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1.
Marilyn?M.?Schapira Brian?L.?Sprague Carrie?N.?Klabunde Anna?N.?A.?Tosteson Asaf?Bitton Jane?S.?Chen Elisabeth?F.?Beaber Tracy?Onega Charles?D.?MacLean Kimberly?Harris Kathleen?Howe Loretta?Pearson Sarah?Feldman Phyllis?Brawarsky Jennifer?S.?Haas 《Journal of general internal medicine》2016,31(10):1148-1155
Background
Despite substantial resources devoted to cancer screening nationally, the availability of clinical practice-based systems to support screening guidelines is not known.Objective
To characterize the prevalence and correlates of practice-based systems to support breast and cervical cancer screening, with a focus on the patient-centered medical home (PCMH).Design
Web and mail survey of primary care providers conducted in 2014. The survey assessed provider (gender, training) and facility (size, specialty training, physician report of National Committee for Quality Assurance (NCQA) PCMH recognition, and practice affiliation) characteristics. A hierarchical multivariate analysis clustered by clinical practice was conducted to evaluate characteristics associated with the adoption of practice-based systems and technology to support guideline-adherent screening.Participants
Primary care physicians in family medicine, general internal medicine, and obstetrics and gynecology, and nurse practitioners or physician assistants from four clinical care networks affiliated with PROSPR (Population-based Research Optimizing Screening through Personalized Regimens) consortium research centers.Main Measures
The prevalence of routine breast cancer risk assessment, electronic health record (EHR) decision support, comparative performance reports, and panel reports of patients due for routine screening and follow-up.Key Results
There were 385 participants (57.6 % of eligible). Forty-seven percent (47.0 %) of providers reported NCQA recognition as a PCMH. Less than half reported EHR decision support for breast (48.8 %) or cervical cancer (46.2 %) screening. A minority received comparative performance reports for breast (26.2 %) or cervical (19.7 %) cancer screening, automated reports of patients overdue for breast (18.7 %) or cervical (16.4 %) cancer screening, or follow-up of abnormal breast (18.1 %) or cervical (17.6 %) cancer screening tests. In multivariate analysis, reported NCQA recognition as a PCMH was associated with greater use of comparative performance reports of guideline-adherent breast (OR 3.23, 95 % CI 1.58–6.61) or cervical (OR 2.56, 95 % CI 1.32–4.96) cancer screening and automated reports of patients overdue for breast (OR 2.19, 95 % CI 1.15–41.7) or cervical (OR. 2.56, 95 % CI 1.26–5.26) cancer screening.Conclusions
Providers lack systems to support breast and cervical cancer screening. Practice transformation toward a PCMH may support the adoption of systems to achieve guideline-adherent cancer screening in primary care settings.2.
Liliana E. Pezzin Mallory B. O’Niel Ann B. Nattinger 《Journal of general internal medicine》2009,24(2):446
RATIONALE
Adjuvant hormone therapy (HT) based on tamoxifen (TX) or aromatase inhibitors (AIs) has become the standard of care for treating hormone receptor -positive (HR+) breast cancer (BC) over the past 20 years. Based on clinical trial results, AI use is recommended by the American Society of Clinical Oncology for treatment of postmenopausal women with HR+ breast cancer. AIs, however, are significantly more expensive than TX, raising concerns about access and use of effective treatment among women of lower socio-economic status.OBJECTIVES
To examine the relationship between adjuvant HT modality and experience of financial hardship among a cohort of older BC survivors. Also, to examine the extent to which financial concerns affect the probability of switching between adjuvant HT modalities.DESIGN
Population-based, prospective survey study.PARTICIPANTS
Elderly (65+) women who had an incident BC surgery in 2003 and who reported receiving adjuvant HT during the first 12 months post-surgery.METHODS
Multivariate regression models.RESULTS
Use of AIs was associated with a significantly higher probability of financial hardship. Women who had taken only an AI were more likely to experience financial difficulty than women who took only TX (OR?=?1.4; 95% CI: 1.1–1.7), but women who switched between TX and AI were not more likely to experience financial difficulty. Breast cancer survivors with no drug coverage (OR?=?4.5; 95% CI: 3.3–5.9) or partial drug coverage (OR?=?3.6; 95% CI: 2.8–4.5) were more likely to experience financial difficulty compared to those with full coverage. Lack of drug coverage was also the main factor associated with the likelihood that BC survivors did not switch adjuvant HT modalities.CONCLUSIONS
Adjuvant HTs have important economic consequences for BC survivors. These consequences are ameliorated by full, but not partial, drug coverage.3.
GLP-1 Receptor Agonists and Cardiovascular Disease: a Meta-Analysis of Recent Cardiac Outcome Trials
Xiaoming Jia Mahboob Alam Yumei Ye Mandeep Bajaj Yochai Birnbaum 《Cardiovascular drugs and therapy / sponsored by the International Society of Cardiovascular Pharmacotherapy》2018,32(1):65-72
Purpose
The aim of this study is to examine the cardioprotective properties of Glucagon-like peptide-1 receptor agonist, a class of antihyperglycemic therapy, via meta-analysis of four recently published cardiovascular outcomes trials.Methods
Meta-analysis was performed pooling data from the ELIXA, LEADER, SUSTAIN-6 and EXSCEL trials. A random effects model was used to generate risk ratio with 95% confidence interval for cardiovascular and safety outcomes.Results
A total of 33,457 patients were included in the meta-analysis. Based on the study, GLP-1R agonists significantly reduced all-cause mortality (RR 0.89; 95% CI 0.82 to 0.96) and cardiovascular mortality (RR 0.88; 95% CI 0.80 to 0.97) when compared to placebo. When long-acting agents were analyzed alone, reduction in major adverse cardiac events (RR 0.88; 95% CI 0.81 to 0.97) and non-fatal strokes (RR 0.87; 95% CI 0.76 to 0.99) also showed significance.Conclusion
Overall, GLP-1R agonists appear to have cardioprotective properties likely via modification of metabolic parameters such as glycemic control, weight loss, and improvement in blood pressure. Additional studies are warranted to compare cardiovascular outcomes among the different agents.4.
Danielle E. Rose Melissa M. Farmer Elizabeth M. Yano Donna L. Washington 《Journal of general internal medicine》2013,28(2):524-528
BACKGROUND
Heart disease is the leading cause of death for women in the United States, accounting for 24.5 % of all deaths among women. Earlier research has demonstrated racial/ethnic differences in prevalence of cardiovascular (CVD) risk factors.OBJECTIVE
To empirically examine the prevalence of CVD risk factors among a national sample of women Veterans by race/ethnicity, providing the first portrait of women Veterans’ cardiovascular care needs.DESIGN AND PARTICIPANTS
Cross-sectional, national population-based telephone survey of 3,611 women Veterans.MEASUREMENTS
Women Veterans were queried about presence of diabetes, hypertension, obesity, tobacco use and physical activity. Four racial/ethnic categories were created: Hispanic, Non-Hispanic White (White), Non-Hispanic Black (Black), and Other. Logistic regressions were conducted for each risk factor to test for racial/ethnic differences, controlling for age (under 40 vs. 40 and over).KEY RESULTS
Racial/ethnic differences in CVD risk factors persisted after adjusting for age. Black women Veterans were more likely to report a diagnosis of diabetes (OR: 2.58, 95 % CI: 1.07, 6.21) or hypertension (OR: 2.31, 95 % CI: 1.10, 4.83) and be obese (OR: 2.06, 95 % CI: 1.05, 3.91) than White women Veterans. Hispanic women Veterans were more likely than White women Veterans to report diabetes (OR: 4.20, 95 % CI: 1.15, 15.39) and daily smoking (OR: 3.38, 95 % CI: 1.01, 11.30), but less likely to report a hypertension diagnosis (OR 0.21, 95% CI: 0.07, 0.64) or to be obese (OR: 0.39, 95 % CI: 0.18, 0.81).CONCLUSIONS
Among women Veterans, CVD risks vary by race/ethnicity. Black women Veterans consistently face higher CVD risk compared to White women Veterans, while results are mixed for Hispanic women Veterans.5.
Christina Mangurian Dean Schillinger John W. Newcomer Eric Vittinghoff Susan Essock Zheng Zhu Wendy Dyer Julie Schmittdiel 《Journal of general internal medicine》2018,33(1):79-86
Background
Severe mental illness (SMI) is associated with increased risk for type 2 diabetes, partly due to adverse metabolic effects of antipsychotic medications. In public health care settings, annual screening rates are 30%. We measured adherence to national diabetes screening guidelines for patients taking antipsychotic medications.Objective
To estimate diabetes screening prevalence among patients with SMI within an integrated health care system, and to assess characteristics associated with lack of screening.Design
Retrospective cohort study.Participants
Antipsychotic-treated adults with SMI. We excluded participants with known diabetes.Main Measures
Primary outcome was screening via fasting glucose test or hemoglobin A1c during a 1-year period.Key Results
In 2014, 16,754 patients with SMI diagnoses were receiving antipsychotics. Seventy-four percent of these patients’ providers ordered diabetes screening tests that year, but only 55% (9247/16,754) received screening. When the observation time frame was extended to 2 years, 73% (12,250/16,754) were screened. Adjusting for sex and race/ethnicity, young adults (aged 18–29 years) were less likely to receive screening than older age groups [adjusted RR (aRR) 1.23–1.57, p < 0.0001]. Compared to whites, screening was more common for Asians (aRR 1.141, 95% CI 1.089–1.195, p < 0.0001), less common for blacks (aRR 0.946, 95% CI 0.898–0.997, p < 0.0375), and no different for Hispanics (aRR 1.030, 95% CI 0.988–1.074, p = 0.165). Smokers were less likely to be screened than non-smokers (aRR 0.93, 95% CI 0.89–0.97, p < 0.0008). Utilization of either mental health or primary care services increased the likelihood of screening.Conclusions
While almost three-fourths of adults with SMI taking antipsychotic medications received a lab order for diabetes screening, only 55% received screening within a 12-month period. Young adults and smokers were less likely to be screened, despite their disproportionate metabolic risk. Future studies should assess the barriers and facilitators with regard to diabetes screening in this vulnerable population at the patient, provider, and system levels.6.
Getachew Mullu Kassa Achenef Asmamaw Muche Abadi Kidanemariam Berhe Gedefaw Abeje Fekadu 《BMC blood disorders》2017,17(1):17
Background
Anemia during pregnancy is one of the most common indirect obstetric cause of maternal mortality in developing countries. It is responsible for poor maternal and fetal outcomes. A limited number of studies were conducted on anemia during pregnancy in Ethiopia, and they present inconsistent findings. Therefore, this review was undertaken to summarize the findings conducted in several parts of the country and present the national level of anemia among pregnant women in Ethiopia.Methods
Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guideline was followed for this systematic review and meta-analysis. The databases used were; PUBMED, Cochrane Library, Google Scholar, CINAHL, and African Journals Online. Search terms used were; anemia, pregnancy related anemia and Ethiopia. Joanna Briggs Institute Meta-Analysis of Statistics Assessment and Review Instrument (JBI-MAStARI) was used for critical appraisal of studies. The meta-analysis was conducted using STATA 14 software. The pooled Meta logistic regression was computed to present the pooled prevalence and relative risks (RRs) of the determinate factors with 95% confidence interval (CI).Results
Twenty studies were included in the meta-analysis with a total of 10, 281 pregnant women. The pooled prevalence of anemia among pregnant women in Ethiopia was 31.66% (95% CI (26.20, 37.11)). Based on the pooled prevalence of the subgroup analysis result, the lowest prevalence of anemia among pregnant women was observed in Amhara region, 15.89% (95% CI (8.82, 22.96)) and the highest prevalence was in Somali region, 56.80% (95% CI (52.76, 60.84)). Primigravid (RR: 0.61 (95% CI: 0.53, 0.71)) and urban women (RR: 0.73 (95% CI: 0.60, 0.88)) were less likely to develop anemia. On the other hand, mothers with short pregnancy interval (RR: 2.14 (95% CI: 1.67, 2.74)) and malaria infection during pregnancy (RR: 1.94 (95% CI: 1.33, 2.82)) had higher risk to develop anemia.Conclusions
Almost one-third of pregnant women in Ethiopia were anemic. Statistically significant association was observed between anemia during pregnancy and residence, gravidity, pregnancy interval, and malaria infection during pregnancy. Regions with higher anemia prevalence among pregnant women should be given due emphasis. The concerned body should intervene on the identified factors to reduce the high prevalence of anemia among pregnant women.7.
Peter C. Smith Susan M. Schmidt Donald Allensworth-Davies Richard Saitz 《Journal of general internal medicine》2009,24(7):783-788
BACKGROUND
Unhealthy alcohol use is prevalent but under-diagnosed in primary care settings.OBJECTIVE
To validate, in primary care, a single-item screening test for unhealthy alcohol use recommended by the National Institute on Alcohol Abuse and Alcoholism (NIAAA).DESIGN
Cross-sectional study.PARTICIPANTS
Adult English-speaking patients recruited from primary care waiting rooms.MEASUREMENTS
Participants were asked the single screening question, “How many times in the past year have you had X or more drinks in a day?”, where X is 5 for men and 4 for women, and a response of >1 is considered positive. Unhealthy alcohol use was defined as the presence of an alcohol use disorder, as determined by a standardized diagnostic interview, or risky consumption, as determined using a validated 30-day calendar method.MAIN RESULTS
Of 394 eligible primary care patients, 286 (73%) completed the interview. The single-question screen was 81.8% sensitive (95% confidence interval (CI) 72.5% to 88.5%) and 79.3% specific (95% CI 73.1% to 84.4%) for the detection of unhealthy alcohol use. It was slightly more sensitive (87.9%, 95% CI 72.7% to 95.2%) but was less specific (66.8%, 95% CI 60.8% to 72.3%) for the detection of a current alcohol use disorder. Test characteristics were similar to that of a commonly used three-item screen, and were affected very little by subject demographic characteristics.CONCLUSIONS
The single screening question recommended by the NIAAA accurately identified unhealthy alcohol use in this sample of primary care patients. These findings support the use of this brief screen in primary care.8.
Background
Invasive infection with Streptococcus pneumoniae (pneumococci) causes significant morbidity and mortality. Case series and experimental data have shown that the capsular serotype is involved in the pathogenesis and a determinant of disease outcome.Methods
Retrospective review of 464 cases of invasive disease among adults diagnosed between 1990 and 2001. Multivariate Cox proportional hazard analysis.Results
After adjustment for other markers of disease severity, we found that infection with serotype 3 was associated with an increased relative risk (RR) of death of 2.54 (95% confidence interval (CI): 1.22–5.27), whereas infection with serotype 1 was associated with a decreased risk of death (RR 0.23 (95% CI, 0.06–0.97)). Additionally, older age, relative leucopenia and relative hypothermia were independent predictors of mortality.Conclusion
Our study shows that capsular serotypes independently influenced the outcome from invasive pneumococcal disease. The limitations of the current polysaccharide pneumococcal vaccine warrant the development of alternative vaccines. We suggest that the virulence of pneumococcal serotypes should be considered in the design of novel vaccines.9.
Shivan J. Mehta Christopher D. Jensen Virginia P. Quinn Joanne E. Schottinger Ann G. Zauber Reinier Meester Adeyinka O. Laiyemo Stacey Fedewa Michael Goodman Robert H. Fletcher Theodore R. Levin Douglas A. Corley Chyke A. Doubeni 《Journal of general internal medicine》2016,31(11):1323-1330
Background
Screening outreach programs using population health management principles offer services uniformly to all eligible persons, but racial/ethnic colorectal cancer (CRC) screening patterns in such programs are not well known.Objective
To examine the association between race/ethnicity and the receipt of CRC screening and timely follow-up of positive results before and after implementation of a screening program.Design
Retrospective cohort study of screen-eligible individuals at the Kaiser Permanente Northern California community-based integrated healthcare delivery system (2004–2013).Subjects
A total of 868,934 screen-eligible individuals 51–74 years of age at cohort entry, which included 662,872 persons in the period before program implementation (2004–2006), 654,633 during the first 3 years after implementation (2007–2009), and 665,268 in the period from 4 to 7 years (2010–2013) after program implementation.Intervention
A comprehensive system-wide long-term effort to increase CRC that included leadership alignment, goal-setting, and quality assurance through a PHM approach, using mailed fecal immunochemical testing (FIT) along with offering screening at office visits.Main Measures
Differences over time and by race/ethnicity in up-to-date CRC screening (overall and by test type) and timely follow-up of a positive screen. Race/ethnicity categories included non-Hispanic white, non-Hispanic black, Hispanic/Latino, Asian/Pacific Islander, Native American, and multiple races.Key Results
From 2004 to 2013, age/sex-adjusted CRC screening rates increased in all groups, including 35.2 to 81.1 % among whites and 35.6 to 78.0 % among blacks. Screening rates among Hispanics (33.1 to 78.3 %) and Native Americans (29.4 to 74.5 %) remained lower than those for whites both before and after program implementation. Blacks, who had slightly higher rates before program implementation (adjusted rate ratio [RR]?=?1.04, 99 % CI: 1.02–1.05), had lower rates after program implementation (RR for period from 4 to 7 years?=?0.97, 99 % CI: 0.96–0.97). There were also substantial improvements in timely follow-up of positive screening results.Conclusions
In this screening program using core PHM principles, CRC screening increased markedly in all racial/ethnic groups, but disparities persisted for some groups and developed in others, which correlated with levels of adoption of mailed FIT.10.
Amy E. Street Jaimie L. Gradus Hannah L. Giasson Dawne Vogt Patricia A. Resick 《Journal of general internal medicine》2013,28(2):556-562
BACKGROUND
The changing scope of women’s roles in combat operations has led to growing interest in women’s deployment experiences and post-deployment adjustment.OBJECTIVES
To quantify the gender-specific frequency of deployment stressors, including sexual and non-sexual harassment, lack of social support and combat exposure. To quantify gender-specific post-deployment mental health conditions and associations between deployment stressors and posttraumatic stress disorder (PTSD), to inform the care of Veterans returning from the current conflicts.DESIGN
National mail survey of OEF/OIF Veterans randomly sampled within gender, with women oversampled.SETTING
The community.PARTICIPANTS
In total, 1,207 female and 1,137 male Veterans from a roster of all Operation Enduring Freedom/Operation Iraqi Freedom (OEF/OIF) Veterans. Response rate was 48.6 %.MAIN MEASURES
Deployment stressors (including combat and harassment stress), PTSD, depression, anxiety and alcohol use, all measured via self-report.KEY RESULTS
Women were more likely to report sexual harassment (OR?=?8.7, 95% CI: 6.9, 11) but less likely to report combat (OR?= 0?.62, 95 % CI: 0.50, 0.76). Women and men were equally likely to report symptoms consistent with probable PTSD (OR = 0?.87, 95 % CI: 0.70, 1.1) and symptomatic anxiety (OR ?= ?1.1, 9 5% CI: 0.86, 1.3). Women were more likely to report probable depression (OR?=?1.3, 95 % CI: 1.1, 1.6) and less likely to report problematic alcohol use (OR ?= 0?.59, 9 5% CI: 0.47, 0.72). With a five-point change in harassment stress, adjusted odds ratios for PTSD were 1.36 (95 % CI: 1.23, 1.52) for women and 1.38 (95 % CI: 1.19, 1.61) for men. The analogous associations between combat stress and PTSD were 1.31 (95 % CI: 1.24, 1.39) and 1.31 (95 % CI: 1.26, 1.36), respectively.CONCLUSIONS
Although there are important gender differences in deployment stressors—including women’s increased risk of interpersonal stressors—and post-deployment adjustment, there are also significant similarities. The post-deployment adjustment of our nation’s growing population of female Veterans seems comparable to that of our nation’s male Veterans.11.
James S. Goodwin Kristin Sheffield Shuang Li Alai Tan 《Journal of general internal medicine》2016,31(11):1308-1314
Background
Obtaining cancer screening on patients with limited life expectancy has been proposed as a measure for low quality care for primary care physicians (PCPs). However, administrative data may underestimate life expectancy in patients who undergo screening.Objective
To determine the association between receipt of screening mammography or PSA and overall survival.Design
Retrospective cohort study from 1/1/1999 to 12/31/2012. Receipt of screening was assessed for 2001–2002 and survival from 1/1/2003 to 12/31/2012. Life expectancy was estimated as of 1/1/03 using a validated algorithm, and was compared to actual survival for men and women, stratified by receipt of cancer screening.Participants
A 5 % sample of Medicare beneficiaries aged 69–90 years as of 1/1/2003 (n?=?906,723).Interventions
Receipt of screening mammography in 2001–2002 for women, or a screening PSA test in 2002 for men.Main Measures
Survival from 1/1/2003 through 12/31/2012.Key Results
Subjects were stratified by life expectancy based on age and comorbidity. Within each stratum, the subjects with prior cancer screening had actual median survivals higher than those who were not screened, with differences ranging from 1.7 to 2.1 years for women and 0.9 to 1.1 years for men. In a Cox model, non-receipt of screening in women had an impact on survival (HR?=?1.52; 95 % CI?=?1.51, 1.54) similar in magnitude to a diagnosis of complicated diabetes or heart failure, and was comparable to uncomplicated diabetes or liver disease in men (HR?=?1.23; 1.22, 1.25).Conclusions
Receipt of cancer screening is a powerful marker of health status that is not captured by comorbidity measures in administrative data. Because life expectancy algorithms using administrative data underestimate the life expectancy of patients who undergo screening, they can overestimate the problem of cancer screening in patients with limited life expectancy.12.
Jason M. Glanz Komal J. Narwaney Shane R. Mueller Edward M. Gardner Susan L. Calcaterra Stanley Xu Kristin Breslin Ingrid A. Binswanger 《Journal of general internal medicine》2018,33(10):1646-1653
Background
Naloxone is a life-saving opioid antagonist. Chronic pain guidelines recommend that physicians co-prescribe naloxone to patients at high risk for opioid overdose. However, clinical tools to efficiently identify patients who could benefit from naloxone are lacking.Objective
To develop and validate an overdose predictive model which could be used in primary care settings to assess the need for naloxone.Design
Retrospective cohort.Setting
Derivation site was an integrated health system in Colorado; validation site was a safety-net health system in Colorado.Participants
We developed a predictive model in a cohort of 42,828 patients taking chronic opioid therapy and externally validated the model in 10,708 patients.Main Measures
Potential predictors and outcomes (nonfatal pharmaceutical and heroin overdoses) were extracted from electronic health records. Fatal overdose outcomes were identified from state vital records. To match the approximate shelf-life of naloxone, we used Cox proportional hazards regression to model the 2-year risk of overdose. Calibration and discrimination were assessed.Key Results
A five-variable predictive model showed good calibration and discrimination (bootstrap-corrected c-statistic?=?0.73, 95% confidence interval [CI] 0.69–0.78) in the derivation site, with sensitivity of 66.1% and specificity of 66.6%. In the validation site, the model showed good discrimination (c-statistic?=?0.75, 95% CI 0.70–0.80) and less than ideal calibration, with sensitivity and specificity of 82.2% and 49.5%, respectively.Conclusions
Among patients on chronic opioid therapy, the predictive model identified 66–82% of all subsequent opioid overdoses. This model is an efficient screening tool to identify patients who could benefit from naloxone to prevent overdose deaths. Population differences across the two sites limited calibration in the validation site.13.
Guangcong Zhang Xiangnan Yu Peng Liu Xiaoxi Huang Xuemei Jiang 《Digestive diseases and sciences》2018,63(12):3207-3219
Background and Aim
The efficacy of nucleoside analogs (NAs) for hepatitis B virus (HBV)-related hepatocellular carcinoma (HCC) after curative treatment remains unclear. The present study aimed to evaluate the efficacy of these agents by conducting a comprehensive meta-analysis of available studies.Methods
We searched several databases including Pubmed, Embase, Cochrane Library, Clinical Trials, and Web of Science, according to PRISMA guidelines. We considered all randomized controlled trials and cohort studies that met the inclusion criteria. Statistical analyses were conducted using Review Manager 5.3 and Stata 14.0.Results
Twenty-one studies with 8752 participants were included in the final analysis. The pooled data showed that patients treated with NAs had significantly lower 1- and 3-year HCC recurrence rates (relative risk [RR] 0.76, 95% confidence interval [CI] 0.65–0.90; P?=?0.001 and RR 0.79, 95% CI 0.71–0.88; P?<?0.001, respectively), but there was no difference in 5-year recurrence rates (RR 0.87, 95% CI 0.74–1.03; P?=?0.10). Regarding overall survival (OS), patients treated with NAs had significantly higher 1-, 3-, and 5-year OS rates (RR 1.05, 95% CI 1.02–1.08; P?=?0.003; RR 1.25, 95% CI 1.16–1.34; P?<?0.001; and RR 1.28, 95% CI 1.18–1.39; P?<?0.001, respectively).Conclusion
NA therapy has the potential to reduce the risk of early recurrence and improve OS in patients with HBV-related HCC after curative treatment, compared with placebo or no treatment. Further research including more homogeneous studies with large sample sizes is required to improve the reliability of these conclusions.14.
Gelareh Sadigh Richard DuszakJr. Kevin C. Ward Renjian Jiang Jeffrey M. Switchenko Kimberly E. Applegate Ruth C. Carlos 《Journal of general internal medicine》2018,33(3):284-290
Background
Screening tests are generally not recommended in patients with advanced cancer and limited life expectancy. Nonetheless, screening mammography still occurs and may lead to follow-up testing.Objective
We assessed the frequency of downstream breast imaging following screening mammography in patients with advanced colorectal or lung cancer.Design
Population-based study.Participants
The study included continuously enrolled female fee-for-service Medicare beneficiaries ≥65 years of age with advanced colorectal (stage IV) or lung (stage IIIB-IV) cancer reported to a Surveillance, Epidemiology, and End Results (SEER) registry between 2000 and 2011.Main Measures
We assessed the utilization of diagnostic mammography, breast ultrasound, and breast MRI following screening mammography. Logistic regression models were used to explore independent predictors of utilization of downstream tests while controlling for cancer type and patient sociodemographic and regional characteristics.Key Results
Among 34,127 women with advanced cancer (23% colorectal; 77% lung cancer; mean age at diagnosis 75 years), 9% (n = 3159) underwent a total of 5750 screening mammograms. Of these, 11% (n = 639) resulted in at least one subsequent diagnostic breast imaging examination within 9 months. Diagnostic mammography was most common (9%; n = 532), followed by ultrasound (6%; n = 334) and MRI (0.2%; n = 14). Diagnostic mammography rates were higher in whites than African Americans (OR, 1.6; p <0.05). Higher ultrasound utilization was associated with more favorable economic status (OR, 1.8; p <0.05).Conclusions
Among women with advanced colorectal and lung cancer, 9% continued screening mammography, and 11% of these screening studies led to at least one additional downstream test, resulting in costs with little likelihood of meaningful benefit.15.
Aims/hypothesis
Diabetes has been shown to be a risk factor for some cancers. Whether diabetes confers the same excess risk of cancer, overall and by site, in women and men is unknown.Methods
A systematic search was performed in PubMed for cohort studies published up to December 2016. Selected studies reported sex-specific relative risk (RR) estimates for the association between diabetes and cancer adjusted at least for age in both sexes. Random-effects meta-analyses with inverse-variance weighting were used to obtain pooled sex-specific RRs and women-to-men ratios of RRs (RRRs) for all-site and site-specific cancers.Results
Data on all-site cancer events (incident or fatal only) were available from 121 cohorts (19,239,302 individuals; 1,082,592 events). The pooled adjusted RR for all-site cancer associated with diabetes was 1.27 (95% CI 1.21, 1.32) in women and 1.19 (1.13, 1.25) in men. Women with diabetes had ~6% greater risk compared with men with diabetes (the pooled RRR was 1.06, 95% CI 1.03, 1.09). Corresponding pooled RRRs were 1.10 (1.07, 1.13) for all-site cancer incidence and 1.03 (0.99, 1.06) for all-site cancer mortality. Diabetes also conferred a significantly greater RR in women than men for oral, stomach and kidney cancer, and for leukaemia, but a lower RR for liver cancer.Conclusions/interpretation
Diabetes is a risk factor for all-site cancer for both women and men, but the excess risk of cancer associated with diabetes is slightly greater for women than men. The direction and magnitude of sex differences varies by location of the cancer.16.
Purpose
There is little information about healthcare utilization for sarcoidosis. This study examined need for hospitalization as a measure of healthcare burden in this disease.Methods
A cohort of Olmsted County, Minnesota residents diagnosed with sarcoidosis between January 1, 1976 and December 31, 2013 was identified using the resources of the Rochester Epidemiology Project. Diagnosis was made based on individual medical record review. For each sarcoidosis subject, one sex- and age-matched comparator without sarcoidosis was randomly selected from the same population. Data on hospitalizations were retrieved electronically from billing data of the Mayo Clinic, the Olmsted Medical Center, and their affiliated hospitals. These data were available from 1987 to 2015. Subjects who died or emigrated from Olmsted County prior to 1987 were excluded.Results
332 incident cases of sarcoidosis and 342 comparators were included. Hospitalization rates were significantly higher among patients with sarcoidosis than comparators [rate ratio (RR) 1.37; 95% confidence interval (CI) 1.24–1.52]. Analysis based on sex revealed a significantly increased rate among females (RR 1.60; 95% CI 1.40–1.82) but not among males (RR 1.06; 95% CI 0.91–1.25). The overall age- and sex-adjusted rates of hospitalization were stable from 1987 to 2015 for both cases and comparators. The average length of stay was similar (4.6 and 4.4 days for sarcoidosis and non-sarcoidosis hospitalizations, respectively, p = 0.87).Conclusion
In this population, patients with sarcoidosis had a significantly higher rate of hospitalization than patients without sarcoidosis, driven by higher rates in females.17.
Ishani Ganguli E. John Orav Eric Weil Timothy G. Ferris Christine Vogeli 《Journal of general internal medicine》2018,33(1):26-33
Background
There is growing interest in coordinating care for high-risk patients through care management programs despite inconsistent results on cost reduction. Early evidence suggests patient-centered benefits, but we know little about how participants engage with the programs and what aspects they value.Objective
To explore care management program participants’ awareness and perceived utility of program offerings.Design
Cross-sectional telephone survey administered December 2015–January 2016.Participants
Patients enrolled in a Boston-area primary care-based care management program.Main measures
Our main outcome was the number of topics in which patients reported having “very helpful” interactions with their care team in the past year. We analyzed awareness of one’s care manager as an intermediate outcome, and then as a primary predictor of the main outcome, along with patient demographics, years in the program, attitudes, and worries as secondary predictors.Key results
The survey response rate was 45.8% (n = 1220); non-respondents were similar to respondents. More respondents reported worrying about family (72.8%) or financial issues (52.5%) than about their own health (41.6%). Seventy-four percent reported care manager awareness, particularly women (OR 1.33, 95% CI 1.01–1.77) and those with more years in the program (OR 1.16, 95% CI 1.03–1.30). While interaction rates ranged from 19.8% to 72.4% across topics, 81.3% rated at least one interaction as very helpful. Those who were aware of their care manager reported very helpful interactions on more topics (OR 2.77, 95% CI 2.15–3.56), as did women (OR 1.25, 95% CI 1.00–1.55), younger respondents (OR 0.98 for older age, 95% CI 0.97–0.99), and those with higher risk scores (OR 1.04, 95% CI 1.02–1.06), preference for deferring treatment decisions to doctors (OR 2.00, 95% CI 1.60–2.50), and reported control over their health (OR 1.67, 95% CI 1.33–2.10).Conclusions
High-risk patients reported helpful interactions with their care team around medical and social determinants of health, particularly those who knew their care manager. Promoting care manager awareness may help participants make better use of the program.18.
Susan?P.?Bell Jeffrey?L.?Schnipper Kathryn?Goggins Aihua?Bian Ayumi?Shintani Christianne?L.?Roumie Anuj?K.?Dalal Terry?A.?Jacobson Kimberly?J.?Rask Viola?Vaccarino Tejal?K.?Gandhi Stephanie?A.?Labonville Daniel?Johnson Erin?B.?Neal Sunil?Kripalani for the Pharmacist Intervention for Low Literacy in Cardiovascular Disease Study Group 《Journal of general internal medicine》2016,31(5):470-477
Background
Reduction in 30-day readmission rates following hospitalization for acute coronary syndrome (ACS) and acute decompensated heart failure (ADHF) is a national goal.Objective
The aim of this study was to determine the effect of a tailored, pharmacist-delivered, health literacy intervention on unplanned health care utilization, including hospital readmission or emergency room (ER) visit, following discharge.Design
Randomized, controlled trial with concealed allocation and blinded outcome assessorsSetting
Two tertiary care academic medical centersParticipants
Adults hospitalized with a diagnosis of ACS and/or ADHFIntervention
Pharmacist-assisted medication reconciliation, inpatient pharmacist counseling, low-literacy adherence aids, and individualized telephone follow-up after dischargeMain Measures
The primary outcome was time to first unplanned health care event, defined as hospital readmission or an ER visit within 30 days of discharge. Pre-specified analyses were conducted to evaluate the effects of the intervention by academic site, health literacy status (inadequate versus adequate), and cognition (impaired versus not impaired). Adjusted hazard ratios (aHR) and 95 % confidence intervals (CI) are reported.Key Results
A total of 851 participants enrolled in the study at Vanderbilt University Hospital (VUH) and Brigham and Women’s Hospital (BWH). The primary analysis showed no statistically significant effect on time to first unplanned hospital readmission or ER visit among patients who received interventions compared to controls (aHR?=?1.04, 95 % CI 0.78-1.39). There was an interaction of treatment effect by site (p?=?0.04 for interaction); VUH aHR?=?0.77, 95 % CI 0.51-1.15; BWH aHR?=?1.44 (95 % CI 0.95-2.12). The intervention reduced early unplanned health care utilization among patients with inadequate health literacy (aHR 0.41, 95 % CI 0.17-1.00). There was no difference in treatment effect by patient cognition.Conclusion
A tailored, pharmacist-delivered health literacy-sensitive intervention did not reduce post-discharge unplanned health care utilization overall. The intervention was effective among patients with inadequate health literacy, suggesting that targeted practice of pharmacist intervention in this population may be advantageous.19.
Hong-Yu Zhang Chun-Lin Zhao Jing Xie Yan-Wei Ye Jun-Feng Sun Zhao-Hui Ding Hua-Nan Xu Li Ding 《International journal of colorectal disease》2016,31(5):951-960
Background
Currently, many surgeons place a prophylactic drain in the abdominal or pelvic cavity after colorectal anastomosis as a conventional treatment. However, some trials have demonstrated that this procedure may not be beneficial to the patients.Objective
To determine whether prophylactic placement of a drain in colorectal anastomosis can reduce postoperative complications.Methods
We systematically searched all the electronic databases for randomized controlled trials (RCTs) that compared routine use of drainage to non-drainage regimes after colorectal anastomosis, using the terms “colorectal” or “colon/colonic” or “rectum/rectal” and “anastomo*” and “drain or drainage.” Reference lists of relevant articles, conference proceedings, and ongoing trial databases were also screened. Primary outcome measures were clinical and radiological anastomotic leakage. Secondary outcome measures included mortality, wound infection, re-operation, and respiratory complications. We assessed the eligible studies for risk of bias using the Cochrane Risk of Bias Tool. Two authors independently extracted data.Results
Eleven RCTs were included (1803 patients in total, 939 patients in the drain group and 864 patients in the no drain group). Meta-analysis showed that there was no statistically significant differences between the drain group and the no drain group in (1) overall anastomotic leakage (relative risk (RR)?=?1.14, 95 % confidence interval (CI) 0.80–1.62, P?=?0.47), (2) clinical anastomotic leakage (RR?=?1.39, 95 % CI 0.80–2.39, P?=?0.24), (3) radiologic anastomotic leakage (RR?=?0.92, 95 % CI 0.56–1.51, P?=?0.74), (4) mortality (RR?=?0.94, 95 % CI 0.57–1.55, P?=?0.81), (5) wound infection (RR?=?1.19, 95 % CI 0.84–1.69, P?=?0.34), (6) re-operation (RR?=?1.18, 95 % CI 0.75–1.85, P?=?0.47), and (7) respiratory complications (RR?=?0.82, 95 % CI 0.55–1.23, P?=?0.34).Conclusions
Routine use of prophylactic drainage in colorectal anastomosis does not benefit in decreasing postoperative complications.20.
Vu Hoang Mahboob Alam Daniel Addison Francisco Macedo Salim Virani Yochai Birnbaum 《Cardiovascular drugs and therapy / sponsored by the International Society of Cardiovascular Pharmacotherapy》2016,30(2):189-198