Background Alcohol screening scores ≥5 on the Alcohol Use Disorders Identification Test–Consumption (AUDIT-C) up to a year before surgery have been associated with postoperative complications, but ...the association with postoperative health care use is unknown. This study evaluated whether AUDIT-C scores in the year before surgery were associated with postoperative hospital length of stay, total ICU days, return to the operating room, and hospital readmission. Study Design This cohort study included male Veterans Affairs patients who completed the AUDIT-C on mailed surveys (October 2003 through September 2006) and were hospitalized for nonemergent noncardiac major operations in the following year. Postoperative health care use was evaluated across 4 AUDIT-C risk groups (scores 0, 1 to 4, 5 to 8, and 9 to 12) using linear or logistic regression models adjusted for sociodemographics, smoking status, surgical category, relative value unit, and time from AUDIT-C to surgery. Patients with AUDIT-C scores indicating low-risk drinking (scores 1 to 4) were the referent group. Results Adjusted analyses revealed that among eligible surgical patients (n = 5,171), those with the highest AUDIT-C scores (ie, 9 to 12) had longer postoperative hospital length of stay (5.8 95% CI, 5.0−6.7 vs 5.0 95% CI, 4.7−5.3 days), more ICU days (4.5 95% CI, 3.2−5.8 vs 2.8 95% CI, 2.6−3.1 days), and increased probability of return to the operating room (10% 95% CI, 6−13% vs 5% 95% CI, 4−6%) in the 30 days after surgery, but not increased hospital readmission within 30 days postdischarge, relative to the low-risk group. Conclusions AUDIT-C screening results could be used to identify patients at risk for increased postoperative health care use who might benefit from preoperative alcohol interventions.
Vitamin D(3) is critical for the regulation of calcium and phosphate homeostasis. In some individuals, mineral homeostasis can be disrupted by long-term therapy with certain antiepileptic drugs and ...the antimicrobial agent rifampin, resulting in drug-induced osteomalacia, which is attributed to vitamin D deficiency. We now report a novel CYP3A4-dependent pathway, the 4-hydroxylation of 25-hydroxyvitamin D(3) (25OHD(3)), the induction of which may contribute to drug-induced vitamin D deficiency. The metabolism of 25OHD(3) was fully characterized in vitro. CYP3A4 was the predominant source of 25OHD(3) hydroxylation by human liver microsomes, with the formation of 4β,25-dihydroxyvitamin D(3) 4β,25(OH)(2)D(3) dominating (V(max)/K(m) = 0.85 ml · min(-1) · nmol enzyme(-1)). 4β,25(OH)(2)D(3) was found in human plasma at concentrations comparable to that of 1α,25-dihydroxyvitamin D(3), and its formation rate in a panel of human liver microsomes was strongly correlated with CYP3A4 content and midazolam hydroxylation activity. Formation of 4β,25(OH)(2)D(3) in primary human hepatocytes was induced by rifampin and inhibited by CYP3A4-specific inhibitors. Short-term treatment of healthy volunteers (n = 6) with rifampin selectively induced CYP3A4-dependent 4β,25(OH)(2)D(3), but not CYP24A1-dependent 24R,25-dihydroxyvitamin D(3) formation, and altered systemic mineral homeostasis. Our results suggest that CYP3A4-dependent 25OHD(3) metabolism may play an important role in the regulation of vitamin D(3) in vivo and in the etiology of drug-induced osteomalacia.
Purpose: Distance to provider might be an important barrier to timely diagnosis and treatment for cancer patients who qualify for Medicaid coverage. Whether driving time or driving distance is a ...better indicator of travel burden is also of interest. Methods: Driving distances and times from patient residence to primary care provider were calculated for 3,917 breast, colorectal (CRC) and lung cancer Medicaid patients in Washington State from 1997 to 2003 using MapQuest.com. We fitted regression models of stage at diagnosis and time‐to‐treatment (number of days between diagnosis and surgery) to test the hypothesis that travel burden is associated with timely diagnosis and treatment of cancer. Findings: Later stage at diagnosis for breast cancer Medicaid patients is associated with travel burden (OR = 1.488 per 100 driving miles, P= .037 and OR = 1.270 per driving hour, P= .016). Time‐to‐treatment after diagnosis of CRC is also associated with travel burden (14.57 days per 100 driving miles, P= .002 and 5.86 days per driving hour, P= .018). Conclusions: Although travel burden is associated with timely diagnosis and treatment for some types of cancer, we did not find evidence that driving time was, in general, better at predicting timeliness of cancer diagnosis and treatment than driving distance. More intensive efforts at early detection of breast cancer and early treatment of CRC for Medicaid patients who live in remote areas may be needed.
OBJECTIVETo evaluate the association of VKORC1 genetic variants with warfarin dose requirements in a Hong Kong Chinese patient population.
METHODSA retrospective study of Hong Kong Chinese patients ...chronically maintained on warfarin was conducted. Single nucleotide polymorphisms (SNPs) in VKORC1 and CYP2C9 were genotyped. Stable warfarin dose data were retrieved from patient medical records.
RESULTSSixty-nine patients were included in the analysis. VKORC1 haplotypes H1 (group A) and H7 (group B) were most common, accounting for 86% and 13% of all haplotypic variation in this cohort. Patients carrying at least one copy of a VKORC1 group B haplotype (n=16) required a significantly higher stable warfarin dose (5.17±1.53 mg/day) than patients that were homozygous for group A haplotypes (n=53; 2.93±1.22 mg; P<0.001). In the VKORC1 A/A group, four patients (5.8%) were heterozygous for CYP2C9*3 and had a lower dose requirement (1.94±0.43 mg) than patients that exhibited the CYP2C9 *1/*1 genotype (3.01±1.23 mg), P=0.004. In multivariate analysis, VKORC1 and CYP2C9 explained 31% and 7.9% of the variability in warfarin dose, respectively.
CONCLUSIONSVKORC1 genotype is the dominant genetic influence on inter-individual variability in warfarin dose in Hong Kong Chinese. The lower mean dose of warfarin in Chinese, relative to Europeans, appears to be a reflection of their preponderance of the ‘low-dose’ VKORC1 H1/H1 (homozygous group A) genotype.
OBJECTIVES: To determine whether benzodiazepine use is associated with incident disability in mobility and activities of daily living (ADLs) in older individuals.
DESIGN: A prospective cohort study.
...SETTING: Four sites of the Established Populations for Epidemiologic Studies of the Elderly.
PARTICIPANTS: This study included 9,093 subjects (aged ≥65) who were not disabled in mobility or ADLs at baseline.
MEASUREMENTS: Mobility disability was defined as inability to walk half a mile or climb one flight of stairs. ADL disability was defined as inability to perform one or more basic ADLs (bathing, eating, dressing, transferring from a bed to a chair, using the toilet, or walking across a small room). Trained interviewers assessed outcomes annually.
RESULTS: At baseline, 5.5% of subjects reported benzodiazepine use. In multivariable models, benzodiazepine users were 1.23 times as likely as nonusers (95% confidence interval (CI)=1.09–1.39) to develop mobility disability and 1.28 times as likely (95% CI=1.09–1.52) to develop ADL disability. Risk for incident mobility was increased with short‐ (hazard ratio (HR)=1.27, 95% CI=1.08–1.50) and long‐acting benzodiazepines (HR=1.20, 95% CI=1.03–1.39) and no use. Risk for ADL disability was greater with short‐ (HR=1.58, 95% CI=1.25–2.01) but not long‐acting (HR=1.11, 95% CI=0.89–1.39) agents than for no use.
CONCLUSION: Older adults taking benzodiazepines have a greater risk for incident mobility and ADL disability. Use of short‐acting agents does not appear to confer any safety benefits over long‐acting agents.
To investigate whether interruptions in radiotherapy are associated with decreased survival in a population-based sample of head-and-neck cancer patients.
Using the Surveillance, Epidemiology, and ...End Results-Medicare linked database we identified Medicare beneficiaries aged 66 years and older diagnosed with local-regional head-and-neck cancer during the period 1997-2003. We examined claims records of 3864 patients completing radiotherapy for the presence of one or more 5-30-day interruption(s) in therapy. We then performed Cox regression analyses to estimate the association between therapy interruptions and survival.
Patients with laryngeal tumors who experienced an interruption in radiotherapy had a 68% (95% confidence interval, 41-200%) increased risk of death, compared with patients with no interruptions. Patients with nasal cavity, nasopharynx, oral, salivary gland, and sinus tumors had similar associations between interruptions and increased risk of death, but these did not reach statistical significance because of small sample sizes.
Treatment interruptions seem to influence survival time among patients with laryngeal tumors completing a full course of radiotherapy. At all head-and-neck sites, the association between interruptions and survival is sensitive to confounding by stage and other treatments. Further research is needed to develop methods to identify patients most susceptible to interruption-induced mortality.
In this prospective study of localized prostate cancer patients and their partners, we analyzed how partner issues evolve over time, focusing on satisfaction with care, influence of cancer treatment, ...and its impact on relationship with patient, cancer worry, and personal activities.
Our study aims were twofold: (i) to determine whether the impact of treatment on patients and partners moderate over time and (ii) if receiving surgery (i.e., radical prostatectomy) influences partner issues more than other treatments.
Patients newly diagnosed with localized prostate cancer and their female partners were recruited from three states to complete surveys by mail at three time points over 12 months.
The four primary outcomes assessed in the partner analysis included satisfaction with treatment, cancer worry, and the influence of cancer and its treatment on their relationship (both general relationship and sexual relationship).
This analysis included 88 patient–partner pairs. At 6 months, partners reported that cancer had a negative impact on their sexual relationship (39%—somewhat negative and 12%—very negative). At 12 months, this proportion increased substantially (42%—somewhat negative and 29%—very negative). Partners were significantly more likely to report that their sexual relationship was worse when the patient reported having surgery (P = 0.0045, odds ratio = 9.8025, 95% confidence interval 2.076–46.296). A minority of partners reported significant negative impacts in other areas involving their personal activities (16% at 6 months and 25% at 12 months) or work life (6% at 6 months, which increased to 12% at 12 months).
From partners' perspectives, prostate cancer therapy has negative impact on sexual relationships and appears to worsen over time. Ramsey SD, Zeliadt SB, Blough DK, Moinpour CM, Hall IJ, Smith JL, Ekwueme DU, Fedorenko CR, Fairweather ME, Koepl LM, Thompson IM, Keane TE, and Penson DF. Impact of prostate cancer on sexual relationships: A longitudinal perspective on intimate partners' experiences. J Sex Med 2013;10:3135–3143.
Study Type – Patient experience (non‐consecutive cohort)
Level of Evidence 3b
What’s known on the subject? and What does the study add?
Decisions about prostate cancer treatment usually involve the ...patient, the patient’s closest family member (e.g. spouse or partner) and the physician, however no study has examined this “triad” of decision makers in detail. Moreover, no study has evaluated the role that prostate cancer patients’ partners play in the treatment decision‐making process.
This study provides evidence that partners are very involved in the treatment decision making between loved ones and providers and often attend clinic visits. Provider encouragement of partner participation was associated with higher partner satisfaction and an increased likelihood of partners reporting very frequent discussions with their loved ones.
OBJECTIVE
• To evaluate the degree to which the partners of prostate cancer patients participate in the shared decision‐making process with the patients’ providers during the time between diagnosis and initiating treatment.
PATIENTS AND METHODS
• We recruited patients with newly diagnosed local‐stage prostate cancer and their partners to complete take‐home surveys after biopsy but before initiating treatment at urology practices in three states.
• We asked partners to describe their roles in the decision‐making process, including participation in clinic visits, and perceptions of encouragement from providers to participate in the treatment decision‐making process. We also asked partners to rate their satisfaction with the patients’ providers.
RESULTS
• Family members of 80% of newly diagnosed patients agreed to participate; most (93%) were partners (i.e. spouses or significant others). Most partners (93%) had direct contact with the patients’ physicians.
• Among the partners who had contact with providers, most (67%) were very satisfied with the patients’ providers and 80% indicated that the doctor encouraged them to participate in the treatment decision. Overall, 91% of partners reported very frequent discussions with their loved one about the pending treatment decision, and 69% reported that their role was to help the patient make a decision.
• In multivariate models, provider encouragement of partner participation was associated with higher partner satisfaction (odds ratio 3.4, 95% CI 1.4–8.4) and an increased likelihood of partners reporting very frequent discussions with their loved one (odds ratio 6.1, 95% CI 1.3–27.7).
CONCLUSIONS
• Partners often attended clinic visits and were very involved in discussions about treatment options with both loved ones and providers.
• Provider encouragement of participation by partners greatly facilitates shared decision‐making between patients and partners.
Kinetics‐based dose targeting is often conducted in hematopoietic cell transplant (HCT) patients conditioned with intravenous (IV) or oral busulfan to lower rates of rejection, nonrelapse mortality, ...and relapse. Using the candidate gene approach, the authors evaluated whether busulfan clearance was associated with polymorphisms in the genes regulating the predominant metabolizing enzymes involved in busulfan conjugation, specifically glutathione S‐transferase (GST) isoenzymes A1 (GSTA1) and M1 (GSTM1). Busulfan clearance was estimated after the morning dose on days 1, 2, and 3; each patient's average clearance was used for analyses. The average (± standard deviation) busulfan clearance was 3.2 ± 0.56 mL/min/kg in the separate population of 95 patients who received oral busulfan and 103 ± 24 ml/min/m2 in the 57 patients who received IV busulfan. Oral busulfan clearance was associated with GSTA1 (P = .008) but not GSTM1 (P = .57) genotypes. However, among the GSTA1 haplotypes (ie, *A*A, *A*B, *B*B), there was significant overlap in the observed oral busulfan clearance and similar rates of achieving the target busulfan exposure. Clearance of IV busulfan was not associated with GSTA1 (P = .21) or GSTM1 (P = .99). These data suggest that personalizing either IV or oral busulfan dosing cannot be simplified on the basis of GSTA1 or GSTM1 genotype.
Modeling risk using generalized linear models Blough, David K.; Madden, Carolyn W.; Hornbrook, Mark C.
Journal of health economics,
04/1999, Letnik:
18, Številka:
2
Journal Article
Recenzirano
Traditionally, linear regression has been the technique of choice for predicting medical risk. This paper presents a new approach to modeling the second part of two-part models utilizing extensions ...of the generalized linear model. The primary method of estimation for this model is maximum likelihood. This method as well as the generalizations quasi-likelihood and extended quasi-likelihood are discussed. An example using medical expense data from Washington State employees is used to illustrate the methods. The model includes demographic variables as well as an Ambulatory Care Group variable to account for prior health status.
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