Health conditions in adults with HIV compared with the general population:A population-based cross-sectional analysis

BACKGROUND: Life expectancy in adults with human immunodeficiency virus (HIV) has increased and managing other health conditions is increasingly important for patients and healthcare planning. The aim of this study was to examine the prevalence and association between different health conditions and HIV status. METHODS: We performed a cross-sectional analysis of adult UK Clinical Practice Research Datalink primary care electronic medical records linked to hospital admissions as of Nov 30, 2015. We examined 47 health condition groups and 304 physical and mental health conditions by HIV status, after adjustment for age, sex, social deprivation status using logistic regression. FINDINGS: There were 964 patients with HIV (61.7% male; 92.8% aged <65 years) and 941,113 non-HIV patients (49.4% male; 75.2% aged <65 years). Condition groups with the greatest prevalence in HIV that were also highly prevalent in adults without HIV included: lipid disorder (41.4% vs 40.2%), and hypertension (19.1% vs 24.6%). Following adjustment, 18 (37.5%) condition groups were more likely in adults with HIV and ten (20.8%) were less likely. Individual conditions that were less likely in adults with HIV included: atrial fibrillation (odds ratio [OR] 0.37 [95% CI 0.20–0.64]) and hypertension (OR_0.78 [0.65–0.94]); rheumatoid arthritis (OR 0.27 [0.05–0.84]); asthma (OR_0.65 (0.53–0.80]); and certain eye diseases such as macular degeneration (OR_0.30 [0.09–0.70]). Meanwhile individual conditions that were more likely included: liver fibrosis, sclerosis, and cirrhosis (OR_3.23 [1.85–5.20]); pulmonary embolism (OR_2.06 [1.15–3.36]); male infertility (OR_2.23 [1.50–3.16]) and female infertility (OR_2.01 [1.34–2.88]); bipolar disorder (OR_2.93 [1.52–5.05]) and depression (OR_1.49 [1.28–1.71]); cervical malignancy (OR_4.64 [1.15–12.15]); and infections. INTERPRETATION: Comorbidity is common in adults with HIV, with physical and mental health conditions spanning a wide spectrum. HIV management should consider multidisciplinary care models to provide optimal patient care. FUNDING: The project was funded by the Bart’s Charity; DRM was funded by a Wellcome Trust Clinical Research Career Development Fellowship; DRM and DMM received funding from the HDR-UK Precision therapeutics programme

Use of Non-Steroidal Anti-Inflammatory Drugs That Elevate Cardiovascular Risk: An Examination of Sales and Essential Medicines Lists in Low-, Middle-, and High-Income Countries

PMCID: PMC3570554This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited

Interprofessional training for final year healthcare students: a mixed methods evaluation of the impact on ward staff and students of a two-week placement and of factors affecting sustainability

BACKGROUND: Multiple care failings in hospitals have led to calls for increased interprofessional training in medical education to improve multi-disciplinary teamwork. Providing practical interprofessional training has many challenges and remains uncommon in medical schools in the UK. Unlike most previous research, this evaluation of an interprofessional training placement takes a multi-faceted approach focusing not only on the impact on students, but also on clinical staff delivering the training and on outcomes for patients. METHODS: We used mixed methods to examine the impact of a two-week interprofessional training placement undertaken on a medical rehabilitation ward by three cohorts of final year medical, nursing and therapy students. We determined the effects on staff, ward functioning and participating students. Impact on staff was evaluated using the Questionnaire for Psychological and Social factors at work (QPSNordic) and focus groups. Ward functioning was inferred from standard measures of care including length of stay, complaints, and adverse events. Impact on students was evaluated using the Readiness for Interprofessional Learning Survey (RIPLS) among all students plus a placement survey among medical students. RESULTS: Between 2007 and 2010, 362 medical students and 26 nursing and therapy students completed placements working alongside the ward staff to deliver patient care. Staff identified benefits including skills recognition and expertise sharing. Ward functioning was stable. Students showed significant improvements in the RIPLS measures of Teamwork, Professional Identity and Patient-Centred Care. Despite small numbers of students from other professions, medical students’ rated the placement highly. Increasing student numbers and budgetary constraints led to the cessation of the placement after three years. CONCLUSIONS: Interprofessional training placements can be delivered in a clinical setting without detriment to care and with benefits for all participants. While financial support is a necessity, it appears that having students from multiple professions is not critical for a valuable training experience; staff from different professions and students from a single profession can work successfully together. Difficulty in aligning the schedules of different student professions is commonly cited as a barrier to interprofessional training. Our experience challenges this and should encourage provision of authentic interprofessional training experience

Systemic antibiotic sales and WHO recommendations, India.

To analyse sales of fixed-dose combination and single antibiotics in India in relation to World Health Organization (WHO) recommendations and national regulatory efforts to control antibiotic sales. We extracted data on sales volumes of systemic antibiotics in India from a market research company sales database. We compared the market share of antibiotic sales in 2020 by WHO AWaRe (Access, Watch and Reserve) category and for those under additional national regulatory controls. We also analysed sales of fixed-dose combinations that were: formally approved for marketing or had a no-objection certificate; on the national essential medicines list; and on the WHO list of not-recommended antibiotics. There were 78 single and 112 fixed-dose combination antibiotics marketed in India, accounting for 7.6 and 4.5 billion standard units of total sales, respectively. Access, Watch and Reserve antibiotics comprised 5.8, 5.6 and 0.1 billion standard units of total market sales, respectively. All additionally controlled antibiotics were Watch and Reserve antibiotics (23.6%; 2.9 billion standard units of total sales). Fixed-dose combinations on the WHO not-recommended list were marketed in 229 formulations, with 114 formulations (49.8%) having no record of formal approval or no-objection certificate. While there were no not-recommended fixed-dose combinations on the national list of essential medicines, 13 of the top-20 selling antibiotic fixed-dose combinations were WHO not-recommended. The sale of Watch group drugs, and antibiotics banned or not approved, needs active investigation and enforcement in India. The evidence base underpinning formal approvals and no-objection certificates for not-recommended fixed-dose combinations should be audited. Analyser les ventes d'antibiotiques en association fixe et à dose unique en Inde, à la lumière des recommandations de l'Organisation mondiale de la Santé (OMS) et des efforts de réglementation à l'échelle nationale visant à contrôler la vente d'antibiotiques. Nous avons prélevé des données relatives aux volumes de vente d'antibiotiques systémiques en Inde dans la base de données commerciales d'une société d'études de marché. Nous avons ensuite comparé la part de marché qu'occupe, en 2020, la vente d'antibiotiques appartenant à chaque catégorie AWaRe (Access, Watch and Reserve) établie par l'OMS, mais aussi de ceux ciblés par des mesures nationales de contrôle supplémentaires. Enfin, nous avons examiné les ventes d'associations fixes: dont la commercialisation a été officiellement approuvée ou qui ont fait l'objet d'un certificat de non-objection; figurant sur la liste nationale de médicaments essentiels; et reprises dans la liste des antibiotiques non recommandés par l'OMS. Nous avons comptabilisé 78 antibiotiques à dose unique et 112 antibiotiques en association fixe sur le marché indien, représentant respectivement 7,6 et 4,5 milliards d'unités standard sur l'ensemble des ventes. Les antibiotiques des catégories Access (dont l'accessibilité est essentielle), Watch (à utiliser sélectivement) et Reserve (de réserve, non recommandés) équivalaient à 5,8 milliards, 5,6 milliards et 0,1 milliard d'unités standard sur le total des transactions. Tous les antibiotiques soumis à des contrôles supplémentaires faisaient partie des catégories Watch et Reserve (23,6%; 2,9 milliards d'unités standard sur l'ensemble des ventes). Des associations fixes déconseillées par l'OMS étaient commercialisées dans 229 formulations, dont 114 (49,8%) ne possédaient ni attestation d'approbation officielle, ni certificat de non-objection. Bien qu'aucune association fixe déconseillée ne soit mentionnée sur la liste nationale de médicaments essentiels, 13 des 20 antibiotiques en association fixe les plus vendus n'étaient pas recommandés par l'OMS. Il est nécessaire de mener une enquête approfondie en Inde sur la vente de médicaments appartenant à la catégorie Watch et d'antibiotiques interdits ou non approuvés, et de prendre des mesures concrètes. Les preuves sur lesquelles reposent les autorisations officielles et les certificats de non-objection pour les associations fixes non recommandées doivent être vérifiées. Analizar las ventas de los antibióticos combinados en dosis fijas y en dosis únicas en la India en relación con las recomendaciones de la Organización Mundial de la Salud (OMS) y los esfuerzos nacionales de regulación para controlar las ventas de los antibióticos. Se extrajeron datos sobre los volúmenes de ventas de antibióticos sistémicos en la India de una base de datos de ventas de empresas de investigación de mercado. Se comparó la cuota de mercado de las ventas de antibióticos en 2020 por categoría AWaRe (Access, Watch and Reserve) de la OMS y para los que estaban sometidos a controles regulatorios nacionales adicionales. También se analizaron las ventas de combinaciones en dosis fijas que estaban: formalmente aprobadas para su comercialización o tenían un certificado de no objeción; en la lista nacional de medicamentos esenciales; y en la lista de antibióticos no recomendados de la OMS. En la India se comercializaron 78 antibióticos en dosis única y 112 antibióticos combinados en dosis fijas, que representaron 7,6 y 4,5 mil millones de unidades estándar de ventas totales, respectivamente. Los antibióticos de acceso, vigilancia y reserva supusieron 5,8, 5,6 y 0,1 mil millones de unidades estándar de las ventas totales del mercado, respectivamente. Todos los antibióticos controlados adicionalmente fueron antibióticos de vigilancia y reserva (23,6 %; 2,9 mil millones de unidades estándar de las ventas totales). Las combinaciones en dosis fijas incluidas en la lista no recomendada de la OMS se comercializaron en 229 formulaciones, de las que 114 (49,8 %) no tenían registro de aprobación formal ni certificado de no objeción. Mientras que no había combinaciones en dosis fijas no recomendadas en la lista nacional de medicamentos esenciales, 13 de las 20 combinaciones en dosis fijas de antibióticos más vendidas no estaban recomendadas por la OMS. Se debe investigar y controlar activamente la venta de medicamentos del grupo Watch y de antibióticos prohibidos o no aprobados en la India. Asimismo, se debe auditar la base de pruebas que sustenta las aprobaciones formales y los certificados de no objeción para las combinaciones en dosis fijas no recomendadas.الغرض تحليل مبيعات تركيبة الجرعة الثابتة، والمضادات الحيوية المفردة في الهند فيما يتعلق بتوصيات منظمة الصحة العالمية (WHO)، والجهود التنظيمية الوطنية للتحكم في مبيعات المضادات الحيوية. الطريقة قمنا باستخراج بيانات عن أحجام مبيعات المضادات الحيوية الجهازية في الهند من قاعدة بيانات مبيعات شركة أبحاث السوق. قمنا بمقارنة الحصة السوقية لمبيعات المضادات الحيوية في عام 2020 حسب فئة AWaRe (الوصول والمراقبة والاحتياطي) التابعة لمنظمة الصحة العالمية (WHO)، وتلك التي تخضع للضوابط التنظيمية الوطنية الإضافية. كما قمنا أيضًا بتحليل مبيعات تركيبات الجرعة الثابتة التي تم: الموافقة عليها رسميًا للتسويق، أو لديها شهادة عدم ممانعة؛ على قائمة الأدوية الأساسية الوطنية؛ وعلى قائمة منظمة الصحة العالمية (WHO) للمضادات الحيوية غير الموصى بها. النتائج تم تسويق مضادات حيوية منها 112 تركيبة ذات جرعة ثابتة، و78 مضادًا حيويًا ذات تركيبة منفردة في الهند، وهو ما يمثل 7.6 و4.5 مليار وحدة قياسية من إجمالي المبيعات على الترتيب. تضم المضادات الحيوية Access وWatch وReserve 5.8 و5.6 و0.1 مليار وحدة قياسية من إجمالي مبيعات السوق على الترتيب. جميع المضادات الحيوية الإضافية الخاضعة للرقابة كانت Watch وReserve (%23.6؛ 2.9 مليار وحدة قياسية من إجمالي المبيعات). تركيبات الجرعة الثابتة الواردة في القائمة غير الموصى بها لدى منظمة الصحة العالمية (WHO) تم تسويقها في 229 مستحضرًا، مع 114 مستحضرًا (49.8%) ليس لها سجل بالموافقة الرسمية أو شهادة عدم ممانعة. على الرغم من عدم وجود تركيبات جرعة ثابتة غير موصى بها في القائمة الوطنية للأدوية الأساسية، فإن 13 من الـ 20 تركيبة جرعة ثابتة من المضادات الحيوية الأكثر مبيعًا لم تكن موصى بها من جانب منظمة الصحة العالمية (WHO). الاستنتاج إن بيع أدوية مجموعة Watch، والمضادات الحيوية المحظورة أو التي لم تحصل على الموافقة، يحتاج إلى تحقيق وإنفاذ فعال في الهند. يجب مراجعة قاعدة الأدلة التي تقوم عليها الموافقات الرسمية، وشهادات عدم الممانعة لتركيبات الجرعة الثابتة غير الموصى بها. 根据世卫组织 (WHO) 推荐的药物目录和控制抗生素销售的国家监管措施,分析印度固定剂量组合抗生素和单一抗生素的销量。. 我们从一家市场调研公司的销售数据库中提取了印度全身性抗生素的销量数据。我们比较了 2020 年按 WHO AWaRe 【可广泛使用 (Access)、谨慎使用 (Watch) 和保留使用 (Reserve)】分级目录和其他国家监管规定分类的抗生素的销售量市场份额。我们还分析了固定剂量组合抗生素(正式批准上市或者具有无异议证明;全国基本药物目录;世卫组织不推荐的抗生素目录)的销量。. 印度有 78 种单一抗生素和 112 种固定剂量组合抗生素上市, 总销量分别为 76 和 45 亿标准单位。可广泛使用 (Access)、谨慎使用 (Watch) 和保留使用 (Reserve) 抗生素的市场总销量分别为 58、56 和 1 亿标准单位。所有额外受监管抗生素均为谨慎使用 (Watch) 和保留使用 (Reserve) 抗生素(占 23.6%,总销售额为 29 亿标准单位)。有 229 种非世卫组织推荐药物目录中的固定剂量组合抗生素上市,其中 114 种(49.8%)没有正式批准或无异议证明。虽然没有国家基本药物清单中不推荐的固定剂量组合抗生素,但在 20 种最畅销的固定剂量组合抗生素中,有 13 种是世卫组织不推荐使用的。. 在印度还需对谨慎使用 (Watch) 类别的药物以及禁用或未批准的抗生素的销量进行积极调查并采取措施。应对不推荐使用的固定剂量组合抗生素取得的正式批准和无异议证明进行审查。. Проанализировать продажи комбинированных препаратов с фиксированными дозами и отдельных антибиотиков в Индии в соответствии с рекомендациями Всемирной организации здравоохранения (ВОЗ) и мерами национального регулирования по контролю за продажами антибиотиков. Авторы извлекли данные об объемах продаж системных антибиотиков в Индии из базы данных по продажам исследовательской компании. Они сравнили рыночную долю продаж антибиотиков в 2020 г. по категориям AWaRe (Access (Доступ), Watch (Наблюдение), Reserve (Резерв)) ВОЗ, а также антибиотиков, на которые распространяются дополнительные национальные регулирующие меры контроля. Авторы также проанализировали продажи комбинированных препаратов с фиксированными дозами, которые были официально одобрены для продажи или имели сертификат об отсутствии возражений, находились в национальном перечне основных лекарственных средств и в списке ВОЗ не рекомендованных для использования антибиотиков. В Индии на рынке представлены 78 отдельных и 112 комбинированных препаратов с фиксированными дозами антибиотиков, что составило 7,6 и 4,5 млрд условных единиц от общего объема продаж соответственно. Антибиотики групп Access, Watch и Reserve составили 5,8; 5,6 и 0,1 млрд условных единиц от общего объема продаж на рынке соответственно. Все дополнительно контролируемые антибиотики относились к антибиотикам групп Watch и Reserve (23,6%; 2,9 млрд условных единиц от общего объема продаж). Комбинированные препараты с фиксированными дозами, включенные в список ВОЗ не рекомендованных для использования антибиотиков, продавались в виде 229 лекарственных форм, при этом 114 форм (49,8%) не имели официального одобрения или сертификата об отсутствии возражений. Хотя в национальном перечне основных лекарственных средств не было нерекомендованных комбинированных препаратов с фиксированными дозами, 13 из 20 наиболее продаваемых комбинированных антибиотиков с фиксированными дозами не были рекомендованы ВОЗ. Продажа антибиотиков группы Watch, а также продажа запрещенных или не имеющих одобрения антибиотиков требует активного расследования и правоприменения в Индии. Необходимо проверить доказательную базу, лежащую в основе официальных одобрений и сертификатов об отсутствии возражений для нерекомендованных комбинированных препаратов с фиксированными дозами

Cardiovascular Risk with Non-Steroidal Anti-Inflammatory Drugs: Systematic Review of Population-Based Controlled Observational Studies

David Henry and colleagues reevaluate the evidence from observational studies on the cardiovascular risk associated with non-steroidal anti-inflammatory drugs

Cardiovascular risk and inhibition of cyclooxygenase - a systematic review of the observational studies of selective and nonselective inhibitors of cyclooxygenase

Context: Evidence that rofecoxib increases the risk of myocardial infarction has led to scrutiny of other nonsteroidal anti-inflammatory drugs (NSAIDs). Regulatory agencies have provided variable advice regarding the cardiovascular risks with older nonselective NSAIDs. Objective: To undertake a systematic review and meta-analysis of controlled observational studies to compare the risks of serious cardiovascular events with individual NSAIDs and cyclooxygenase 2 inhibitors. Data Sources: Searches were conducted of electronic databases (1985-2006), scientific meeting proceedings, epidemiological research Web sites, and bibliographies of eligible studies. Study Selection: Eligible studies were of case-control or cohort design, reported on cardiovascular events (predominantly myocardial infarction) with cyclooxygenase 2 inhibitor, NSAID use, or both with nonuse/remote use of the drugs as the reference exposure. Of 7086 potentially eligible titles, 17 case-control and 6 cohort studies were included. Thirteen studies reported on cyclooxygenase 2 inhibitors, 23 on NSAIDs, and 13 on both groups of drugs. Data Extraction: Two people independently extracted data and assessed study quality with disagreements resolved by consensus. Data Synthesis: Data were combined using a random-effects model. A dose-related risk was evident with rofecoxib, summary relative risk with 25 mg/d or less, 1.33 (95% confidence interval [CI], 1.00-1.79) and 2.19 (95% CI, 1.64-2.91) with more than 25 mg/d. The risk was elevated during the first month of treatment. Celecoxib was not associated with an elevated risk of vascular occlusion, summary relative risk 1.06 (95% CI, 0.91-1.23). Among older nonselective drugs, diclofenac had the highest risk with a summary relative risk of 1.40 (95% CI, 1.16-1.70). The other drugs had summary relative risks close to 1: naproxen, 0.97 (95% CI, 0.87-1.07); piroxicam, 1.06 (95% CI, 0.70-1.59); and ibuprofen, 1.07 (95% CI, 0.97-1.18). Conclusions: This review confirms the findings from randomized trials regarding the risk of cardiovascular events with rofecoxib and suggests that celecoxib in commonly used doses may not increase the risk, contradicts claims of a protective effect of naproxen, and raises serious questions about the safety of diclofenac, an older drug