Longitudinal Studies

Objective: To describe prescribing patterns for 3 common complications associated with spinal cord injury (SCI) and to provide family doctors with strategies for optimizing the care of patients with SCI.

Sources of information: Results of a nationwide survey of prescription medication use among people with SCI in Canada and a longitudinal study of secondary complications associated with SCI.

Main message: Altered neurologic and cardiometabolic function in patients with SCI make it difficult for family physicians to predict optimal medication regimens for these patients. Three common problems seen in primary care among patients with SCI that require pharmacologic treatment are pain (treated in 57% of survey respondents), muscle spasms (54%), and recurrent urinary tract infections (43%). Pain management may require multiple medications, depending on the source or nature of the pain. Some prescription medications recommended for treating pain may be underused in this population, such as amitriptyline, while others may be overused in this population, such as antibiotics for urinary tract infections. Spasticity is often related to an underlying problem such as pain, and treatment of concomitant conditions may also reduce spasticity. Short-acting benzodiazepines were found to have been prescribed for spasticity outside the recommended treatment paradigm at a surprisingly high rate. The longitudinal study of secondary complications associated with SCI led to the development of Actionable Nuggets, an innovative knowledge translation tool for primary care providers.

Conclusion: To provide optimal treatment to patients with SCI, family doctors are encouraged to engage in open communication with them about prescription medications, including aspects of cost, polypharmacy, and therapeutic substitutions. Family physicians should also explore interprofessional collaboration with SCI specialists and allied health providers to provide patients with nonpharmacologic strategies tailored to their activity levels and nutritional needs. The Actionable Nuggets mobile app provides family doctors with brief, actionable, evidence-based information on the top 20 health concerns associated with SCI.

Author/s:

McColl, M. A., Gupta, S., McColl, A., Smith, K.

Clinical Diagnosis of Benign Paroxysmal Positional Vertigo and Vestibular Neuritis

Devin Evans — Thu, 21 Jan 2021 06:00:00 +0000

Date Added:

January 21, 2021

Journal/Publication:

Canadian Medical Association Journal

Publication Date:

February 24, 2020

Issue:

Volume:

192

Pages:

182-186

URL:

Clinical Diagnosis of Benign Paroxysmal Positional Vertigo and Vestibular Neuritis

Type:

Clinical Decision Aids

Format:

Article

DOI (1):

10.1503/cmaj.190334

Keywords

benign paroxysmal positional vertigo

vertigo

vestibular neuritis

PMID (1):

32094268

MeSH

A nice review of how to distinguish BPPV from vestibular neuronitis clinically. James W. Mold, MD, MPH

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• Assess patients with vertigo for focal neurologic signs and symptoms, sustained substantial headache or neck pain, inability to stand and spontaneous vertical nystagmus.

• Perform the Dix–Hallpike test only for patients with episodes of vertigo less than 2 minutes and no nystagmus at rest.

• Perform the head impulse, nystagmus and test of skew (HINTS) plus (plus refers to a test of recent hearing loss) examination only for patients with hours or days of constant, ongoing vertigo and nystagmus at rest.

Author/s:

Johns, Peter, Quinn, James

Standards of Medical Care in Diabetes

Brian Desmarais — Thu, 19 Nov 2020 17:37:56 +0000

Date Added:

November 19, 2020

Journal/Publication:

Diabetes Care

Publication Date:

January 1, 2020

Issue:

Volume:

URL:

Standards of Medical Care in Diabetes

Type:

Meta-analyses, Reviews, and Guidelines

Format:

Article

DOI (1):

https://doi.org/10.2337/dc20-Sint

MeSH

diabetes mellitus, type 2

diabetes mellitus, type 1

risk reduction behavior

Longitudinal Studies

This is the 2020 version of the ADA guidelines. James W. Mold, MD, MPH

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Not available.

Association Between Oral Corticosteroid Bursts and Severe Adverse Events: A Nationwide Population-Based Cohort Study

Brian Desmarais — Thu, 09 Jul 2020 19:43:59 +0000

Date Added:

July 9, 2020

Journal/Publication:

Annals of Internal Medicine

Publication Date:

July 7, 2020

URL:

Association Between Oral Corticosteroid Bursts and Severe Adverse Events: A Nationwide Population-Based Cohort Study

Type:

Clinical Research Results

Format:

Article

DOI (1):

10.7326/M20-0432.

Keywords

oral corticosteroids

MeSH

Longitudinal Studies

Gastrointestinal Hemorrhage

Sepsis

adrenal cortex hormones

Short bursts of oral corticosteroids are associated with an approximately 2-fold increase in GI bleeding, sepsis, and CHF 5 – 30 days following treatment. While the overall rate in this longitudinal study was low (2.7%), it wasn’t clinically insignificant. James W. Mold, MD, MPH

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Abstract

Background: Long-term use of oral corticosteroids has known adverse effects, but the risk from brief oral steroid bursts (≤14 days) is largely unknown.

Objective: To examine the associations between steroid bursts and severe adverse events, specifically gastrointestinal (GI) bleeding, sepsis, and heart failure.

Design: Self-controlled case series.

Setting: Entire National Health Insurance Research Database of medical claims records in Taiwan.

Participants: Adults aged 20 to 64 years with continuous enrollment in the National Health Insurance program from 1 January 2013 to 31 December 2015.

Measurements: Incidence rates of severe adverse events in steroid burst users and non-steroid users, as well as incidence rate ratios (IRRs) for severe adverse events within 5 to 30 and 31 to 90 days after initiation of steroid therapy.

Results: Of 15 859 129 adult participants, 2 623 327 who received a single steroid burst were included. The most common indications were skin disorders and respiratory tract infections. The incidence rates per 1000 person-years in steroid bursts were 27.1 (95% CI, 26.7 to 27.5) for GI bleeding, 1.5 (CI, 1.4 to 1.6) for sepsis, and 1.3 (CI, 1.2 to 1.4) for heart failure. Rates of GI bleeding (IRR, 1.80 [CI, 1.75 to 1.84]), sepsis (IRR, 1.99 [CI, 1.70 to 2.32]), and heart failure (IRR, 2.37 [CI, 2.13 to 2.63]) significantly increased within 5 to 30 days after steroid therapy initiation and attenuated during the subsequent 31 to 90 days.

Limitation: Persons younger than 20 years or older than 64 years were not included.

Conclusion: Oral corticosteroid bursts are frequently prescribed in the general adult population in Taiwan. The highest rates of GI bleeding, sepsis, and heart failure occurred within the first month after initiation of steroid therapy.

Primary funding source: National Health Research Institutes, Ministry of Science and Technology of Taiwan, Chang Gung Medical Foundation, and Eunice Kennedy Shriver National Institute of Child Health and Human Development.

Author/s:

Yao, T., Huang, Y., Chang, S., Tsai, S., Wu, A.C., Tsai, H.

Prophylactic antibiotic therapy effective for chronic obstructive pulmonary disease

Brian Desmarais — Thu, 18 Jun 2020 19:23:20 +0000

Date Added:

June 18, 2020

Journal/Publication:

Cochrane Systematic Review

Publisher:

Cochrane Library

Publication Date:

October 1, 2018

URL:

Prophylactic antibiotic therapy effective for chronic obstructive pulmonary disease

Type:

Meta-analyses, Reviews, and Guidelines

Format:

Article

DOI (1):

10.1002/14651858. CD009764.pub3.

MeSH

Intention to Treat Analysis

Moxifloxacin

anti-bacterial agents

Use of continuous or intermittent macrolide antibiotics reduce COPD exacerbations and improved QOL over a one-year period. There were no serious adverse events. James W. Mold, MD, MPH

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Background

There has been renewal of interest in the use of prophylactic antibiotics to reduce the frequency of exacerbations and improve quality of life in chronic obstructive pulmonary disease (COPD).

Objectives

To determine whether or not regular (continuous, intermittent or pulsed) treatment of COPD patients with prophylactic antibiotics reduces exacerbations or affects quality of life.

Search methods

We searched the Cochrane Airways Group Trials Register and bibliographies of relevant studies. The latest literature search was performed on 27 July 2018.

Selection criteria

Randomised controlled trials (RCTs) that compared prophylactic antibiotics with placebo in patients with COPD.

Data collection and analysis

We used the standard Cochrane methods. Two independent review authors selected studies for inclusion, extracted data, and assessed risk of bias. We resolved discrepancies by involving a third review author.

Main results

We included 14 studies involving 3932 participants in this review. We identified two further studies meeting inclusion criteria but both were terminated early without providing results. All studies were published between 2001 and 2015. Nine studies were of continuous macrolide antibiotics, two studies were of intermittent antibiotic prophylaxis (three times per week) and two were of pulsed antibiotic regimens (e.g. five days every eight weeks). The final study included one continuous, one intermittent and one pulsed arm. The antibiotics investigated were azithromycin, erythromycin, clarithromycin, doxycyline, roxithromycin and moxifloxacin. The study duration varied from three months to 36 months and all used intention‐to‐treat analysis. Most of the pooled results were of moderate quality. The risk of bias of the included studies was generally low.

The studies recruited participants with a mean age between 65 and 72 years and mostly at least moderate‐severity COPD. Five studies only included participants with frequent exacerbations and two studies recruited participants requiring systemic steroids or antibiotics or both, or who were at the end stage of their disease and required oxygen. One study recruited participants with pulmonary hypertension secondary to COPD and a further study was specifically designed to asses whether eradication of Chlamydia pneumoniae reduced exacerbation rates.

The co‐primary outcomes for this review were the number of exacerbations and quality of life.

With use of prophylactic antibiotics, the number of participants experiencing one or more exacerbations was reduced (odds ratio (OR) 0.57, 95% CI 0.42 to 0.78; participants = 2716; studies = 8; moderate‐quality evidence). This represented a reduction from 61% of participants in the control group compared to 47% in the treatment group (95% CI 39% to 55%). The number needed to treat for an additional beneficial outcome with prophylactic antibiotics given for three to 12 months to prevent one person from experiencing an exacerbation (NNTB) was 8 (95% CI 5 to 17). The test for subgroup difference suggested that continuous and intermittent antibiotics may be more effective than pulsed antibiotics (P = 0.02, I² = 73.3%).

The frequency of exacerbations per patient per year was also reduced with prophylactic antibiotic treatment (rate ratio 0.67; 95% CI 0.54 to 0.83; participants = 1384; studies = 5; moderate‐quality evidence). Although we were unable to pool the result, six of the seven studies reporting time to first exacerbation identified an increase (i.e. benefit) with antibiotics, which was reported as statistically significant in four studies.

There was a statistically significant improvement in quality of life as measured by the St George's Respiratory Questionnaire (SGRQ) with prophylactic antibiotic treatment, but this was smaller than the four unit improvement that is regarded as being clinically significant (mean difference (MD) ‐1.94, 95% CI ‐3.13 to ‐0.75; participants = 2237; studies = 7, high‐quality evidence).

Prophylactic antibiotics showed no significant effect on the secondary outcomes of frequency of hospital admissions, change in forced expiratory volume in one second (FEV1), serious adverse events or all‐cause mortality (moderate‐quality evidence). There was some evidence of benefit in exercise tolerance, but this was driven by a single study of lower methodological quality.

The adverse events that were recorded varied among the studies depending on the antibiotics used. Azithromycin was associated with significant hearing loss in the treatment group, which was in many cases reversible or partially reversible. The moxifloxacin pulsed study reported a significantly higher number of adverse events in the treatment arm due to the marked increase in gastrointestinal adverse events (P < 0.001). Some adverse events that led to drug discontinuation, such as development of long QTc or tinnitus, were not significantly more frequent in the treatment group than the placebo group but pose important considerations in clinical practice.

The development of antibiotic resistance in the community is of major concern. Six studies reported on this, but we were unable to combine results. One study found newly colonised participants to have higher rates of antibiotic resistance. Participants colonised with moxifloxacin‐sensitive pseudomonas at initiation of therapy rapidly became resistant with the quinolone treatment. A further study with three active treatment arms found an increase in the degree of antibiotic resistance of isolates in all three arms after 13 weeks treatment.

Authors' conclusions

Use of continuous and intermittent prophylactic antibiotics results in a clinically significant benefit in reducing exacerbations in COPD patients. All studies of continuous and intermittent antibiotics used macrolides, hence the noted benefit applies only to the use of macrolide antibiotics prescribed at least three times per week. The impact of pulsed antibiotics remains uncertain and requires further research.

The studies in this review included mostly participants who were frequent exacerbators with at least moderate‐severity COPD. There were also older individuals with a mean age over 65 years. The results of these studies apply only to the group of participants who were studied in these studies and may not be generalisable to other groups.

Because of concerns about antibiotic resistance and specific adverse effects, consideration of prophylactic antibiotic use should be mindful of the balance between benefits to individual patients and the potential harms to society created by antibiotic overuse. Monitoring of significant side effects including hearing loss, tinnitus, and long QTc in the community in this elderly patient group may require extra health resources.

Author/s:

Herath, S.

Secondhand Smoke Exposure and Subsequent Academic Performance Among U.S. Youth

Brian Desmarais — Wed, 20 May 2020 18:03:46 +0000

Date Added:

May 20, 2020

Journal/Publication:

American Journal of Preventive Medicine

Publication Date:

March 5, 2020

URL:

Secondhand Smoke Exposure and Subsequent Academic Performance Among U.S. Youth

Type:

Clinical Research Results

Format:

Article

DOI (1):

10.1016/j.amepre.2019.12.020

MeSH

adolescent

Longitudinal Studies

Tobacco Smoke Pollution

cohort studies

fungi

academic performance

This longitudinal cohort study (RCTs impossible in this case) of adolescents (age 12-16) found a dose response relationship between second hand smoke exposure and reduced school performance. James W. Mold, MD, MPH

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Abstract

Introduction: Previous research shows the associations between secondhand smoke exposure and health consequences among youth, but less is known about its effect on academic performance. This study examines a dose-response relationship between secondhand smoke exposure and subsequent academic performance among U.S. youth.

Methods: Data were from a nationally representative sample of youth non-tobacco users (aged 12-16 years) in Wave 2 (2014-2015) who completed Wave 3 (2015-2016) of the Population Assessment of Tobacco and Health Study (n=9,020). Past-7-day number of hours exposed to secondhand smoke at Wave 2 and academic performance at Wave 3 (1=Mostly As to 9=Mostly Fs) were assessed. Weighted multivariable linear regression models were used to examine the association between hours of self-reported secondhand smoke exposure at Wave 2 and academic performance at Wave 3 (1=Mostly Fs, 9=Mostly As), adjusting for covariates including sociodemographics, prior academic performance, internalizing and externalizing problems, and substance use problems. Analyses were conducted in 2019.

Results: More than 30% of U.S. youth non-tobacco users were exposed to secondhand smoke in the past 7 days. Compared with unexposed youth at Wave 2, those who were exposed for 1-9 hours had poorer academic performance at Wave 3 (adjusted regression coefficient= -0.11, 95% CI= -0.18, -0.04), and those who were exposed for ≥10 hours at Wave 2 had even poorer academic performance (adjusted regression coefficient = -0.31, 95% CI= -0.45, -0.18).

Conclusions: A dose-response relationship was observed between secondhand smoke exposure and academic performance among U.S. youth. Reducing youth secondhand smoke exposure may promote academic performance and subsequent educational attainment.

Author/s:

Choi, K., Chen-Sankey, J.C., Merianos, A.L., McGruder,C., Yerger, V.

Secondhand Smoke Exposure and Subsequent Academic Performance Among U.S. Youth

Brian Desmarais — Wed, 20 May 2020 18:02:18 +0000

Date Added:

May 20, 2020

Journal/Publication:

American Journal of Preventive Medicine

Publication Date:

March 5, 2020

URL:

Secondhand Smoke Exposure and Subsequent Academic Performance Among U.S. Youth

Type:

Clinical Research Results

Format:

Article

DOI (1):

10.1016/j.amepre.2019.12.020

MeSH

adolescent

Longitudinal Studies

Tobacco Smoke Pollution

cohort studies

fungi

academic performance

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Abstract

Author/s:

Choi, K., Chen-Sankey, J.C., Merianos, A.L., McGruder,C., Yerger, V.

Pets Are Associated with Fewer Peer Problems and Emotional Symptoms, and Better Prosocial Behavior: Findings from the Longitudinal Study of Australian Children

Brian Desmarais — Wed, 22 Apr 2020 23:44:31 +0000

Date Added:

April 22, 2020

Journal/Publication:

Journal of Pediatrics

Publication Date:

February 21, 2020

URL:

Pets Are Associated with Fewer Peer Problems and Emotional Symptoms, and Better Prosocial Behavior: Findings from the Longitudinal Study of Australian Children

Type:

Clinical Research Results

Format:

Article

DOI (1):

10.1016/j.jpeds.2020.01.012.

Keywords

MeSH

Family Characteristics

social change

Surveys and Questionnaires

This study supports pet ownership to support healthy childhood development. James W. Mold, MD, MPH

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Abstract

OBJECTIVE:

To investigate the longitudinal association between pet ownership and children's social-emotionaldevelopment.

STUDY DESIGN:

Two time-points of data from the Longitudinal Study of Australian Children were analyzed for children at ages 5 (n = 4242) and 7 (n = 4431) years. The Strengths and Difficulties Questionnaire (SDQ) measured children's social-emotional development. Pet ownership status and type (dog, cat, other) as well as sociodemographic and other potential confounders were collected. Longitudinal panel regression models were used.

RESULTS:

Overall, 27% of children had abnormal scores on 1 or more SDQ scales. By age 7, 75% of children had pets with ownership highest in single-child households. Owning any type of pet was associated with decreased odds of abnormal scores for emotional symptoms (OR, 0.81; 95% CI, 0.67-0.99), peer problems (OR, 0.71; 95% CI, 0.60-0.84), and prosocial behavior (OR, 0.70; 95% CI, 0.38-0.70), compared with non-pet owners. Dog ownership was associated with decreased odds of abnormal scores on any of the SDQ scales (OR, 0.81; 95% CI, 0.71-0.93). For children without any siblings, only the prosocial behavior scale was significantly associated with pet ownership (OR, 0.21; 95% CI, 0.07-0.66). In longitudinal models, cat-only and dog-only groups were associated with feweremotional symptoms and peer problems compared with non-pet owners.

CONCLUSIONS:

Early school age is an important period for family pet acquisition. Pets may protect children from developing social-emotional problems and should be taken into account when assessing child development and school readiness. Children without siblings may benefit most in terms of their prosocial behavior.

Author/s:

Christian, H., Mitrou, F., Cunneen, R., Zubrick, S.R.

Screening for Alcohol Use and Brief Counseling of Adults — 13 States and the District of Columbia, 2017

John Bayhi — Sat, 14 Mar 2020 20:31:53 +0000

Date Added:

March 14, 2020

Journal/Publication:

MMWR Morbidity and Mortality Weekly Report

Publisher:

Centers for Disease Control and Prevention

Publication Date:

March 13, 2020

Issue:

Volume:

Pages:

265-270

URL:

Screening for Alcohol Use and Brief Counseling of Adults — 13 States and the District of Columbia, 2017

Type:

Meta-analyses, Reviews, and Guidelines

Format:

Article

DOI (1):

10.15585/mmwr.mm6910a3

Keywords

alcohol use

screening and brief intervention

alcohol SBI

binge drinking

PMID (1):

32163383

MeSH

Behavioral Risk Factor Surveillance System

Fetal Alcohol Spectrum Disorders

Public Health Practice

health personnel

Evidence-Based Medicine

insurance coverage

Telephone

Centers for Disease Control and Prevention

U.S.

Longitudinal Studies

The CDC recommends screening all adults for binge drinking with a single question and recommending reduction to those who screen positive. James W. Mold, MD, MPH

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What is already known about this topic?

Binge drinking increases the risk for adverse health conditions and death. Alcohol screening and brief intervention (SBI), recommended by the U.S. Preventive Services Task Force (USPSTF) for all adults in primary care, is effective in reducing binge drinking.

What is added by this report?

In 2017, 81% of survey respondents were asked by their health care provider about alcohol consumption and 38% about binge drinking at a checkup in the past 2 years. Among those asked about alcohol use and who reported current binge drinking, 80% received no advice to reduce their drinking.

What are the implications for public health practice?

Implementation of alcohol SBI as recommended by USPSTF, coupled with population-level evidence-based interventions, can reduce binge drinking among U.S. adults.

Author/s:

McKnight-Eily, LR, Okoro, CA, Turay, K, Acero, C, Hungerford, D

Screening for Colon Cancer in Older Adults: Risks, Benefits, and When to Stop

Brian Desmarais — Fri, 03 Jan 2020 19:11:46 +0000

Date Added:

January 3, 2020

Journal/Publication:

The Mayo Clinic Proceedings

Publication Date:

January 1, 2020

Issue:

Volume:

Pages:

184–196

URL:

Screening for Colon Cancer in Older Adults: Risks, Benefits, and When to Stop

Type:

Meta-analyses, Reviews, and Guidelines

Format:

Article

DOI (1):

https://doi.org/10.1016/j.mayocp.2019.02.021

Keywords

MeSH

A fair and balanced review of CRC screening in older people from Mayo. James W. Mold, MD, MPH

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Colorectal cancer (CRC) is the fourth leading cause of cancer and second leading cause of mortality from cancer in the United States. As the population ages, decisions regarding the initiation and cessation of screening and surveillance for CRC are of increasing importance. In elderly patients, the risks of CRC and the presenting signs and symptoms are similar to those in younger patients. Screening and ongoing surveillance should be considered in patients who have a life expectancy of 10 years or more. Life expectancy estimates can be calculated using online calculators. If screening is deemed appropriate, the choice of which test to use first is unclear. Currently, there are a number of modalities available to screen for CRC, including both invasive modalities (eg, colonoscopy, sigmoidoscopy, capsule colonoscopy, and computed tomographic colonography) and noninvasive modalities (fecal immunochemical test, stool DNA testing, and blood testing). Colonoscopy and other invasive testing options are considered safe, but the risks of complications of the bowel preparation, the procedure, and sedation medications are all increased in older patients. In contrast, noninvasive testing provides a safe initial test; however, it is important to consider the increased false-positive rates in the elderly, and a positive test result will usually necessitate colonoscopy to establish the diagnosis. Ongoing screening and surveillance should be a shared decision-making process with the patient based on multiple factors including the patient’s morbidity and mortality risk from CRC and his or her underlying comorbidities, the patient’s functional status, and the patient’s preferences for screening. Ultimately, the decision to initiate or discontinue screening for CRC in older patients should be done based on a case-by-case individualized discussion.

Author/s:

Nee, J., Chippendale, R. Z., Feuerstein, J.D.

Building a Group-Based Opioid Treatment (GBOT) blueprint: a qualitative study delineating GBOT implementation

John Bayhi — Thu, 02 Jan 2020 21:06:56 +0000

Date Added:

January 2, 2020

Journal/Publication:

Addiction Science & Clinical Practice

Publisher:

BioMed Central Ltd

Publication Date:

December 27, 2019

Issue:

Volume:

URL:

Building a Group-Based Opioid Treatment (GBOT) blueprint: a qualitative study delineating GBOT implementation

Type:

Practice Management Research Results

Format:

Article

DOI (1):

10.1186/s13722-019-0176-y

Keywords

Buprenorphine-naloxone

GBOT

Group psychotherapy

Group visit

Implementation science

Shared medical appointment

Group-Based Opioid Treatment

PMID (1):

31882001

MeSH

Humans

Focus Groups

Patient Participation

outpatients

motivation

opioid-related disorders

This article could be helpful to medical directors, practice facilitators, and QI managers who are tasked with creating systems for addressing patients with opioid use disorders. James W. Mold, MD, MPH

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BACKGROUND:

Group-Based Opioid Treatment (GBOT) has recently emerged as a mechanism for treating patients with opioid use disorder (OUD) in the outpatient setting. However, the more practical "how to" components of successfully delivering GBOT has received little attention in the medical literature, potentially limiting its widespread implementation and utilization. Building on a previous case series, this paper delineates the key components to implementing GBOT by asking: (a) What are the core components to GBOT implementation, and how are they defined? (b) What are the malleable components to GBOT implementation, and what conceptual framework should providers use in determining how to apply these components for effective delivery in their unique clinical environment?

METHODS:

To create a blueprint delineating GBOT implementation, we integrated findings from a previously conducted and separately published systematic review of existing GBOT studies, conducted additional literature review, reviewed best practice recommendations and policies related to GBOT and organizational frameworks for implementing health systems change. We triangulated this data with a qualitative thematic analysis from 5 individual interviews and 2 focus groups representing leaders from 5 different GBOT programs across our institution to identify the key components to GBOT implementation, distinguish "core" and "malleable" components, and provide a conceptual framework for considering various options for implementing the malleable components.

RESULTS:

We identified 6 core components to GBOT implementation that optimize clinical outcomes, comply with mandatory policies and regulations, ensure patient and staff safety, and promote sustainability in delivery. These included consistent group expectations, team-based approach to care, safe and confidential space, billing compliance, regular monitoring, and regular patient participation. We identified 14 malleable components and developed a novel conceptual framework that providers can apply when deciding how to employ each malleable component that considers empirical, theoretical and practical dimensions.

CONCLUSION:

While further research on the effectiveness of GBOT and its individual implementation components is needed, the blueprint outlined here provides an initial framework to help office-based opioid treatment sites implement a successful GBOT approach and hence potentially serve as future study sites to establish efficacy of the model. This blueprint can also be used to continuously monitor how components of GBOT influence treatment outcomes, providing an empirical framework for the ongoing process of refining implementation strategies.

Author/s:

Sokol, R, Albanese, M, Chew, A, Early, J, Grossman, E, Roll, D, Sawin, G, Wu, DJ, Schuman-Olivier, Z

Estimates of all cause mortality and cause specific mortality associated with proton pump inhibitors among US veterans: cohort study

John Bayhi — Wed, 18 Sep 2019 17:02:59 +0000

Date Added:

September 18, 2019

Journal/Publication:

BMJ

Publisher:

BMJ Publishing Group Limited

Publication Date:

May 29, 2019

Issue:

I1580

Volume:

365

URL:

Estimates of all cause mortality and cause specific mortality associated with proton pump inhibitors among US veterans: cohort study

Type:

Clinical Research Results

Format:

Article

DOI (1):

10.1136/bmj.l1580

Keywords

proton pump inhibitors

PMID (1):

31147311

MeSH

aged

cardiovascular diseases/mortality

cause of death

cohort studies

female

gastrointestinal neoplasms/mortality

Peptic Ulcer/prevention & control

proton pump inhibitors/therapeutic use

renal insufficiency

chronic/mortality

risk factors

United States/epidemiology

veterans health/statistics & numerical data

Predictably PPIs are not as safe for long term use as we had hoped. It’s not wise to mess with Mother Nature. James W. Mold, MD, MPH

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OBJECTIVE:

To estimate all cause mortality and cause specific mortality among patients taking proton pump inhibitors (PPIs).

DESIGN:

Longitudinal observational cohort study.

SETTING:

US Department of Veterans Affairs.

PARTICIPANTS:

New users of PPIs (n=157 625) or H2 blockers (n=56 842).

MAIN OUTCOME MEASURES:

All cause mortality and cause specific mortality associated with taking PPIs (values reported as number of attributable deaths per 1000 patients taking PPIs).

RESULTS:

There were 45.20 excess deaths (95% confidence interval 28.20 to 61.40) per 1000 patients taking PPIs. Circulatory system diseases (number of attributable deaths per 1000 patients taking PPIs 17.47, 95% confidence interval 5.47 to 28.80), neoplasms (12.94, 1.24 to 24.28), infectious and parasitic diseases (4.20, 1.57 to 7.02), and genitourinary system diseases (6.25, 3.22 to 9.24) were associated with taking PPIs. There was a graded relation between cumulative duration of PPI exposure and the risk of all cause mortality and death due to circulatory system diseases, neoplasms, and genitourinary system diseases. Analyses of subcauses of death suggested that taking PPIs was associated with an excess mortality due to cardiovascular disease (15.48, 5.02 to 25.19) and chronic kidney disease (4.19, 1.56 to 6.58). Among patients without documented indication for acid suppression drugs (n=116 377), taking PPIs was associated with an excess mortality due to cardiovascular disease (22.91, 11.89 to 33.57), chronic kidney disease (4.74, 1.53 to 8.05), and upper gastrointestinal cancer (3.12, 0.91 to 5.44). Formal interaction analyses suggested that the risk of death due to these subcauses was not modified by a history of cardiovascular disease, chronic kidney disease, or upper gastrointestinal cancer. Taking PPIs was not associated with an excess burden of transportation related mortality and death due to peptic ulcer disease (as negative outcome controls).

CONCLUSIONS:

Taking PPIs is associated with a small excess of cause specific mortality including death due to cardiovascular disease, chronic kidney disease, and upper gastrointestinal cancer. The burden was also observed in patients without an indication for PPI use. Heightened vigilance in the use of PPI may be warranted.

Author/s:

Xie, Y, Bowe, B, Yan, Y, Xian, H, Li, T, Al-Aly, Z