Correlates of specialty substance use treatment among adults with opioid use disorders

AimsTo identify factors associated with the receipt of specialty substance use treatment among adults with opioid use disorders (OUD).DesignCross-sectional study based on 2010–2014 National Surveys on Drug Use and Health (NSDUH).Setting and participantsAdults with a past-year OUD (n = 2488). The sample is representative of non-institutionalized US adults.MeasurementsPast-year OUD was determined using DSM-IV criteria. Past-year specialty substance use treatment was defined as receiving treatment for drug use at any of the following locations: rehabilitation facilities, hospitals (inpatient only), outpatient mental health centers, private doctors' offices, or methadone clinics. Multivariable logistic regression models were used to measure the independent association between potential correlates and specialty substance use treatment receipt.FindingsOf adults with an OUD, 8.3% received past-year specialty substance use treatment. In a fully adjusted logistic regression model, the following factors were associated with increased odds of receiving specialty substance use treatment: ≥ 35 years old (adjusted Odds Ratio (aOR) = 2.55, 95% Confidence Interval (CI) = 1.04–6.26); unemployment (aOR = 1.92, 95% CI = 1.02–3.61); not in the labor force (aOR = 2.16, 95% CI = 1.15–4.06); never been married (aOR = 2.14, 95% CI = 1.04–4.39); arrested in past 12 months (aOR = 4.43, 95% CI = 2.45–7.99); opioid dependence (aOR = 3.82, 95% CI = 2.06–7.10); alcohol use disorder (aOR = 2.44, 95% CI = 1.44–4.11); and another drug use disorder (aOR = 3.22, 95% CI = 1.95–5.32). Living in a non-metropolitan county (aOR = 0.29, 95% CI = 0.12–0.68) and fair/poor health (aOR = 0.38, 95% CI = 0.17–0.86) were associated with decreased odds of receiving specialty substance use treatment.ConclusionsThese findings suggest a need for the following efforts: strategies to increase individuals' recognition of their need for OUD treatment, expansion of insurance coverage for substance use treatment, expansion of earlier intervention services, adoption of a chronic care approach to substance use treatment, and an expansion of treatment capacity for rural communities.     

Piperacillin/tazobactam and risk of acute kidney injury in adults hospitalized with infection without vancomycin: a multi-centre real-world data analysis

BackgroundThere is uncertainty about whether piperacillin/tazobactam (PT) increases the risk of acute kidney injury (AKI) in patients without concomitant use of vancomycin. This study compared the risk of hospital-acquired AKI (HA-AKI) among adults treated with PT or antipseudomonal β-lactams (meropenem, ceftazidime) without concomitant use of vancomycin.MethodsThis real-world study analysed the data from China Renal Data System and assessed the risk of HA-AKI in adults hospitalized with infection after exposure to PT, meropenem or ceftazidime in the absence of concomitant vancomycin. The primary outcome was any stage of HA-AKI according to the Kidney Disease Improving Global Outcomes guidelines. A multi-variable Cox regression model and different propensity score (PS) matching models were used.ResultsAmong the 29,441 adults [mean (standard deviation) age 62.44 (16.84) years; 17,980 females (61.1%)] included in this study, 14,721 (50%) used PT, 9081 (31%) used meropenem and 5639 (19%) used ceftazidime. During a median follow-up period of 8 days, 2601 (8.8%) develped HA-AKI. The use of PT was not associated with significantly higher risk of HA-AKI compared with meropenem [adjusted hazard ratio (aHR) 1.07, 95% confidence interval (CI) 0.97–1.19], ceftazidime (aHR 1.09, 95% CI 0.92–1.30) or both agents (aHR 1.07, 95% CI 0.97–1.17) after adjusting for confounders. Results were consistent in stratified analyses, PS matching using logistic regression or random forest methods to generate a PS, and in an analysis restricting outcomes to AKI stage 2–3.ConclusionsWithout concomitant use of vancomycin, the risk of AKI following PT therapy is comparable with that of meropenem or ceftazidime among adults hospitalized with infection.     

Increased risk of HIV and other drug-related harms associated with injecting in public places: national bio-behavioural survey of people who inject drugs

BackgroundWhilst injecting drugs in public places is considered a proxy for high risk behaviour among people who inject drugs (PWID), studies quantifying its relationship with multiple drug-related harms are lacking and none have examined this in the context of an ongoing HIV outbreak (located in Glasgow, Scotland). We aimed to: 1) estimate the prevalence of public injecting in Scotland and associated risk factors; and 2) estimate the association between public injecting and HIV, current HCV, overdose, and skin and soft tissue infections (SSTI).MethodsCross-sectional, bio-behavioural survey (including dried blood spot testing to determine HIV and HCV infection) of 1469 current PWID (injected in last 6 months) recruited by independent interviewers from 139 harm reduction services across Scotland during 2017–18. Primary outcomes were: injecting in a public place (yes/no); HIV infection; current HCV infection; self-reported overdose in the last year (yes/no) and SSTI the last year (yes/no). Multi-variable logistic regression was used to determine factors associated with public injecting and to estimate the association between public injecting and drug-related harms (HIV, current HCV, overdose and SSTI).ResultsPrevalence of public injecting was 16% overall in Scotland and 47% in Glasgow city centre. Factors associated with increased odds of public injecting were: recruitment in Glasgow city centre (aOR=5.45, 95% CI 3.48–8.54, p<0.001), homelessness (aOR=3.68, 95% CI 2.61–5.19, p<0.001), high alcohol consumption (aOR=2.42, 95% CI 1.69–3.44, p<0.001), high injection frequency (≥4 per day) (aOR=3.16, 95% CI 1.93–5.18, p<0.001) and cocaine injecting (aOR=1.46, 95% CI 1.00 to 2.13, p = 0.046). Odds were lower for those receiving opiate substitution therapy (OST) (aOR=0.37, 95% CI 0.24 to 0.56, p<0.001) and older age (per year increase) (aOR=0.97, 95% CI 0.95 to 0.99, p = 0.013). Public injecting was associated with an increased risk of HIV infection (aOR=2.11, 95% CI 1.13–3.92, p = 0.019), current HCV infection (aOR=1.49, 95% CI 1.01–2.19, p = 0.043), overdose (aOR=1.59, 95% CI 1.27–2.01, p<0.001) and SSTI (aOR=1.42, 95% CI 1.17–1.73, p<0.001).ConclusionsThese findings highlight the need to address the additional harms observed among people who inject in public places and provide evidence to inform proposals in the UK and elsewhere to introduce facilities that offer safer drug consumption environments.     

Non-vitamin K Antagonist Oral Anticoagulants Versus Warfarin in Patients with Atrial Fibrillation and Liver Disease: A Meta-Analysis and Systematic Review

Background

The effect of non-vitamin K antagonist oral anticoagulants (NOACs) in patients with atrial fibrillation (AF) and liver disease remains largely unresolved. Therefore, we performed a meta-analysis to compare the efficacy and safety of NOACs with warfarin in this population.

Methods

We systematically searched the Cochrane Library, PubMed, and Embase databases for studies reporting the comparisons of NOACs with warfarin in patients with AF and liver disease. A random-effects model was selected to pool the risk ratios (RRs) and 95% confidence intervals (CIs).

Results

A total of six studies with 41,954 participants were included in this meta-analysis. In AF patients with liver disease, compared with warfarin use, the use of NOACs was associated with reduced risks of all-cause death (RR 0.78, 95% CI 0.66–0.93), major bleeding (RR 0.68, 95% CI 0.53–0.88), and intracranial hemorrhage (RR 0.49, 95% CI 0.41–0.59), but had comparable risks of stroke or system embolism (RR 0.80, 95% CI 0.57–1.12) and gastrointestinal bleeding (RR 0.90, 95% CI 0.61–1.34). In AF patients with cirrhosis, NOACs significantly reduced the risks of major bleeding (RR 0.53, 95% CI 0.37–0.76), gastrointestinal bleeding (RR 0.57, 95% CI 0.38–0.84), and intracranial hemorrhage (RR 0.55, 95% CI 0.31–0.97) compared with warfarin.

Conclusions

Based on current publications, the use of NOACs is at least non-inferior to warfarin in patients with AF and liver disease.

     

Stroke risk reduction outweighed bleeding risk increase from vitamin K antagonist treatment among nonvalvular atrial fibrillation patients with high stroke risk and low bleeding risk

Objective: Warfarin is widely used for stroke prevention in patients with nonvalvular atrial fibrillation (NVAF). We compared the rates of stroke and major bleeding in NVAF patients with a high stroke risk and low bleeding risk profile during warfarin treated (W+) and warfarin untreated (W?) periods.

Method: Insurance claims from six commercial, Medicaid or Medicare databases were analyzed from 2000 to 2014. NVAF patients treated with warfarin, with a CHADS₂/CHA₂DS₂-VASc score ≥2, and an ATRIA score ≤3 at baseline were identified. Incidence rate ratios (IRRs) of stroke and major bleeding were calculated for W?+?versus W? episodes of person-time, as well as for first 30 days versus beyond 30 days of W?+?episodes.

Results: Among 316,145 patients, anticoagulant prophylaxis with warfarin significantly reduced stroke risk, with IRRs ranging from 0.48 (95% CI: 0.46–0.51) to 0.80 (95% CI: 0.70–0.91), and increased major bleeding risk, with IRRs ranging from 1.13 (95% CI: 1.10–1.15) to 1.95 (95% CI: 1.10–3.45). Stroke and major bleeding rates were higher during the first 30 days of W?+?than beyond.

Conclusion: In NVAF patients at high risk for stroke and low risk for bleeding, our data confirm the effectiveness of anticoagulation for stroke prevention. The decrease in stroke risk of anticoagulation may outweigh the risk of major bleeding events, particularly among elderly patients. Potential risks of warfarin during initiation warrant attention, especially among patients who stop and start therapy repeatedly.     

Risk of bleeding and hypoprothrombinaemia associated with NMTT side chain antibiotics: using cefoperazone as a test case

A retrospective cohort study was performed to determine the incidence of hypoprothrombinaemia and bleeding in patients receiving cefoperazone, a third-generation cephalosporin that contains an NMTT side chain. 374 patients receiving cefoperazone from February 1983 to March 1986 at a teaching hospital in Philadelphia were compared with 497 patients receiving either ceftizoxime or cefotaxime during the same period, and with 476 patients receiving ceftazidime from April 1985 to December 1987. Adverse events (any bleeding episodes, decrease in haemoglobin, prolongation of prothrombin time (PT), and prolongation of partial thromboplastin times (PTT)) were evaluated, if occurring during the period from the start of cephalosporin therapy, or the start of therapy with one of the two control drugs, for 14 days after the last date of the first course of therapy were recorded. An increased risk of hypoprothrombinaemia was associated with the use of cefoperazone: the prothrombin time was prolonged by 5 s or more in 12.3% of patients receiving cefoperazone vs. 5.8% of patients receiving ceftizoxime or cefotaxime, and vs. 5.8% receiving ceftazidime; the adjusted odds ratios (95% CIs) were 3.6 (1.7-7.4) and 3.8 (1.8-7.8), respectively, and these increased at higher doses of cephalosporin. No protection was apparent from the administration of vitamin K prior to or during the course of cephalosporin. No overall increased risks were observed for bleeding (adjusted odds ratios (95% CIs) were 1.1 (0.8-1.4) vs. ceftizoxime or cefotaxime, and 0.9 (0.6-1.2) vs. ceftazidime), decrease in haemoglobin, or increased partial thromboplastin time. In subgroup analyses, increased risks of bleeding were observed with high dose cefoperazone use [2.8 (1.5-5.5) vs. ceftizoxime or cefotaxime, and 2.3 (1.1-4.6) vs. ceftazidime]. Patients receiving NMTT side chain antibiotics should be monitored for hypoprothrombinaemia, but any increase in bleeding is likely to be small, and prophylactic vitamin K is probably not warranted.     

The efficacy and safety of novel oral anticoagulants for the preventive treatment in atrial fibrillation patients: a systematic review and meta-analysis

Abstract

Background: Novel oral anticoagulants, including direct factor Xa inhibitors and direct factor IIa inhibitors, have been used to prevent stroke in patients with atrial fibrillation (AF) for a decade. In this study, the efficacy and safety of the novel oral anticoagulants were assessed in AF patients.

Methods: No language restrictions were applied. Study selection and data extraction were carried out by searching PubMed, EMBASE, OVID, the BIOSIS, the Web of Science, Clinical Trials Registers, Cochrane Central Register of Controlled Trials and the China Academic Library and Information System. Each database was searched from its inception date to June 2013. Using odds ratio (OR) as an indicator, we systematically evaluated the primary efficacy endpoints and safety endpoints, as well as 10 secondary endpoints.

Result: Compared to the control drugs, the novel oral anticoagulants showed an OR decreased by 26% (OR: 0.74, 95% confidence interval (CI): 0.62–0.88) for stroke or systemic embolism, decreased by 24% (OR: 0.76, 95% CI: 0.64–0.90) for major bleeding, decreased by 10% (OR: 0.90, 95% CI: 0.84–0.95) for death from any cause, decreased by 27% for disabling or fatal stroke (OR: 0.73, 95% CI: 0.54–0.97), decreased by 31% (OR: 0.69, 95% CI: 0.60–0.8) for fatal bleeding, and decreased by 8% (OR: 0.92, 95% CI: 0.88–0.95) for serious adverse events. However, there was no significant difference in acute myocardial infarction, systemic embolism, major bleeding or clinically relevant non-major, all bleeding events, all adverse events and liver function disorder, between the novel oral anticoagulants and control drugs (p?>?0.05).

Conclusions: Compared to the control drugs, the novel oral anticoagulants showed higher efficiency and safety in patients with AF, as evidenced by their superior performance not only in reducing the risk of stroke or systemic embolism with a lower risk of major bleeding but also in decreasing the incidence of death from any cause, disabling or fatal stroke, serious adverse events and fatal bleeding.     

Is there truly an increase in risk of cardiovascular and hematological adverse events with vascular endothelial growth factor receptor tyrosine kinase inhibitors?

ABSTRACT

Objectives: Recent studies have shown an increase risk of cardiovascular and hematological adverse events associated with vascular endothelial growth factor tyrosine kinase inhibitors (VEGF-TKIs). The authors hypothesize that the original studies may have produced exaggerated results because of the small baseline risks involved.

Methods: A meta-analysis that included 71 trials, 8 different VEGFR-TKIs, and 11 adverse events were re-analyzed. The outcome of interest was re-defined as the complementary outcome (i.e. remaining free of an adverse event). The inverse variance heterogeneity model was used to pool the effect size.

Results: VEGFR-TKIs decreased the risk of remaining free of hypertension by 7% (RR 0.93; 95%CI:0.88–0.97). Specific VEGFR-TKIs; pazopanib, regorafenib, and nintedanib were associated with a decrease risk of remaining free of an arterial thrombotic event (RR 0.96; 95%CI:0.93–0.99), thrombocytopenia (RR 0.91; 95%CI:0.89–0.93), and bleeding (RR 0.96; 95%CI:0.93–0.99) respectively. VEGFR-TKIs were not associated with the thrombotic event, myocardial infarction, stroke, venous thrombotic event, pulmonary embolism, left ventricular dysfunction, or QTc interval prolongation.

Conclusion: VEGFR-TKIs are associated with a small increase in the risk of patients developing hypertension, arterial thrombotic events, thrombocytopenia, and bleeding. Previous studies overestimated the actual risk associated with VEGFR-TKIs by analyzing the outcome with the lower baseline risk.     

Efficacy and safety analysis of new P2Y12 inhibitors versus clopidogrel in patients with percutaneous coronary intervention: a meta-analysis

Objective:

New P2Y₁₂ inhibitors, classified as oral (prasugrel and ticagrelor) and intravenous (cangrelor and elinogrel) drugs, have shown improved antithrombotic effects compared with clopidogrel in patients with acute coronary syndrome (ACS) or patients undergoing percutaneous coronary intervention (PCI) in landmark trials. The purpose of this study was to perform a meta-analysis of randomized trials that compared new P2Y₁₂ inhibitors with clopidogrel to determine their efficacy and safety in patients undergoing PCI.

Methods:

Randomized controlled trials of at least 4 weeks, comparing new P2Y₁₂ inhibitors with clopidogrel in PCI, were identified using the electronic databases Cochrane Central Register of Controlled Trials, Medline, PubMed, Web of Science, and Google Scholar from January 1, 1980, to July 31, 2014.

Main outcome measures:

The primary efficacy endpoints were all-cause death and major adverse cardiovascular events (MACEs). The primary safety endpoint was thrombolysis in myocardial infarction (TIMI) major bleeding.

Results:

Twelve studies including 71,097 patients met the inclusion criteria. New P2Y₁₂ inhibitors significantly reduced all-cause death (odds ratio [OR]: 0.81; 95% confidence interval [CI] 0.73–0.90, p?p?p?p?=?0.03) and cardiovascular death (OR 0.82; 95% CI 0.73–0.92, p?=?0.001) compared with clopidogrel. There were no significant differences between stroke (OR 0.87; 95% CI 0.72–1.05, p?=?0.14) and major bleeding events (OR 1.22; 95% CI 0.99–1.52, p?=?0.06) between the new P2Y₁₂ inhibitor and clopidogrel groups.

Conclusion:

New P2Y₁₂ inhibitors decreased death in patients undergoing PCI compared with clopidogrel with a considerable safety and tolerability profile; however, the risk/benefit ratio of ischemic and bleeding events should be further investigated.     

Understanding of medications and associations with adherence,unmet needs,and perceived control of risk factors at two years post-stroke

BackgroundIt is unclear whether survivors of stroke or transient ischemic attack (TIA) routinely receive, and understand, education about secondary prevention medications.ObjectivesTo investigate whether survivors of stroke/TIA understand explanations about their prescribed prevention medications and associations with medication adherence, control of risk factors, and unmet needs.MethodsA survey was administered among survivors of stroke/TIA (random sample N = 1500) from the Australian Stroke Clinical Registry (Victoria and Queensland, 2016). Participants reported whether they understood explanations about each prescribed medication, as well as their unmet needs, perceived control of risk factors, and 30-day medication adherence. Linked pharmacy claims data were also used to determine medication adherence in the previous two years (proportion of days covered ≥80%). Outcomes were analyzed using multivariable logistic regression or multivariable negative binomial regression for frequency of unmet needs.ResultsOverall, 630/1455 eligible survivors completed the survey at ≈2.5 years post-admission (median age 69 years; 37% female). Most participants reported using prevention medications (76% antihypertensive; 84% antithrombotic; 76% lipid-lowering) but only 66–75% reported they understood explanations about their medication (75% antihypertensive; 66% antithrombotic; 74% lipid-lowering). Participants who understood explanations about their medication more often reported 30-day adherence for antihypertensive (adjusted odds ratios [aOR]: 1.96; 95% CI: 1.20–3.19), antithrombotic (aOR: 2.03; 95% CI: 1.31–3.14) and lipid-lowering medications (aOR: 1.73; 95% CI: 1.08–2.76). Similar associations were observed for antihypertensive and antithrombotic medications when pharmacy claims data were used to infer 2-year medication adherence. Understanding explanations about medications was also associated with perceived control of risk factors (hypertension: aOR: 11.08; 95% CI: 6.04–20.34; cholesterol aOR: 8.26; 95% CI: 4.72–14.47) and up to 33% fewer unmet needs related to secondary prevention.ConclusionsExpanded efforts are needed to improve the delivery of information about prevention medications to promote medication adherence, control of risk factors, and potentially prevent unmet needs following stroke/TIA.     

Safety,effectiveness, and health care cost comparisons among elderly patients with venous thromboembolism prescribed warfarin or apixaban in the United States Medicare population

Abstract

Objective: To compare safety, effectiveness, and healthcare costs of major bleeding (MB), clinically relevant non-major (CRNM) bleeding, recurrent venous thromboembolism (VTE), and all-cause hospitalization among elderly Medicare VTE patients prescribed warfarin vs apixaban.

Methods: Using 100% Medicare data, elderly patients prescribed apixaban or warfarin within 30 days after a VTE encounter were identified. Patients had continuous health plan enrollment and no parenteral or oral anticoagulant use ≤6 months preceding the VTE encounter. Cohorts were balanced using 1:1 propensity score matching (PSM). Cox proportional hazard models were used to assess the risk of MB, CRNM bleeding, recurrent VTE, and all-cause hospitalization. Generalized linear and two-part models were used to estimate MB-, recurrent VTE-, and all-cause related costs (per patient per month [PPPM]).

Results: In the pre-matched cohort, 25,284 (66.9%) patients were prescribed warfarin and 12,515 (33.1%) apixaban. After 1:1 PSM, 11,363 matched pairs of apixaban-warfarin patients were included for a mean follow-up of 4.0 and 4.4 months, respectively. Matched cohorts had a mean age of 78 years and mean Charlson Comorbidity Index score of 2.9. Warfarin was associated with a higher risk of MB (hazard ratio [HR]?=?1.31; 95% confidence interval [CI]?=?1.10–1.57) and CRNM bleeding (HR?=?1.31; 95% CI?=?1.19–1.43) vs apixaban. The risks of recurrent VTE (HR?=?0.96; 95% CI?=?0.70–1.33) and all-cause hospitalization (HR?=?1.05; 95% CI?=?0.99–1.12) were similar among warfarin and apixaban patients. Warfarin patients had higher MB-related ($147 vs $75; p?=?.003) and all-cause costs PPPM ($3,267 vs $3,033; p?<?.001), but similar recurrent VTE-related medical costs PPPM ($30 vs $36; p?=?.516) vs apixaban patients.

Conclusions: Warfarin was associated with significantly higher risk of MB and CRNM bleeding as well as higher MB-related and all-cause costs vs apixaban patients. Recurrent VTE risk and costs were similar among warfarin and apixaban patients.     

Analysis of risk factors and establishment of a risk prediction model for post-transplant diabetes mellitus after kidney transplantation

IntroductionPost-transplant diabetes mellitus (PTDM) is a known side effect in transplant recipients administered immunosuppressant drugs, such as tacrolimus. This study aimed to investigate the risk factors related to PTDM, and establish a risk prediction model for PTDM. In addition, we explored the effect of PTDM on the graft survival rate of kidney transplantation recipients.MethodsPatients with pre-diabetes mellitus before kidney transplant were excluded, and 495 kidney transplant recipients were included in our study, who were assigned to the non-PTDM and PTDM groups. The cumulative incidence was calculated at 3 months, 6 months, 1 year, 2 years, and 3 years post-transplantation. Laboratory tests were performed and the tacrolimus concentration, clinical prognosis, and adverse reactions were analyzed. Furthermore, binary logistic regression analysis was used to identify the independent risk factors of PTDM.ResultsAge ≥ 45 years (adjusted odds ratio [aOR] 2.25, 95% confidence interval [CI] 1.14–3.92; P = 0.015), body mass index (BMI) > 25 kg/m² (aOR 3.12, 95% CI 2.29–5.43, P < 0.001), tacrolimus concentration > 10 ng/mL during the first 3 months post-transplantation (aOR 2.46, 95%CI 1.41–7.38; P < 0.001), transient hyperglycemia (aOR 4.53, 95% CI 1.86–8.03; P < 0.001), delayed graft function (DGF) (aOR 1.31, 95% CI 1.05–2.39; P = 0.019) and acute rejection (aOR 2.16, 95% CI 1.79–4.69; P = 0.005) were identified as independent risk factors of PTDM. The PTDM risk prediction model was developed by including the above six risk factors, and the area under the receiver operating characteristic curve was 0.916 (95% CI 0.862–0.954, P < 0.001). Furthermore, the cumulative graft survival rate was significantly higher in the non- PTDM group than in the PTDM group.ConclusionsRisk factors related to PTDM were age ≥ 45 years, BMI > 25 kg/m², tacrolimus concentration > 10 ng/mL during the first 3 months post-transplantation, transient hyperglycemia, DGF and acute rejection.     

Frequency and risk factors for mental disorders following pancreatitis: a nationwide cohort study

Objective: To investigate the frequency and risk factors for mental disorders following pancreatitis.

Methods: Patients with acute pancreatitis (AP) and chronic pancreatitis (CP) were identified (n?=?18,074) from a nationwide database in New Zealand (1998–2015). They were followed from their first hospital admissions for AP or CP to incident mental disorders. Hazard ratios (HR) and 95% confidence intervals (CI) were estimated using multivariable Cox regression analyses.

Results: CP (vs AP) was associated with a significantly higher risk of mental disorders (adjusted HR?=?2.00 [95% CI?=?1.53–2.62]). Pre-existing diabetes (adjusted HR?=?8.99 [95% CI?=?6.23–12.96] for AP and adjusted HR?=?3.42 [95% CI?=?2.37–4.96] for CP) and post-pancreatitis diabetes mellitus (adjusted HR?=?7.10 [95% CI?=?4.14–12.19] for AP and adjusted HR?=?2.97 [95% CI?=?1.83–4.82] for CP) were risk factors for mental disorders in individuals following pancreatitis. Severe (adjusted HR?=?2.07 [95% CI?=?1.39–3.06] vs mild) and recurrent (adjusted HR?=?1.62 [95% CI?=?1.07–2.45] vs single episode) attacks were associated with significantly higher risks of mental disorders following AP.

Conclusions: Patients following CP, recurrent AP, severe AP, and those with diabetes are at high risk for developing mental disorders.     

Risk of stroke/systemic embolism,major bleeding and associated costs in non-valvular atrial fibrillation patients who initiated apixaban,dabigatran or rivaroxaban compared with warfarin in the United States Medicare population

Objective: To compare the risk and cost of stroke/systemic embolism (SE) and major bleeding between each direct oral anticoagulant (DOAC) and warfarin among non-valvular atrial fibrillation (NVAF) patients.

Methods: Patients (≥65 years) initiating warfarin or DOACs (apixaban, rivaroxaban, and dabigatran) were selected from the Medicare database from 1 January 2013 to 31 December 2014. Patients initiating each DOAC were matched 1:1 to warfarin patients using propensity score matching to balance demographics and clinical characteristics. Cox proportional hazards models were used to estimate the risks of stroke/SE and major bleeding of each DOAC vs. warfarin. Two-part models were used to compare the stroke/SE- and major-bleeding-related medical costs between matched cohorts.

Results: Of the 186,132 eligible patients, 20,803 apixaban–warfarin pairs, 52,476 rivaroxaban–warfarin pairs, and 16,731 dabigatran–warfarin pairs were matched. Apixaban (hazard ratio [HR]?=?0.40; 95% confidence interval [CI] 0.31, 0.53) and rivaroxaban (HR?=?0.72; 95% CI 0.63, 0.83) were significantly associated with lower risk of stroke/SE compared to warfarin. Apixaban (HR?=?0.51; 95% CI 0.44, 0.58) and dabigatran (HR?=?0.79; 95% CI 0.69, 0.91) were significantly associated with lower risk of major bleeding; rivaroxaban (HR?=?1.17; 95% CI 1.10, 1.26) was significantly associated with higher risk of major bleeding compared to warfarin. Compared to warfarin, apixaban ($63 vs. $131) and rivaroxaban ($93 vs. $139) had significantly lower stroke/SE-related medical costs; apixaban ($292 vs. $529) and dabigatran ($369 vs. $450) had significantly lower major bleeding-related medical costs.

Conclusions: Among the DOACs in the study, only apixaban is associated with a significantly lower risk of stroke/SE and major bleeding and lower related medical costs compared to warfarin.     

Acceptability of implementing community-based drug checking services for people who use drugs in three United States cities: Baltimore,Boston and Providence

BackgroundNorth America is experiencing a rising trend of opioid overdose exacerbated primarily in recent years through adulteration of the heroin supply with fentanyl and its analogues. The east coast of the United States has been particularly hard hit by the epidemic. In three east coast states of Maryland, Massachusetts and Rhode Island, fentanyl has been detected in over half of all overdoses with available toxicology screens. To determine the acceptability of drug checking involving fentanyl test strips (FTS) or other technologies among those at high risk for overdose, we assessed correlates of intention to utilize such services and logistical preferences among people who use drugs (PWUD).MethodsThrough FORECAST (the Fentanyl Overdose REduction Checking Analysis STudy), street-based PWUD (N = 334) were recruited in Baltimore, Maryland, Boston, Massachusetts, and Providence, Rhode Island. Questionnaires 7were administered from June to October 2017 and ascertained drug use, overdose history, fentanyl knowledge, and drug checking intent and logistical preferences. Pearson’s χ² and logistic regression determined factors associated with drug checking intent.ResultsOverall, 84% were concerned about fentanyl, 63% had ever overdosed, and 42% had ever witnessed a fatal overdose. Ninety percent felt drug checking would help them prevent an overdose, the majority of those interested would utilize drug checking at least daily (54%). Factors independently associated with intent to use drug checking included: older age (aOR: 1.5, 95% CI: 1.3–1.8); homelessness (aOR: 0.6, 95% CI: 0.5–0.7); being non-white (aOR: 2.0, 95% CI: 1.0–4.0); witnessing ≥1 fatal overdose (aOR: 1.6, 95% CI:1.1–2.3); and suspected recent fentanyl exposure (aOR: 1.8, 95% CI: 1.1–3.1).ConclusionsThe majority of PWUD endorsed drug checking for overdose prevention, with intent amplified by having witnessed a fatal overdose and recent fentanyl exposure. Drug checking should be part of a comprehensive approach to address the risks associated with the proliferation of fentanyl.     

Changes in risk behaviours during and following treatment for hepatitis C virus infection among people who inject drugs: The ACTIVATE study

BackgroundThe risk of hepatitis C virus (HCV) reinfection due to continued injecting risk behaviours might remain a barrier to HCV treatment among people who inject drugs. We aimed to evaluate changes in risk behaviours during and following HCV treatment among people with ongoing injecting drug use or receiving opioid substitution treatment (OST).MethodsACTIVATE was an international multicentre clinical trial conducted between 2012 and 2014. Participants with HCV genotypes 2/3 infection were treated with peg-interferon/ribavirin for 12 or 24 weeks and completed a self-administered behavioural questionnaire at each study visit. The impact of time in treatment and follow-up on longitudinally measured recent (past month) behavioural outcomes was evaluated using generalized estimating equations.ResultsAmong 93 enrolled participants (83% male, median age 41 years), 55 (59%) had injected in the past month. Any injecting drug use decreased during HCV treatment and follow-up (OR 0.89 per incremental study visit; 95% CI 0.83–0.95). No significant changes were found in ≥daily injecting (OR 0.98; 95% CI 0.89–1.07), use of non-sterile needles (OR 0.94; 95% CI 0.79–1.12), sharing of injecting paraphernalia (OR 0.87; 95% CI 0.70–1.07) or non-injecting drug use (OR 1.01; 95% CI 0.92–1.10). Hazardous alcohol use decreased throughout (OR 0.56; 95% CI 0.40–0.77) and OST increased between enrolment and end of treatment (OR 1.48; 95% CI 1.07–2.04).ConclusionsRecent injecting drug use and hazardous alcohol use decreased, while OST increased during and following HCV treatment among participants with ongoing injecting drug use. These findings support further expansion of HCV care among PWID.     

Using actor-partner interdependence modeling to understand recent illicit opioid use and injection drug use among men in community supervision and their female partners in New York City

BackgroundThe United States’ opioid crisis disproportionately affects individuals in the criminal justice system. Intimate partners can be a source of social support that helps reduce substance use, or they can serve as a driver of continued or increased substance use. Better understanding of the association between intimate partner characteristics and illicit opioid use and injection drug use among individuals in community supervision could be vital to developing targeted interventions.MethodsUsing actor-partner interdependence models, we examined individual and partner characteristics associated with recent illicit opioid use and injection drug use among males in community supervision settings in New York City (n = 229) and their female partners (n = 229).ResultsHigher levels of depression (aOR 1.98, 95% CI [1.39–2.82], p ≤ 0.01) and anxiety (aOR 1.98, 95% CI [1.42–2.75], p ≤ 0.01) were associated with recent opioid use among males in community supervision. Females with a partner having higher levels of anxiety were more likely to have recently used opioids (aOR 1.52, 95% CI [1.06–2.16], p ≤ 0.05). Males with a female partner with higher levels of anxiety (aOR 2.16, 95% CI [1.31–3.56], p ≤ 0.01) or depression (aOR 1.70, 95% CI [1.01–2.86], p ≤ 0.05) were more likely to recently inject drugs. Women with a male partner who had been in prison were more likely to have recently injected drugs (aOR 3.71, 95% CI [1.14–12.12], p ≤ 0.05), but women who had a male partner who had been arrested in the past three months were less likely to have recently injected (aOR 0.08, 95% CI [0.02–0.46], p ≤ 0.01).ConclusionsResults suggest that recent individual illicit opioid use and injection drug use is associated not only with individual-level factors, but also with partner factors, highlighting the need for couple-based approaches to address the opioid epidemic.     

Uric acid and incident chronic kidney disease in dyslipidemic individuals

Background: Elevated uric acid (UA) is a recognized risk factor for chronic kidney disease (CKD). This study aimed to investigate whether this association exists in dyslipidemic patients receiving multifactorial treatment.

Methods: An observational study conducted in Greece including 1,269 dyslipidemic individuals followed-up in a lipid clinic for ≥3 years. Estimated glomerular filtration rate (eGFR) was calculated by CKD-EPI equation and CKD was defined as ≤60?mL/min/1.73 m². The correlation was assessed between UA levels and the CKD risk after adjusting for potential confounding factors, after defining the following UA quartiles: Q1: ?6?mg/dL.

Results: After excluding patients with baseline eGFR <60?mL/min/1.73 m², gout and those taking UA-lowering drugs, 1,095 individuals were eligible; of those, 91% and 69% were treated with statins and anti-hypertensive drugs, respectively. During their follow-up (6 years; IQR?=?4–10), 11.9% of the subjects developed CKD, whereas the median annual eGFR decline was 0.69?mL/min/1.73 m² (IQR?=?0.45–2.33). Multivariate analysis showed that baseline UA levels (HR?=?1.26; 95% CI?=?1.09–1.45, p?=?.001), female gender (HR?=?1.74; 95% CI?=?1.14–2.65, p?=?.01), age (HR?=?1.10; 95% CI?=?1.07–1.12, p?p?=?.03), cardiovascular disease (HR?=?1.62; 95% CI?=?1.02–2.58, p?=?.04), decreased baseline renal function (eGFR <90?mL/min/1.73 m²) (HR?=?2.38; 95% CI?=?1.14–4.81, p?=?.02), and low-density lipoprotein cholesterol reduction (HR?=?0.995; 95% CI?=?0.991–0.998, p?=?.01) were associated with incident CKD. Additionally, patients with UA ≥6?mg/dL exhibited a higher risk of incident CKD compared with those in the lowest UA quartile (HR?=?2.01; 95% CI?=?1.11–3.65, p?=?.02).

Conclusion: Higher UA levels are correlated with a higher risk of incident CKD in dyslipidemic individuals taking multifactorial treatment.     

Parental health-seeking behavior on self-medication,antibiotic use,and antimicrobial resistance in children

Aim and ObjectivesThe study sought to identify parental trends in children's self-medication, health-seeking behavior, knowledge of self-medication, antibiotic use, and antimicrobial resistance in Asir, Saudi Arabia.MethodsA web-based cross-sectional study was carried out by a survey questionnaire. Snow Ball sampling technique was used to select the Eight hundred and sixteen parents with children in the Asir region by WhatsApp and email, and 650 participants who met the inclusion criteria consented to participate in the study.ResultsThere were 1809 episodes of childhood illnesses reported during the study period. The mean scores are on knowledge at 8.11 ± 2.43, favorable attitude at 17.60 ± 1.17, and practice was 7.72 ± 1.72, and a significant correlation was found between knowledge, attitude, and practice (KAP) at p = 0.01. Out of 624, the majority of parents showed strong knowledge and proficiency in antibiotics. However, the attitude scores of over 50% towards the usage of antibiotics were subpar. Around 54% of parents were self-medicating their children and 43% were unaware that skipping doses contributes to anti-microbial resistance (AMR). The facilitators for self-medication were male gender (aOR: 2.13; 95% CI: 1.26–3.98, p < 0.05), having more children (aOR: 2.78; 95% CI: 1.27–4.12 p < 0.01), professional qualification (aOR:3.07; 95% CI 1.57– 4.68; p < 0.01), residing in urban area (aOR: 3.17; 95% CI: 2.13–5.61, p < 0.05), working in health care (aOR: 5.99; 95% CI: 1.78–18.2, p < 0.01) and high income (aOR: 3.57; 95% CI: 2.08–6.34, p < 0.05).ConclusionsThe findings indicated that the majority of parents had unfavorable views and improper practices of antibiotic usage. Strategic education programs to the targeted population, especially to the parents about side effects of antibiotics, dangerous consequences of self-medication, and crucial AMR concerns must be addressed immediately.