RESUMO
Background: Anxiety disorders are highly prevalent and cause significant distress, disability, and cost. Medication adverse effects and interactions increase in mid-life and late-life, highlighting the need for effective non-pharmacological interventions. Objectives: We aimed to evaluate the extent of evidence supporting exercise interventions for anxiety and subthreshold anxiety disorders in mid-life and late-life. Design: Systematic review. Data Sources and Methods: We searched MEDLINE, PsycINFO, Embase, Emcare, Ovid Nursing, CINAHL Plus, Cochrane Library, Health Collection, Humanities & Social Sciences Collection, and https://clinicaltrials.gov databases for trials published January 1994-May 2019. Randomised controlled trials of exercise interventions involving aerobic exercise or resistance training for adults aged 40 years and above with anxiety or subthreshold anxiety disorders in residential or health settings were identified. The primary outcome was change in anxiety. We excluded trials including participants aged below 40 years, participants with diagnosis of separation anxiety, selective mutism, obsessive-compulsive disorder, acute stress disorder and post-traumatic stress disorder, and head-to-head comparisons of interventions. Trial quality was assessed using the Cochrane Risk of Bias Tool and evidence synthesised in narrative form. Results: Four trials totalling 132 participants met inclusion criteria, although some had methodological limitations. Interventions included a home-based resistance training intervention, supervised group-based aerobic intervention, Tai Chi intervention, and supervised group-based aerobic and strength intervention. Three trials included late-life participants and the fourth mid-life. Three trials demonstrated greater reductions in anxiety in the intervention group compared with control. The fourth trial showed pre-post reductions in anxiety in both groups, with between-group difference not reaching statistical significance. Conclusion: There is limited supportive evidence suggesting that exercise interventions have potential to be effective, feasible and safe non-pharmacological interventions for anxiety and subthreshold anxiety disorders in mid-life and late-life. The heterogeneity, limited number and high risk of bias of some trials meant that we were not able to conduct a meta-analysis. Tailoring of interventions may improve uptake and reduce dropout. The paucity of research in this area with only four included trials demonstrates the urgent need for future and larger trials to provide proof of concept, data about effective types and doses of exercise interventions, and guidance to community, clinical, and public health services.
RESUMO
Objectives. The objectives of this study were (1) to assess the impact of the 2016 Centers for Disease Control and Prevention (CDC) Guideline for Prescribing Opioids for Chronic Pain (GPOCP) on tramadol and opioid prescription rates in patients with chronic kidney disease (CKD), (2) to identify if tramadol was being properly dosed based on kidney function, and (3) to identify the number of clinically relevant drug-drug interactions related to tramadol. Design. Retrospective cohort study. Setting and Participants. Patients with a diagnosis of CKD stage IV or V or end-stage renal disease (ESRD) with a hospital discharge were identified. Participants were distributed into a pre-GPOCP cohort (January to December 2015) and post-GPOCP cohort (January 2017 to May 31, 2018) based on their hospital discharge date. Participants were then further divided into three categories: those who were discharged with a new prescription for tramadol, those who were discharged with a prescription for another opioid product, or those who were discharged with no new opioid or tramadol prescription. Outcome Measures. The primary outcome was incidence of new outpatient tramadol and opioid hospital discharge prescriptions. The secondary outcomes were the number of correctly dosed tramadol discharge prescriptions based on kidney function and incidence of clinically significant drug-drug interactions with tramadol. Results. New tramadol and opioid prescription rates upon hospital discharge for CKD stage IV and V and ESRD patients decreased from 76 (2.5%) to 54 (1.1%) and from 145 (4.7%) to 119 (2.5%), respectively (P < .001). Among the patients discharged with a new tramadol prescription, 113 (86.9%) patients did not have any clinically significant drug-drug interactions, and 94 (72.3%) patients were dosed correctly based on kidney function. Conclusion. The incidence of new outpatient tramadol and opioid prescriptions at discharge was significantly lower after the CDC GPOCP publication than before the publication.
