surge during survey administration (AOR 1.56, 95% CI, 1.07-2.28). Higher perceived COVID-19 risk was associated with increased interest in quitting smoking (AOR 1.72, 95% CI 1.01-2.92). During the pandemic, 32% (95% CI, 27-37%) of smokers increased, 37% (95% CI, 33-42%) decreased, and 31% (95% CI, 26-35%) did not change their cigarette consumption. Increased smoking was associated with higher perceived stress (AOR 1.49, 95% CI 1.16-1.91). Overall, 11% (95% CI, 8-14%) of respondents who smoked in January 2020 (pre-COVID-19) had quit smoking at survey (mean, 6 months later) while 28% (95% CI, 22-34%) of former smokers relapsed. Higher perceived COVID-19 risk was associated with higher odds of quitting and lower odds of relapse. CONCLUSIONS: Most smokers believed that smoking increased COVID-19 risk. Smokers' responses to the pandemic varied, with increased smoking related to stress and increased quitting associated with perceived COVID-19 vulnerability.

2.
J Addict Med ; 2021 Jun 17.
Artigo em Inglês | MEDLINE | ID: mdl-34145185

RESUMO

INTRODUCTION: Emergency department (ED) initiated opioid use disorder (OUD) care is effective; however, real-world predictors of patient engagement are lacking. OBJECTIVE: This program evaluation examined predictors of ED-based OUD treatment and subsequent engagement. METHOD: Program evaluation in Boston, MA. Adult patients who met criteria for OUD during an ED visit in 2019 were included. Patients were included if a diagnosis of OUD or opioid-related overdose was associated with the ED visit or if they met previously validated criteria for OUD within the previous 12 months. We assessed predictors of ED-OUD treatment receipt and subsequent engagement, using Healthcare Effectiveness Data and Information Set definition of initial encounter within 14 days of discharge and either 2 subsequent encounters or a subsequent buprenorphine prescription within 34 days of the initial encounter. We used generalized estimating equations for panel data. RESULTS: During 2019, 1946 patients met criteria for OUD. Referrals to Bridge Clinic were made for 207 (11%), buprenorphine initiated for 106 (5%), and home induction buprenorphine kits given to 56 (3%). Following ED discharge, 237 patients (12%) had a visit within 14 days, 122 (6%) had ≥2 additional visits, and 207 (11%) received a subsequent buprenorphine prescription. Young, White, male patients were most likely to receive ED-OUD care. Patients who received ED-OUD care were more likely to have subsequent treatment engagement (adjusted rate ratio: 2.30, 95% confidence intervals: 1.62-3.27). Referrals were made less often than predicted for Black (-49%) or Hispanic/Latinx (-25%) patients. CONCLUSIONS: Initiating treatment for OUD in the ED was associated with increased engagement in outpatient addiction care.

3.
Sci Adv ; 7(24)2021 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-34117054

RESUMO

The current opioid epidemic warrants a better understanding of genetic and environmental factors that contribute to opioid addiction. Here we report an increased prevalence of vitamin D (VitD) deficiency in patients diagnosed with opioid use disorder and an inverse and dose-dependent association of VitD levels with self-reported opioid use. We used multiple pharmacologic approaches and genetic mouse models and found that deficiencies in VitD signaling amplify exogenous opioid responses that are normalized upon restoration of VitD signaling. Similarly, physiologic endogenous opioid analgesia and reward responses triggered by ultraviolet (UV) radiation are repressed by VitD signaling, suggesting that a feedback loop exists whereby VitD deficiency produces increased UV/endorphin-seeking behavior until VitD levels are restored by cutaneous VitD synthesis. This feedback may carry the evolutionary advantage of maximizing VitD synthesis. However, unlike UV exposure, exogenous opioid use is not followed by VitD synthesis (and its opioid suppressive effects), contributing to maladaptive addictive behavior.

4.
J Acquir Immune Defic Syndr ; 87(5): 1119-1127, 2021 08 15.
Artigo em Inglês | MEDLINE | ID: mdl-33871409

RESUMO

BACKGROUND: Although many patients with Kaposi sarcoma (KS) in sub-Saharan Africa are diagnosed with AIDS Clinical Trials Group (ACTG) T1 disease, T1 staging insufficiently captures clinical heterogeneity of advanced KS. Using a representative community-based sample, we detailed disease severity at diagnosis to inform KS staging and treatment in sub-Saharan Africa. METHODS: We performed rapid case ascertainment on people living with HIV, aged 18 years or older, newly diagnosed with KS from 2016 to 2019 at 3 clinic sites in Kenya and Uganda to ascertain disease stage as close as possible to diagnosis. We reported KS severity using ACTG and WHO staging criteria and detailed measurements that are not captured in the current staging systems. RESULTS: We performed rapid case ascertainment within 1 month for 241 adults newly diagnosed with KS out of 389 adult patients with suspected KS. The study was 68% men with median age 35 years and median CD4 count 239. Most of the patients had advanced disease, with 82% qualifying as ACTG T1 and 64% as WHO severe/symptomatic KS. The most common ACTG T1 qualifiers were edema (79%), tumor-associated ulceration (24%), extensive oral KS (9%), pulmonary KS (7%), and gastrointestinal KS (4%). There was marked heterogeneity within T1 KS, with 25% of patients having 2 T1 qualifying symptoms and 3% having 3 or more. CONCLUSION: Most of the patients newly diagnosed with KS had advanced stage disease, even in the current antiretroviral therapy "treat-all" era. We observed great clinical heterogeneity among advanced stage patients, leading to questions about whether all patients with advanced KS require the same treatment strategy.


Assuntos
Sarcoma de Kaposi/patologia , Adulto , Feminino , Infecções por HIV/complicações , Humanos , Quênia , Masculino , Estadiamento de Neoplasias , Sarcoma de Kaposi/complicações , Índice de Gravidade de Doença , Uganda
5.
J Subst Abuse Treat ; 122: 108248, 2021 03.
Artigo em Inglês | MEDLINE | ID: mdl-33509420

RESUMO

Recovery coaches, trained peers with a history of substance use disorder (SUD) who are formally embedded in the health care team, may be a cost-effective approach to support outpatient management of SUD treatment. Although recovery coach programs are scaling nationwide, limited data exist to support their impact on costs or clinical outcomes. This study aimed to evaluate the integration of peer recovery coaches in general medical settings. Staff hired and trained nine recovery coaches as a part of a health system-wide effort to redesign SUD care. We examined reductions in acute care utilization and increases in outpatient treatment utilization among patients connected to a recovery coach. Additionally, we examined buprenorphine treatment engagement and opioid abstinence among a subset of patients who initiated buprenorphine prior to or within 30 days of their first recovery coach contact. We hypothesized recovery coach contact would strengthen outpatient SUD treatment and be associated with reductions in SUD severity and preventable acute care utilization. We included patients with an initial recovery coach contact between January 2015 and September 2017 in the main analyses (N = 1171). We assessed utilization outcomes via medical records over one year, comparing the six months before and after first recovery coach contact. We used chart review to extract toxicology results and buprenorphine treatment engagement for the subset of patients initiated on buprenorphine (n = 135). In the six months following recovery coach contact, there was a 44% decrease in patients hospitalized and a 9% decrease in patients with an ED visit. There was a 66% increase in outpatient utilization across primary care, community health center visits, mental health, and laboratory visits. Among patients who initiated buprenorphine, current recovery coach contact was associated with significantly increased odds of buprenorphine treatment engagement (OR = 1.89; 95% CI: 1.49-2.39; p < 0.001) and opioid abstinence (OR = 1.32; 95% CI: 1.02-1.70; p < 0.001). Recovery coaches may be an impactful and potentially cost-effective addition to an SUD care team, but future research is needed that uses a matched comparison condition.


Assuntos
Buprenorfina , Transtornos Relacionados ao Uso de Opioides , Assistência Ambulatorial , Analgésicos Opioides/uso terapêutico , Buprenorfina/uso terapêutico , Humanos , Tratamento de Substituição de Opiáceos , Transtornos Relacionados ao Uso de Opioides/tratamento farmacológico
6.
Addict Behav ; 115: 106794, 2021 04.
Artigo em Inglês | MEDLINE | ID: mdl-33385757

RESUMO

AIMS: Among people with cancer, dual alcohol and tobacco use increases risk for morbidity and mortality. Most smoking cessation clinical trials with this patient population have excluded individuals with problematic alcohol use. This investigation examined whether problematic alcohol use affects smoking cessation in cancer patients. METHODS: Mixed-methods secondary analysis of data from the Smokefree Support Study, a randomized-controlled trial examining the efficacy of Intensive (IT; n = 153) vs. Standard Treatment (ST; n = 150) for smoking cessation in newly diagnosed cancer patients. Problematic alcohol use was assessed at enrollment using the Cut-Down-Annoyed-Guilty-Eye-Opener (CAGE), weekly frequency of alcohol use and binge drinking measures. Alcohol use was categorized as: no current alcohol use, moderate and problematic use. The primary outcome was biochemically-confirmed cigarette abstinence at 6-months. A subset of patients (n = 72) completed qualitative exit-interviews. RESULTS: Among all participants, biochemically-confirmed cigarette abstinence rates were 25% (n = 32), 28% (n = 27), and 36% (n = 20) for participants reporting no current alcohol use, moderate use, and problematic use, respectively (p = 0.33). In logistic regression analysis, neither problematic alcohol use (AOR = 0.96, 95% CI = 0.35-2.67, p = .94) nor the problematic use by study arm interaction (AOR = 2.22, 95% CI = 0.59-8.39, p = .24) were associated with biochemically-confirmed 6-month abstinence. Qualitatively, participants reported that drinking alcohol triggers urges to smoke. CONCLUSION: Newly diagnosed cancer patients reporting problematic alcohol use were not less likely to quit smoking than those without. Additional research is needed to investigate whether problematic alcohol users may benefit from smoking and alcohol behavior change interventions at the time of cancer diagnosis.


Assuntos
Neoplasias , Abandono do Hábito de Fumar , Produtos do Tabaco , Humanos , Neoplasias/epidemiologia , Fumar/epidemiologia , Dispositivos para o Abandono do Uso de Tabaco
7.
Drug Alcohol Depend ; 218: 108438, 2021 01 01.
Artigo em Inglês | MEDLINE | ID: mdl-33271434

RESUMO

BACKGROUND: Cigarette smoking may increase the risk of COVID-19 complications, reinforcing the urgency of smoking cessation in populations with high smoking prevalence such as individuals with opioid use disorder (OUD). Whether the COVID-19 pandemic has altered perceptions, motivation to quit, or tobacco use among cigarette smokers and nicotine e-cigarette vapers with OUD is unknown. METHODS: A telephone survey was conducted in March-July 2020 of current cigarette smokers or nicotine vapers with OUD who were stable on buprenorphine treatment at five Boston (MA) area community health centers. The survey assessed respondents' perceived risk of COVID-19 due to smoking or vaping, interest in quitting, quit attempts and change in tobacco consumption during the pandemic. RESULTS: 222/520 patients (43 %) completed the survey, and 145 were asked questions related to COVID-19. Of these, 61 % smoked cigarettes only, 13 % vaped nicotine only, and 26 % were dual users. Nearly 80 % of participants believed that smoking and vaping increased their risk of COVID-19 infection or complications. Smokers with this belief reported an increased interest in quitting (AOR 4.6, 95 % CI:1.7-12.4). Overall, 49 % of smokers and 42 % of vapers reported increased interest in quitting due to the pandemic; 24 % and 20 %, respectively, reported attempting to quit since the pandemic. However, 35 % of smokers and 27 % of vapers reported increasing smoking and vaping, respectively, during the pandemic. CONCLUSIONS: Most patients with OUD believed that smoking and vaping increased their vulnerability to COVID-19, half reported increased interest in quitting, but others reported increasing smoking and vaping during the COVID-19 pandemic.


Assuntos
Atitude , Buprenorfina/uso terapêutico , COVID-19 , Fumar Cigarros/psicologia , Antagonistas de Entorpecentes/uso terapêutico , Transtornos Relacionados ao Uso de Opioides/tratamento farmacológico , Transtornos Relacionados ao Uso de Opioides/psicologia , Pandemias , Vaping/psicologia , Adulto , Idoso , Boston , Estudos Transversais , Sistemas Eletrônicos de Liberação de Nicotina , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Abandono do Hábito de Fumar , Adulto Jovem
9.
Subst Abus ; : 1-8, 2020 Dec 03.
Artigo em Inglês | MEDLINE | ID: mdl-33270549

RESUMO

BACKGROUND: Substance use disorder (SUD) treatment in general medical settings remains underutilized. We evaluated 5 years of a hospital-wide SUD initiative which included an inpatient addiction consult team (ACT), low-threshold Bridge Clinic, recovery coaches, and office-based addiction treatment (OBAT) nurses. Methods: Naturalistic registry study. We calculated frequencies of patient contacts, types of substance use diagnoses, and medication treatment initiation and duration. Results: From 2014 to 2019, 7,036 unique patients were seen, including 4,959 by ACT, 1,197 in Bridge Clinic, 2,250 by a recovery coach, and 979 by an OBAT nurse. The median age was 47, 31% were women, 80% were white, 7% were black, 6% were Hispanic/Latinx, and 25% were experiencing homelessness. Alcohol use disorder was seen in 62%, opioid use disorder in 54%, cocaine use disorder in 29%, benzodiazepine use disorder in 14%, and stimulant use disorder in 7%. Co-occurring medical and psychiatric illnesses were common; 35% had hepatitis C, 59% depression, 66% anxiety, and 13% schizophrenia. 1,623 patients received a prescription for buprenorphine during the study period (42% of patients with OUD), 877 for oral naltrexone, and 163 for extended-release naltrexone. The mean length of continuous treatment was 178.4 days for buprenorphine, 47.7 days for oral naltrexone, and 1.29 injections for extended-release naltrexone. Conclusion: A hospital SUD initiative effectively initiated SUD pharmacotherapy with naltrexone and buprenorphine. Medication treatment episodes were longer with buprenorphine.

10.
JAMA ; 324(14): 1406-1418, 2020 10 13.
Artigo em Inglês | MEDLINE | ID: mdl-33048154

RESUMO

Importance: Persistent smoking may cause adverse outcomes among patients with cancer. Many cancer centers have not fully implemented evidence-based tobacco treatment into routine care. Objective: To determine the effectiveness of sustained telephone counseling and medication (intensive treatment) compared with shorter-term telephone counseling and medication advice (standard treatment) to assist patients recently diagnosed with cancer to quit smoking. Design, Setting, and Participants: This unblinded randomized clinical trial was conducted at Massachusetts General Hospital/Dana-Farber/Harvard Cancer Center and Memorial Sloan Kettering Cancer Center. Adults who had smoked 1 cigarette or more within 30 days, spoke English or Spanish, and had recently diagnosed breast, gastrointestinal, genitourinary, gynecological, head and neck, lung, lymphoma, or melanoma cancers were eligible. Enrollment occurred between November 2013 and July 2017; assessments were completed by the end of February 2018. Interventions: Participants randomized to the intensive treatment (n = 153) and the standard treatment (n = 150) received 4 weekly telephone counseling sessions and medication advice. The intensive treatment group also received 4 biweekly and 3 monthly telephone counseling sessions and choice of Food and Drug Administration-approved cessation medication (nicotine replacement therapy, bupropion, or varenicline). Main Outcome and Measures: The primary outcome was biochemically confirmed 7-day point prevalence tobacco abstinence at 6-month follow-up. Secondary outcomes were treatment utilization rates. Results: Among 303 patients who were randomized (mean age, 58.3 years; 170 women [56.1%]), 221 (78.1%) completed the trial. Six-month biochemically confirmed quit rates were 34.5% (n = 51 in the intensive treatment group) vs 21.5% (n = 29 in the standard treatment group) (difference, 13.0% [95% CI, 3.0%-23.3%]; odds ratio, 1.92 [95% CI, 1.13-3.27]; P < .02). The median number of counseling sessions completed was 8 (interquartile range, 4-11) in the intensive treatment group. A total of 97 intensive treatment participants (77.0%) vs 68 standard treatment participants (59.1%) reported cessation medication use (difference, 17.9% [95% CI, 6.3%-29.5%]; odds ratio, 2.31 [95% CI, 1.32-4.04]; P = .003). The most common adverse events in the intensive treatment and standard treatment groups, respectively, were nausea (n = 13 and n = 6), rash (n = 4 and n = 1), hiccups (n = 4 and n = 1), mouth irritation (n = 4 and n = 0), difficulty sleeping (n = 3 and n = 2), and vivid dreams (n = 3 and n = 2). Conclusions and Relevance: Among smokers recently diagnosed with cancer in 2 National Cancer Institute-designated Comprehensive Cancer Centers, sustained counseling and provision of free cessation medication compared with 4-week counseling and medication advice resulted in higher 6-month biochemically confirmed quit rates. However, the generalizability of the study findings is uncertain and requires further research. Trial Registration: ClinicalTrials.gov Identifier: NCT01871506.


Assuntos
Aconselhamento/métodos , Neoplasias/diagnóstico , Abandono do Hábito de Fumar/psicologia , Temperança/psicologia , Dispositivos para o Abandono do Uso de Tabaco , Idoso , Bupropiona/efeitos adversos , Bupropiona/uso terapêutico , Cotinina/análise , Aconselhamento/estatística & dados numéricos , Técnicas de Apoio para a Decisão , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Entrevista Motivacional , Satisfação do Paciente , Seleção de Pacientes , Saliva/química , Fumar/tratamento farmacológico , Fumar/epidemiologia , Fumar/psicologia , Agentes de Cessação do Hábito de Fumar/efeitos adversos , Agentes de Cessação do Hábito de Fumar/uso terapêutico , Telefone , Dispositivos para o Abandono do Uso de Tabaco/efeitos adversos , Vareniclina/efeitos adversos , Vareniclina/uso terapêutico
11.
PLoS One ; 15(10): e0238720, 2020.
Artigo em Inglês | MEDLINE | ID: mdl-33031440

RESUMO

BACKGROUND: Global HIV funding cutbacks have been accompanied by the adoption of user fees to address funding gaps in treatment programs. Our objective was to assess the impact of user fees on HIV care utilization and medication adherence in Nigeria. METHODS: We conducted a retrospective analysis of patients enrolled in care before (October 2012-September 2013) and after (October 2014-September 2015) the introduction of user fees in a Nigerian clinic. We assessed pre- vs. post-user fee patient characteristics and enrollment trends, and determined risk of care interruption, loss to follow-up, and optimal medication adherence. RESULTS: After fees were instituted, there was a 66% decline in patient enrollment and 75% decline in number of ART doses dispensed. There was no difference in the proportion of female clients (64% vs 63%, p = 0.46), average age (36 vs. 37 years, p = 0.15), or median baseline CD4 (220/ul vs. 222/uL, p = 0.24) in pre- and post-fee cohorts. There was an increase in clients employed and/or had tertiary education (24% vs. 32%, p<0.001). Compared to pre-fee patients, the post-fee period had a 48% decreased risk of care interruption (aRR = 0.52, 95%CI:0.39-0.69), 22% decreased LTFU risk (aRR = 0.64, 95%CI:0.96), and 27% decreased odds of optimal medication adherence (aOR = 0.7, 3 95%CI 0.59-0.89). CONCLUSIONS: Patients enrolled in care after introduction of user fees in Nigeria were more likely to be educated or employed, and effectively retained in care after starting ART. However, fees were accompanied by a drastic reduction in new patient enrollment, suggesting that many patients may have been marginalized from HIV care.


Assuntos
Fármacos Anti-HIV/economia , Fármacos Anti-HIV/uso terapêutico , Infecções por HIV/tratamento farmacológico , Infecções por HIV/economia , Adesão à Medicação , Adulto , Instituições de Assistência Ambulatorial/economia , Estudos de Coortes , Honorários e Preços , Feminino , Gastos em Saúde , Humanos , Perda de Seguimento , Masculino , Nigéria , Pacientes Desistentes do Tratamento , Estudos Retrospectivos
12.
Subst Abus ; : 1-8, 2020 Sep 03.
Artigo em Inglês | MEDLINE | ID: mdl-32881639

RESUMO

BACKGROUND: It is unknown whether post-discharge navigation enhances the impact of hospital-initiated addiction care. This study tested the incremental benefit of telephonic linkage to a post-discharge navigator for patients who received an addiction consultation during hospitalization. Methods: A two-arm, randomized controlled trial of 395 hospitalized adults with substance use disorder who received an addiction consultation. The intervention group received post-discharge phone calls from a navigator to review the recommended treatment plan and address barriers to engagement on days 3, 7, 14, and 21. The primary outcome was days of alcohol or drug use in the past 30 assessed by Timeline Follow-back at 1 month. Results: Follow-up assessment completion rates were 46% at 1 month, and 41%, at 2 months. At baseline, intervention and control groups did not differ in substance use patterns; 45% reported primary alcohol use, 43% drugs, and 12% both. Heroin was the most common drug. At baseline, mean days of past 30-day alcohol or drug use were 13.6 in the intervention and 14.9 in the control group. The median number of navigation calls completed was 3 out of 4. At 1 month, both groups reported less use (decrease of 4.8 in intervention vs. 4.2 days in control group, p = 0.49). There were no differences between groups at 2 months. Compared to controls, participants who received all four calls had a greater decrease in use with a mean 8.6 days decrease from baseline (difference of 4.4 days, p = 0.0009). Conclusion: Post-discharge telephonic patient navigation did not further improve substance use outcomes following addiction consultation.

14.
J Stroke Cerebrovasc Dis ; 29(8): 104903, 2020 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-32689580

RESUMO

PURPOSE: Evaluate reversal strategies in atrial fibrillation (AF) patients with warfarin-associated intracranial hemorrhage (ICH) in clinical care. MATERIALS AND METHODS: Observational cohort of AF patients with warfarin-associated ICH at two referral hospitals (2007-2010), with patient features, reversal agents, and outcomes collected from medical records. RESULTS: Among 498 ICH patients 403 received fresh frozen plasma (FFP) without 3-factor prothrombin complex concentrates (PCCs) or recombinant factor VIIa (rFVIIa), 65 received PCCs or rFVIIa, mostly with FFP, and 30 received no acute reversal agents. Median time from presentation to reversal agent administration was 3.4 h (IQR 2.3-5.3). INR was reversed to ≤1.4 by 6 h post-presentation in 46% of patients receiving PCCs/rFVIIa versus 15% receiving FFP alone (p<0.0001). Among PCCs/rFVIIa recipients, 31% died in-hospital vs. 24% receiving FFP alone (p=0.27). Adjusted OR for death accounting for age and Glasgow Coma Score was 0.78 (0.36-1.69) for PCCs/rFVIIa vs FFP only and 1.16 (0.59-2.27) comparing those reaching vs. not reaching INR ≤ 1.4 at 6 h. CONCLUSIONS: Treatment with PCCs/rFVIIa led to faster INR reversal than treatment with FFP alone. Neither treatment with PCCs/rFVIIa nor rapid INR reversal was associated with improved survival. Delays receiving PCCs may largely eliminate the benefit of treatment.


Assuntos
Anticoagulantes/efeitos adversos , Fibrilação Atrial/tratamento farmacológico , Fatores de Coagulação Sanguínea/uso terapêutico , Coagulação Sanguínea/efeitos dos fármacos , Coagulantes/uso terapêutico , Fator VIIa/uso terapêutico , Hemorragias Intracranianas/terapia , Plasma , Varfarina/efeitos adversos , Idoso , Idoso de 80 Anos ou mais , Fibrilação Atrial/diagnóstico , Fatores de Coagulação Sanguínea/efeitos adversos , Boston , Coagulantes/efeitos adversos , Fator VIIa/efeitos adversos , Feminino , Humanos , Coeficiente Internacional Normatizado , Hemorragias Intracranianas/induzido quimicamente , Hemorragias Intracranianas/diagnóstico , Masculino , Estudos Retrospectivos , Fatores de Tempo , Resultado do Tratamento
15.
Prev Med ; 140: 106216, 2020 11.
Artigo em Inglês | MEDLINE | ID: mdl-32693177

RESUMO

The workplace is a key channel for delivering tobacco cessation treatment to a population. Employers can provide workplace-based programs and/or financial incentives such as health insurance benefits that cover the cost of treatment accessed outside the workplace. Little is known about the effect of combining these strategies. We tested the benefit of adding a workplace cessation program, Partners in Helping You Quit (PiHQ), to comprehensive health insurance coverage of smoking cessation medications by Partners HealthCare, a large Boston-based healthcare delivery system. PiHQ offers biweekly telephone-based behavioral support, additional automated calls, and medication care coordination for 3 months then monthly telephone monitoring for 9 months. In a pragmatic randomized trial, employees who smoked were informed about the insurance benefit, then randomly assigned (2:1) to PiHQ or to active referral to a free 3-month phone-based community program, Massachusetts Quitline (QL). Outcomes were assessed at 3, 6, and 12 months. During 2015-2018, 106 smokers (n = 73 PiHQ, n = 33 QL) enrolled (64% female; 75% white, 21% black; mean age 46 years, mean cigarettes/day = 13). More PiHQ than QL participants made a quit attempt by 3 months (82 vs. 61%, p < .02) and achieved the primary outcome, verified past 7-day cigarette abstinence at 6 months (31 vs. 12%, odds ratio 3.34, 95% CI, 1.05-10.60). Among participants using behavioral support, PiHQ participants completed more scheduled calls and rated counseling helpfulness higher than did QL participants. These results suggest that employers can enhance the impact of providing comprehensive health insurance coverage of smoking cessation medication by adding a phone-based worksite cessation program.


Assuntos
Abandono do Hábito de Fumar , Boston , Aconselhamento , Atenção à Saúde , Feminino , Humanos , Masculino , Massachusetts , Pessoa de Meia-Idade , Dispositivos para o Abandono do Uso de Tabaco
17.
Int J Drug Policy ; 79: 102752, 2020 Apr 21.
Artigo em Inglês | MEDLINE | ID: mdl-32330837

RESUMO

BACKGROUND: Clonidine, gabapentin, and promethazine are commonly used by people who use opioids, including heroin, raising concern for increased morbidity and mortality in a vulnerable population. We aimed to characterize how and why individuals use opioids in combination with these three psychoactive medications (PAMs). METHODS: Participants (n = 103) were a convenience sample of adults attending a syringe service program who reported using a PAM in addition to opioids or opioid agonist therapies (buprenorphine or methadone). Face-to-face structured interviews consisted of closed and open-ended questions. RESULTS: Patterns of PAM use varied. Risky use, including use of high doses and with other sedating medications, was common. Most individuals reported multiple medical reasons for use, even while reporting the PAM had mind-altering effects. Use of high doses of PAMs was associated with a history of overdose. Among those with a history of overdose, 32% reported that a PAM was involved. CONCLUSION: The use of clonidine, gabapentin and promethazine among individuals who use opioids is complex. Providers should take individualized approaches to PAM prescribing, recognizing both the risks of PAMs and the potential unintended consequences of supply-side interventions in the era of the overdose crisis. Harm reduction interventions are needed to prevent PAM-involved overdoses.

18.
Trials ; 21(1): 336, 2020 Apr 16.
Artigo em Inglês | MEDLINE | ID: mdl-32299470

RESUMO

BACKGROUND: Tobacco smoking remains the leading preventable cause of death in the US. A hospital admission provides smokers with a unique opportunity to stop smoking because it requires temporary tobacco abstinence while illness may enhance motivation to quit. Hospital interventions must continue post-discharge to increase tobacco abstinence long-term, but how best to accomplish this remains unclear. Building on two previous randomized controlled trials, each of which tested smoking cessation interventions that began in hospital and continued after discharge, this trial compares two interventions that provide sustained smoking cessation treatment after hospital discharge with the goal of improving long-term smoking cessation rates among hospitalized smokers. METHODS/DESIGN: Helping HAND 4 is a three-site randomized controlled trial that compares the effectiveness of two active interventions for producing validated past 7-day tobacco abstinence 6 months after hospital discharge. Smokers who are admitted to three hospitals receive a standard in-hospital smoking intervention, and those who plan to quit smoking after discharge are recruited and randomly assigned to two interventions that begin at discharge, Personalized Tobacco Care Management (PTCM) or Quitline eReferral. Each lasts 3 months. At discharge, PTCM provides 8 weeks of free nicotine replacement (NRT; a participant's choice of patch, gum, lozenge, or a combination) and then proactive smoking cessation support using an automated communication platform and live contact with a tobacco treatment specialist who is based in the health care system. In the eReferral condition, a direct referral is made from the hospital electronic health record to a community-based resource, the state's telephone quitline. The quitline provides up to 8 weeks of free NRT and offers behavioral support via a series of phone calls from a trained coach. Outcomes are assessed at 1, 3, and 6 months after discharge. The study hypothesis is that PTCM will produce higher quit rates than eReferral. DISCUSSION: Helping HAND 4 is a pragmatic trial that aims to evaluate interventions in real-world conditions. This project will give hospital systems critical evidence-based tools for meeting National Hospital Quality Measures for tobacco treatment and maximizing their ability to improve cessation rates and overall health for the millions of smokers hospitalized annually in the US. TRIAL REGISTRATION: Prospectively registered prior to start of enrollment at Clinicaltrials.gov, NCT03603496 (July 27, 2018). https://register.clinicaltrials.gov/prs/app/action/SelectProtocol?sid=S00084MJ&selectaction=Edit&uid=U00002G7&ts=2&cx=ff0oxn.


Assuntos
Assistência ao Convalescente/métodos , Fumar Cigarros/terapia , Alta do Paciente , Fumantes , Abandono do Hábito de Fumar/métodos , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Boston/epidemiologia , Fumar Cigarros/epidemiologia , Análise Custo-Benefício , Feminino , Seguimentos , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Multicêntricos como Assunto , Pennsylvania/epidemiologia , Ensaios Clínicos Pragmáticos como Assunto , Tennessee/epidemiologia , Dispositivos para o Abandono do Uso de Tabaco , Resultado do Tratamento , Adulto Jovem
19.
BMC Cancer ; 20(1): 347, 2020 Apr 23.
Artigo em Inglês | MEDLINE | ID: mdl-32326897

RESUMO

INTRODUCTION: The relationships among PIK3CA mutations, medication use and tumor progression remains poorly understood. Aspirin use post-diagnosis may modify components of the PI3K pathway, including AKT and mTOR, and has been associated with lower risk of breast cancer recurrence and mortality. We assessed time to metastasis (TTM) and survival with respect to aspirin use and tumor PIK3CA mutations among women with metastatic breast cancer. METHODS: Patients with hormone receptor positive, HER2 negative (HR+/HER2-) metastatic breast cancer treated in 2009-2016 who received tumor genotyping were included. Aspirin use between primary and metastatic diagnosis was extracted from electronic medical records. TTM and survival were estimated using Cox proportional hazards regression. RESULTS: Among 267 women with metastatic breast cancer, women with PIK3CA mutated tumors had longer TTM than women with PIK3CA wildtype tumors (7.1 vs. 4.7 years, p = 0.008). There was a significant interaction between PIK3CA mutations and aspirin use on TTM (p = 0.006) and survival (p = 0.026). PIK3CA mutations were associated with longer TTM among aspirin non-users (HR = 0.60 95% CI:0.44-0.82 p = 0.001) but not among aspirin users (HR = 1.57 0.86-2.84 p = 0.139). Similarly, PIK3CA mutations were associated with reduced mortality among aspirin non-users (HR = 0.70 95% CI:0.48-1.02 p = 0.066) but not among aspirin users (HR = 1.75 95% CI:0.88-3.49 p = 0.110). CONCLUSIONS: Among women who develop metastatic breast cancer, tumor PIK3CA mutations are associated with slower time to progression and mortality only among aspirin non-users. Larger studies are needed to confirm this finding and examine the relationship among aspirin use, tumor mutation profile, and the overall risk of breast cancer progression.


Assuntos
Aspirina/administração & dosagem , Biomarcadores Tumorais/genética , Neoplasias da Mama/mortalidade , Classe I de Fosfatidilinositol 3-Quinases/genética , Mutação , Recidiva Local de Neoplasia/mortalidade , Neoplasias Hormônio-Dependentes/mortalidade , Adulto , Anti-Inflamatórios não Esteroides/administração & dosagem , Protocolos de Quimioterapia Combinada Antineoplásica/uso terapêutico , Biomarcadores Tumorais/metabolismo , Neoplasias da Mama/tratamento farmacológico , Neoplasias da Mama/genética , Neoplasias da Mama/patologia , Feminino , Seguimentos , Humanos , Pessoa de Meia-Idade , Metástase Neoplásica , Recidiva Local de Neoplasia/tratamento farmacológico , Recidiva Local de Neoplasia/genética , Recidiva Local de Neoplasia/patologia , Neoplasias Hormônio-Dependentes/tratamento farmacológico , Neoplasias Hormônio-Dependentes/genética , Neoplasias Hormônio-Dependentes/secundário , Prognóstico , Receptor ErbB-2/metabolismo , Receptores de Estrogênio/metabolismo , Receptores de Progesterona/metabolismo , Estudos Retrospectivos , Taxa de Sobrevida
20.
BMC Cancer ; 20(1): 71, 2020 Jan 29.
Artigo em Inglês | MEDLINE | ID: mdl-31996161

RESUMO

BACKGROUND: Kaposi's sarcoma (KS) is one of the most common HIV-associated malignancies in sub-Saharan Africa. Worldwide, the availability of antiretroviral therapy (ART) has improved KS survival. In resource-rich settings, survival has also benefited from chemotherapy, which is widely available. Little is known, however, about the epidemiology of chemotherapy use for HIV-associated KS in resource-limited regions such as sub-Saharan Africa. METHODS: We identified all patients newly diagnosed with HIV-related KS from 2009 to 2012 in the 26-clinic AMPATH network, a large community-based care network in Kenya. We ascertained disease severity at diagnosis, frequency of initiation of chemotherapy, and distribution of chemotherapeutic regimens used. Indications for chemotherapy included AIDS Clinical Trial Group T1 stage and/or "severe" disease defined by WHO KS treatment guidelines. RESULTS: Of 674 patients diagnosed with KS, charts were available for 588; 61% were men, median age was 35 years, and median CD4 at KS diagnosis was 185 cells/µl. At time of diagnosis, 58% had at least one chemotherapy indication, and 22% had more than one indication. For patients with a chemotherapy indication, cumulative incidence of chemotherapy initiation (with death as a competing event) was 37% by 1 month and 56% by 1 year. Median time from diagnosis to chemotherapy initiation was 25 days (IQR 1-50 days). In multivariable regression, patients with > 3 chemotherapy indications at time of diagnosis had a 2.30 (95% CI 1.46-3.60) increased risk of rapid chemotherapy initiation (within 30 days of diagnosis) compared to those with only one chemotherapy indication (p < 0.001). Initial regimens were bleomycin-vincristine (78%), adriamycin-bleomycin-vincristine (11%), etoposide (7%), and gemcitabine (4%). CONCLUSIONS: A substantial fraction of patients with KS in East Africa are diagnosed at advanced disease stage. For patients with chemotherapy indications, nearly half did not receive chemotherapy by one year. Liposomal anthracyclines, often used in resource-rich settings, were not first line. These findings emphasize challenges in East Africa cancer care, and highlight the need for further advocacy for improved access to higher quality chemotherapy in this setting.


Assuntos
Serviços de Saúde Comunitária , Infecções por HIV/epidemiologia , Atenção Primária à Saúde , Sarcoma de Kaposi/epidemiologia , Adulto , Protocolos de Quimioterapia Combinada Antineoplásica/efeitos adversos , Protocolos de Quimioterapia Combinada Antineoplásica/uso terapêutico , Feminino , Infecções por HIV/complicações , Infecções por HIV/imunologia , Infecções por HIV/virologia , Humanos , Incidência , Quênia/epidemiologia , Masculino , Pessoa de Meia-Idade , Prognóstico , Sarcoma de Kaposi/diagnóstico , Sarcoma de Kaposi/tratamento farmacológico , Sarcoma de Kaposi/etiologia , Índice de Gravidade de Doença , Adulto Jovem
SELEÇÃO DE REFERÊNCIAS
DETALHE DA PESQUISA
...