ABSTRACT
BACKGROUND: This study assessed the sociodemographic, functional, and clinical determinants of antithrombotic treatment in patients with nonvalvular atrial fibrillation (NVAF) attended in the internal medicine setting. METHODS: A multicenter, cross-sectional study was conducted in NVAF patients who attended internal medicine departments for either a routine visit (outpatients) or hospitalization (inpatients). RESULTS: A total of 961 patients were evaluated. Their antithrombotic management included: no treatment (4.7%), vitamin K antagonists (VKAs) (59.6%), direct oral anticoagulants (DOACs) (21.6%), antiplatelets (6.6%), and antiplatelets plus anticoagulants (7.5%). Permanent NVAF and congestive heart failure were associated with preferential use of oral anticoagulation over antiplatelets, while intermediate-to high-mortality risk according to the PROFUND index was associated with a higher likelihood of using antiplatelet therapy instead of oral anticoagulation. Longer disease duration and institutionalization were identified as determinants of VKA use over DOACs. Female gender, higher education, and having suffered a stroke determined a preferential use of DOACs. CONCLUSIONS: This real-world study showed that most elderly NVAF patients received oral anticoagulation, mainly VKAs, while DOACs remained underused. Antiplatelets were still offered to a proportion of patients. Longer duration of NVAF and institutionalization were identified as determinants of VKA use over DOACs. A poor prognosis according to the PROFUND index was identified as a factor preventing the use of oral anticoagulation.
Subject(s)
Anticoagulants/therapeutic use , Atrial Fibrillation/complications , Stroke/prevention & control , Administration, Oral , Aged , Aged, 80 and over , Ambulatory Care , Cognition Disorders/complications , Cross-Sectional Studies , Drug Therapy, Combination , Educational Status , Factor Xa Inhibitors/therapeutic use , Female , Humans , Male , Platelet Aggregation Inhibitors/therapeutic use , Prognosis , Spain , Stroke/etiology , Watchful Waiting/statistics & numerical dataABSTRACT
OBJETIVO: Describir las características clínicas, las razones del inicio de la terapia y los efectos del tratamiento en la fase inicial de disponibilidad de evolocumab en las unidades de lípidos/medicina interna de España. MÉTODOS: Estudio retrospectivo, observacional, a partir de las historias clínicas de pacientes consecutivos que iniciaron tratamiento con evolocumab (de febrero de 2016 a julio de 2017) en 20 unidades de medicina interna en España. Se revisaron las características demográficas y clínicas de los pacientes, el tratamiento hipolipemiante y la evolución de los perfiles lipídicos entre 12semanas antes y 12±4semanas después del inicio de evolocumab. RESULTADOS: Se analizaron 136 pacientes: el 64,0% eran hombres, con edad media (desviación estándar, DE) de 56,6 (11,5) años. El 75,0% tenían hipercolesterolemia familiar (4 homocigotos), de los que el 51,0% habían sufrido al menos un evento cardiovascular. El 61,0% del total de pacientes presentaban enfermedad cardiovascular aterosclerótica (ECVA). Al inicio de evolocumab, el 61,0% de los pacientes tomaban estatinas de alta intensidad y el 60,3% estaban recibiendo ezetimiba. La media (DE) de los niveles de cLDL al inicio de evolocumab fue de 169,1 (56,6) mg/dl. En 46,4% de los pacientes el cLDL fue superior a 160mg/dl y en el 26,5% ≥190mg/dl. Durante el período de observación, evolocumab produjo reducciones significativas de cLDL del 55,7% (p < 0,0001), alcanzando unos valores medios de 74,3mg/dl. En la semana12 el 53,8% de los pacientes alcanzaron niveles de cLDL <70mg/dl y el 26,9% <50mg/dl. CONCLUSIONES: En las unidades de lípidos/medicina interna evolocumab se prescribió predominantemente en pacientes con hipercolesterolemia familiar con o sin ECVA. El uso inicial de evolocumab se ajustó a las pautas de la Sociedad Española de Arteriosclerosis (SEA) de 2016, estando las concentraciones de cLDL claramente por encima de los umbrales recomendados para inicio de tratamiento. El tratamiento con evolocumab en la práctica clínica redujo los niveles de cLDL en torno al 55%, cifra comparable a los ensayos clínicos, lo que permitió alcanzar los objetivos terapéuticos en la mayoría de los casos
OBJECTIVE: To describe the clinical characteristics, the reasons for initiating therapy, and the effects of treatment in the initial phase of evolocumab availability in lipid/internal medicine units in Spain. METHODS: Retrospective, observational study, based on the medical records of consecutive patients initiating treatment with evolocumab (from February 2016 to July 2017) in 20 internal medicine units in Spain. A review was made of the demographic and clinical characteristics of the patients, the lipid lowering treatment, and the evolution of the lipid profiles between 12weeks pre-initiation and 12±4weeks post-initiation of evolocumab. RESULTS: A total of 136 patients were analysed, of whom 64.0% were men, and the mean age (standard deviation, SD) was 56.6 (11.5) years. The large majority (75%) had familial hypercholesterolaemia (4 homozygous), and 51.0% of them had suffered at least one cardiovascular event. Atherosclerotic cardiovascular disease (ASCVD) was present in 61% of all patients. At initiation of evolocumab, 61.0% of the patients were taking high-intensity statins, and 60.3% were receiving ezetimibe. The mean (and SD) of LDL-C levels at initiation of evolocumab was 169.1 (56.6) mg/dL. The LDL-C was greater than 160mg/dL in 46.4% of patients, and ≥190mg/dL in 26.5%. During the observation period, evolocumab produced significant reductions in LDL-C of 55.7% (P<.0001), achieving mean values of 74.3mg/dL. At week12, more than half (53.8%) of patients achieved LDL-C levels <70mg/dL, and 26.9% <50mg/dL. CONCLUSIONS: In the lipid/internal medicine units, evolocumab was mainly prescribed in patients with familial hypercholesterolaemia, with or without ASCVD. The initial use of evolocumab was in accordance with the guidelines of the Spanish Society of Arteriosclerosis (SEA) of 2016, with LDL-C levels being well above the recommended thresholds for treatment initiation. Evolocumab treatment in clinical practice reduced LDL-C levels by about 55%, a similar reduction to that reported in clinical trials. Most patients achieved LDL-C goals
Subject(s)
Humans , Male , Middle Aged , Antibodies, Monoclonal/administration & dosage , Hyperlipoproteinemia Type II/drug therapy , Treatment Outcome , Hospital Units , Retrospective Studies , Confidence Intervals , Body Mass Index , Risk FactorsABSTRACT
OBJECTIVE: To describe the clinical characteristics, the reasons for initiating therapy, and the effects of treatment in the initial phase of evolocumab availability in lipid/internal medicine units in Spain. METHODS: Retrospective, observational study, based on the medical records of consecutive patients initiating treatment with evolocumab (from February 2016 to July 2017) in 20 internal medicine units in Spain. A review was made of the demographic and clinical characteristics of the patients, the lipid lowering treatment, and the evolution of the lipid profiles between 12weeks pre-initiation and 12±4weeks post-initiation of evolocumab. RESULTS: A total of 136 patients were analysed, of whom 64.0% were men, and the mean age (standard deviation, SD) was 56.6 (11.5) years. The large majority (75%) had familial hypercholesterolaemia (4 homozygous), and 51.0% of them had suffered at least one cardiovascular event. Atherosclerotic cardiovascular disease (ASCVD) was present in 61% of all patients. At initiation of evolocumab, 61.0% of the patients were taking high-intensity statins, and 60.3% were receiving ezetimibe. The mean (and SD) of LDL-C levels at initiation of evolocumab was 169.1 (56.6) mg/dL. The LDL-C was greater than 160mg/dL in 46.4% of patients, and ≥190mg/dL in 26.5%. During the observation period, evolocumab produced significant reductions in LDL-C of 55.7% (P<.0001), achieving mean values of 74.3mg/dL. At week12, more than half (53.8%) of patients achieved LDL-C levels <70mg/dL, and 26.9% <50mg/dL. CONCLUSIONS: In the lipid/internal medicine units, evolocumab was mainly prescribed in patients with familial hypercholesterolaemia, with or without ASCVD. The initial use of evolocumab was in accordance with the guidelines of the Spanish Society of Arteriosclerosis (SEA) of 2016, with LDL-C levels being well above the recommended thresholds for treatment initiation. Evolocumab treatment in clinical practice reduced LDL-C levels by about 55%, a similar reduction to that reported in clinical trials. Most patients achieved LDL-C goals.
Subject(s)
Antibodies, Monoclonal, Humanized/administration & dosage , Anticholesteremic Agents/administration & dosage , Atherosclerosis/drug therapy , Hyperlipoproteinemia Type II/drug therapy , Aged , Atherosclerosis/epidemiology , Cholesterol, LDL/blood , Ezetimibe/administration & dosage , Female , Humans , Hydroxymethylglutaryl-CoA Reductase Inhibitors/administration & dosage , Hyperlipoproteinemia Type II/epidemiology , Male , Middle Aged , Retrospective Studies , SpainABSTRACT
BACKGROUND AND OBJECTIVES: Although both residents and teaching faculty endorse its value, a recent review of family medicine residency programs confirms minimal formal family systems theory training. We consider the historical context of family systems training in family medicine and other competing priorities in practice and residency curricula. METHODS: We developed a longitudinal family systems curriculum, delivered in the third year of a 4-year residency program, and evaluated 2 years of the program using scales to assess self-reported confidence, knowledge and skills. RESULTS: Our curriculum evaluation showed significant improvement in all self-rating scales for all resident participants. CONCLUSIONS: We concluded the curriculum was successful in generating greater appreciation of family systems thinking and increased self-reported knowledge and skills for intervening and supporting families in the clinical setting. Further study is needed to evaluate change in clinical practice and whether these changes will be sustainable.
Subject(s)
Clinical Competence , Curriculum , Family Practice/education , Family , Internship and Residency , Systems Integration , Education, Medical, Graduate , Faculty , HumansABSTRACT
Reviewing with resident physicians their preciously recorded video of patient encounters is an effective method for teaching not only communications and interpersonal skills but also such subjects as agenda negotiation, visit efficiency, shared decision making, and overall medical care. Video allows for effective coaching while minimizing observer effect. Many residency programs use video review processes for evaluation and coaching, yet there is paucity of literature on the subject, and no consensus on best processes or equipment. Recent advances in the design of digital media devices has made it easier to conduct video review in everyday medical settings, but also creates new challenges in ensuring security and confidentiality. In this article, we have outlined the infrastructure and process needed to design and implement such a program as well as possible pitfalls that should be attended to in order to ensure patient confidentiality as well as resident safety.
