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1.
Abdom Radiol (NY) ; 45(6): 1866-1871, 2020 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-32270260

RESUMO

The role of the radiologist in the diagnosis and management of patients with endometriosis is increasing. Improvement in MRI imaging techniques has improved detection rate of subtle manifestations of endometriosis by radiologists. Therefore, the role of imaging in the diagnosis and follow-up after treatment is also likely to increase. Knowledge of new medical management pathways used in treating patients with endometriosis-related pain is important. The knowledge of various medication regimens will allow radiologists to continue to evaluate baseline disease, and to potentially assess for imaging response/stability to these medications. This article will review the current medical therapies in use in the management of endometriosis-related pain and describe potential imaging-related findings expected with these therapies.

2.
Abdom Radiol (NY) ; 45(6): 1569-1586, 2020 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-32193592

RESUMO

Endometriosis is a common entity causing chronic pain and infertility in women. The gold standard method for diagnosis is diagnostic laparoscopy, which is invasive and costly. MRI has shown promise in its ability to diagnose endometriosis and its efficacy for preoperative planning. The Society of Abdominal Radiology established a Disease-Focused Panel (DFP) to improve patient care for patients with endometriosis. In this article, the DFP performs a literature review and uses its own experience to provide technical recommendations on optimizing MRI Pelvis for the evaluation of endometriosis.

3.
Drug Saf ; 2020 Mar 16.
Artigo em Inglês | MEDLINE | ID: mdl-32180134

RESUMO

INTRODUCTION: Clinical practice guidelines recommend co-prescribing naloxone to patients at high risk of opioid overdose, but few such patients receive naloxone. High costs of naloxone may contribute to limited dispensing. OBJECTIVE: The aim of this study was to evaluate rates and costs of dispensing naloxone to patients receiving opioid prescriptions and at high risk for opioid overdose. METHODS: Using claims data from a large US commercial insurance company, we conducted a retrospective cohort study of new opioid initiators between January 2014 and December 2018. We identified patients at high risk for overdose defined as a diagnosis of opioid use disorder, prior overdose, an opioid prescription of ≥ 50 mg morphine equivalents/day for ≥ 90 days, and/or concurrent benzodiazepine prescriptions. RESULTS: Among 5,292,098 new opioid initiators, 616,444 (12%) met criteria for high risk of overdose during follow-up, and, of those, 3096 (0.5%) were dispensed naloxone. The average copayment was US$24.83 for naloxone (standard deviation [SD] 67.66) versus US$9.74 for the index opioid (SD 19.75). The average deductible was US$6.18 for naloxone (SD 27.32) versus US$3.74 for the index opioid (SD 25.56), with 94% and 88% having deductibles of US$0 for their naloxone and opioid prescriptions, respectively. The average out-of-pocket cost was US$31.01 for naloxone (SD 73.64) versus US$13.48 for the index opioid (SD 34.95). CONCLUSIONS: Rates of dispensing naloxone to high risk patients were extremely low, and prescription costs varied greatly. Since improving naloxone's affordability may increase access, whether naloxone's high cost is associated with low dispensing rates should be evaluated.

4.
AJR Am J Roentgenol ; 214(5): 1152-1157, 2020 May.
Artigo em Inglês | MEDLINE | ID: mdl-32097031

RESUMO

OBJECTIVE. The objective of this article is to assess radiologist concordance in characterizing thyroid nodules using the American College of Radiology Thyroid Imaging Reporting and Data System (TI-RADS), focusing on the effect of radiologist experience on reader concordance. MATERIALS AND METHODS. Three experienced and three less experienced radiologists assessed 150 thyroid nodules using the TI-RADS lexicon. Percent concordance was determined for various endpoints. RESULTS. Interreader concordance for the five TI-RADS categories was 87.2% for shape, 81.2% for composition, 76.1% for echogenicity, 72.9% for margins, and 69.8% for echogenic foci. Concordance for individual features was 96.3% for rim calcifications, 90.8% for macrocalcifications, 90.1% for spongiform, 83.5% for comet tail artifact, and 77.7% for punctate echogenic foci. Concordance for the TI-RADS level and recommendation for fine-needle aspiration (FNA) were 50.4% and 78.9%, respectively. Concordance was significantly (p < 0.05) higher for less experienced readers in identifying margins (84.3% vs 67.4%), echogenic foci (76.9% vs 69.3%), comet tail artifact (89.6% vs 79.2%), and punctate echogenic foci (85.3% vs 75.5%), and lower for peripheral rim calcifications (95.0% vs 97.8 %), but was not different (p > 0.05) for the remaining categories and features. CONCLUSION. A range of TI-RADS categories, features, and recommendations for FNA had generally moderate interreader agreement among six radiologists. Our results show that concordance for numerous characteristics was significantly higher for the less experienced versus the more experienced readers. These results suggest that less experienced readers relied more on the explicit TI-RADS criteria, whereas the experienced radiologists partially relied on their accumulated experience when forming impressions. However, the overall TI-RADS level and recommendation for FNA were unaffected, supporting the robustness of the TI-RADS lexicon and its continued use in practice.

5.
Pharmacoepidemiol Drug Saf ; 29(4): 404-408, 2020 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-31849154

RESUMO

PURPOSE: An increasing number of new medications are being developed and approved for psoriatic arthritis (PsA). To generate real-world evidence on comparative safety and effectiveness of these drugs, a claims-based algorithm that can accurately identify PsA is greatly needed. METHODS: To identify patients with PsA, we developed seven claims-based algorithms based on a combination of diagnosis codes and medication dispensing using the claims data from Medicare parts A/B/D linked to electronic medical records (2012-2014). Two physicians independently conducted a chart review using the treating physician's diagnosis of PsA as the gold standard. We calculated the positive predictive value (PPV) and 95% confidence intervals of each algorithm. RESULTS: Of the total 2157 records identified by the seven algorithms, 45% of the records had relevant clinical data to determine the presence of PsA. The PPV of the algorithms ranged from 75.2% (algorithm 1: ≥2 diagnosis codes for PsA and ≥1 diagnosis code for psoriasis) to 88.6% (algorithm 7: ≥2 diagnosis codes for PsA with ≥1 code by rheumatologist and ≥1 dispensing for PsA medication). Having ≥2 diagnosis codes and ≥1 dispensing for PsA medications (algorithm 6) also had PPV of 82.4%. CONCLUSIONS: All seven claims-based algorithms demonstrated a moderately high PPV of 75% to 89% in identifying PsA. The use of ≥2 diagnosis codes plus ≥1 prescription claim for PsA appears to be a valid and efficient tool in identifying PsA patients in the claims data, while broader algorithms based on diagnoses without a prescription claim also have reasonably good PPVs.

6.
Magn Reson Med ; 83(1): 94-108, 2020 01.
Artigo em Inglês | MEDLINE | ID: mdl-31400028

RESUMO

PURPOSE: To propose a highly accelerated, high-resolution dynamic contrast-enhanced MRI (DCE-MRI) technique called GRASP-Pro (golden-angle radial sparse parallel imaging with imProved performance) through a joint sparsity and self-calibrating subspace constraint with automated selection of contrast phases. METHODS: GRASP-Pro reconstruction enforces a combination of an explicit low-rank subspace-constraint and a temporal sparsity constraint. The temporal basis used to construct the subspace is learned from an intermediate reconstruction step using the low-resolution portion of radial k-space, which eliminates the need for generating the basis using auxiliary data or a physical signal model. A convolutional neural network was trained to generate the contrast enhancement curve in the artery, from which clinically relevant contrast phases are automatically selected for evaluation. The performance of GRASP-Pro was demonstrated for high spatiotemporal resolution DCE-MRI of the prostate and was compared against standard GRASP in terms of overall image quality, image sharpness, and residual streaks and/or noise level. RESULTS: Compared to GRASP, GRASP-Pro reconstructed dynamic images with enhanced sharpness, less residual streaks and/or noise, and finer delineation of the prostate without prolonging reconstruction time. The image quality improvement reached statistical significance (P < 0.05) in all the assessment categories. The neural network successfully generated contrast enhancement curves in the artery, and corresponding peak enhancement indexes correlated well with that from the manual selection. CONCLUSION: GRASP-Pro is a promising method for rapid and continuous DCE-MRI. It enables superior reconstruction performance over standard GRASP and allows reliable generation of artery enhancement curve to guide the selection of desired contrast phases for improving the efficiency of GRASP MRI workflow.

7.
Abdom Radiol (NY) ; 2019 Nov 14.
Artigo em Inglês | MEDLINE | ID: mdl-31728612

RESUMO

Endometriosis is a common gynecologic disorder characterized by the presence of ectopic endometrial tissue outside the endometrial cavity. Magnetic Resonance Imaging (MRI) has become a mainstay for diagnosis and staging of this disease. In the literature, significant heterogeneity exists in the descriptions of imaging findings and anatomic sites of involvement. The Society of Abdominal Radiology's Endometriosis Disease-Focused Panel presents this consensus document to establish an MRI lexicon for endometriosis MRI evaluation and anatomic localization.

8.
Appl Ergon ; 81: 102880, 2019 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-31422276

RESUMO

The purpose of this study was to quantify biomechanical and cardiovascular exposure while making beds with and without interventions (mattress lift tool and fitted sheet). Sixteen female hotel room cleaners participated in this multifactorial (tool and sheet) laboratory study of crossover design. Exertion in the upper extremity (<2) and back (<3) was consistently lower when using the tool and fitted sheet (p < 0.05). The average number of lifts per bed was reduced by 48% with an 18 s increase in cycle time per bed. Peak forearm flexor activity was significantly lower when using a tool(p < 0.05). Spinal lateral plane range of motion (p < 0.02) and maximum twisting velocity (p < 0.03) were lowest using the tool and fitted sheet together. Interventions such as a mattress lift tool used with a fitted sheet reduced the number of mattress lifts and lowered perceived exertion among hotel room cleaners while making beds.


Assuntos
Ergonomia/instrumentação , Serviço de Limpeza/métodos , Remoção/efeitos adversos , Doenças Musculoesqueléticas/prevenção & controle , Doenças Profissionais/prevenção & controle , Adulto , Roupas de Cama, Mesa e Banho , Leitos , Fenômenos Biomecânicos , Estudos Cross-Over , Desenho de Equipamento , Feminino , Antebraço/fisiopatologia , Humanos , Dor Lombar/etiologia , Dor Lombar/prevenção & controle , Pessoa de Meia-Idade , Doenças Musculoesqueléticas/etiologia , Doenças Profissionais/etiologia , Esforço Físico/fisiologia , Fatores de Risco , Coluna Vertebral/fisiopatologia , Carga de Trabalho
9.
Artigo em Inglês | MEDLINE | ID: mdl-31376333

RESUMO

OBJECTIVE: To compare the risk of serious infections between the TNF inhibitor (TNFi) plus methotrexate (MTX) versus triple therapy among RA patients in a real-world setting. METHODS: Using claims data from Truven MarketScan (2003-2014), we conducted a cohort study to compare RA patients on MTX who added a TNFi (TNFi plus MTX group) versus hydroxychloroquine and sulfasalazine (triple therapy group). The primary outcome was any serious infection (i.e., a composite endpoint of hospitalized bacterial and opportunistic infections, or herpes zoster). Secondary outcomes were individual components of the composite endpoint. To adjust for baseline confounding, we used propensity score (PS)-based fine stratification and weighting. A weighted Cox proportional hazards model estimated the hazard ratio (HR) and 95% confidence interval (CI) of the outcomes. RESULTS: After PS stratification (PSS) and weighting, we included a total of 45,208 TNFi plus MTX initiators and 1,387 triple therapy initiators. Mean age was 53 years and 70% female. The incidence rate of any serious infection per 100 person-years was 2.46 in TNFi plus MTX and 2.03 in triple therapy. The PSS-weighted HR (95% CI) for any serious infection comparing TNFi plus MTX versus triple therapy was 1.23 (0.87-1.74). For the secondary outcomes, the PSS-weighted HR (95% CI) was 1.41 (0.85-2.34) for bacterial infection and 0.80 (0.55-1.18) for herpes zoster. CONCLUSION: In this real-world cohort of RA patients, we noted no substantially different risk of any serious infection, bacterial infection or herpes zoster after initiating TNFi plus MTX versus triple therapy although confidence intervals were wide. This article is protected by copyright. All rights reserved.

10.
Ann Intern Med ; 2019 Jul 30.
Artigo em Inglês | MEDLINE | ID: mdl-31357213

RESUMO

Background: Prior studies evaluating risk for severe urinary tract infections (UTIs) with sodium-glucose cotransporter-2 (SGLT-2) inhibitors have reported conflicting findings. Objective: To assess whether patients initiating use of SGLT-2 inhibitors were at increased risk for severe UTI events compared with those initiating use of dipeptidyl peptidase-4 (DPP-4) inhibitors or glucagon-like peptide-1 receptor (GLP-1) agonists. Design: Population-based cohort study. Setting: 2 large, U.S.-based databases of commercial claims (March 2013 to September 2015). Participants: Within each database, 2 cohorts were created and matched 1:1 on propensity score. Patients were aged 18 years or older, had type 2 diabetes mellitus, and were initiating use of SGLT-2 inhibitors versus DPP-4 inhibitors (cohort 1) or GLP-1 agonists (cohort 2). Measurements: The primary outcome was a severe UTI event, defined as a hospitalization for primary UTI, sepsis with UTI, or pyelonephritis; the secondary outcome was outpatient UTI treated with antibiotics. Hazard ratios [HRs] were estimated in each propensity score-matched cohort, with adjustment for more than 90 baseline characteristics. Results: After 1:1 matching on propensity score, 123 752 patients were identified in cohort 1 and 111 978 in cohort 2 in the 2 databases. In cohort 1, persons newly receiving SGLT-2 inhibitors had 61 severe UTI events (incidence rate [IR] per 1000 person-years, 1.76), compared with 57 events in the DPP-4 inhibitor group (IR, 1.77) (HR, 0.98 [95% CI, 0.68 to 1.41]). In cohort 2, those receiving SGLT-2 inhibitors had 73 events (IR, 2.15), compared with 87 events in the GLP-1 agonist group (IR, 2.96) (HR, 0.72 [CI, 0.53 to 0.99]). Findings were robust across sensitivity analyses; within several subgroups of age, sex, and frailty; and for canagliflozin and dapagliflozin individually. In addition, SGLT-2 inhibitors were not associated with increased risk for outpatient UTIs (cohort 1: HR, 0.96 [CI, 0.89 to 1.04]; cohort 2: HR, 0.91 [CI, 0.84 to 0.99]). Limitation: Generalizability of the study findings may be limited to patients with commercial insurance. Conclusion: In a large cohort of patients seen in routine clinical practice, risk for severe and nonsevere UTI events among those initiating SGLT-2 inhibitor therapy was similar to that among patients initiating treatment with other second-line antidiabetic medications. Primary Funding Source: Brigham and Women's Hospital, Division of Pharmacoepidemiology and Pharmacoeconomics.

11.
J Magn Reson Imaging ; 50(5): 1614-1619, 2019 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-30990941

RESUMO

BACKGROUND: Evaluation of prostate MRI relies on diffusion-weighted imaging (DWI), commonly distorted by susceptibility artifacts, thereby creating a need for approaches to correct such distortion. PURPOSE: To compare geometric distortion on prostate MRI between standard DWI and a geometric distortion correction method for DWI described as static distortion correction DWI (SDC DWI). STUDY TYPE: Retrospective case study. POPULATION: Thirty patients (ages 31-81 years) undergoing prostate MRI. SEQUENCE: Geometric distortions from echo planar imaging were corrected with the SDC DWI protocol, which first acquires a B0 -field map to estimate geometric distortions. ASSESSMENT: Contours of the prostate were placed on axial T2 -weighted imaging (T2 WI) as an anatomic standard. Pixel shifts and apparent diffusion coefficient (ADC) values were compared between prostate contours applied to the SDC DWI and standard DWI sequences. Detailed characterization of the impact of SDC DWI was performed in three representative patients. STATISTICAL TESTS: One-way analysis of variance (ANOVA) test, Spearman correlation test, and Bland-Altman plots were calculated. RESULTS: There was significantly greater overlap of the SDC DWI prostate region of interest (ROI) with T2 WI than standard DWI with T2 WI (10.56 cm2 ± 3.14, P < 0.05). R2 of ADC values from standard DWI vs. SDC DWI in the 30 patients ranged from 0.02-0.94 (mean 0.60). A patient without susceptibility artifact demonstrated minimal pixel shift ranging from 0.6-1.3 mm and high correlation of ADC values (R2 = 0.89) between SDC DWI and standard DWI. A patient with rectal gas showed greater pixel shift (range: -2.5 to -0.5 mm) and less ADC value correlation (R2 = 0.69). A patient with a pelvic phlebolith adjacent to the prostate showed an even greater pixel shift (range: 10-16 mm) and decreased ADC correlation (R2 = 0.21). DATA CONCLUSION: SDC DWI appears to correct for susceptibility-related pixel shifts in the prostate compared with standard DWI, which may have value for assessing prostate lesions obscured by geometric warping. Level of Evidence 4 Technical Efficacy Stage 1 J. Magn. Reson. Imaging 2019;50:1614-1619.

12.
J Magn Reson Imaging ; 49(7): e282-e294, 2019 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-30637854

RESUMO

BACKGROUND: Uterine fibroids are a common benign tumor and can be symptomatic, necessitating resection. Surgical myomectomy is an effective treatment option with a risk of disseminating occult uterine leiomyosarcoma (LMS), creating a need for an effective presurgical screening protocol. Clinical collaboration with contrast-enhanced MRI including T2 and diffusion-weighted imaging (DWI) can be utilized as a screening exam. PURPOSE: To review the accuracy and feasibility of an interdisciplinary prospective contrast-enhanced MRI pelvis with DWI screening system for LMS prior to fibroid resection. STUDY TYPE: Retrospective cohort study. POPULATION: In all, 1960 adult female patients aged 18-87 undergoing screening MRI pelvis prior to uterine fibroid resection. FIELD STRENGTH/SEQUENCE: T1 and T2 -weighted imaging, DWI, and contrast-enhanced images were acquired at 1.5 T and 3.0 T. ASSESSMENT: Each radiologist at the time of clinical study prospectively designated a confidence level of presence of LMS in the impression, which was reviewed retrospectively. A separate retrospective evaluation of the histologically proven LMS and the false positives was performed for the presence of five MRI features of LMS including low ADC values, intermediate/high T2 signal intensity, irregular margins, hemorrhage, and necrosis. A preliminary cost-effectiveness analysis was performed, comparing the costs of treatment of uterine fibroids with vs. without a collaborative screening protocol using MRI. STATISTICAL TESTS: Sensitivity, specificity, positive predictive value, and negative predictive value were obtained from the prospective evaluations. Student's t-tests were used to compare demographics and apparent diffusion coefficient values between LMS and false-positive results. RESULTS: We prospectively identified LMS patients with 100% sensitivity and 97% specificity. Preliminary cost analysis demonstrated that the MR screening protocol increased life expectancy by 0.04 years at a cost of $12,937 per life-year gained. DATA CONCLUSION: MRI is an effective and potentially economic screening test, especially with standardized reporting and coordination with clinicians. LEVEL OF EVIDENCE: 3 Technical Efficacy Stage: 2 J. Magn. Reson. Imaging 2019.

13.
J Manag Care Spec Pharm ; 25(1): 113-121, 2019 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-30589630

RESUMO

BACKGROUND: The approval of new oral disease-modifying drugs (DMDs), such as fingolimod, dimethyl fumarate (DMF), and teriflunamide, has considerably expanded treatment options for relapsing forms of multiple sclerosis (MS). However, data describing the use of these agents in routine clinical practice are limited. OBJECTIVE: To describe time trends and identify factors associated with oral DMD treatment initiation and switching among individuals with MS. METHODS: Using data from a large sample of commercially insured patients, we evaluated changes over time in the proportion of MS patients who initiated treatment with an oral DMD and who switched from an injectable DMD to an oral DMD between 2009 and 2014 in the United States. We evaluated predictors of oral DMD use using conditional logistic regression in 2 groups matched on calendar time: oral DMD initiators matched to injectable DMDs initiators and oral DMD switchers matched to those who switched to a second injectable DMD. RESULTS: Our cohort included 7,576 individuals who initiated a DMD and 1,342 who switched DMDs, of which oral DMDs accounted for 6% and 39%, respectively. Oral DMD initiation and switching steadily increased from 5% to 16% and 35% to 84%, respectively, between 2011 and 2014, with DMF being the most commonly used agent. Of the potential predictors with clinical significance, a recent neurologist consultation (OR = 1.60; 95% CI = 1.20-2.15) and emergency department visit (OR = 1.43; 95% CI = 1.01-2.01) were significantly associated with oral DMD initiation. History of depression was noted to be a potential predictor of oral DMD initiation; however, the estimate for this predictor did not reach statistical significance (OR = 1.35; 95% CI = 0.99-1.84). No clinically relevant factors measured in our data were associated with switching to an oral DMD. CONCLUSIONS: Oral DMDs were found to be routinely used as second-line treatment. However, we identified few factors predictive of oral DMD initiation or switching, which implies that their selection is driven by patient and/or physician preferences. DISCLOSURES: This study was funded by CVS Caremark through an unrestricted research grant to Brigham and Women's Hospital. Shrank and Matlin were employees of, and shareholders in, CVS Health at the time of the study; they report no financial interests in products or services that are related to the subject of this study. Spettell is an employee of, and shareholder in, Aetna. Chitnis serves on clinical trial advisory boards for Novartis and Genzyme-Sanofi; has consulted for Bayer, Biogen Idec, Celgene, Novartis, Merck-Serono, and Genentech-Roche; and has received research support from NIH, National Multiple Sclerosis Society, Peabody Foundation, Consortium for MS Centers, Guthy Jackson Charitable Foundation, EMD-Serono, Novartis Biogen, and Verily. Desai reports receiving a research grant from Merck for unrelated work. Gagne is principal investigator of a research grant from Novartis Pharmaceuticals Corporation to the Brigham and Women's Hospital and has received grant support from Eli Lilly, all for unrelated work. He is also a consultant to Aetion and Optum. Minden reports grants from Biogen and other fees from Genentech, EMD Serano, Avanir, and Novartis, unrelated to this study. The other authors have no conflicts to report. This study was presented as a poster at the International Society for Pharmacoepidemiology 32nd Annual Meeting; August 25-28, 2016; Dublin, Ireland.


Assuntos
Imunossupressores/uso terapêutico , Seguro de Serviços Farmacêuticos/estatística & dados numéricos , Adesão à Medicação/estatística & dados numéricos , Esclerose Múltipla/tratamento farmacológico , Preferência do Paciente/estatística & dados numéricos , Administração Oral , Adulto , Estudos de Coortes , Crotonatos/administração & dosagem , Crotonatos/uso terapêutico , Fumarato de Dimetilo/administração & dosagem , Fumarato de Dimetilo/uso terapêutico , Prescrições de Medicamentos/estatística & dados numéricos , Feminino , Cloridrato de Fingolimode/administração & dosagem , Cloridrato de Fingolimode/uso terapêutico , Humanos , Imunossupressores/administração & dosagem , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Toluidinas/administração & dosagem , Toluidinas/uso terapêutico , Estados Unidos , Adulto Jovem
14.
Circ Cardiovasc Qual Outcomes ; 11(7): e004684, 2018 07.
Artigo em Inglês | MEDLINE | ID: mdl-29991646

RESUMO

BACKGROUND: Continuation of antiplatelet therapy beyond 12 months after a drug-eluting stent procedure reduced the risk of a major adverse cardiovascular and cerebrovascular event (MACCE) in the DAPT trial (Dual Antiplatelet Therapy). Observational studies have evaluated outcomes related to different durations of therapy but are susceptible to bias. METHODS AND RESULTS: Using deidentified claims from commercially insured and Medicare populations in the United States, we compared how increasingly stringent definitions of exposure affect associations between antiplatelet continuation versus discontinuation and MACCE, myocardial infarction, and intracerebral hemorrhage or gastrointestinal bleeding in patients meeting DAPT trial inclusion criteria between 2004 and 2013. Therapy continuation at 12 months was defined as (1) having antiplatelet supply on hand versus not (landmark time); (2) refilling within 30 days versus not among individuals with antiplatelet supply; (3) criteria 2 plus continuous prior antiplatelet use; and (4) criteria 2 and 3 plus a cardiologist visit in months 10 to 12. Propensity score-adjusted hazard ratios were compared. Cohort sizes were 53 679, 27 524, 16 971, and 7948, respectively, of which 20% were discontinuers on average. Increasing restriction led to progressively larger associations with continued treatment: cohort 1 MACCE hazard ratio, 0.79 (0.73, 0.87); myocardial infarction, 0.74 (0.65, 0.83); bleed, 1.03 (0.96, 1.11) versus cohort 4 MACCE hazard ratio, 0.66 (0.48, 0.91); myocardial infarction, 0.56 (0.37, 0.86); bleed, 1.24 (0.95, 1.61). Estimates trended toward DAPT trial estimates and were associated with reduced levels of exposure misclassification. CONCLUSIONS: In an example of long-term antiplatelet use, increasing restrictions on the definition of therapy continuation yielded results consistent with trial estimates by reducing exposure misclassification.


Assuntos
Intervenção Coronária Percutânea , Inibidores da Agregação de Plaquetas/administração & dosagem , Demandas Administrativas em Assistência à Saúde , Idoso , Viés , Transtornos Cerebrovasculares/epidemiologia , Transtornos Cerebrovasculares/prevenção & controle , Mineração de Dados/métodos , Bases de Dados Factuais , Esquema de Medicação , Feminino , Hemorragia/induzido quimicamente , Hemorragia/epidemiologia , Humanos , Masculino , Medicare , Pessoa de Meia-Idade , Infarto do Miocárdio/epidemiologia , Infarto do Miocárdio/prevenção & controle , Estudos Observacionais como Assunto , Intervenção Coronária Percutânea/efeitos adversos , Intervenção Coronária Percutânea/instrumentação , Inibidores da Agregação de Plaquetas/efeitos adversos , Pontuação de Propensão , Medição de Risco , Fatores de Risco , Stents , Fatores de Tempo , Resultado do Tratamento , Estados Unidos/epidemiologia
15.
JAMA Netw Open ; 1(3): e180826, 2018 07 06.
Artigo em Inglês | MEDLINE | ID: mdl-30646034

RESUMO

Importance: Osteoporosis medication treatment is recommended after hip fracture, yet contemporary estimates of rates of initiation and clinical benefit in the patient population receiving routine care are not well documented. Objectives: To report osteoporosis treatment initiation rates between January 1, 2004, and September 30, 2015, and to estimate the risk reduction in subsequent nonvertebral fractures associated with treatment initiation in patients with hip fracture. Design, Setting, and Participants: In this cohort study, data from a commercial insurance claims database from the United States were analyzed. Patients 50 years and older who had a hip fracture and were not receiving treatment with osteoporosis medications before their fracture were included. Exposure: Prescription dispensing of an osteoporosis medication within 180 days of a hip fracture hospitalization. Main Outcomes and Measures: Each initiation episode was matched with 10 nonuse episodes on person-time after the index hip fracture event to preclude immortal time bias and followed up for the outcome of nonvertebral fracture until change in exposure or a censoring event. An instrumental variable analysis using 2-stage residual inclusion method was conducted using calendar year, specialist access, geographical variation in prescribing patterns, and hospital preference. Results: Among 97 169 patients with a hip fracture identified, the mean (SD) age was 80.2 (10.8) years, and 64 164 (66.0%) were women. A continuous decline over the study years was observed in osteoporosis medication initiation rates from 9.8% (95% CI, 9.0%-10.6%) in 2004 to 3.3% (95% CI, 2.9%-3.8%) in 2015. In the effectiveness analyses, the hospital preference instrumental variable had a stronger association with treatment (pseudo R2 = 0.20) than the other 3 instrumental variables (specialist access: pseudo R2 = 0.04; calendar year: pseudo R2 = 0.05; and geographic variation: pseudo R2 = 0.07). Instrumental variable analysis with hospital preference suggested a rate difference of 4.2 events (95% CI, 1.1-7.3) per 100 person-years in subsequent fractures associated with osteoporosis treatment initiation compared with nonuse in an additive hazard model. Conclusions and Relevance: Low rates of osteoporosis treatment initiation after a hip fracture in recent years were observed. Clinically meaningful reduction in subsequent nonvertebral fracture rates associated with treatment suggests that improving prescriber adherence to guidelines and patient adherence to prescribed regimens may result in notable public health benefit.


Assuntos
Conservadores da Densidade Óssea/uso terapêutico , Difosfonatos/uso terapêutico , Fraturas do Quadril/prevenção & controle , Osteoporose/tratamento farmacológico , Fraturas por Osteoporose/prevenção & controle , Idoso , Idoso de 80 Anos ou mais , Estudos de Coortes , Prescrições de Medicamentos/estatística & dados numéricos , Feminino , Fraturas do Quadril/etiologia , Humanos , Masculino , Osteoporose/complicações , Fraturas por Osteoporose/etiologia
16.
Acad Radiol ; 25(1): 26-39, 2018 01.
Artigo em Inglês | MEDLINE | ID: mdl-30711054

RESUMO

Funding for research has become increasingly difficult to obtain in an environment of decreasing clinical revenue, increasing research costs, and growing competition for federal and nonfederal funding sources. This paper identifies critical requirements to build and sustain a successful radiology research program (eg, key personnel and leadership, research training and mentorship, infrastructure, institutional and departmental funding or support), reviews the current state of available funding for radiology (including federal, nonfederal, philanthropy, crowdfunding, and industry), and describes promising opportunities for future funding (eg, health services, comparative effectiveness, and patient-centered outcomes research). The funding climate, especially at the federal level, changes periodically, so it is important to have radiology-specific organizations such as the American College of Radiology and the Academy of Radiology Research serving as our key advocates. Key to obtaining any funding, no matter what the source, is a well-formulated grant proposal, so a review of opportunities specifically available to radiologists to develop and hone their grant-writing skills is provided. Effective and sustained funding for radiology research has the potential to cultivate young researchers, bolster quality research, and enhance health care. Those interested in pursuing research need to be aware of the ever-changing funding landscape, research priority areas, and the resources available to them to succeed. To succeed, radiology researchers need to think about diversification and flexibility in their interests, developing multidisciplinary and multi-institutional projects, and engaging a broader base of stakeholders that includes patients.


Assuntos
Administração Financeira/organização & administração , Organização do Financiamento/organização & administração , Radiologia , Pesquisa/economia , Humanos , Estados Unidos
17.
BMJ Case Rep ; 20172017 Apr 24.
Artigo em Inglês | MEDLINE | ID: mdl-28438794

RESUMO

A 61-year-old Asian man presented with severe right upper quadrant pain which had been worsening for several months. Laboratory results indicated elevated aspartate aminotransferase and alanine aminotransferase. The subsequent ultrasound, CT and MRI showed a large cystic mass with solid components and severe intrahepatic and extrahepatic biliary ductal dilatation. The mass was resected and pathology showed a well-demarcated mucinous cystic lesion with polygonal cells containing ovoid nuclei and abundant pink oncocytic cytoplasm. These findings are characteristic of intraductal oncocytic papillary neoplasm (IOPN), a rare subtype of intraductal papillary neoplasm of the liver. IOPN occurs most frequently in the Asian regions endemic to clonorchiasis and hepatolithiasis; however, cases have been reported in the Western world as well. Patients with IOPN are male or female and typically middle-aged. Treatment is typically resection. Prognosis is favourable and recurrence is rare. The 5-year survival rate is upwards of 80%.


Assuntos
Neoplasias dos Ductos Biliares/diagnóstico , Carcinoma Papilar/diagnóstico , Neoplasias Hepáticas/diagnóstico , Neoplasias dos Ductos Biliares/patologia , Neoplasias dos Ductos Biliares/cirurgia , Ductos Biliares Intra-Hepáticos/patologia , Carcinoma Papilar/patologia , Carcinoma Papilar/cirurgia , Diagnóstico Diferencial , Diagnóstico por Imagem , Hepatectomia/métodos , Humanos , Testes de Função Hepática , Neoplasias Hepáticas/patologia , Neoplasias Hepáticas/cirurgia , Masculino , Pessoa de Meia-Idade
18.
J Manag Care Spec Pharm ; 23(4): 494-502, 2017 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-28345442

RESUMO

BACKGROUND: Attempts to predict who is at risk of future nonadherence have largely focused on predictions at the time of therapy initiation; however, these users are only a small proportion of all patients on therapy at any point in time. Methods to predict nonadherence for established medication users, which have not been previously described in the literature, would be helpful to guide efforts to enhance the use of evidence-based therapies. OBJECTIVE: To test approaches for adherence prediction among prevalent statin users, namely the use of short-term filling behavior, investigator-specified predictors from medical and pharmacy administrative claims, and the empirical selection of potential predictors using the high-dimensional propensity score variable selection algorithm. METHODS: Medical and prescription claims data from a large national health insurer were used to create a cohort of patients who filled statin medication prescriptions in January 2012. We defined 6 groups of adherence predictors and estimated 10 main models to predict medication adherence in the full cohort. The same was done for the population stratified based on the days supply of the index statin prescription (≤ 30 days vs. > 30 days). RESULTS: The study cohort consisted of 93,777 individuals, 58.4% of which were adherent to statins during follow-up. The use of 3 pre-index adherence predictors alone achieved a c-statistic of 0.70. Investigator-specified and empirically selected pharmacy, medical, and demographic variables did substantially worse (0.57-0.60). The use of 3 indicators of post-index adherence achieved a higher c-statistic than the best-performing model using pre-index information (0.74 vs. 0.72). The addition of 3 pre-index adherence predictors further improved discrimination (0.78). CONCLUSIONS: This analysis demonstrated the ability to predict adherence among medication users using filling behavior before and immediately after an index prescription fill. DISCLOSURES: This work was supported by an unrestricted grant from CVS Health to Brigham and Women's Hospital. Shrank, Brennan, and Matlin were employees and shareholders at CVS Health at the time of this manuscript preparation; they report no financial interests in products or services that are related to the subject of the manuscript. Franklin has received consulting fees from Aetion. Chourdry has received grants from the National Heart, Lung, and Blood Institute, PhRMA Foundation, Merck, Sanofi, AstraZeneca, and MediSafe. Spettell is an employee of, and shareholder in, Aetna. The other authors have nothing to disclose. Krumme, Choudhry, Tong, and Franklin contributed to the study design, interpretation of results, and manuscript drafting. Tong prepared and analyzed the data. Isaman, Spettell, Shrank, Brennan, and Matlin provided interpretation of results and critical manuscript revisions.


Assuntos
Inibidores de Hidroximetilglutaril-CoA Redutases/uso terapêutico , Cooperação do Paciente/estatística & dados numéricos , Estudos de Coortes , Feminino , Previsões , Humanos , Seguro Saúde/estatística & dados numéricos , Masculino , Adesão à Medicação , Pessoa de Meia-Idade , Modelos Estatísticos , Pontuação de Propensão , Estudos Retrospectivos , Fatores Socioeconômicos
19.
JAMA Intern Med ; 177(5): 624-631, 2017 05 01.
Artigo em Inglês | MEDLINE | ID: mdl-28241271

RESUMO

Importance: Forgetfulness is a major contributor to nonadherence to chronic disease medications and could be addressed with medication reminder devices. Objective: To compare the effect of 3 low-cost reminder devices on medication adherence. Design, Setting, and Participants: This 4-arm, block-randomized clinical trial involved 53 480 enrollees of CVS Caremark, a pharmacy benefit manager, across the United States. Eligible participants were aged 18 to 64 years and taking 1 to 3 oral medications for long-term use. Participants had to be suboptimally adherent to all of their prescribed therapies (with a medication possession ratio of 30% to 80%) in the 12 months before randomization. Participants were stratified on the basis of the medications they were using at randomization: medications for cardiovascular or other nondepression chronic conditions (the chronic disease stratum) and antidepressants (the antidepressant stratum). In each stratum, randomization occurred within blocks defined by whether all of the patient's targeted medications were dosed once daily. Patients were randomized to receive in the mail a pill bottle strip with toggles, digital timer cap, or standard pillbox. The control group received neither notification nor a device. Data were collected from February 12, 2013, through March 21, 2015, and data analyses were on the intention-to-treat population. Main Outcomes and Measures: The primary outcome was optimal adherence (medication possession ratio ≥80%) to all eligible medications among patients in the chronic disease stratum during 12 months of follow-up, ascertained using pharmacy claims data. Secondary outcomes included optimal adherence to cardiovascular medications among patients in the chronic disease stratum as well as optimal adherence to antidepressants. Results: Of the 53 480 participants, mean (SD) age was 45 (12) years and 56% were female. In the primary analysis, 15.5% of patients in the chronic disease stratum assigned to the standard pillbox, 15.1% assigned to the digital timer cap, 16.3% assigned to the pill bottle strip with toggles, and 15.1% assigned to the control arm were optimally adherent to their prescribed treatments during follow-up. There was no statistically significant difference in the odds of optimal adherence between the control and any of the devices (standard pillbox: odds ratio [OR], 1.03 [95% CI, 0.95-1.13]; digital timer cap: OR, 1.00 [95% CI, 0.92-1.09]; and pill bottle strip with toggles: OR, 0.94 [95% CI, 0.85-1.04]). In direct comparisons, the odds of optimal adherence were higher with a standard pillbox than with the pill bottle strip (OR, 1.10 [95% CI, 1.00-1.21]). Secondary analyses yielded similar results. Conclusions and Relevance: Low-cost reminder devices did not improve adherence among nonadherent patients who were taking up to 3 medications to treat common chronic conditions. The devices may have been more effective if coupled with interventions to ensure consistent use or if targeted to individuals with an even higher risk of nonadherence. Trial Registration: clinicaltrials.gov Identifier: NCT02015806.


Assuntos
Antidepressivos/uso terapêutico , Doença Crônica/tratamento farmacológico , Transtorno Depressivo/tratamento farmacológico , Adesão à Medicação/estatística & dados numéricos , Sistemas de Alerta , Adolescente , Adulto , Feminino , Humanos , Modelos Logísticos , Masculino , Pessoa de Meia-Idade , Razão de Chances , Estados Unidos , Adulto Jovem
20.
J Pediatr ; 182: 239-244.e1, 2017 03.
Artigo em Inglês | MEDLINE | ID: mdl-28012694

RESUMO

OBJECTIVES: To describe the rates of pediatric antibiotic use across 6 countries on 3 continents. STUDY DESIGN: Cross-national analysis of 7 pediatric cohorts in 6 countries (Germany, Italy, South Korea, Norway, Spain, and the US) was performed for 2008-2012. Antibiotic dispensings were identified and grouped into subclasses. We calculated the rates of antimicrobial prescriptions per person-year specific to each age group, comparing the rates across different countries. RESULTS: A total of 74 744 302 person-years from all participating centers were included in this analysis. Infants in South Korea had the highest rate of antimicrobial consumption, with 3.41 prescribed courses per child-year during the first 2 years of life. This compares with 1.6 in Lazio, Italy; 1.4 in Pedianet, Italy; 1.5 in Spain; 1.1 in the US; 1.0 in Germany; and 0.5 courses per child-year in Norway. Of antimicrobial prescriptions written in Norway, 64.8% were for first-line penicillins, compared with 38.2% in Germany, 31.8% in the US, 27.7% in Spain, 25.1% in the Italian Pedianet population, 9.8% in South Korea, and 8% in the Italian Lazio population. CONCLUSIONS: We found substantial differences of up to 7.5-fold in pediatric antimicrobial use across several industrialized countries from Europe, Asia, and North America. These data reinforce the need to develop strategies to decrease the unnecessary use of antimicrobial agents.


Assuntos
Antibacterianos/uso terapêutico , Infecções Bacterianas/tratamento farmacológico , Uso de Medicamentos/estatística & dados numéricos , Adolescente , Fatores Etários , Criança , Pré-Escolar , Estudos de Coortes , Estudos Transversais , Feminino , Alemanha , Humanos , Incidência , Lactente , Internacionalidade , Itália , Masculino , Noruega , República da Coreia , Estudos Retrospectivos , Espanha , Estados Unidos
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