Health Policy

A review of pharmacological interactions between HIV or hepatitis C virus medications and opioid agonist therapy: implications and management for clinical practice

A review of pharmacological interactions between HIV or hepatitis C virus medications and opioid agonist therapy: implications and management for clinical practice
Expert Review of Clinical Pharmacology, Vol. 6, no. 3, pp. 249-269. DOI: 10.1586/ecp.13.18

Bruce, R.D., D.E. Moody, F.L. Altice, M.N. Gourevitch, and G.H. Friedland

Global access to opioid agonist therapy and HIV/hepatitis C virus (HCV) treatment is expanding but when used concurrently, problematic pharmacokinetic and pharmacodynamic interactions may occur. Articles published from 1966 to 2012 in Medline were reviewed using the following keywords: HIV, AIDS, HIV therapy, HCV, HCV therapy, antiretroviral therapy, highly active antiretroviral therapy, drug interactions, methadone and buprenorphine. In addition, a review of abstracts from national and international meetings and conference proceedings was conducted; selected reports were reviewed as well. The metabolism of both opioid and antiretroviral therapies, description of their known interactions and clinical implications and management of these interactions were reviewed. Important pharmacokinetic and pharmacodynamic drug interactions affecting either methadone or HIV medications have been demonstrated within each class of antiretroviral agents. Drug interactions between methadone, buprenorphine and HIV medications are known and may have important clinical consequences. Clinicians must be alert to these interactions and have a basic knowledge regarding their management.

Overweight, obesity, and inactivity and urban design in rapidly growing Chinese cities

Overweight, obesity, and inactivity and urban design in rapidly growing Chinese cities
Health & Place, 21, 29-38.

Day, K, M Alfonzo, Y F Chen, Z Guo, and K K Lee

China faces rising rates of overweight, obesity, and physical inactivity among its citizens. Risk is highest in China’s rapidly growing cities and urban populations. Current urban development practices and policies in China heighten this risk. These include policies that support decentralization in land use planning; practices of neighborhood gating; and policies and practices tied to motor vehicle travel, transit planning, and bicycle and pedestrian infrastructure. In this paper, we review cultural, political, and economic issues that influence overweight, obesity, and inactivity in China. We examine key urban planning features and policies that shape urban environments that may compromise physical activity as part of everyday life, including walking and bicycling. We review the empirical research to identify planning and design strategies that support physical activity in other high-density cities in developing and developed countries. Finally, we identify successful strategies to increase physical activity in another growing, high-density city – New York City – to suggest strategies that may have relevance for rapidly urbanizing Chinese cities.

Race/Ethnicity-Specific Associations of Urinary Phthalates with Childhood Body Mass in a Nationally Representative Sample

Race/Ethnicity-Specific Associations of Urinary Phthalates with Childhood Body Mass in a Nationally Representative Sample
Environmental Health Perspectives. 121:501-506.

Trasande, Leonardo, Teresa M Attina, S Sathyanarayana, Adam J Spanier, Jan Blustein.

Background: Phthalates have antiandrogenic effects and may disrupt lipid and carbohydrate metabolism. Racial/ethnic subpopulations have been documented to have varying urinary phthalate concentrations and prevalences of childhood obesity.

Objective: We examined associations between urinary phthalate metabolites and body mass outcomes in a nationally representative sample of U.S. children and adolescents.

Methods: We performed stratified and whole-sample cross-sectional analyses of 2,884 children 6–19 years of age who participated in the 2003–2008 National Health and Nutrition Examination Survey. Multivariable linear and logistic analyses of body mass index z-score, overweight, and obesity were performed against molar concentrations of low-molecular-weight (LMW), high-molecular-weight (HMW), and di-2-ethylhexylphthalate (DEHP) metabolites, controlling for sex, television watching, caregiver education, caloric intake, poverty–income ratio, race/ethnicity, serum cotinine, and age group. We used sensitivity analysis to examine robustness of results to removing sample weighting, normalizing phthalate concentrations for molecular weight, and examining different dietary intake covariates.

Results: In stratified, multivariable models, each log unit (roughly 3-fold) increase in LMW metabolites was associated with 21% and 22% increases in odds (95% CI: 1.05–1.39 and 1.07–1.39, respectively) of overweight and obesity, and a 0.090-SD unit increase in BMI z-score (95% CI: 0.003–0.18), among non-Hispanic blacks. Significant associations were not identified in any other racial/ethnic subgroup or in the study sample as a whole after controlling for potential confounders, associations were not significant for HMW or DEHP metabolites, and results did not change substantially with sensitivity analysis.

Conclusions: We identified a race/ethnicity–specific association of phthalates with childhood obesity in a nationally representative sample. Further study is needed to corroborate the association and evaluate genetic/epigenomic predisposition and/or increased phthalate exposure as possible explanations for differences among racial/ethnic subgroups.

Surgical Decompression is Associated with Decreased Mortality in Patients with Sepsis and Ureteral Calculi

Surgical Decompression is Associated with Decreased Mortality in Patients with Sepsis and Ureteral Calculi
Journal of Urology, Vol. 189, no. 3, pp. 946-951. DOI: 10.1016/j.juro.2012.09.088

Borofsky, M.S., D. Walter,O. Shah, D.S. Goldfarb, A.C. Mues, and D.V. Makarov

Purpose: The combination of sepsis and ureteral calculus is a urological emergency. Traditional teaching advocates urgent decompression with nephrostomy tube or ureteral stent placement, although published outcomes validating this treatment are lacking. National practice patterns for such scenarios are currently undefined. Using a retrospective study design, we defined the surgical decompression rate in patients admitted to the hospital with severe infection and ureteral calculi. We determined whether a mortality benefit is associated with this intervention.

Materials and Methods: Patient demographics and hospital characteristics were extracted from the 2007 to 2009 Nationwide Inpatient Sample. We identified 1,712 patients with ureteral calculi and sepsis. Multivariate logistic regression was performed to determine the association between mortality and surgical decompression.

Results: Of the patients 78% underwent surgical decompression. Mortality was higher in those not treated with surgical decompression (19.2% vs 8.82%, p <0.001). Lack of surgical decompression was independently associated with an increased OR of mortality even when adjusting for patient demographics, comorbidities and geographic region of treatment (OR 2.6, 95% CI 1.9–3.7).

Conclusions: Absent surgical decompression is associated with higher odds of mortality in patients with sepsis and ureteral calculi. Further research to determine predictors of surgical decompression is necessary to ensure that all patients have access to this life saving therapy.

Environmental and individual factors affecting menu labeling utilization: a qualitative research study

Environmental and individual factors affecting menu labeling utilization: a qualitative research study
Journal of the Academy of Nutrition and Dietetics. 2013 May;113(5):667-72. doi: 10.1016/j.jand.2012.11.011. Epub 2013 Feb 9.

Jennifer Schindler, Kamila Kiszko, Courtney Abrams, Nadia Islam, Brian Elbel

Obesity is a prominent public health concern that disproportionally affects low-income and minority populations. Recent policies mandating the posting of calories on menus in fast-food chain restaurants have not proven to uniformly influence food choice. This qualitative research study used focus groups to study individual and environmental factors affecting the use of these menu labels among low-income minority populations. Ten focus groups targeting low-income residents (n=105) were held at various community organizations throughout New York City over a 9-month period in 2011. The focus groups were conducted in Spanish, English, or a combination of both languages. In late 2011 and early 2012, transcripts were coded through the process of thematic analysis using Atlas.ti for naturally emerging themes, influences, and determinants of food choice. Few participants used menu labels, despite awareness. The most frequently cited as barriers to menu label use included: price and time constraints, confusion and lack of understanding about caloric values, as well as the priority of preference, hunger, and habitual ordering habits. Based on the individual and external influences on food choice that often take priority over calorie consideration, a modified approach may be necessary to make menu labels more effective and user-friendly.

Centralization of Radical Prostatectomy in the United States

Centralization of Radical Prostatectomy in the United States
Journal of Urology, Vol. 189, no. 2, pp. 500-506. DOI: 10.1016/j.juro.2012.10.012

Anderson, C.B., D.F. Penson, S. Ni, D.V. Makarov, and D.A. Barocas

Purpose: Radical prostatectomy is a common treatment for organ confined prostate cancer and its use is increasing. We examined how the increased volume is being distributed and what hospital characteristics are associated with increasing volume.

Materials and Methods: We identified all men age 40 to less than 80 years who underwent radical prostatectomy for prostate cancer from 2000 to 2008 in the NIS (Nationwide Inpatient Sample) (586,429). Ownership of a surgical robot was determined using the 2007 AHA (American Hospital Association) Annual Survey. The association between hospital radical prostatectomy volume and hospital characteristics, including ownership of a robot, was explored using multivariate linear regression.

Results: From 2000 to 2008 there was a 74% increase in the number of radical prostatectomies performed (p = 0.05) along with a 19% decrease in the number of hospitals performing radical prostatectomy (p <0.001), resulting in an increase in annual hospital radical prostatectomy volume (p = 0.009). Several hospital variables were associated with greater radical prostatectomy volume including teaching status, urban location, large bed size and ownership of a robot in 2007. On multivariate analysis the year, teaching status, large bed size, urban location and presence of a robot were associated with higher hospital radical prostatectomy volume.

Conclusions: Use of radical prostatectomy increased significantly between 2000 and 2008, most notably after 2005. The increase in radical prostatectomy resulted in centralization to select hospitals, particularly those in the top radical prostatectomy volume quartile and those investing in robotic technology. Our findings support the hypothesis that hospitals with the greatest volume increases are specialty centers already performing a high volume of radical prostatectomy procedures.

Long-Term Satisfaction and Predictors of Use of Intracorporeal Injections for Post-Prostatectomy Erectile Dysfunction

Long-Term Satisfaction and Predictors of Use of Intracorporeal Injections for Post-Prostatectomy Erectile Dysfunction
Journal of Urology, Vol. 189, no. 1, pp. 238-242. DOI: 10.1016/j.juro.2012.08.089

Prabhu, V., J.P. Alukal, J. Laze, D.V. Makarov, and H. Lepor

Purpose: Intracorporeal injections have low use rates and high discontinuation rates. We examined factors associated with intracorporeal injection use, long-term satisfaction with intracorporeal injection and reasons for discontinuation in men treated with radical prostatectomy.

Materials and Methods: Between October 2000 and September 2003, 731 men who underwent open radical retropubic prostatectomy were enrolled in a prospective outcomes study. The 8-year followup evaluation included the UCLA-PCI, and a survey capturing intracorporeal injection use, satisfaction and reasons for discontinuation. Logistic regression was used to determine associations between intracorporeal injection use and preoperative variables.

Results: The 8-year self-assessment was completed by 368 (50.4%) men. Of these men 140 (38%) indicated prior or current intracorporeal injection use, with only 34 using intracorporeal injection at 8 years. Overall, 44% of the men were satisfied with intracorporeal injections. Reasons for discontinuation included dislike (47%), pain (33%), return of erection (19%), inefficacy (14%) and no partner (6%). Men trying intracorporeal injections had greater preoperative UCLA-PCI sexual function scores (75.2 vs 65.62, p = 0.00005) as well as greater decreases in this score at 3 months (p = 0.0002) and 2 years (p = 0.003). Higher preoperative sexual function scores were independently associated with the use of intracorporeal injections in a model adjusted for age, marital status, nerve sparing status and body mass index (OR 1.021, 95% CI 1.008–1.035).

Conclusions: Men pursuing intracorporeal injections have better baseline erectile function and experience greater deterioration in erectile function during the early postoperative period. Despite the high efficacy of injections, many men discontinue intracorporeal injections due to dislike or discomfort. Satisfaction rates for intracorporeal injections indicate their long-term role in restoring sexual function in men with post-prostatectomy erectile dysfunction.

A new approach to understanding racial disparities in prostate cancer treatment

A new approach to understanding racial disparities in prostate cancer treatment
Journal of Geriatric Oncology, Vol. 4, no. 1, pp. 1-8. DOI: 10.1016/j.jgo.2012.07.005

Presley, C.J., A.C. Raldow, L.D. Cramer, P.R. Soulos, J.B. Long, J.B. Yu, D.V. Makarov, and C.P. Gross

Objective: Previous studies addressing racial disparities in treatment for early-stage prostate cancer have focused on the etiology of undertreatment of black men. Our objective was to determine whether racial disparities are attributable to undertreatment, overtreatment, or both.

Methods: Using the SEER-Medicare dataset, we identified men 67–84 years-old diagnosed with localized prostate cancer from 1998 to 2007. We stratified men into clinical benefit groups using tumor aggressiveness and life expectancy. Low-benefit was defined as low-risk tumors and life expectancy < 10 years; high-benefit as moderate-risk tumors and life expectancy ≥ 10 years; all others were intermediate-benefit. Logistic regression modeled the association between race and treatment (radical prostatectomy or radiotherapy) across benefit groups.

Results: Of 68,817 men (9.8% black and 90.2% white), 56.2% of black and 66.3% of white men received treatment (adjusted odds ratio (OR) = 0.65; 95% CI, 0.62–0.69). The percent of low-, intermediate-, and high-benefit men who received treatment was 56.7%, 68.4%, and 79.6%, respectively (P = < 0.001). In the low-benefit group, 51.9% of black vs. 57.2% of white patients received treatment (OR = 0.74; 95% CI, 0.67–0.81) compared to 57.2% vs. 69.6% in the intermediate-benefit group (OR = 0.64; 95% CI, 0.59–0.70). Racial disparity was largest in the high-benefit group (64.2% of black vs. 81.4% of white patients received treatment; OR = 0.57; 95% CI, 0.48–0.68). The interaction between race and clinical benefit was significant (P < 0.001).

Conclusion: Racial disparities were largest among men most likely to benefit from treatment. However, a substantial proportion of both black and white men with a low clinical benefit received treatment, indicating a high level of overtreatment.

Who Experiences Discrimination in Brazil? Evidence From a Large Metropolitan Region

Who Experiences Discrimination in Brazil? Evidence From a Large Metropolitan Region
International Journal for Equity in Health, 2012 Dec 18;11:80. doi: 10.1186/1475-9276-11-80

Macinko, J., P. Mullachery, F.A. Proietti, and M.F. Lima-Costa

Introduction Perceived discrimination is related to poor health and has been offered as one explanation for the persistence of health inequalities in some societies. In this study, we explore the prevalence and correlates of perceived discrimination in a large, multiracial Brazilian metropolitan area.

Methods The study uses secondary analysis of a regionally representative household survey conducted in 2010 (n=12,213). Bivariate analyses and multiple logistic regression assess the magnitude and statistical significance of covariates associated with reports of any discrimination and with discrimination in specific settings, including when seeking healthcare services, in the work environment, in the family, in social occasions among friends or in public places, or in other situations.

Results Nearly 9% of the sample reported some type of discrimination. In multivariable models, reports of any discrimination were higher among people who identify as black versus white (OR 1.91), higher (OR 1.21) among women than men, higher (OR 1.33) among people in their 30’s and lower (OR 0.63) among older individuals. People with many health problems (OR 4.97) were more likely to report discrimination than those with few health problems. Subjective social status (OR 1.23) and low social trust (OR 1.27) were additional associated factors. Perceived discrimination experienced while seeking healthcare differed from all other types of discrimination, in that it was not associated with skin color, social status or trust, but was associated with sex, poverty, and poor health.

Conclusions There appear to be multiple factors associated with perceived discrimination in this population that may affect health. Policies and programs aimed at reducing discrimination in Brazil will likely need to address this wider set of interrelated risk factors across different populations.


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