Risk of myocardial infarction with use of selected nonsteroidal anti-inflammatory drugs in spondyloarthritis patients

BACKGROUND: Spondyloarthritis (SpA) is associated with increased risk of myocardial infarction (MI); the risk may be due to the underlying inflammatory disease, or also due to medications that increase MI risk, such as certain non-steroidal anti-inflammatory drugs (NSAIDs). OBJECTIVES: 1. To describe the risk of myocardial infarction (MI) among patients with spondyloarthritis who are prescribed NSAIDs 2. To compare the pattern of MI risk with specific NSAID use among spondyloarthritis patients with the pattern of risk among patients with osteoarthritis (OA) METHODS: Nested case-control studies were performed using 1994–2015 data from The Health Improvement Network (THIN). Underlying cohorts included adult patients with incident SpA or OA had >1 NSAID prescriptions and no history of MI. In each cohort, we matched cases of incident MI to four controls without MI. NSAID use was categorized as: (A) current (prescription end date 0–180 days prior to index date), (B) recent (181–365 days), or (C) remote (>365 days). We performed conditional logistic regression to compare the odds of current or recent NSAID use relative to remote use of any NSAID, considering diclofenac and naproxen specifically. RESULTS: Within the SpA cohort of 8140 and the OA cohort of 244,399, there were 115 and 6287 MI cases, respectively. After adjustment, among SpA subjects, current diclofenac use was associated with an OR of 3.05 (95% CI 1.48–6.29; Table 2) for MI. Naproxen use was not associated with any increase (adjusted OR 1.25, 95% CI 0.56–2.78). A ratio of ORs for SpA/diclofenac relative to OA/diclofenac was 2.35 (1.10–4.90).2019-06-12T00:00:00

An internet-based intervention with brief nurse support to manage obesity in primary care (POWeR+): a pragmatic, parallel-group, randomised controlled trial

Background The obesity epidemic has major public health consequences. Expert dietetic and behavioural counselling with intensive follow-up is effective, but resource requirements severely restrict widespread implementation in primary care, where most patients are managed. We aimed to estimate the effectiveness and cost-effectiveness of an internet-based behavioural intervention (POWeR+) combined with brief practice nurse support in primary care. Methods We did this pragmatic, parallel-group, randomised controlled trial at 56 primary care practices in central and south England. Eligible adults aged 18 years or older with a BMI of 30 kg/m2 or more (or ≥28 kg/m2 with hypertension, hypercholesterolaemia, or diabetes) registered online with POWeR+—a 24 session, web-based, weight management intervention lasting 6 months. After registration, the website automatically randomly assigned patients (1:1:1), via computer-generated random numbers, to receive evidence-based dietetic advice to swap foods for similar, but healthier, choices and increase fruit and vegetable intake, in addition to 6 monthly nurse follow-up (control group); web-based intervention and face-to-face nurse support (POWeR+Face-to-face [POWeR+F]; up to seven nurse contacts over 6 months); or web-based intervention and remote nurse support (POWeR+Remote [POWeR+R]; up to five emails or brief phone calls over 6 months). Participants and investigators were masked to group allocation at the point of randomisation; masking of participants was not possible after randomisation. The primary outcome was weight loss averaged over 12 months. We did a secondary analysis of weight to measure maintenance of 5% weight loss at months 6 and 12. We modelled the cost-effectiveness of each intervention. We did analysis by intention to treat, with multiple imputation for missing data. This trial is registered as an International Standard Randomised Controlled Trial, number ISRCTN21244703. Findings Between Jan 30, 2013, and March 20, 2014, 818 participants were randomly assigned to the control group (n=279), the POWeR+F group (n=269), or the POWeR+R group (n=270). Weight loss averaged over 12 months was recorded in 666 (81%) participants. The control group lost almost 3 kg over 12 months (crude mean weight: baseline 104·38 kg [SD 21·11; n=279], 6 months 101·91 kg [19·35; n=136], 12 months 101·74 kg [19·57; n=227]). The primary imputed analysis showed that compared with the control group, patients in the POWeR+F group achieved an additional weight reduction of 1·5 kg (95% CI 0·6–2·4; p=0·001) averaged over 12 months, and patients in the POWeR+R group achieved an additional 1·3 kg (0·34–2·2; p=0·007). 21% of patients in the control group had maintained a clinically important 5% weight reduction at month 12, compared with 29% of patients in the POWeR+F group (risk ratio 1·56, 0·96–2·51; p=0·070) and 32% of patients in the POWeR+R group (1·82, 1·31–2·74; p=0·004). The incremental overall cost to the health service per kg weight lost with the POWeR+ interventions versus the control strategy was £18 (95% CI −129 to 195) for POWeR+F and –£25 (−268 to 157) for POWeR+R; the probability of being cost-effective at a threshold of £100 per kg lost was 88% and 98%, respectively. No adverse events were reported. Interpretation Weight loss can be maintained in some individuals by use of novel written material with occasional brief nurse follow-up. However, more people can maintain clinically important weight reductions with a web-based behavioural program and brief remote follow-up, with no increase in health service costs. Future research should assess the extent to which clinically important weight loss can be maintained beyond 1 year

Cardiovascular disease risk factor responses to a type 2 diabetes care model including nutritional ketosis induced by sustained carbohydrate restriction at 1 year: An open label, non-randomized, controlled study

Additional file 1: Table S1. Detailed baseline characteristics for participants in the continuous care intervention (CCI) and usual care (UC) groups

Avoiding disclosure of individually identifiable health information: a literature review

Achieving data and information dissemination without arming anyone is a central task of any entity in charge of collecting data. In this article, the authors examine the literature on data and statistical confidentiality. Rather than comparing the theoretical properties of specific methods, they emphasize the main themes that emerge from the ongoing discussion among scientists regarding how best to achieve the appropriate balance between data protection, data utility, and data dissemination. They cover the literature on de-identification and reidentification methods with emphasis on health care data. The authors also discuss the benefits and limitations for the most common access methods. Although there is abundant theoretical and empirical research, their review reveals lack of consensus on fundamental questions for empirical practice: How to assess disclosure risk, how to choose among disclosure methods, how to assess reidentification risk, and how to measure utility loss.public use files, disclosure avoidance, reidentification, de-identification, data utility

Anaemia in pregnancy among Aboriginal and Torres Strait Islander women of Far North Queensland: a retrospective cohort study

Aim: Anaemia during pregnancy is common worldwide. In Australia between 7.1% and 11% of mothers have been reported to have anaemia in pregnancy. Higher rates are reported for Aboriginal and Torres Strait Islander women (Townsville: 34.2%, remote Northern Territory: 50%). The present study describes anaemia in pregnancy among Aboriginal and Torres Strait Islander women of Far North Queensland. Methods: Health service information was analysed for 2076 Aboriginal and Torres Strait Islander women who gave birth between 2006 and 2010. The prevalence of anaemia in pregnancy, characteristics of the mothers and pregnancy outcomes were described. Logistic regression for bivariate analyses and multivariable linear modelling with and without imputed data were used to compare those mothers who had anaemia in pregnancy with those who did not. Results: More than half of Aboriginal and Torres Strait Islander women (54.5% (95% CI: 52.4%, 56.7%)) had anaemia in pregnancy. For mothers who gave birth in 2009 and 2010 (n = 1796) with more complete data, those who were iron deficient during pregnancy were more likely to be anaemic (RR: 1.40, P = <0.001). Mothers (29.0%) from localities of relative socioeconomic advantage had lower risk of anaemia in pregnancy (RR: 0.86, P = 0.003), as did mothers (31.9%) who were obese (RR: 0.87, P = 0.013). Conclusions: The prevalence of anaemia in pregnancy among Aboriginal and Torres Strait Islander women of Far North Queensland is high. Prevention and treatment of anaemia will improve the health of these mothers, and possibly the health and early development of their children

Information technologies for pain management

Millions of people around the world suffer from pain, acute or chronic and this raises the importance of its screening, assessment and treatment. The importance of pain is attested by the fact that it is considered the fifth vital sign for indicating basic bodily functions, health and quality of life, together with the four other vital signs: blood pressure, body temperature, pulse rate and respiratory rate. However, while these four signals represent an objective physical parameter, the occurrence of pain expresses an emotional status that happens inside the mind of each individual and therefore, is highly subjective that makes difficult its management and evaluation. For this reason, the self-report of pain is considered the most accurate pain assessment method wherein patients should be asked to periodically rate their pain severity and related symptoms. Thus, in the last years computerised systems based on mobile and web technologies are becoming increasingly used to enable patients to report their pain which lead to the development of electronic pain diaries (ED). This approach may provide to health care professionals (HCP) and patients the ability to interact with the system anywhere and at anytime thoroughly changes the coordinates of time and place and offers invaluable opportunities to the healthcare delivery. However, most of these systems were designed to interact directly to patients without presence of a healthcare professional or without evidence of reliability and accuracy. In fact, the observation of the existing systems revealed lack of integration with mobile devices, limited use of web-based interfaces and reduced interaction with patients in terms of obtaining and viewing information. In addition, the reliability and accuracy of computerised systems for pain management are rarely proved or their effects on HCP and patients outcomes remain understudied. This thesis is focused on technology for pain management and aims to propose a monitoring system which includes ubiquitous interfaces specifically oriented to either patients or HCP using mobile devices and Internet so as to allow decisions based on the knowledge obtained from the analysis of the collected data. With the interoperability and cloud computing technologies in mind this system uses web services (WS) to manage data which are stored in a Personal Health Record (PHR). A Randomised Controlled Trial (RCT) was implemented so as to determine the effectiveness of the proposed computerised monitoring system. The six weeks RCT evidenced the advantages provided by the ubiquitous access to HCP and patients so as to they were able to interact with the system anywhere and at anytime using WS to send and receive data. In addition, the collected data were stored in a PHR which offers integrity and security as well as permanent on line accessibility to both patients and HCP. The study evidenced not only that the majority of participants recommend the system, but also that they recognize it suitability for pain management without the requirement of advanced skills or experienced users. Furthermore, the system enabled the definition and management of patient-oriented treatments with reduced therapist time. The study also revealed that the guidance of HCP at the beginning of the monitoring is crucial to patients' satisfaction and experience stemming from the usage of the system as evidenced by the high correlation between the recommendation of the application, and it suitability to improve pain management and to provide medical information. There were no significant differences regarding to improvements in the quality of pain treatment between intervention group and control group. Based on the data collected during the RCT a clinical decision support system (CDSS) was developed so as to offer capabilities of tailored alarms, reports, and clinical guidance. This CDSS, called Patient Oriented Method of Pain Evaluation System (POMPES), is based on the combination of several statistical models (one-way ANOVA, Kruskal-Wallis and Tukey-Kramer) with an imputation model based on linear regression. This system resulted in fully accuracy related to decisions suggested by the system compared with the medical diagnosis, and therefore, revealed it suitability to manage the pain. At last, based on the aerospace systems capability to deal with different complex data sources with varied complexities and accuracies, an innovative model was proposed. This model is characterized by a qualitative analysis stemming from the data fusion method combined with a quantitative model based on the comparison of the standard deviation together with the values of mathematical expectations. This model aimed to compare the effects of technological and pen-and-paper systems when applied to different dimension of pain, such as: pain intensity, anxiety, catastrophizing, depression, disability and interference. It was observed that pen-and-paper and technology produced equivalent effects in anxiety, depression, interference and pain intensity. On the contrary, technology evidenced favourable effects in terms of catastrophizing and disability. The proposed method revealed to be suitable, intelligible, easy to implement and low time and resources consuming. Further work is needed to evaluate the proposed system to follow up participants for longer periods of time which includes a complementary RCT encompassing patients with chronic pain symptoms. Finally, additional studies should be addressed to determine the economic effects not only to patients but also to the healthcare system

Exploring flexible polynomial regression as a method to align routine clinical outcomes with daily data capture through remote technologies

BACKGROUND: Clinical outcomes are normally captured less frequently than data from remote technologies, leaving a disparity in volumes of data from these different sources. To align these data, flexible polynomial regression was investigated to estimate personalised trends for a continuous outcome over time. METHODS: Using electronic health records, flexible polynomial regression models inclusive of a 1st up to a 4th order were calculated to predict forced expiratory volume in 1 s (FEV1) over time in children with cystic fibrosis. The model with the lowest AIC for each individual was selected as the best fit. The optimal parameters for using flexible polynomials were investigated by comparing the measured FEV1 values to the values given by the individualised polynomial. RESULTS: There were 8,549 FEV1 measurements from 267 individuals. For individuals with > 15 measurements (n = 178), the polynomial predictions worked well; however, with < 15 measurements (n = 89), the polynomial models were conditional on the number of measurements and time between measurements. The method was validated using BMI in the same population of children. CONCLUSION: Flexible polynomials can be used to extrapolate clinical outcome measures at frequent time intervals to align with daily data captured through remote technologies