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Elgendy I.Y.,Florida College | Huo T.,Florida College | Chik V.,North Florida South Georgia Veterans Health System | Pepine C.J.,Florida College | Bavry A.A.,Florida College
American Journal of Hypertension | Year: 2015

Background The efficacy and safety of angiotensin receptor blockers (ARBs) in the older population is unclear. Objectives To determine the efficacy and safety of ARBs in older patients. Methods Randomized trials that compared ARBs to control and reported clinical outcomes in patients with a mean age of 65 years or older were included. Random-effects summary risk ratios (RRs) were constructed. Results A total of 16 trials met our selection criteria, which yielded 113,386 patients. ARBs were associated with a marginal increased risk of allcause mortality (RR: 1.03, 95% confidence interval (CI): 1.00-1.06, P = 0.05), a nonsignificant increased risk of myocardial infarction (RR: 1.04, 95% CI: 0.96-1.12, P = 0.36), a marginal reduction in heart failure hospitalization (RR: 0.86, 95% CI: 0.74-1.00, P = 0.06), and a significant reduction in the risk of stroke (RR: 0.93, 95% CI: 0.87-0.99, P = 0.03). ARBs were associated with an increased risk of acute kidney injury (RR: 1.48, 95% CI: 1.24-1.77, P < 0.001), hypotension (RR: 1.56, 95% CI: 1.24-1.97, P < 0.001), and hyperkalemia (RR: 1.57, 95% CI: 1.13-2.19, P = 0.008). On the sensitivity analysis including placebo-controlled trials, the risk of all-cause mortality was no longer significant (P = 0.2), while the remainder of the outcomes did not change. Conclusion In older patients, the benefit of ARBs compared with control was strongest for stroke reduction, with no (or weak) associations for allcause mortality, myocardial infarction, and heart failure hospitalization. Benefit was offset by an increased risk of acute kidney injury, hypotension, and hyperkalemia. Thus, ARBs should be used with caution in older patients when clinically indicated. © Published by Oxford University Press on behalf of American Journal of Hypertension Ltd 2014.

Sisco S.M.,North Florida South Georgia Veterans Health System
Journal of aging and health | Year: 2013

This article investigated how a multicomponent memory intervention affected memory for prose. We compared verbatim and paraphrased recall for short stories immediately and 1, 2, 3, and 5 years post-intervention in the Advanced Cognitive Training for Independent and Vital Elderly (ACTIVE) sample. We studied 1,912 ACTIVE participants aged 65 to 91. Participants were randomized into one of three training arms (Memory, Reasoning, Speed of Processing) or a no-contact Control group; about half of the trained participants received additional booster training 1 and 3 years post-intervention. Memory-trained participants showed higher verbatim recall than non-memory-trained participants. Booster-memory training led to higher verbatim recall. Memory training effects were evident immediately following training and not after 1 year following training. Results suggest that multifactorial memory training can improve verbatim recall for prose, but the effect does not last without continued intervention.

Franck A.J.,North Florida South Georgia Veterans Health System | Smith R.E.,Gv Sonny Montgomery Va Medical Center
Journal of the American Pharmacists Association | Year: 2010

Objective: To evaluate the effect of age, symptom duration, symptom presentation, presenting location, and type of acute upper respiratory tract infection (URI) on the receipt of inappropriate antibiotic prescriptions in adult patients. Methods: A retrospective cross-sectional study was conducted within a U.S. Department of Veterans Affairs health system. A total of 500 adult patients with acute URI during a 1-year study period were randomly selected and evaluated for receipt of antibiotic prescriptions. Patients were excluded if they had an indication for antibiotics based on Centers for Disease Control and Prevention criteria, concomitant infection, or unreviewable patient record. Patients were grouped and compared by age, symptom duration, symptom presentation (purulence of secretions), presenting location, and type of URI. Results: Overall, antibiotics were prescribed to 77% (219 of 283) of patients included in the study. Patients with purulent symptoms received a higher proportion of antibiotic prescriptions compared with those without purulent symptoms (P < 0.01). Patients seen in routine primary care received a lower proportion of antibiotic prescriptions compared with those seen in the emergency department or urgent care/primary care walk-in clinic (P < 0.01). No significant difference was observed in the proportion of antibiotic prescriptions based on symptom duration (P = 0.99) or age (P = 0.19). Patients with acute sinusitis or bronchitis received a higher proportion of antibiotics than those with acute pharyngitis or nonspecific URI (P < 0.01). Conclusion: Despite evidence-based practice guidelines for the rational use of antibiotics in patients with upper respiratory tract infections, these conditions are being treated inappropriately. Patient and provider factors play a role in the receipt of antibiotics. Further efforts, including those by pharmacists, are needed to improve the use of antibiotics for acute URI in adult patients.

Bavry A.A.,North Florida South Georgia Veterans Health System | Bavry A.A.,University of Florida | Thomas F.,University of Tennessee Health Science Center | Allison M.,University of California at San Diego | And 5 more authors.
Circulation: Cardiovascular Quality and Outcomes | Year: 2014

Background-Conclusive data about cardiovascular toxicity of nonsteroidal anti-inflammatory drugs (NSAIDs) are sparse. We hypothesized that regular NSAID use is associated with increased risk for cardiovascular events in postmenopausal women, and that this association is stronger with greater cyclooxygenase (cox)-2 when compared with cox-1 inhibition. Methods and Results-Postmenopausal women enrolled in the Women's Health Initiative were classified as regular users or nonusers of nonaspirin NSAIDs. Cox regression examined NSAID use as a time-varying covariate and its association with the primary outcome of total cardiovascular disease defined as cardiovascular death, nonfatal myocardial infarction, or nonfatal stroke. Secondary analyses considered the association of selective cox-2 inhibitors (eg, celecoxib), nonselective agents with cox-2>cox-1 inhibition (eg, naproxen), and nonselective agents with cox-1>cox-2 inhibition (eg, ibuprofen) with the primary outcome. Overall, 160 801 participants were available for analysis (mean follow-up, 11.2 years). Regular NSAID use at some point in time was reported by 53 142 participants. Regular NSAID use was associated with an increased hazard for cardiovascular events versus no NSAID use (hazard ratio [HR], 1.10; 95% confidence interval, 1.06-1.15; P<0.001). Selective cox-2 inhibitors were associated with a modest increased hazard for cardiovascular events (hazard ratio, 1.13; 1.04-1.23; P=0.004 and celecoxib only: HR, 1.13; 1.01-1.27; P=0.031). Among aspirin users, concomitant selective cox-2 inhibitor use was no longer associated with increased hazard for cardiovascular events. There was an increased risk for agents with cox-2>cox-1 inhibition (HR, 1.17; 1.10-1.24; P<0.001 and naproxen only: HR, 1.22; 1.12-1.34; P<0.001). This harmful association remained among concomitant aspirin users. We did not observe a risk elevation for agents with cox-1>cox-2 inhibition (HR, 1.01; 0.95-1.07; P=0.884 and ibuprofen only: HR, 1.00; 0.93-1.07; P=0.996). Conclusions-Regular use of selective cox-2 inhibitors and nonselective NSAIDs with cox-2>cox-1 inhibition showed a modestly increased hazard for cardiovascular events. Nonselective agents with cox-1>cox-2 inhibition were not associated with increased cardiovascular risk. © 2014 American Heart Association, Inc.

Carnaby-Mann G.,University of Florida | Crary M.A.,University of Florida | Schmalfuss I.,North Florida South Georgia Veterans Health System | Amdur R.,University of Florida
International Journal of Radiation Oncology Biology Physics | Year: 2012

Purpose: Dysphagia after chemoradiotherapy is common. The present randomized clinical trial studied the effectiveness of preventative behavioral intervention for dysphagia compared with the "usual care." Methods and Materials: A total of 58 head-and-neck cancer patients treated with chemoradiotherapy were randomly assigned to usual care, sham swallowing intervention, or active swallowing exercises (pharyngocise). The intervention arms were treated daily during chemoradiotherapy. The primary outcome measure was muscle size and composition (determined by T 2-weighted magnetic resonance imaging). The secondary outcomes included functional swallowing ability, dietary intake, chemosensory function, salivation, nutritional status, and the occurrence of dysphagia-related complications. Results: The swallowing musculature (genioglossus, hyoglossuss, and mylohyoid) demonstrated less structural deterioration in the active treatment arm. The functional swallowing, mouth opening, chemosensory acuity, and salivation rate deteriorated less in the pharyngocise group. Conclusion: Patients completing a program of swallowing exercises during cancer treatment demonstrated superior muscle maintenance and functional swallowing ability. © 2012 Elsevier Inc. All rights reserved.

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