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1.
MMWR Morb Mortal Wkly Rep ; 69(11): 298-302, 2020 Mar 20.
Artigo em Inglês | MEDLINE | ID: mdl-32191686

RESUMO

In 2017, prescription opioids were involved in 36% of opioid-involved overdose deaths in the United States (1). Prescription opioids can be obtained by prescription or through diversion (the channeling of regulated drugs from legal to illegal sources) (2). Among new heroin users, 66%-83% reported that their opioid use began with the misuse of a prescription opioid (3). "Misuse" is generally defined as drugs taken for a purpose other than that directed by the prescribing physician, in greater amounts, more often, or for a longer duration than prescribed (2). Exposure to prescription opioids can be lessened by ensuring recommended prescribing, thereby potentially reducing the risk for misuse, opioid use disorder, and overdose (4). Sex and age groups with high exposure to prescription opioids are not well defined. Using a retail pharmaceutical database from IQVIA,* nationwide trends in opioid prescription fill rates for adult outpatients by age and sex were examined during 2008-2018. Opioid prescription fill rates were disproportionately higher among men and women aged ≥65 years and women of all ages. For reasons not well understood, these disparities persisted over 11 years even as the opioid fill rate declined for each age group and sex. Interventions to improve prescribing practices by following evidence-based guidelines that include weighing the benefits and risks for using prescription opioids for each patient and adopting a multimodal approach to pain management could improve patient safety while ameliorating pain. These efforts might need to consider the unique needs of women and older adults, who have the highest opioid prescription fill rates.


Assuntos
Assistência Ambulatorial/estatística & dados numéricos , Analgésicos Opioides/uso terapêutico , Prescrições de Medicamentos/estatística & dados numéricos , Disparidades em Assistência à Saúde/estatística & dados numéricos , Adulto , Fatores Etários , Idoso , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Fatores Sexuais , Estados Unidos , Adulto Jovem
2.
BMJ ; 368: m283, 2020 03 04.
Artigo em Inglês | MEDLINE | ID: mdl-32131996

RESUMO

OBJECTIVE: To examine the associations between stopping treatment with opioids, length of treatment, and death from overdose or suicide in the Veterans Health Administration. DESIGN: Observational evaluation. SETTING: Veterans Health Administration. PARTICIPANTS: 1 394 102 patients in the Veterans Health Administration with an outpatient prescription for an opioid analgesic from fiscal year 2013 to the end of fiscal year 2014 (1 October 2012 to 30 September 2014). MAIN OUTCOME MEASURES: A multivariable Cox non-proportional hazards regression model examined death from overdose or suicide, with the interaction of time varying opioid cessation by length of treatment (≤30, 31-90, 91-400, and >400 days) as the main covariates. Stopping treatment with opioids was measured as the time when a patient was estimated to have no prescription for opioids, up to the end of the next fiscal year (2014) or the patient's death. RESULTS: 2887 deaths from overdose or suicide were found. The incidence of stopping opioid treatment was 57.4% (n=799 668) overall, and based on length of opioid treatment was 32.0% (≤30 days), 8.7% (31-90 days), 22.7% (91-400 days), and 36.6% (>400 days). The interaction between stopping treatment with opioids and length of treatment was significant (P<0.001); stopping treatment was associated with an increased risk of death from overdose or suicide regardless of the length of treatment, with the risk increasing the longer patients were treated. Hazard ratios for patients who stopped opioid treatment (with reference values for all other covariates) were 1.67 (≤30 days), 2.80 (31-90 days), 3.95 (91-400 days), and 6.77 (>400 days). Descriptive life table data suggested that death rates for overdose or suicide increased immediately after starting or stopping treatment with opioids, with the incidence decreasing over about three to 12 months. CONCLUSIONS: Patients were at greater risk of death from overdose or suicide after stopping opioid treatment, with an increase in the risk the longer patients had been treated before stopping. Descriptive data suggested that starting treatment with opioids was also a risk period. Strategies to mitigate the risk in these periods are not currently a focus of guidelines for long term use of opioids. The associations observed cannot be assumed to be causal; the context in which opioid prescriptions were started and stopped might contribute to risk and was not investigated. Safer prescribing of opioids should take a broader view on patient safety and mitigate the risk from the patient's perspective. Factors to address are those that place patients at risk for overdose or suicide after beginning and stopping opioid treatment, especially in the first three months.


Assuntos
Analgésicos Opioides/uso terapêutico , Overdose de Drogas/epidemiologia , Suicídio/estatística & dados numéricos , Veteranos/estatística & dados numéricos , Suspensão de Tratamento/estatística & dados numéricos , Adulto , Idoso , Prescrições de Medicamentos , Humanos , Pessoa de Meia-Idade , Padrões de Prática Médica , Modelos de Riscos Proporcionais , Estados Unidos/epidemiologia
3.
Pneumologie ; 74(3): 149-158, 2020 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-32143230

RESUMO

INTRODUCTION: Inhalative treatments with metered dose aerosols and dry powder inhalers are the backbone of the pharmacotherapy for asthma and COPD. In the last decade many new and generic inhalative bronchodilators were launched at the German market, both monotherapies and fixed dose double bronchodilator (LABA/LAMA, beta adrenergic and antimuscarinic) or LABA and inhaled corticosteroid (ICS) and triple (LABA/LAMA/ICS) combinations. According to two surveys in 2015 among respiratory physicians we expected a high proportion of patients receiving duplicate prescriptions, e. g. a fixed dose new LABA/LAMA combination in addition to an existing ICS/LABA fixed dose combination. METHODOLOGY: We searched the database of a large mail order pharmacy (DocMorris) to identify duplicate prescriptions of inhalative drugs for a patient by the same or by two or more different physicians during a 3 months period. RESULTS: Unexpectedly, we found as little as around 1 % duplicate prescriptions for the same patient. Duplicate prescriptions involving combination products were found to be much more common than duplicate prescriptions of different mono-products. Irrespective the low percentage number of all prescriptions we saw in just one large mail order pharmacy several thousands of erroneous prescriptions. CONCLUSION: At least in the setting of this mail order pharmacy duplicate (i. e. contraindicated and potentially dangerous) prescriptions are relatively rare. Prescribers and pharmacists should be aware of the issue of duplicates - especially when prescribing or filling prescriptions with combination products.


Assuntos
Corticosteroides/administração & dosagem , Broncodilatadores/administração & dosagem , Prescrições de Medicamentos/estatística & dados numéricos , Padrões de Prática Médica , Medicamentos sob Prescrição/uso terapêutico , Doença Pulmonar Obstrutiva Crônica/tratamento farmacológico , Administração por Inalação , Agonistas de Receptores Adrenérgicos beta 2 , Bases de Dados Factuais , Quimioterapia Combinada , Humanos , Antagonistas Muscarínicos
4.
R I Med J (2013) ; 103(2): 45-48, 2020 Mar 02.
Artigo em Inglês | MEDLINE | ID: mdl-32122101

RESUMO

Pain is universal, yet the prevalence of overdose and treatment of pain varies significantly between the United States (US) and Western Europe. Overdose deaths are seven times more common in the US compared to Western Europe. Cultural perceptions of pain, perception and treatment of opioid use disorder, pharmaceutical advertising, and rates and regulation of prescribing of opioids represent examples of factors that may be related to such differences between the US and Western Europe. As Rhode Island continues to battle the devastating and well-documented national opioid overdose epidemic, we should consider how cultural, regulatory differences, and economic factors may influence pain and its treatment.


Assuntos
Analgésicos Opioides/uso terapêutico , Dor Crônica/tratamento farmacológico , Overdose de Drogas/mortalidade , Prescrições de Medicamentos/estatística & dados numéricos , Transtornos Relacionados ao Uso de Opioides/epidemiologia , Oxicodona/administração & dosagem , Padrões de Prática Médica/estatística & dados numéricos , Dor Aguda/tratamento farmacológico , Analgésicos Opioides/envenenamento , Comparação Transcultural , Overdose de Drogas/epidemiologia , Europa (Continente)/epidemiologia , Humanos , Oxicodona/envenenamento , Manejo da Dor/métodos , Rhode Island/epidemiologia
5.
Br J Anaesth ; 124(3): 281-291, 2020 03.
Artigo em Inglês | MEDLINE | ID: mdl-32000975

RESUMO

BACKGROUND: Many patients use opioids chronically before surgery; it is unclear if surgery alters the likelihood of ongoing opioid consumption in these patients. METHODS: We performed a population-based matched cohort study of adults in Ontario, Canada undergoing one of 16 non-orthopaedic surgical procedures and who were chronically using opioids, defined as (1) an opioid prescription that overlapped the index date and (2) either a total of 120 or more cumulative calendar days of filled opioid prescriptions, or 10 or more prescriptions filled in the prior year. Each surgical patient was matched based on age, sex, Charlson comorbidity index, and daily preoperative opioid dose to three non-surgical patients who were also chronic opioid users. The primary outcome was time to opioid discontinuation. RESULTS: The cohort included 4755 surgical and 14 265 matched non-surgical patients. After adjustment for sociodemographic characteristics and comorbidities, surgery was associated with an increased likelihood of opioid discontinuation (adjusted hazard ratio: 1.34, 95% confidence interval [CI]: 1.27, 1.42). Among surgical patients, factors associated with a reduced odds of discontinuation included a mean preoperative opioid dose above 90 morphine milligram equivalents (adjusted odds ratio [aOR]: 0.39; 95% CI: 0.32, 0.49) or filling a prescription for oxycodone (aOR: 0.73; 95% CI: 0.56, 0.98). Receipt of an in-patient Acute Pain Service consultation (aOR: 1.34; 95% CI: 1.06, 1.69) or residing in the highest neighbourhood income quintile (aOR: 1.35; 95% CI: 1.04, 1.79) were associated with a greater odds of opioid discontinuation. CONCLUSIONS: For chronic opioid users, surgery was associated with an increased likelihood of discontinuation of opioids in the following year compared with non-surgical chronic opioid users.


Assuntos
Analgésicos Opioides/administração & dosagem , Transtornos Relacionados ao Uso de Opioides/epidemiologia , Dor Pós-Operatória/tratamento farmacológico , Procedimentos Cirúrgicos Operatórios/métodos , Idoso , Analgésicos Opioides/uso terapêutico , Estudos de Casos e Controles , Doença Crônica , Estudos de Coortes , Esquema de Medicação , Prescrições de Medicamentos/estatística & dados numéricos , Uso de Medicamentos/estatística & dados numéricos , Feminino , Humanos , Estimativa de Kaplan-Meier , Masculino , Pessoa de Meia-Idade , Ontário/epidemiologia , Período Pós-Operatório , Suspensão de Tratamento/estatística & dados numéricos
6.
BMJ ; 368: m331, 2020 02 19.
Artigo em Inglês | MEDLINE | ID: mdl-32075790

RESUMO

OBJECTIVE: To assess the association between macrolide antibiotics prescribing during pregnancy and major malformations, cerebral palsy, epilepsy, attention deficit hyperactivity disorder, and autism spectrum disorder in children. DESIGN: Population based cohort study. SETTING: The UK Clinical Practice Research Datalink. PARTICIPANTS: The study cohort included 104 605 children born from 1990 to 2016 whose mothers were prescribed one macrolide monotherapy (erythromycin, clarithromycin, or azithromycin) or one penicillin monotherapy from the fourth gestational week to delivery. Two negative control cohorts consisted of 82 314 children whose mothers were prescribed macrolides or penicillins before conception, and 53 735 children who were siblings of the children in the study cohort. MAIN OUTCOME MEASURES: Risks of any major malformations and system specific major malformations (nervous, cardiovascular, gastrointestinal, genital, and urinary) after macrolide or penicillin prescribing during the first trimester (four to 13 gestational weeks), second to third trimester (14 gestational weeks to birth), or any trimester of pregnancy. Additionally, risks of cerebral palsy, epilepsy, attention deficit hyperactivity disorder, and autism spectrum disorder. RESULTS: Major malformations were recorded in 186 of 8632 children (21.55 per 1000) whose mothers were prescribed macrolides and 1666 of 95 973 children (17.36 per 1000) whose mothers were prescribed penicillins during pregnancy. Macrolide prescribing during the first trimester was associated with an increased risk of any major malformation compared with penicillin (27.65 v 17.65 per 1000, adjusted risk ratio 1.55, 95% confidence interval 1.19 to 2.03) and specifically cardiovascular malformations (10.60 v 6.61 per 1000, 1.62, 1.05 to 2.51). Macrolide prescribing in any trimester was associated with an increased risk of genital malformations (4.75 v 3.07 per 1000, 1.58, 1.14 to 2.19, mainly hypospadias). Erythromycin in the first trimester was associated with an increased risk of any major malformation (27.39 v 17.65 per 1000, 1.50, 1.13 to 1.99). No statistically significant associations were found for other system specific malformations or for neurodevelopmental disorders. Findings were robust to sensitivity analyses. CONCLUSIONS: Prescribing macrolide antibiotics during the first trimester of pregnancy was associated with an increased risk of any major malformation and specifically cardiovascular malformations compared with penicillin antibiotics. Macrolide prescribing in any trimester was associated with an increased risk of genital malformations. These findings show that macrolides should be used with caution during pregnancy and if feasible alternative antibiotics should be prescribed until further research is available. TRIAL REGISTRATION: ClinicalTrials.gov NCT03948620.


Assuntos
Anormalidades Induzidas por Medicamentos/etiologia , Antibacterianos/efeitos adversos , Macrolídeos/efeitos adversos , Efeitos Tardios da Exposição Pré-Natal/induzido quimicamente , Anormalidades Induzidas por Medicamentos/epidemiologia , Transtorno do Deficit de Atenção com Hiperatividade/induzido quimicamente , Transtorno do Deficit de Atenção com Hiperatividade/epidemiologia , Transtorno do Espectro Autista/induzido quimicamente , Transtorno do Espectro Autista/epidemiologia , Anormalidades Cardiovasculares/induzido quimicamente , Anormalidades Cardiovasculares/epidemiologia , Paralisia Cerebral/induzido quimicamente , Paralisia Cerebral/epidemiologia , Estudos de Coortes , Bases de Dados Factuais , Prescrições de Medicamentos/estatística & dados numéricos , Epilepsia/induzido quimicamente , Epilepsia/epidemiologia , Feminino , Humanos , Recém-Nascido , Gravidez , Primeiro Trimestre da Gravidez , Efeitos Tardios da Exposição Pré-Natal/epidemiologia , Estudos Retrospectivos , Sensibilidade e Especificidade , Reino Unido/epidemiologia
7.
Eur J Endocrinol ; 182(4): 423-428, 2020 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-32061160

RESUMO

Objectives: Male hypogonadism is associated with higher risk of co-morbidity and premature mortality. It is, therefore, of utmost importance to identify young men who are at the highest risk of testosterone deficiency and who may benefit from preventive measures. In this context, infertile men constitute a high-risk group. The extent of testosterone replacement therapy (TRT) among infertile men, defined as men who have to undergo assisted reproduction for fatherhood, is currently unknown. Therefore, we evaluated the pattern of prescription of TRT in the years following child conception among men who have fathered children with the help of intracytoplasmic sperm injection (ICSI) or in vitro fertilization (IVF). Design: By sourcing data from national population registries, hazard ratio (HR) for subsequent TRT was assessed for IVF and ICSI-treated men and compared to those who conceived spontaneously with age Cox regression analysis adjusted for age, educational level and previous intake of medicines for metabolic diseases. Results: ICSI and IVF fathers had increased incidence of newly prescribed TRT compared to fathers conceiving spontaneously (ICSI: HR = 3.81, 95% CI = 3.09-4.69, P < 0.001; IVF: HR = 1.54, 95% CI = 1.15-2.05, P = 0.003). After adjustment for prescription of medication for one or more components of the MetS prior to TRT, the risk estimates attenuated but remained robust both for ICSI-treated (HR = 3.17 (95% CI: 2.56-3.9) and IVF-treated men (HR = 1.06 (95% CI: 1.05-1.07). Conclusion: Men who have to utilise powerful techniques, such as ICSI for fathering children, may be at risk for testosterone deficiency. Routine endocrine evaluation of men seeking fertility treatment is hence warranted.


Assuntos
Prescrições de Medicamentos/estatística & dados numéricos , Terapia de Reposição Hormonal/estatística & dados numéricos , Infertilidade Masculina/terapia , Injeções de Esperma Intracitoplásmicas/estatística & dados numéricos , Testosterona/uso terapêutico , Adulto , Fertilização In Vitro/estatística & dados numéricos , Humanos , Infertilidade Masculina/etiologia , Masculino , Pessoa de Meia-Idade , Modelos de Riscos Proporcionais , Sistema de Registros , Suécia , Testosterona/deficiência
9.
Einstein (Sao Paulo) ; 18: eAO4433, 2020.
Artigo em Inglês, Português | MEDLINE | ID: mdl-31939523

RESUMO

OBJECTIVE: To describe the pharmaceutical interventions of a vertical clinical pharmacy service to promote the rational use of intravenous omeprazole. METHODS: A prospective and descriptive study carried out at a university hospital in the Midwestern Region of Brazil, from November 2014 to May 2015. The service consisted of the analysis of adequacy of the route of administration of omeprazole in relation to the clinical conditions of the patient, as well as the use of the appropriate diluent. Interventions were recorded in medical records and subsequently evaluated for acceptance. RESULTS: A total of 770 prescriptions were evaluated. Interventions related to diluent replacement were more accepted (p<0.001), and surgeons were the specialty that used the intravenous route inappropriately (p<0.001). CONCLUSION: Although partially accepted, pharmaceutical interventions could contribute to improve patient safety, since they allowed the use of a safer route of administration.


Assuntos
Administração Intravenosa/métodos , Omeprazol/administração & dosagem , Serviço de Farmácia Hospitalar/normas , Inibidores da Bomba de Prótons/administração & dosagem , Adulto , Distribuição por Idade , Idoso , Brasil , Prescrições de Medicamentos/estatística & dados numéricos , Feminino , Hospitais Universitários , Humanos , Masculino , Erros de Medicação/estatística & dados numéricos , Pessoa de Meia-Idade , Segurança do Paciente , Estudos Prospectivos , Distribuição por Sexo
14.
BMJ ; 368: l6968, 2020 01 29.
Artigo em Inglês | MEDLINE | ID: mdl-31996352

RESUMO

OBJECTIVE: To examine the distribution and patterns of opioid prescribing in the United States. DESIGN: Retrospective, observational study. SETTING: National private insurer covering all 50 US states and Washington DC. PARTICIPANTS: An annual average of 669 495 providers prescribing 8.9 million opioid prescriptions to 3.9 million patients from 2003 through 2017. MAIN OUTCOME MEASURES: Standardized doses of opioids in morphine milligram equivalents (MMEs) and number of opioid prescriptions. RESULTS: In 2017, the top 1% of providers accounted for 49% of all opioid doses and 27% of all opioid prescriptions. In absolute terms, the top 1% of providers prescribed an average of 748 000 MMEs-nearly 1000 times more than the middle 1%. At least half of all providers in the top 1% in one year were also in the top 1% in adjacent years. More than two fifths of all prescriptions written by the top 1% of providers were for more than 50 MMEs a day and over four fifths were for longer than seven days. In contrast, prescriptions written by the bottom 99% of providers were below these thresholds, with 86% of prescriptions for less than 50 MMEs a day and 71% for fewer than seven days. Providers prescribing high amounts of opioids and patients receiving high amounts of opioids persisted over time, with over half of both appearing in adjacent years. CONCLUSIONS: Most prescriptions written by the majority of providers are under the recommended thresholds, suggesting that most US providers are careful in their prescribing. Interventions focusing on this group of providers are unlikely to effect beneficial change and could induce unnecessary burden. A large proportion of providers have established relationships with their patients over multiple years. Interventions to reduce inappropriate opioid prescribing should be focused on improving patient care, management of patients with complex pain, and reducing comorbidities rather than seeking to enforce a threshold for prescribing.


Assuntos
Analgésicos Opioides/uso terapêutico , Prescrição Inadequada/prevenção & controle , Administração dos Cuidados ao Paciente/normas , Médicos , Padrões de Prática Médica , Adulto , Prescrições de Medicamentos/normas , Prescrições de Medicamentos/estatística & dados numéricos , Feminino , Humanos , Revisão da Utilização de Seguros/estatística & dados numéricos , Masculino , Médicos/classificação , Médicos/estatística & dados numéricos , Padrões de Prática Médica/estatística & dados numéricos , Padrões de Prática Médica/tendências , Medicamentos sob Prescrição/uso terapêutico , Melhoria de Qualidade , Estudos Retrospectivos , Estados Unidos/epidemiologia
16.
An Bras Dermatol ; 95(1): 20-24, 2020.
Artigo em Inglês | MEDLINE | ID: mdl-31899062

RESUMO

BACKGROUND: Despite the economic burden of psoriasis for patients and societies, scant information exists regarding the impact and burden of the disease in Argentina. OBJECTIVE: The objective of this study was to estimate medical resource consumption and direct health care costs for patients with moderate/severe psoriasis in Buenos Aires, Argentina from the perspective of the payer. METHODS: Adults with moderate/severe psoriasis (severity was defined as receiving systemic treatment), during January 2010-January 2014, aged 18 years and older, members of the Italian Hospital Medical Care Program with at least 18 months of follow-up were included. All data on hospitalizations, drug prescription, outpatient episodes, consultations, and investigations/tests in the 12 months before inclusion in the study were considered for the estimation of medical resource consumption and direct health care costs. First-quarter 2018 costs were obtained from the IHMCP and converted into US dollars (using the January 2018 exchange rate). RESULTS: A total of 791 patients were included. The mean age at diagnosis was 34±12 years. Almost 65% of the patients had a dermatologist as their usual source of care, 43% had internists, and 14% had rheumatologists. The average yearly direct cost was US$ 5326 (95% CI: 4125-7896) per patient per year. STUDY LIMITATION: The single center design and the retrospective nature are the main limitations. CONCLUSION: This is the first Argentine study that evaluated the costs of moderate/severe psoriasis by taking into consideration the direct medical costs of the disease.


Assuntos
Custos de Cuidados de Saúde/estatística & dados numéricos , Psoríase/economia , Adulto , Argentina , Prescrições de Medicamentos/economia , Feminino , Hospitalização/economia , Humanos , Masculino , Pessoa de Meia-Idade , Encaminhamento e Consulta/economia , Estudos Retrospectivos , Índice de Gravidade de Doença , Estatísticas não Paramétricas , Fatores de Tempo , Adulto Jovem
17.
BMC Health Serv Res ; 20(1): 6, 2020 Jan 02.
Artigo em Inglês | MEDLINE | ID: mdl-31898496

RESUMO

BACKGROUND: Care goals are often implicit, although their identification is a key element of any prescription process. This study aimed to describe the clinical goals of drug prescriptions in general practice, their determinants and the agreement between physicians and patients. METHODS: This was a cross-sectional study conducted by 11 resident trainees acting as observers in 23 general practices. The residents recorded the indication and main physician's goal for all drugs prescribed during five consultation days in each practice in December 2015, and the main patient's goal for a sub-sample of consultations. We used an eight-category generic classification of prescription goals, including three specific (mortality, morbidity and cure), three non-specific (symptoms, quality of life, functioning) and two non-specified (other goal, no goal) categories. Analyses were based on a multivariable, multilevel model and on the kappa statistic applied to the sub-sample of consultations. RESULTS: The sample encompassed 2141 consultations and 5036 drugs. The main physicians' goal of drug prescriptions was to relieve symptoms (43.3%). The other goals were to decrease the risk of morbidity (22.4%), to cure disease (11.7%), to improve quality of life (10.6%), to decrease the risk of mortality (8.5%) and to improve functioning (1.8%). The choice of a specific goal was more frequent in patients with the following characteristics: over 50 (OR [1.09;1.15]), of male gender (OR [1.09;1.39]), with full financial coverage for a long-term condition (OR [1.47;1.97]), known by the physician (OR [1.19;2.23]), or with a somatic health problem (OR [2.56;4.17]). Cohen's kappa for drug prescription goals between the patients and the physicians was 0.26 (0.23-0.30). CONCLUSIONS: Physicians' goals are poorly shared with patients. It remains to be assessed whether it is possible to collect and discuss information on prescription goals on a daily basis.


Assuntos
Prescrições de Medicamentos , Clínicos Gerais/psicologia , Padrões de Prática Médica , Atenção Primária à Saúde , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Estudos Transversais , Feminino , França , Medicina Geral , Clínicos Gerais/estatística & dados numéricos , Metas , Humanos , Masculino , Pessoa de Meia-Idade , Relações Médico-Paciente , Adulto Jovem
18.
Environ Pollut ; 256: 113340, 2020 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-31662257

RESUMO

BACKGROUND: Evidence of health effects following early life exposure to short-to-medium duration of high pollution levels is extremely limited. OBJECTIVES: We aimed to evaluate the associations between: 1. intrauterine exposure to fine particulate matter (PM2.5) from coal mine fire emissions and the frequencies of general practitioner attendances and dispensations of prescribed asthma inhalers, steroid skin creams, and antibiotics during the first year of life; 2. infant exposure and those outcomes during the year following the fire. METHODS: All participants were recruited from the Latrobe Valley of Victoria, Australia. Participants' 24-h average and hourly peak mine fire-specific PM2.5 exposures from 09/02/2014 to 31/03/2014 were estimated using chemical transport modelling. Outcome data were obtained from the Australian Medicare Benefits Schedule and Pharmaceutical Benefits Scheme from each child's birth to 31/12/2016. We used negative binomial and logistic regression models to independently assess risks of the outcomes associated with every 10 and 100 µg m-3 increase in average or peak PM2.5 exposure, respectively, while adjusting for potential confounders. RESULTS: We included 286 of 311 children whose parents consented to be linked, comprising 77 with no exposure, 88 with intrauterine exposure and 121 with exposure in infancy. 10- and 100- µg m-3 increases in average and peak PM2.5 exposure during infancy were associated with greater incidence of antibiotics being dispensed during the year following the fire: the adjusted incidence rate ratios were 1.24 (95% CI 1.02, 1.50, p = 0.036) and 1.14 (1.00, 1.31, p = 0.048) respectively. No other significant associations were observed. CONCLUSION: Exposure to coal mine fire emissions during infancy was associated with increased dispensing of antibiotics. This could reflect increased childhood infections or increased prescriptions of antibiotics in the year following the fire.


Assuntos
Poluição do Ar/análise , Asma/epidemiologia , Infecções Bacterianas/epidemiologia , Dermatite Atópica/epidemiologia , Uso de Medicamentos/estatística & dados numéricos , Exposição Ambiental/análise , Efeitos Tardios da Exposição Pré-Natal/epidemiologia , Poluentes Atmosféricos/análise , Asma/terapia , Infecções Bacterianas/terapia , Criança , Minas de Carvão , Dermatite Atópica/terapia , Prescrições de Medicamentos/estatística & dados numéricos , Feminino , Fogo , Humanos , Incidência , Lactente , Masculino , Material Particulado/análise , Gravidez , Efeitos Tardios da Exposição Pré-Natal/terapia , Fatores de Tempo , Vitória/epidemiologia
19.
Urology ; 136: 105-111, 2020 02.
Artigo em Inglês | MEDLINE | ID: mdl-31715273

RESUMO

OBJECTIVE: To evaluate temporal trends in prescriptions for extended-duration pharmacologic prophylaxis (EDPP) intended to prevent venous thromboembolism following radical cystectomy (RC). MATERIALS AND METHODS: We used OptumLabs Data Warehouse, a national administrative claims database, to identify patients undergoing RC for bladder cancer from 2012 to 2017. Rates of outpatient prescriptions for EDPP following RC were assessed, and rate over time was evaluated using the Cochran-Armitage test for trend. Multivariable logistic regression was used to examine associations between clinical and practice-level characteristics with EDPP prescriptions. RESULTS: A total of 2054 patients were identified, including 386 (19%) who received an EDPP prescription. The rate of EDPP prescriptions increased significantly over the study period, from 9% of cases in 2012 to 26% of cases in 2017 (P <.001). On multivariable logistic regression, age <65 (OR 1.79, 95% CI 1.39-2.33; P <.001), receipt of neoadjuvant chemotherapy (OR 1.33, 95% CI 1.04-1.71; P = .02), more recent procedure year (OR 4.11, 95% CI 2.35-7.18; P <.001), treatment in a public as compared to a for-profit hospital (OR 3.38, 95% CI 1.31-8.74; P = .01), and treatment at a hospital with residency training (OR 4.45, 95% CI 1.26-15.7; P = .02) or a surgical robot (OR 3.44, 95% CI 1.31-9.08; P = .01) were significantly associated with increased odds of receiving EDPP. CONCLUSION: EDPP following RC has increased over time, but is still provided for only a minority of patients. These data may be useful for guiding quality improvement efforts given recent literature supporting the use of EDPP.


Assuntos
Anticoagulantes/administração & dosagem , Cistectomia , Complicações Pós-Operatórias/prevenção & controle , Tromboembolia Venosa/prevenção & controle , Idoso , Estudos de Coortes , Cistectomia/métodos , Prescrições de Medicamentos/estatística & dados numéricos , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Fatores de Tempo
20.
Postgrad Med ; 132(1): 37-43, 2020 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-31549932

RESUMO

Objective: Our institution implemented six multimodal, sliding scale protocols for managing pain in non-surgical inpatients. The purpose of this study was to compare the use of these acute pain protocols with traditional prescribing in regard to pain management efficacy and safety measures.Methods: This retrospective cohort study evaluated hospital in-patients who were prescribed one of the protocols during the first 6 months following implementation, admitted to the hospitalist service, and had received at least two doses of PRN analgesic medication within a 24-hour period. Data collected included baseline demographics, verbal pain rating scores to determine time to achieve analgesia, total opioid use in oral morphine equivalent doses (MEDs), and safety measures. A sample of patients admitted during the same time frame, meeting inclusion/exclusion criteria, but who received traditional analgesic prescribing served as controls.Results: Forty-six adult, non-surgical patients were included in the analysis, and 46 served as controls. The average baseline pain scores were similar between groups (7.26 in protocol, 7.43 in control, p = 0.684). Protocol patients required significantly less time to achieve meaningful analgesia (average 507.52 min) compared to the control group (894.33 min, p = 0.045). Patients in the protocol group used an average of 35.81 MEDs per day compared to 65.77 MEDs in controls (p = 0.019). Patients in the protocol group used significantly fewer PRN analgesic doses (12.70 vs. 24.02, p < 0.0001).Conclusion: Analysis of the implementation of acute pain management protocols indicates that using standardized pain management protocols of opioids, non-opioids, and medications to prevent opioid-related adverse events is more effective than traditional analgesic prescribing for our patient population.


Assuntos
Dor Aguda/tratamento farmacológico , Analgésicos/uso terapêutico , Prescrições de Medicamentos , Medição da Dor/métodos , Analgésicos Opioides/uso terapêutico , Protocolos Clínicos , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Resultado do Tratamento
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