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1.
J Clin Psychiatry ; 75(5): 477-89; quiz 489, 2014 May.
Artigo em Inglês | MEDLINE | ID: mdl-24922485

RESUMO

OBJECTIVE: To evaluate the efficacy of repetitive transcranial magnetic stimulation (rTMS) in patients with major depressive disorder (MDD) and 2 or more prior antidepressant treatment failures (often referred to as treatment-resistant depression [TRD]). These patients are less likely to recover with medications alone and often consider nonpharmacologic treatments such as rTMS. DATA SOURCES: We searched MEDLINE, EMBASE, the Cochrane Library, PsycINFO, and the International Pharmaceutical Abstracts for studies comparing rTMS with a sham-controlled treatment in TRD patients ages 18 years or older. STUDY SELECTION: We included 18 good- or fair-quality TRD studies published from January 1, 1980, through March 20, 2013. DATA EXTRACTION: We abstracted relevant data, assessed each study's internal validity, and graded strength of evidence for change in depressive severity, response rates, and remission rates. RESULTS: rTMS was beneficial compared with sham for all outcomes. rTMS produced a greater decrease in depressive severity (high strength of evidence), averaging a clinically meaningful decrease on the Hamilton Depression Rating Scale (HDRS) of more than 4 points compared with sham (mean decrease = -4.53; 95% CI, -6.11 to -2.96). rTMS resulted in greater response rates (high strength of evidence); those receiving rTMS were more than 3 times as likely to respond as patients receiving sham (relative risk = 3.38; 95% CI, 2.24 to 5.10). Finally, rTMS was more likely to produce remission (moderate strength of evidence); patients receiving rTMS were more than 5 times as likely to achieve remission as those receiving sham (relative risk = 5.07; 95% CI, 2.50 to 10.30). Limited evidence and variable treatment parameters prevented conclusions about which specific treatment options are more effective than others. How long these benefits persist remains unclear. CONCLUSIONS: For MDD patients with 2 or more antidepressant treatment failures, rTMS is a reasonable, effective consideration.


Assuntos
Transtorno Depressivo Maior/terapia , Transtorno Depressivo Resistente a Tratamento/terapia , Estimulação Magnética Transcraniana/métodos , Humanos
2.
Pharmacogenomics ; 14(13): 1593-603, 2013 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-24088130

RESUMO

AIM: This study aimed to assess the effectiveness of genotype-guided warfarin dosing. PATIENTS & METHODS: A total of 109 adults were randomized to receive initial dosing as determined by an algorithm containing genetic (VKORC1 and CYP2C9) plus clinical information or only clinical information. Primary end points were the number of anticoagulation visits and the time in therapeutic range (TTR) over 90 days. Secondary end points included time to therapeutic dose, International Normalized Ratios of >4, emergency visits, hospitalizations, hemorrhagic events, thrombotic events and mortality. RESULTS: Neither primary end point was significantly different between groups (anticoagulation visits: 6.96 vs 6.37, p = 0.51; TTR: 0.40 vs 0.43, p = 0.59). Fewer emergency visits, hospitalizations, major hemorrhagic events, thrombotic events and deaths occurred in the genetic plus clinical group than in the clinical only group, but these differences were not statistically significant. CONCLUSION: Genotype-guided dosing did not decrease the number of anticoagulation visits or improve TTR. Our trial was not powered to detect anything but large differences for utilization and health outcomes.


Assuntos
Anticoagulantes/uso terapêutico , Varfarina/uso terapêutico , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Hidrocarboneto de Aril Hidroxilases/genética , Coagulação Sanguínea/genética , Citocromo P-450 CYP2C9 , Relação Dose-Resposta a Droga , Feminino , Genótipo , Humanos , Coeficiente Internacional Normatizado/métodos , Masculino , Pessoa de Meia-Idade , Resultado do Tratamento , Vitamina K Epóxido Redutases/genética , Adulto Jovem
3.
J Am Geriatr Soc ; 61(8): 1399-409, 2013 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-23869936

RESUMO

OBJECTIVES: In response to the need for an evidence-based review of factors within long-term care settings that affect the quality of care, this review compared characteristics of nursing homes and other residential long-term care settings for people with dementia and their informal family caregivers with respect to health and psychosocial outcomes. DESIGN: Databases were searched for literature published between 1990 and March 2012 that met review criteria, including that at least 80% of the subject population had dementia. RESULTS: Fourteen articles meeting review criteria that were of at least fair quality were found: four prospective cohort studies, nine randomized controlled trials (RCTs), and one nonrandomized controlled trial. Overall, low or insufficient strength of evidence was found regarding the effect of most organizational characteristics, structures, and processes of care on health and psychosocial outcomes for people with dementia and no evidence for informal caregivers. Findings of moderate strength of evidence indicate that pleasant sensory stimulation reduces agitation for people with dementia. Also, although the strength of evidence is low, protocols for individualized care and to improve function result in better outcomes for these individuals. Finally, outcomes do not differ between nursing homes and residential care or assisted living settings for people with dementia except when medical care is indicated. CONCLUSION: Given the paucity of high-quality studies in this area, additional research is needed to develop a sufficient evidence base to support consumer selection, practice, and policy regarding the best settings and characteristics of settings for residential long-term care of people with dementia.


Assuntos
Doença de Alzheimer/terapia , Moradias Assistidas , Instituição de Longa Permanência para Idosos/organização & administração , Assistência de Longa Duração/organização & administração , Casas de Saúde/organização & administração , Idoso , Idoso de 80 Anos ou mais , Doença de Alzheimer/psicologia , Estudos de Coortes , Prática Clínica Baseada em Evidências/organização & administração , Humanos , Estudos Prospectivos , Agitação Psicomotora/psicologia , Agitação Psicomotora/terapia , Indicadores de Qualidade em Assistência à Saúde , Ensaios Clínicos Controlados Aleatórios como Assunto , Meio Social
4.
Psychiatr Serv ; 63(11): 1125-30, 2012 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-23117509

RESUMO

OBJECTIVE: The purpose of this project was to engage a diverse group of stakeholders (N=38) to help establish priorities to guide patient-centered outcomes research (PCOR) in serious mental illness. METHODS: Three meetings, two Web-based and one on site, were held to generate and prioritize an initial list of topics. Topics were then sorted and organized into common themes. RESULTS: About 140 topics were identified and sorted into 21 main themes, ranked by priority. Three of the top four themes focused on how research was conducted, particularly the need to develop consensus measurement and outcomes definitions; improving infrastructure for research, longitudinal studies, and new data sets and investigators; and developing PCOR methodology. Stakeholders also identified a need to focus on service delivery, treatment settings, and structure of the delivery of care. CONCLUSIONS: Engagement by a broad group of stakeholders in a transparent process resulted in the identification of priority areas for PCOR. Stakeholders clearly indicated a need to fundamentally change how research on serious mental illness is conducted and a critical need for the development of methodology and infrastructure. Most current PCOR has been focused on relatively short-term outcomes, but real world, long-term studies providing guidance for treatment over the lifetime of a serious mental illness are needed.


Assuntos
Consenso , Transtornos Mentais , Avaliação de Resultados em Cuidados de Saúde , Assistência Centrada no Paciente , Pesquisa , Prática Clínica Baseada em Evidências , Processos Grupais , Humanos , Índice de Gravidade de Doença , Estados Unidos , Comunicação por Videoconferência
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