Submitted by Rosivalda Pereira (mrs.pereira@ufma.br) on 2017-09-04T19:14:43Z No. of bitstreams: 1 NaineLinhares.pdf: 1959096 bytes, checksum: 70c3a3e71cd261754aee39ee11844fb7 (MD5) / Made available in DSpace on 2017-09-04T19:14:43Z (GMT). No. of bitstreams: 1 NaineLinhares.pdf: 1959096 bytes, checksum: 70c3a3e71cd261754aee39ee11844fb7 (MD5) Previous issue date: 2016-09-30 / Fundação de Amparo à Pesquisa e ao Desenvolvimento Científico e Tecnológico do Maranhão / Coordenação de Aperfeiçoamento de Pessoal de Nível Superior / Introduction: With a broaden life expectancy, women experience perimenopause longer, under the influence of hormonal changes, which favor the development of several cardiovascular risk factors, including those that make up the Metabolic Syndrome. It is a complex disorder characterized by a range of lipid and non-lipid factors which predispose individuals to risk of developing cardiovascular disease and type 2 diabetes. Objective: Determine the prevalence of metabolic syndrome and its components grouping in climacteric women. Methodology: Analytical cross-sectional study, conducted from November 2012 to September 2013, at the Serviço Ambulatorial de Ginecologia do Hospital Universitário da Universidade Federal do Maranhão. The sample consisted of 277 women between 40 and 65 years who agreed to participate. Data collection was performed through a questionnaire on the day of a medical appointment previously scheduled by the patient. Biochemical tests were performed at the Hospital Universitário Unidade Presidente Dutra. For the diagnosis of the syndrome, we used the criteria of the International Diabetes Federation. Data were tabulated in Microsoft Excel 2013, and the statistical analysis was proceeded using Stata 14.0. Results: We evaluated 109 (39,3%) premenopausal and 168 (60,7%) postmenopausal women. The average age was 46.2±3.9 years for premenopausal women and 54.6±5.4 years for postmenopausal women. There was a predominance of brown women, completed high school, married and with income up to 1 minimum wage. Metabolic Syndrome was observed in 62 (22.4%) patients, 29 (46,8%) premenopausal and 33 (53,2%) postmenopausal. The prevalence of syndrome components was higher in postmenopausal women. Among carriers, 44 (71%) presented waist circumference plus 2 factors. The most common factors combination was waist circumference, blood glucose and triglycerides, found in 14 women (31,8%). Conclusion: The high prevalence of metabolic syndrome in postmenopausal women reinforces the need to develop and implement public politics to offer orientation and an integral therapy approach for this population at risk. / Introdução: Com a ampliação da expectativa de vida, as mulheres vivem no climatério por mais tempo, sob a influência de alterações hormonais que propiciam o desenvolvimento de diversos fatores de risco cardiovascular, dentre eles os que compõem a Síndrome Metabólica. Trata-se de um transtorno complexo, caracterizado por um conjunto de fatores lipídicos e não-lipídicos que predispõe indivíduos ao risco de desenvolver doenças cardiovasculares e diabetes tipo 2. Objetivo: Determinar a prevalência da síndrome metabólica e o agrupamento dos seus componentes em mulheres climatéricas. Metodologia: Estudo transversal analítico, realizado entre novembro de 2012 e setembro de 2013, no Serviço Ambulatorial de Ginecologia do Hospital Universitário da Universidade Federal do Maranhão. A amostra foi composta por 277 mulheres entre 40 e 65 anos de idade que concordaram em participar. A coleta de dados foi feita por meio de Ficha Protocolo no dia da consulta previamente agendada pela paciente. Os exames bioquímicos foram realizados no Hospital Universitário Unidade Presidente Dutra. Para o diagnóstico de Síndrome Metabólica, foram utilizados os critérios da International Diabetes Federation. Os dados foram tabulados no Microsoft Excel 2013 e a análise estatística dos resultados foi procedida no programa estatístico Stata 14.0. Resultados: Foram avaliadas 109 (39,3%) mulheres na pré-menopausa e 168 (60,7%) na menopausa. A idade média das mulheres na pré-menopausa foi 46,2±3,9 anos e das mulheres na menopausa foi 54,6±5,4 anos. Houve predomínio de mulheres pardas, com Ensino Médio completo, casadas e com renda de até 1 salário mínimo. A Síndrome Metabólica foi observada em 62 (22,4%) pacientes, sendo 29 (46,8%) na pré-menopausa e 33 (53,2%) na menopausa. A prevalência dos componentes da síndrome foi maior no grupo da menopausa. Dentre as portadoras, 44 (71%) apresentaram circunferência abdominal alterada mais 2 componentes. A combinação mais frequente foi circunferência abdominal, glicemia e triglicérides presente em 14 mulheres (31,8%). Conclusão: A prevalência elevada de síndrome metabólica nas mulheres menopausadas reforça a necessidade de desenvolver e implementar políticas públicas para oferecer orientação e uma abordagem terapêutica integral para essa população de risco.

BackgroundIndividuals from low socio-economic backgrounds have higher rates of morbidity and premature mortality from cardiovascular risk factors compared to those from more affluent backgrounds.Hearty Lives Dundee is a complex intervention which aims to address this health inequality. The intervention targets cardiovascular health checks at population groups who are likely to be at high risk, but tend not to engage with traditional services. Practitioners have tried to increase engagement with the target groups through a number of strategies. These included community and workplace-based assessments, and General Practice-run health checks supported by an outreach facility. The aim of this thesis was to explore what works at increasing patient uptake of cardiovascular health checks, for what groups, in what circumstances, and why?MethodsA Realistic Evaluation was undertaken using a mixed methods approach. Routine data was extracted from the Hearty Lives database and descriptive statistics reported on patients attending the community-based opportunistic service and the GP-based service. A total of thirty semi-structured interviews and one focus group (n=5) were conducted with patient attenders and non-attenders of community and General Practice-based health checks. Seven staff from the Hearty Lives programme were also interviewed. Thematic analysis was undertaken using Ritchie and Spencer’s Framework approach.ResultsAttenders at health checks were more likely to be female and older, regardless of the setting. Uptake varied by the number and type of invitation method. Cardiovascular risk was greater in the target population presenting opportunistically but was confounded by the older age of this group.Patient engagement relied on the interaction of a number of factors which varied according to setting; accessibility, invitation method, personal circumstances, cues to action and barriers. A continuum existed from barriers to motivators to attendance depending on the presence or absence of a cue to action, e.g. family history or symptoms. The concept of preventive health checks for cardiovascular disease was not well understood as some patients did not perceive a need to attend without symptoms. Additionally, the health check was viewed as optional by many and not treated with the same seriousness as perceived ‘compulsory’ cancer screenings.DiscussionThe complex lives of the intended target population merit a range of accessible services to reduce barriers to preventive health care. The Realistic Evaluation approach provided transferable knowledge of how to effectively engage with people from different backgrounds and care utilisation preferences, which could easily inform similar NHS services.

Cardiovascular disease remains a leading a cause of mortality and morbidity. Primary prevention is known to reduce the incidence of cardiovascular disease. The use of medication is currently targeted at those at increased predicted risk of cardiovascular disease using risk prediction tools developed from large epidemiological studies. However these have poor external validity particularly for those at low or intermediate risk: a significant number of cardiovascular events still occurs in these groups. We hypothesised that screening for asymptomatic pre-clinical cardiovascular disease using B-type natriuretic peptide (BNP) and whole body contrast enhanced magnetic resonance imaging (MRI) could identify those at low/intermediate risk or disease whowill develop clinical disease and thus facilitate improved targeting of primary prevention at those most likely to benefit. The Tayside Screening for Cardiac Events (TASCFORCE) study is a prospective normal volunteer cohort study. Men and women aged 40 years or older free from cardiovascular disease and with a predicted 10-year coronary heart disease risk less than 20% were recruited. All had comprehensive baseline cardiovascular risk information and a BNP level measured. If the BNP level was greater than the median for their gender participants were invited to attend for a whole body contrast enhancedMRI scan comprising cardiac imaging and whole body angiography. The images were analysed to measure left ventricular mass (LVM), left ventricular volumes and left ventricular function. These were indexed for body size using height, height1.7, height2.7 and body surface area. Angiogram images were analysed for the presence and degree of intraluminal stenosis. All participants are being followed up using anonymised electronic data linkage for incident cardiovascular disease and death. 4423 participants (39.3% male) were recruited between November 2007 and February 2013. Median age was 51.2 years. The median 10-year coronary heart disease (CHD) 23 risk was 2% and 13.6% had a CHD risk of 10-19.9% (intermediate risk). The medianBNP results for men and women were 7.5 and 15.3 pg/ml respectively. Age, female sex and high density lipoprotein were independently associated with BNP level. Heart rate, total cholesterol and ex-smoking status were independently inversely associated with BNP level. 1528 (74.8% of those invited) underwent an MRI scan. Mean left ventricular mass was 129.2g and 87.0g for men and women respectively. LVM and left ventricular mass index (LVMI) were significantly higher in men than women. The vast majority (94.6%) of arterial segments analysed were normal and 50.6% of individuals had no evidence of luminal stenosis. From follow up data obtained 2 years after the end of recruitment 18,364 person years at risk were analysed. 17 cardiovascularevents and no deaths occurred in those not invited for an MRI scan based on their BNP result and 16 events and 1 death occurred in those invited for an MRI scan. There was no significant difference in event rates between those with above and below median BNP levels, between those with higher or lower LVM or LVMI or between those with and without the presence of stenosis on angiography. As expected we have not demonstrated the ability of LVM, LVMI or stenosis burden determined using magnetic resonance imaging to predict cardiovascular disease in a population at low or intermediate risk of CHD. We have also not demonstrated the ability of BNP to identify those at low orintermediate risk of CHD who will develop clinical CV disease. However it is the pre-planned longer-term follow up where difference might be expected. The low number of events at this early stage in follow up mean that it is difficult to draw firm conclusions. As follow up continues and further events accumulate we hope to determine if these measures will be shown to predict cardiovascular events in future analyses. We have characterised the normal values and distribution of a range of left ventricular structural and functional parameters derived using a steady state free precision sequence MRI in a population at low or intermediate risk of CHD which will provide a useful reference for normal values that are different to other imaging modalities including chocardiography and other protocols of MRI scanning.

Desenvolvemos estudo entre trabalhadores de uma destilaria do interior paulista com o objetivo de identificar o perfil de trabalhadores do sexo masculino quanto aos fatores de risco cardiovasculares. O referencial teórico foi o Modelo de “Campo de Saúde" que compõe os elementos de biologia humana, meio ambiente, estilo de vida e organização dos serviços de saúde. A população estudada constituiu-se de 123 trabalhadores, com idade entre 18 e 71 anos, que desenvolviam atividades no setor da indústria. Os dados foram obtidos através da entrevista individual feita pelo pesquisador na própria destilaria onde os mesmos atuavam. Ao término de cada entrevista procedeu-se a verificação da pressão arterial pelo método indireto, em seguida o exame antropométrico que constituiu-se da medida de peso e altura. Os níveis tensionais foram obtidos através de duas medidas com utilização do aparelho oscilométrico da marca Dixtal (modo automático) e manguitos de bolsa de borracha compatíveis com a circunferência braquial do indivíduo. Com relação a biologia humana, 10,6% dos trabalhadores apresentou obesidade grau I, 17,0% obesidade grau II; em 11,4% dos indivíduos identificamos valores de pressão arterial sistólica ³ 140 mmHg e em 12,2% com pressão arterial diastólica ³ 90 mmHg; quanto aos antecedentes familiares, 32,5% referiram história familiar positiva de doença hipertensiva, 26,0% de acidente vascular cerebral e 27,6 de diabetes melitus. Quanto ao meio ambiente, 60,2% possuíam o 1º grau incompleto, 49,6% eram casados e 97,6% tinham o único emprego. No tocante ao estilo de vida, 40,7% referiram realizar algum tipo de atividade física, 16,3% eram fumantes, 65,9% indicaram consumo de bebida alcoólica e 49,6% referiram ingerir alimentos preparados com muito sal. Em relação ao atendimento de saúde todos trabalhadores participantes no estudo possuíam convênio médico, além daquele oferecido pela própria empresa. Os dados revelam existência de hábitos autocriados que podem ser modificados e que se constituem em fatores de risco cardiovascular; realçamos a necessidade de promoção de ações educativas visando à prevenção dessas doenças. / This study was developed among workers of a distillery in the interior of São Paulo State aiming at identifying the profile of male workers with regard to risk factors of cardiovascular diseases. The theoretical framework was based on the “Health Field" Model, which composes the elements of human biology, environment, lifestyle and organization of health services. The studied population consisted of 123 workers aged 18 to 71 years who performed their activities in the factory. Data were obtained by means of individual interviews conducted by the researcher in the facilities of the distillery where the subjects worked. At the end of each interview, each individual’s arterial pressure was measured by means of the indirect method, which was followed by the assessment of their anthropometric measures, namely height and weight. Tension levels were obtained through two measurements with the use of an oscillometric device (automatic mode) manufactured by Dixtal and rubber-bag cuffs which were compatible with the individual’s brachial circumference. With regard to human biology, 10.6% of the workers presented level-1 obesity and 17% had level-2 obesity, 11.4% of the individuals, systolic arterial pressure values were found to be 140mmHG and in 12.2% diastolic arterial pressure values were found to be 90mmHG. Concerning their family history, 32,5% reported a family history with the presence of hypertensive disease consisting of cerebral vascular accidents (26.0%) and diabetes mellitus (27.6%). As to the environment, 60.2% had incomplete elementary school education, 49.6% were married and 97.6% had only one job. Concerning lifestyle, 40.7% reported the habit to perform some type of physical activity, 16.3% were smokers, 65.9% indicated the consumption of alcoholic beverages and 49.6% reported to ingest food prepared with a high amount of salt. As to healthcare, all the workers participating in the study had a medical insurance in addition to that provided by the company. Data showed the existence of self-created habits which consisted in risk factors of cardiovascular diseases. Since such habits can be modified, the need to promote educational action aiming at the prevention of such diseases is emphasized.

Submitted by Rosina Valeria Lanzellotti Mattiussi Teixeira (rosina.teixeira@unisantos.br) on 2015-04-08T14:05:18Z No. of bitstreams: 1 Ariadna Ferraz de Oliveira.pdf: 1770875 bytes, checksum: 77e12b007af8b61cd0e33958f5fd15a8 (MD5) / Made available in DSpace on 2015-04-08T14:05:18Z (GMT). No. of bitstreams: 1 Ariadna Ferraz de Oliveira.pdf: 1770875 bytes, checksum: 77e12b007af8b61cd0e33958f5fd15a8 (MD5) Previous issue date: 2014-08-25 / Coordenação de Aperfeiçoamento de Pessoal de Nível Superior - CAPES / Introduction: environmental pollution and its impact on health is now considered a public health problem. Despite the incessant search for an environment with cleaner air, pollution levels are still unhealthy and are related to the human morbidity and mortality. Objective: to evaluate the relationship between exposure to air pollution and hospitalizations in the Sistema Único de Saúde (SUS) of the elderly for cardiovascular diseases (CVD) totals in residents of the cities of Cubatão and São Paulo between 2000 to 2012, stratified by sex. Methods: This is an ecological study of temporal series. Schedules data were obtained on the levels of PM10, CO, SO2, NO2 and O3, minimum temperature and humidity average along the Environmental sanitation technology company in the State of São Paulo-CETESB. The hospitalizations in the Sistema Único de Saúde (SUS) were obtained from the database of the SUS (DATASUS). Descriptive analysis was performed and the Pearson correlation analysis. The association of air pollutants and cardiovascular admissions was assessed using a polynomial distributed lag model through 7 days after exposure. The log of cardiovascular admissions was regressed assuming a Poisson distribution in a generalized linear model adjusted for long time trend, weekdays, temperature and humidity. The percentage increases in the cardiovascular admissions were calculated based on the interquartile range of the air pollutants. It was adopted a significance level of 5%. Results: In the study period were admitted in the SUS 1,287,204 (19.7%) seniors, these 358970 (27.9%) with cardiovascular diseases in São Paulo. In Cubatão 13,998 were admitted (14.4%) seniors, these 3,729 (26.6%) for cardiovascular diseases. In São Paulo associations were observed between the pollutants PM10, SO2, NO2 and CO and the CVD. For each increase of an interquartile range in level of PM10 (24.42 ¿g/m3) increase hospitalizations in 2.04% (CI95%: 1.42%-2.66%), for SO2 (7.48 ¿g/m3) the increase is 2.22% (CI95%: 1.60%-2.84%), for NO2 (51.89 ¿g/m3) is 2.55% (CI95%: 1.96% ¿ 3.14%) and CO (1.33 ppm) is 1.06% (CI95%: 0.50%-1.62%). In Cubatão only the PM10 presented effect on hospitalization for CVD, where for each increase of an interquartile range in level of PM10 (39.40 ¿g/m3) increase the hospitalizations in 6.01% (CI95%: 1.61%-10.41%). Conclusion: The air pollutants continue to be one of the factors that contribute to the increase in the number of hospitalizations for cardiovascular diseases. / Introdução: A poluição ambiental e suas consequências sobre a saúde é hoje considerada um problema de saúde pública. Apesar da busca incessante por um ambiente com ar mais limpo, os níveis de poluição ainda se apresentam prejudiciais à saúde e estão relacionados com a morbidade e mortalidade humana. Objetivo: Avaliar a relação entre exposição à poluição do ar e internações no Sistema Único de Saúde (SUS) de idosos por doenças cardiovasculares totais (DCV) estratificado por sexo em residentes dos municípios de Cubatão e São Paulo entre 2000 a 2012. Métodos: Este é um estudo ecológico de series temporais. Foram obtidos dados horários sobre os níveis de PM10, CO, SO2, NO2 e O3, temperatura mínima e umidade média junto a Companhia de Tecnologia de Saneamento Ambiental do Estado de São Paulo - CETESB. As internações hospitalares no Sistema Único de Saúde (SUS) foram obtidas através do banco de dados do SUS (DATASUS). Foi realizada análise descritiva e análise de correlação de Pearson. Foram utilizados modelos polinomiais lineares generalizados de regressão de Poisson defasados de até 7 dias após exposição. Foi adotado o nível de significância p = 5%. Resultados: Em São Paulo foram observadas associações entre os poluentes PM10, SO2, NO2 e CO e as DCV, que elevaram o número das internações em 2,04% (IC95%: 1,42 ¿ 2,66), 2,22 % (IC95%: 1,60 ¿ 2,84), 2,55 % (IC95%: 1,96 ¿ 3,14) e 1,06% (IC95%: 0,50 ¿ 1,62), respectivamente. Em Cubatão apenas o PM10 apresentou efeito significativo para as internações por DCV com um aumento de 6,01% (IC95%: 1,61 ¿ 10,41). Conclusão: Os poluentes atmosféricos continuam sendo um dos fatores que contribuem para o aumento do número de internações hospitalares por doenças cardiovasculares. Faz-se necessário planejar e implantar ações que visem a melhoria de políticas de controle de poluentes visando um ambiente mais limpo e saudável.

The purpose of this study was to determine if supplementation of two grams of fish oil for 90 days would significantly lower cardiovascular disease (CVD) risk in Hispanics with type 2 diabetes. The Hispanic American population is at an increased risk for CVD. Eicosapentaenoic Acid (EPA) and Docosahexaenoic Acid (DHA) in fish oil have been found to reduce risk of CVD. Subjects were randomly divided into two groups and received either two grams of fish oil or corn oil (control) per day for 90 days. Before and after the trial, participant blood lipids and plasma fatty acids were evaluated. Respired air samples were obtained to evaluate plasma fatty acids. Although analysis of blood lipids and plasma fatty acids did not show sufficient evidence to disprove the null hypothesis, this study is an important model for future studies concerning fish oil to lower CVD risk in Hispanics with type 2 diabetes.

Studies have indicated that approximately 30% of people with heart disease experience major depressive disorder (MDD). Despite strong clinical evidence of a link between the two diseases, the neurobiological processes involved in the relationship are poorly understood. A growing number of studies are revealing similar neuroanatomical and neurochemical abnormalities resulting from both depression and heart disease. The locus coeruleus (LC) is a group of neurons in the pons that synthesize and release norepinephrine, and that is known to play a significant role in depression pathobiology. For example, there is evidence that tyrosine hydroxylase (TH) is elevated in the LC in depression. In addition, there is evidence that the LC plays a role in cardiovascular autonomic regulation. The hippocampus is another region that exhibits abnormalities in both depression and heart disease. In this study, the levels of TH in the hippocampus and LC were examined in the guinea pig pressure-overload model of heart disease. TH levels were also measured in the pressure-overload model treated with vagal nerve stimulation, a new investigational therapeutic intervention in heart disease. This study found that there were no changes in TH levels in the LC or the hippocampus of the pressure-overload model or in the pressure-overload model treated with vagal nerve stimulation.

Objective: To examine the association between subclinical atherosclerosis (ascertained as coronary artery calcium; CAC) in asymptomatic individuals in the Central Appalachian region of the United States and individual- and geographic-level factors. Methods: Data were obtained from participants in CAC screening during 2012 and 2016. CAC score was assessed as CAC=0 (no plaque), 1≤CAC≤99 (mild plaque), 100≤CAC≤399 (moderate plaque), and CAC≥400 (severe plaque). Additionally, data on demographics (age, sex, and race), medical conditions, lifestyle factors, and family history of coronary artery disease (CAD) were obtained. Further, zip codes of place of residence for participants were used to generate geographic-level data. Descriptive statistics were used to estimate the prevalence of CAC, and multinomial logistic regression models were used to delineate significant factors. Results: Of 1512 participants, 57.6% had CAC>0. The prevalence of mild, moderate, and severe plaques was 31.6%, 16.3%, and 9.7%, respectively. Demographic, medical conditions, lifestyle factors, and family history of CAD were associated with increased risk for subclinical atherosclerosis. Further, the proportion of minority residents significantly increased the risk for severe plaque [RRR=1.06; p-value=0.04] and the proportion of residents on government assistance significantly decreased the risk for mild plaque [RRR=0.93; p-value=0.03]. Conclusion: The results imply that the proportion of minority residents in a geographic area is associated with increased relative risk for subclinical atherosclerosis, while the proportion of residents on government assistance decreased such risk. However, future geographic or neighborhood-level studies with larger sample size are needed to delineate further the consistency of these results in the Central Appalachian population.

Objectives: The central Appalachian region of the United States is disproportionately burdened with cardiovascular diseases (CVD) and associated risk factors; however, research to inform clinical practice and policies and programs is sparse. This study aimed to examine the association between multiple modifiable risk factors for CVD and hypertension in asymptomatic patients in central Appalachia. Methods: Between January 2011 and December 2012, 1629 asymptomatic individuals from central Appalachia participated in screening for subclinical atherosclerosis. Participants were asked to report their hypertension status (yes/no). In addition, data on two nonmodifiable risk factors (sex, age) and five modifiable risk factors (obesity, diabetes mellitus, hypercholesterolemia, smoking, and sedentary lifestyle) were collected. Multivariable logistic regression analyses were conducted to assess association between hypertension and risk factors. Results: Of the 1629 participants, approximately half (49.8%) had hypertension. Among people with hypertension, 31.4% were obese and 62.3% had hypercholesterolemia. After adjusting for sex and age, obesity and diabetes mellitus were associated with a more than twofold increased odds of having hypertension (odds ratio [OR] 2.02, confidence interval [CI] 1.57–2.60 and OR 2.30, CI 1.66–3.18, respectively). Hypercholesterolemia and sedentary lifestyle were associated with higher odds for hypertension (OR 1.26, CI 1.02–1.56 and OR 1.38, CI 1.12–1.70, respectively), compared with referent groups. Having two, three, and four to five modifiable risk factors was associated with increased odds of having hypertension by about twofold (OR 1.72, CI 1.21–2.44), 2.5-fold (OR 2.55, CI 1.74–3.74), and sixfold (OR 5.96, CI 3.42–10.41), respectively. Conclusions: This study suggests that the odds of having hypertension increases with a higher number of modifiable risk factors for CVD. As such, implementing an integrated CVD program for treating and controlling modifiable risk factors for hypertension would likely decrease the future risk of CVD.

The advent of effective oral, molecular-targeted drugs in oncology has changed many incurable malignancies such as chronic myeloid leukemia into chronic diseases similar to coronary artery disease and diabetes mellitus. Oral agents including monoclonal antibodies, kinase inhibitors and hormone receptor blockers offer cancer patients incremental improvements in both overall survival and quality of life. As it is imperative to recognize and manage side effects of platelet inhibitors, beta blockers, statins, HIV drugs, and fluoroquinolones by all healthcare providers, the same holds true for these newer targeted therapies, patients may present to their generalist or other subspecialist with drug-related symptoms. Cardiovascular adverse events are among the most frequent, and potentially serious, health issues in outpatient clinics, and among the most frequent side effects of targeted chemotherapy. Data support improved patient outcomes and satisfaction when primary care and other providers are cognizant of chemotherapy side effects, allowing for earlier intervention and reduction in morbidity and health care costs. With the implementation of accountable care and pay-for-performance, improved communication between generalists and subspecialists is essential to deliver cost-effective patient care.