RESUMO
Background: There is limited real-world data of lipid control and healthcare costs among patients with and without Atherosclerotic Cardiovascular Disease (ASCVD) in Latin America. Methods: A retrospective cohort study including patients with LDL-cholesterol (LDL-C) assessment from 2015 to 2017 was performed in a health insurance database. Patient characteristics, comorbidities and laboratory data were collected, and International Classification of Diseases (ICD) codes were used to identify a subcohort of patients with ASCVD (secondary prevention) and assess the proportion of these patients with LDL-C controlled. Lipid control among patients without ASCVD (primary prevention) and healthcare costs in one year in the overall population were also assessed. Results: From the 17,434 patients selected, 5,208 (29.8%) had ASCVD. The mean age of these patients in secondary prevention was 68.9 (±12.3) years and 47.8% were male patients. LDL-C < 70 mg/dL was identified in 19.1% of the ASCVD population and only 4.1% had an LDL-C < 50 mg/dL. LDL control was worse in women compared to men (13.1% vs. 25.7%; P < 0.01). The average cost in one year was 3,591 American dollars (USD) per patient in primary prevention compared to 8,210 dollars per year for patients in secondary prevention (P < 0.01). While outpatient costs accounted for 59.8% of the total cost in the primary prevention group, the main cost of the secondary prevention population was related to hospital costs (54.1%). Conclusion: Despite the favorable evidence for intensive cholesterol reduction, the evaluation of large real-world database with more than 17,000 individuals showed that the targets of guideline recommendations have not yet been adequately incorporated into clinical practice. Average annual cost per patient in secondary prevention is more than twice compared to primary prevention. Hospital expenses account for most of the cost in the secondary prevention group, while outpatient costs predominate in primary prevention.
Assuntos
Aterosclerose , Custos de Cuidados de Saúde , Humanos , Masculino , Feminino , Estudos Retrospectivos , Idoso , Aterosclerose/economia , Aterosclerose/epidemiologia , Aterosclerose/prevenção & controle , Custos de Cuidados de Saúde/estatística & dados numéricos , Brasil/epidemiologia , Pessoa de Meia-Idade , LDL-Colesterol/sangue , Seguimentos , Prevenção Secundária/economiaRESUMO
OBJECTIVES: Helicobacter pylori gastric infection strongly correlates with gastric diseases such as chronic gastritis, functional dyspepsia, and complications such as peptic ulcers and gastric cancer. In developing countries, systemic therapies are not usually successful due to elevated antibiotic resistance. Additionally, oral H. pylori infection and periodontal disease correlate with gastric treatment failures. This study aimed to explore the effect of an integral therapy, comprising oral hygiene and concomitant systemic treatment, to increase the eradication of gastric infection and recurrences. MATERIALS AND METHODS: A prospective, randomized, four-arm, parallel-group, open-label clinical trial was conducted to investigate the efficacy of integral therapy to eradicate gastric H. pylori infection and avoid recurrences in double-positive (real-time PCR oral and gastric infection) patients. Oral hygiene involved mouthwash with neutral electrolyzed water (NEW), with or without periodontal treatment. One hundred patients were equally distributed into four groups: NS, NS-PT, NEW, and NEW-PT. All patients had concomitant systemic therapy and additionally, the following oral treatments: mouthwash with normal saline (NS), periodontal treatment and mouthwash with normal saline (NS-PT), mouthwash with NEW (NEW), and periodontal treatment and mouthwash with NEW (NEW-PT). Gastric and oral infection and symptoms were evaluated one and four months after treatments. RESULTS: Integral therapy with NEW-PT increased gastric eradication rates compared with NS or NS-PT (84%-96% vs. 20%-56%; p < 0.001). Even more, a protective effect of 81.2% (RR = 0.1877; 95% CI: 0.0658-0.5355; p = 0.0018) against recurrences and 76.6% (RR = 0.2439; 95% CI: 0.1380-0.4310; p < 0.001) against treatment failure (eradication of infection and associated symptoms) was observed in patients from the NEW and NEW-PT groups. CONCLUSIONS: Implementation of oral hygiene and systemic treatment can increase the eradication of gastric infection, associated symptoms, and recurrences. NEW is recommended as an antiseptic mouthwash due to its efficacy and short- and long-term safety.
Assuntos
Antibacterianos , Infecções por Helicobacter , Helicobacter pylori , Antissépticos Bucais , Higiene Bucal , Humanos , Infecções por Helicobacter/tratamento farmacológico , Infecções por Helicobacter/microbiologia , Helicobacter pylori/efeitos dos fármacos , Helicobacter pylori/isolamento & purificação , Masculino , Feminino , Antissépticos Bucais/uso terapêutico , Antissépticos Bucais/administração & dosagem , Estudos Prospectivos , Adulto , Pessoa de Meia-Idade , Higiene Bucal/métodos , Antibacterianos/uso terapêutico , Antibacterianos/administração & dosagem , Resultado do Tratamento , Recidiva , Prevenção Secundária/métodos , Idoso , Terapia CombinadaRESUMO
BACKGROUND: Adhering to a diet adequate in macronutrients is crucial for the secondary prevention of cardiovascular diseases. OBJECTIVE: To assess the prevalence of adherence to recommendations for the consumption of dietary fatty acids for the prevention and treatment of cardiovascular diseases and to estimate whether the presence of certain cardiovascular risk factors would be associated with adherence. METHODS: Cross-sectional study using baseline data from 2,358 participants included in the "Brazilian Cardioprotective Nutritional Program Trial". Dietary intake and cardiovascular risk factors were assessed. Adequate intake of polyunsaturated fatty acids (PUFA) was considered as ≥10% of total daily energy intake; for monounsaturated fatty acids (MUFA), 20%; and for saturated fatty acids (SFA), <7% according to the Brazilian Society of Cardiology. A significance level of 5% was considered in the statistical analysis. RESULTS: No participant adhered to all recommendations simultaneously, and more than half (1,482 [62.9%]) did not adhere to any recommendation. Adherence exclusively to the SFA recommendation was the most prevalent, fulfilled by 659 (28%) participants, followed by adherence exclusively to the PUFA (178 [7.6%]) and MUFA (5 [0.2%]) recommendations. There was no association between the number of comorbidities and adherence to nutritional recommendations (p = 0.269). Participants from the Brazilian Northeast region showed a higher proportion of adherence to SFA consumption recommendations (38.42%) and lower adherence to PUFA intake (3.52%) (p <0.001) compared to other regions. CONCLUSIONS: Among the evaluated sample, there was low adherence to nutritional recommendations for dietary fatty acid consumption.
FUNDAMENTO: A adesão à uma alimentação adequada em macronutrientes é fundamental para a prevenção secundária de doenças cardiovasculares. OBJETIVO: Avaliar a prevalência de adesão às recomendações de consumo de ácidos graxos para prevenção e tratamento de doenças cardiovasculares, e estimar se a presença de determinados fatores de risco cardiovascular estaria associada à adesão. MÉTODOS: Estudo transversal com os dados de linha de base de 2358 participantes do estudo "Brazilian Cardioprotective Nutritional Program Trial". Dados de consumo alimentar, e fatores de risco cardiovascular foram avaliados. Foi considerada, de acordo com a Sociedade Brasileira de Cardiologia, uma ingestão adequada de ácidos graxos poli-insaturados (AGPI) ≥10% do consumo total de energia diária, para ácidos graxos monoinsaturados (AGM), 20% e para ácidos graxos saturados (AGS), <7%. Na análise estatística foi considerando nível de significância de 5%. RESULTADOS: Nenhum participante aderiu a todas as recomendações de forma simultânea e mais da metade (1482 [62,9%]) não aderiu a nenhuma recomendação. A adesão exclusivamente à recomendação de AGS foi a mais prevalente, sendo cumprida por 659 (28%) dos participantes, seguida da adesão exclusivamente à recomendação de AGP (178 [7,6%]) e de AGM (5 [0,2%]). Não houve associação entre o número de comorbidades e a adesão às recomendações nutricionais (p =0,269). Os participantes da região Nordeste do país apresentaram maior proporção de adesão às recomendações para consumo de AGS (38,42%), e menor para ingestão de AGPI (3,52%) (p <0,001) em comparação às demais. CONCLUSÕES: Na amostra avaliada, evidenciou-se baixa adesão às recomendações nutricionais para consumo de ácidos graxos.
Assuntos
Doenças Cardiovasculares , Ácidos Graxos , Humanos , Gorduras na Dieta , Doenças Cardiovasculares/etiologia , Prevenção Secundária , Estudos Transversais , Ácidos Graxos Insaturados , Ácidos Graxos MonoinsaturadosRESUMO
Objective: To evaluate the efficacy of a cardiac rehabilitation program (CRP) in improving adherence to non-pharmacological secondary prevention in patients with acute coronary syndrome (ACS). Method: Retrospective study of patients with ACS referred to CRP in a tertiary hospital from 2018 to 2021. Pre-post differences in adherence to physical activity, Mediterranean diet, smoking, and motivation to change were analyzed. Age, sex, and baseline motivation were analyzed in predicting change in adherence. Results: 418 patients were included. At the end of the CRP, the adherence to the mediterranean diet increased (p < 0.05; d = 0.83), frequency of physical activity increased by 2.16 (p < 0.05), and motivation to change remained constant (p = 0.94). Both women and men improved their adherence to the mediterranean diet. Both sexes performed more physical activity at the end of the CRP (1.89 times more in men and 4 times more in women; p < 0.05). An association was found between initial motivation and greater changes in adherence to the mediterranean diet (p < 0.05). An inversely proportional difference was observed between age and adherence to the mediterranean diet (p < 0.05). Conclusions: The CRP, in our hospital environment, has an effect of improving adherence to the mediterranean diet and physical exercise in patients with ACS. The change in adherence to the diet increases as the motivation to change the baseline increases, and age is inversely related to the change in adherence.
Objetivo: Evaluar la eficacia de un programa de rehabilitación cardiaca (PRC) sobre la mejora de la adherencia a las medidas de prevención secundaria no farmacológicas en pacientes con síndrome coronario agudo (SCA). Método: Estudio retrospectivo con pacientes con SCA derivados a PRC en un hospital terciario de 2018 a 2021. Se analizaron diferencias pre-post de adherencia a actividad física, dieta mediterránea, tabaquismo y motivación al cambio. Se analizaron la edad, el sexo y la motivación basal en la predicción del cambio de adherencia. Resultados: Se incluyeron 418 pacientes. Al final del PRC aumentó la adherencia a la dieta mediterránea (p < 0.05; d = 0.83), la frecuencia de actividad física aumentó 2,16 (p < 0.05) y la motivación al cambio se mantuvo constante (p = 0.94). Tanto las mujeres como los hombres mejoraron la adherencia a la dieta mediterránea. Ambos sexos realizaron más ejercicio físico al final del PRC (1.89 veces más los hombres y 4 las mujeres; p < 0.05). Se encontró una asociación entre motivación inicial y mayores cambios en la adherencia a la dieta mediterránea (p < 0.05). Se observó una diferencia inversamente proporcional entre la edad y la adherencia a la dieta mediterránea (p < 0.05). Conclusiones: El PRC, en nuestro medio hospitalario, mejora la adherencia a la dieta mediterránea y al ejercicio físico en los pacientes con SCA. La adherencia a la dieta mediterránea aumenta a medida que lo hace la motivación al cambio basal, mientras que la edad está inversamente relacionada con el cambio de adherencia.
Assuntos
Síndrome Coronariana Aguda , Reabilitação Cardíaca , Dieta Mediterrânea , Exercício Físico , Motivação , Cooperação do Paciente , Humanos , Síndrome Coronariana Aguda/reabilitação , Masculino , Feminino , Estudos Retrospectivos , Pessoa de Meia-Idade , Cooperação do Paciente/estatística & dados numéricos , Reabilitação Cardíaca/métodos , Idoso , Prevenção Secundária/métodos , Fatores Etários , Fatores SexuaisRESUMO
BACKGROUND: Prevention of Plasmodium vivax malaria recurrence is essential for malaria elimination in Brazil. We evaluated the real-world effectiveness of an updated treatment algorithm for P vivax radical cure in the Brazilian Amazon. METHODS: In this non-interventional observational study, we used retrospective data from the implementation of a P vivax treatment algorithm at 43 health facilities in Manaus and Porto Velho, Brazil. The treatment algorithm consisted of chloroquine (25 mg/kg over 3 days) and point-of-care quantitative glucose-6-phosphate dehydrogenase (G6PD) testing followed by single-dose tafenoquine 300 mg (G6PD normal, aged ≥16 years, not pregnant and not breastfeeding), 7-day primaquine 0·5 mg/kg per day (G6PD intermediate or normal, aged ≥6 months, not pregnant, and not breastfeeding or breastfeeding for >1 month), or primaquine 0·75 mg/kg per week for 8 weeks (G6PD deficient, aged ≥6 months, not pregnant, and not breastfeeding or breastfeeding for >1 month). P vivax recurrences were identified from probabilistic linkage of routine patient records from the Brazilian malaria epidemiological surveillance system. Recurrence-free effectiveness at day 90 and day 180 was estimated using Kaplan-Meier analysis and hazard ratios (HRs) by multivariate analysis. This clinical trial is registered with ClinicalTrials.gov, NCT05096702, and is completed. FINDINGS: Records from Sept 9, 2021, to Aug 31, 2022, included 5554 patients with P vivax malaria. In all treated patients of any age and any G6PD status, recurrence-free effectiveness at day 180 was 75·8% (95% CI 74·0-77·6) with tafenoquine, 73·4% (71·9-75·0) with 7-day primaquine, and 82·1% (77·7-86·8) with weekly primaquine. In patients aged at least 16 years who were G6PD normal, recurrence-free effectiveness until day 90 was 88·6% (95% CI 87·2-89·9) in those who were treated with tafenoquine (n=2134) and 83·5% (79·8-87·4) in those treated with 7-day primaquine (n=370); after adjustment for confounding factors, the HR for recurrence following tafenoquine versus 7-day primaquine was 0·65 (95% CI 0·49-0·86; p=0·0031), with similar outcomes between the two treatments at day 180 (log-rank p=0·82). Over 180 days, median time to recurrence in patients aged at least 16 years who were G6PD normal was 92 days (IQR 76-120) in those treated with tafenoquine and 68 days (52-94) in those treated with 7-day primaquine. INTERPRETATION: In this real-world setting, single-dose tafenoquine was more effective at preventing P vivax recurrence in patients aged at least 16 years who were G6PD normal compared with 7-day primaquine at day 90, while overall efficacy at 180 days was similar. The public health benefits of the P vivax radical cure treatment algorithm incorporating G6PD quantitative testing and tafenoquine support its implementation in Brazil and potentially across South America. FUNDING: Brazilian Ministry of Health, Municipal and State Health Secretariats; Fiocruz; Medicines for Malaria Venture; Bill & Melinda Gates Foundation; Newcrest Mining; and the UK Government. TRANSLATION: For the Portuguese translation of the abstract see Supplementary Materials section.
Assuntos
Aminoquinolinas , Antimaláricos , Malária Vivax , Plasmodium vivax , Primaquina , Humanos , Malária Vivax/tratamento farmacológico , Malária Vivax/prevenção & controle , Primaquina/uso terapêutico , Primaquina/administração & dosagem , Estudos Retrospectivos , Antimaláricos/uso terapêutico , Antimaláricos/administração & dosagem , Feminino , Masculino , Adulto , Brasil/epidemiologia , Aminoquinolinas/uso terapêutico , Aminoquinolinas/administração & dosagem , Adolescente , Criança , Adulto Jovem , Pessoa de Meia-Idade , Plasmodium vivax/efeitos dos fármacos , Pré-Escolar , Lactente , Prevenção Secundária/métodos , Cloroquina/uso terapêutico , Cloroquina/administração & dosagem , Recidiva , Resultado do Tratamento , IdosoRESUMO
INTRODUCCIÓN: La osteoporosis se define como una enfermedad esquelética, caracterizada por una disminución de la resistencia ósea que predispone al paciente a un mayor riesgo de fractura (1). Puede dividirse en osteoporosis primaria y secundaria que, a su vez, puede ser de diversos tipos (2). La masa y densidad ósea se mantienen bastante constantes cuando se para el crecimiento y sigue hasta los 50 años aproximadamente (3). Existen 4 categorías de diagnóstico según la evaluación mediante DXA: masa ósea normal, baja masa ósea (osteopenia), osteoporosis y osteoporosis severa. Según la definición de osteoporosis de la OMS, la enfermedad afecta aproximadamente al 6,3% de los hombres mayores de 50 años y al 21,2% de las mujeres del mismo rango de edad en todo el mundo (4). En toda Europa en 2019 (Unión Europea, más Suiza y el Reino Unido), se estima que 32 millones de personas mayores de 50 años tienen osteoporosis, lo que equivale al 5,6% de la población europea total mayor de 50 años, o aproximadamente 25,5 millones de mujeres (22,1% de mujeres mayores de 50 años) y 6,5 millones de hombres (6,6% de los hombres mayores de 50 años) (5). Los principales factores de riesgo que contribuyen a la osteoporosis son factores antropométricos como la edad o el género, factores clínicos como enfermedades gastrointestinales, hematológicas o menopausia prematura y factores ambientales tales como el tabaquismo, la actividad física o la elevada ingesta de alcohol (3, 6, 7). OBJETIVOS: Evaluar las FLS en la prevención de nuevas fracturas por fragilidad en personas de ≥ 50 años que hayan tenido al menos una fractura por fragilidad (prevención secundaria) en términos de eficacia/efectividad, económicos y organizativos. MATERIAL Y MÉTODOS: Para evaluar la eficacia/efectividad de las FLS, se realizó una revisión sistemática (RS) de la evidencia disponible para evaluar las FLS en la prevención de fracturas secundarias. Se incluyeron ensayos clínicos aleatorizados (ECA) y estudios observacionales (cohortes prospectivas y retrospectivas, controlados antes y después y no controlados antes y después) publicados en castellano, catalán o inglés, que evaluaran a personas mayores o con edad igual a 50 años que hubieran tenido al menos una fractura por fragilidad. Se excluyó pacientes con fractura con traumatismo de alta energía, sin fractura o con fractura patológica o secundaria (por ejemplo, a enfermedades neoplásicas, iatrogénicas u otras). Se incluyó atención en FLS de cualquier tipo de acuerdo a la clasificación de Ganda et al. 2013 (13): A, B, C y D. Se excluyeron las atenciones geriátricas generales. Se incluyeron estudios cuyo comparador fuera la atención mediante otros dispositivos asistenciales diferentes a la FLS y cuyos desenlaces de interés fueran: inicio del tratamiento, adherencia al tratamiento, caídas, nuevas fracturas, mortalidad, calidad de vida y realización de densitometría ósea. La evaluación de riesgo de sesgo de los estudios se realizó en cuanto a los desenlaces y varió según el diseño del estudio primario. RESULTADOS: Eficacia/Efectividad de las FLS: La RS de la literatura llevada a cabo en el presente informe para evaluar las FLS en comparación a la práctica clínica habitual en la prevención de fracturas secundarias identificó un total de 92 estudios en 100 referencias: 21 ECA reportados en 24 estudios (26-49), un estudio antes y después controlado (50), 21 estudios de cohorte en 22 artículos (51-73) y 49 estudios antes y después no controlados en 53 artículos (54, 62, 74-124). En pacientes de ≥50 años que hubieran tenido al menos una fractura por fragilidad, las FLS poseen efectos positivos en comparación a la práctica clínica habitual para el inicio del tratamiento y la realización de densitometría ósea (certeza de la evidencia baja según GRADE). Las FLS de tipo A, B y D podrían ser efectivas y aumentar el número de pacientes que empiezan el tratamiento con fármacos antiosteoporóticos. Las FLS tipo A, B, C y D aumentarían la realización de densitometrías óseas en estos pacientes. En pacientes de ≥50 años que hubieran tenido al menos una fractura por fragilidad, las FLS tipo A en comparación con la práctica clínica habitual sugieren que podrían no tener efecto en la adherencia al tratamiento y la calidad de vida de los pacientes (certeza de la evidencia baja según GRADE). Para los desenlaces de nuevas fracturas, mortalidad y caídas, la evidencia actual es muy incierta para medir su efecto en las FLS en relación con la práctica clínica habitual (certeza de la evidencia muy baja según GRADE). Aspectos económicos: La RS de la literatura identificó un total de 21 estudios (125-145), 10 de los cuales pudieron clasificarse como una intervención mediante FLS de tipo A (125-129, 131-133, 141, 145), 4 como FLS de tipo B (134-136)(130), 4 como FLS de tipo C (137-140) y ninguna de FLS de tipo D. Aspectos organizativos: Los aspectos organizativos que impactan en la implementación de las FLS son la existencia de la figura de un coordinador, la ubicación de la FLS y su intensidad asistencial. Asimismo, la duración del seguimiento en las FLS, el tipo de ubicación de la fractura y el género de los pacientes atendidos que podrían impactar en las decisiones de manejo clínico. Las FLS españolas se encuentran mayoritariamente en hospitales y centros sanitarios de titularidad pública. Las fracturas por fragilidad más atendidas en España son las de cadera, seguidas por las fracturas vertebrales clínicas y las de antebrazo y húmero. En la mayoría de FLS españolas, existe una estructura organizativa bien establecida que favorece la atención de las fracturas por fragilidad, aunque se identifican áreas de mejora como el seguimiento a largo plazo de los pacientes y los registros de actividad de las FLS. CONCLUSIONES: En pacientes ≥50 años con al menos una fractura por fragilidad y en comparación a la práctica clínica habitual, las FLS de tipo A, B y D podrían aumentar el número de pacientes que inician tratamiento antiosteoporótico, mientras que en las FLS de tipo C podrían no tener efecto. Las FLS de cualquier tipo (A, B, C y D) podrían aumentar la realización de densitometría ósea en estos pacientes. En cuanto a la adherencia al tratamiento y la calidad de vida, las FLS de tipo A podrían no tener ningún efecto en estos pacientes. Finalmente, la evidencia es muy incierta acerca de los efectos de las FLS para la aparición de nuevas fracturas, mortalidad y caídas. En relación con los aspectos económicos, los estudios sugieren que las FLS tipo A, B y C son coste-efectivas para el abordaje de pacientes ≥50 años con al menos una fractura por fragilidad en comparación a la práctica clínica habitual. En las FLS tipo D no se ha encontrado evidencia, mientras que en las de tipo desconocido los estudios económicos respaldan su coste-efectividad fundamentalmente en pacientes menores de 80 años. La adopción de FLS por parte del Sistema Nacional de Salud tendría un impacto presupuestario total de alrededor de 1.066 millones de euros (2023-2027). En España las FLS, con una estructura organizativa bien establecida, se encuentran mayoritariamente en hospitales y centros sanitarios de titularidad pública, donde se atienden mayoritariamente fracturas de cadera, vertebrales, de antebrazo y húmero.
INTRODUCTION: Osteoporosis is a skeletal disease, characterized by a decrease in bone strength that predisposes the patient to an increased risk of fracture (1). Osteoporosis can be classified as primary or secondary. Moreover, both categories can be of various types (2). Bone mass and density remain moderately constant once growth stops and until about the age of 50 years (3). There are four diagnostic categories as assessed by DXA (Dual-energy X-ray absorptiometry): normal bone mass, low bone mass (osteopenia), osteoporosis and severe osteoporosis. According to the World Health Organisation (WHO) osteoporosis: the disease affects approximately 6.3% of men over 50 years of age and 21.2% of women in the same age range worldwide (4). Across Europe, in 2019 (European Union, Switzerland, and the United Kingdom), an estimated 32 million people over the age of 50 had osteoporosis. This is equivalent to 5.6% of the total European population over the age of 50, or approximately 25.5 million women (22.1% of women over 50) and 6.5 million men (6.6% of men over 50) (5). The main risk factors contributing to osteoporosis are anthropometric factors such as age or gender, clinical factors -gastrointestinal diseases, haematological diseases or premature menopause-, and environmental factors -smoking, physical activity or high alcohol intake- (3,6,7). OBJECTIVES: To evaluate FLS in the prevention of new fragility fractures in people aged ≥50 years who have had at least one fragility fracture (secondary prevention) in terms of efficacy/effectiveness, economic and organizational. MATERIAL AND METHODS: To evaluate the efficacy/effectiveness of FLS, a systematic review (SR) of the available evidence to evaluate FLS in the prevention of secondary fractures was carried out. We included randomized clinical trials (RCT) and observational studies (prospective and retrospective cohorts, controlled before-andafter, and uncontrolled before- and-after studies) published in Spanish, Catalan or English, which evaluated people over the age of 50 years who had at least one fragility fracture. Patients with fracture with high-energy trauma, without fracture or with pathological or secondary fracture (for example, to neoplastic, iatrogenic or other diseases) were excluded. FLS care of any type was included according to the classification of Ganda et al. 2013 (13): A, B, C and D. General geriatric care was also excluded. We included studies whose comparator was health care through other care devices apart from FLS and whose outcomes of interest were the following ones: start of treatment, adherence to treatment, falls, new fractures, mortality, quality of life and bone densitometry. The risk of bias assessment of the studies was carried out at the level of the outcomes and varied according to the design of the primary study. RESULTS: Efficacy/Effectiveness of FLS: The SR of the literature conducted in this report to evaluate FLS compared to usual clinical practice in the prevention of secondary fractures. A total number of 92 studies in 100 references were identified: 21 RCT reported in 24 studies (26-49), one controlled before-and-after study (50), 21 cohort studies in 22 articles (51-73) and 49 uncontrolled before-andafter studies in 53 articles (54,62,74-124). In patients aged ≥50 years who have had at least one fragility fracture, FLS had positive effects compared to standard clinical practice for initiation of treatment and performance of bone densitometry (low certainty of evidence according to GRADE). Type A, B and D FLS could be effective and increase the number of patients starting treatment with anti-osteoporotic drugs. FLS type A, B, C and D would increase the performance of bone densitometry in these patients. In patients aged ≥50 years who have had at least one fragility fracture, FLS type A compared to standard clinical practice suggests that they may have no effect on patients' adherence to treatment and quality of life (low certainty of evidence according to GRADE). For the outcomes of new fractures, mortality and falls, the current evidence is very uncertain to measure their effect on FLS in relation to usual clinical practice (very low certainty of evidence according to GRADE). Organisational aspects: The organizational aspects that impact on the implementation of FLS are the existence of the figure of a coordinator, the location of the FLS and its care intensity. Moreover, the duration of follow-up in FLS, the type of location of the fracture and the gender of the patients attended could have an impact on clinical management decisions. The majority of Spanish FLS are in public hospitals and health care centres. The most common fragility fractures treated in Spain are those of the hip, followed by vertebral fractures and those of the forearm and humerus. In the majority of Spanish FLS, there is a well-established organizational structure which supports the health care of fragility fractures, although as well as the long-term follow-up of patients and the activity registers of the FLS. CONCLUSIONS: In patients aged ≥50 years w ith at least one fragility fracture and com pared to usual clinical practice, FLS types A, B and D may increase the number of patients who start anti-osteoporotic treatment, while FLS type C may have no effect. In terms of treatment adherence and quality of life, FLS type A may have no effect in these patients. Finally, the evidence is very uncertain about the effects of FLS on the appearance of new fractures, mortality and falls. In relation to economic aspects, studies suggest that FLS types A, B and C are cost-effective for the management of patients ≥50 years with at least one fragility fracture compared to standard clinical practice. No evidence was found for type D FLS, while for those of unknown type, economic studies support their cost-effectiveness mainly in patients under 80 years of age. The adoption of FLS by the Spanish National Health System would have a total budgetary impact of around 1,066 million euros (2023-2027). In Spain, FLS, with a well-established organizational structure, are mainly in public owned hospitals and health care centres where hip, vertebral, forearm and humerus fractures are mainly treated.
Assuntos
Humanos , Fraturas Ósseas/prevenção & controle , Prevenção Secundária/organização & administração , Avaliação em Saúde/economia , Análise Custo-Benefício/economiaRESUMO
This study aimed to investigate the effects of Mindfulness-Based Relapse Prevention (MBRP) in decision-making, inhibitory control and impulsivity compared to Treatment as Usual (TAU) for individuals with Substance Use Disorders (SUD's) in Brazil. A randomized clinical trial was conducted with participants from a therapeutic community (n = 122). Decision-making (Iowa Gambling Task), impulsivity dimensions (UPPS-P Scale), and inhibitory control (Stroop Color-Word Test) were assessed before and after the MBRP 8-week intervention. GLM Multivariate analysis was used to evaluate the effects of MBRP on different impulsivity measures. The results showed that MBRP+TAU improved the general decision-making score (p = 0,008) compared to TAU. However, no significant effects were found in impulsivity dimensions and inhibitory control in individuals with SUDs in the therapeutic community. This study found improvement in decision-making in the total IGT score; however, no effect for self-reported impulsivity and inhibitory control among middle-aged patients after an 8-weeks intervention of MBRP protocol in an inpatient setting. It adds information to the subject, with implications and possible directions to be followed by the next clinical trials with patients with SUDs in treatment. Trial registration: EnsaiosClinicos.gov.br: RBR-6c9njc.
Assuntos
Jogo de Azar , Atenção Plena , Transtornos Relacionados ao Uso de Substâncias , Pessoa de Meia-Idade , Humanos , Atenção Plena/métodos , Transtornos Relacionados ao Uso de Substâncias/terapia , Comportamento Impulsivo , Prevenção Secundária/métodosRESUMO
Background: Higher medication adherence reduces the risk of new cardiovascular events. However, there are individual and health system barriers that lead to lower adherence. The polypill has demonstrated benefits in cardiovascular morbidity and mortality mainly driven by an increase in adherence. We aim to evaluate the impact of the polypill on adherence to cardiovascular medication, its efficacy and safety in cardiovascular disease (CVD) prevention. Methods: A systematic review following PRISMA guidelines was conducted. Databases were searched from January 2003 to December 2022. We included randomized, pragmatic, or real-world clinical trials and observational studies. The primary outcome was medication adherence, secondary outcomes were efficacy in cardiovascular disease in primary and secondary prevention and safety. Results: From the 490 publications screened, 13 met the inclusion criteria and were incorporated into a comparative table Of those included, 70% were randomized controlled trials (RCTs) and 53.8% focused on secondary prevention. Most of the studies received a high and moderate quality rating. Self-report, pill counting and, the Morisky scale were the most frequent methods to evaluate adherence (84.6%). Compared with standard medication, the polypill improved overall medication adherence by 13%, with percentages ranging from 7.6% to 34.9%. Moreover, a potential benefit was also observed in reducing Major Adverse Cardiovascular Events (MACE), particularly in secondary prevention studies, with hazard ratios ranged between 0.43 to 0.76. Compared to standard care, the profile of side effects was similar. Conclusion: The polypill is an effective, safe, and practical strategy to improve adherence in people at risk of CVD. Although there is a demonstrated benefit in reducing MACE, predominantly in secondary prevention, there are still gaps in its efficacy in primary prevention and reducing total mortality. Therefore, the importance of obtaining long-term results of the polypill effect and how this strategy can be implemented in real practice.