RESUMO
BACKGROUND: Models of interdisciplinary primary care (IPC) may improve upon traditional primary care approaches in addressing addiction and social determinants of health. OBJECTIVE: To compare the trends in health care utilization in the year before and after enrollment in an IPC clinic model, and explore the variations in temporal patterns for patients with histories of high emergency department (ED) use, homelessness, and/or substance use disorders (SUDs). DESIGN AND PARTICIPANTS: Interrupted time series study of utilization among IPC patients. MAIN MEASURES: Quarterly ED, inpatient, primary care, and behavioral health visits were abstracted from administrative data before and after IPC enrollment. Negative binomial segmented regressions estimated changes in health care utilization over time. We used interactions to test for statistical differences in temporal patterns for IPC subgroups. RESULTS: Among IPC patients (n=994), enrollment was associated with overall reductions in ED, inpatient, and behavioral health visits (p's<0.001) and increases in primary care (p's<0.001). Temporal patterns of ED visits, hospitalizations, and behavioral health differed across IPC subgroups (interaction p's<0.001). For those with histories of high ED use (n=265), ED, inpatient, and behavioral health visits decreased after enrollment (level change incidence rate ratios [IRRs]=0.57-0.69) and continued to decline over time (post-enrollment IRRs=0.80-0.88). Among other patients with homeless experiences (n=123), there were initial declines in hospitalizations (IRR=0.33) and overall declines in behavioral health visits (level change and post-enrollment IRRs=0.46-0.94). Other patients with SUDs had initial declines in hospitalizations (IRR=0.46), and post-enrollment declines in rates of specialty SUD visits (IRR=0.92). For all patients, primary care visits initially increased (level change IIRs=2.47-1.34) then gradually declined (post-enrollment IRRs=0.92-0.92). CONCLUSIONS: An IPC model of care reduces acute care and behavioral health service use, particularly for patients with historically high ED use. IPC models may improve patient and system outcomes of vulnerable patient populations with social, clinical, and addiction morbidities.
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Transtornos Relacionados ao Uso de Substâncias , Veteranos , Humanos , Determinantes Sociais da Saúde , Serviços de Saúde , Atenção à Saúde , Serviço Hospitalar de Emergência , Transtornos Relacionados ao Uso de Substâncias/epidemiologia , Transtornos Relacionados ao Uso de Substâncias/terapia , Atenção Primária à SaúdeRESUMO
Previous reports suggest race/ethnic and sex heterogeneity in the association between the Pro12Ala polymorphism of the peroxisome proliferator-activated receptor gamma (PPARG) gene and cognitive decline. Tests of verbal memory, processing speed, and verbal fluency and a composite global Z-score were used to assess cognitive performance longitudinally in a large (n=11,620) biracial cohort of older adults in the Atherosclerosis Risk in Communities Neurocognitive Study from midlife to older age. Linear mixed models were used to estimate associations between the Ala12 allele and cognitive performance over 20 years of follow-up. Heterogeneity was present for rate of cognitive decline as measured by the global Z-score by race, sex, and Ala12 allele status (P=0.01 for 4-way interaction term: race×sex×time×Ala12 carrier status). Stratified analysis showed a significantly increased rate of global cognitive decline over the 20-year follow-up for carriers of the Ala12 allele compared with noncarriers among black male individuals (-0.92 SD decline vs. -0.57 SD; P=0.02) but not among black female, white male, or white female individuals. Decline in global cognitive function among black male Ala12 carriers was primarily driven by decline in verbal memory. Our data underscore the context-dependent association between the Pro12Ala polymorphism and cognitive decline, specifically race/ethnic background and sex.
Assuntos
Negro ou Afro-Americano/genética , Disfunção Cognitiva/genética , PPAR gama/genética , Polimorfismo Genético , População Branca/genética , Negro ou Afro-Americano/estatística & dados numéricos , Alelos , Envelhecimento Cognitivo , Disfunção Cognitiva/diagnóstico , Disfunção Cognitiva/etnologia , Feminino , Predisposição Genética para Doença , Genótipo , Humanos , Estudos Longitudinais , Masculino , Pessoa de Meia-Idade , Testes Neuropsicológicos , Estudos Prospectivos , Fatores Sexuais , População Branca/estatística & dados numéricosRESUMO
Objective: We investigated the association between the peroxisome proliferator-activated receptor (PPAR)-gamma Pro12Ala polymorphism and cognitive decline in older adults. Methods: Participants from a population-based cohort of older Hispanic and non-Hispanic white adults (n = 492) were administered the Mini Mental State Examination (MMSE), a multi-domain cognitive screening tool, and the Behavioral Dyscontrol Scale (BDS), a measure of executive cognitive function, at baseline and at follow-up, an average of 22 months later. Multiple linear regression was used to investigate the association between the two cognitive test scores and the Pro12Ala polymorphism. Results: At baseline, presence of the Ala12 allele was not significantly associated with MMSE score (P = 0.62) nor with BDS score (P = 0.85). Heterogeneity was present for cognitive decline as measured by the MMSE among ethnic, sex and Ala12 allele status (P = 0.04 for three-way interaction term). Stratification by the cross-classification of sex and ethnicity revealed significantly greater declines in MMSE score among male Hispanic carriers of the Ala12 allele compared to male Hispanic non-carriers (decline = 4.0 versus 1.6 points; P = 0.02). A significant difference in decline between Ala12 carriers and non-carriers was not present among the other sex/ethnic groups. Conclusions: Carriers of the PPAR-γ Ala12 allele showed greater cognitive decline compared to non-carriers as detected by the MMSE but the risk varied across sex and ethnic groups. Male Ala12 carriers of Hispanic origin may be a high-risk group for cognitive decline.
Assuntos
Transtornos Cognitivos/genética , Cognição , Envelhecimento Cognitivo/psicologia , Hispânico ou Latino/genética , PPAR gama/genética , Polimorfismo de Nucleotídeo Único , População Branca/genética , Fatores Etários , Idoso , Idoso de 80 Anos ou mais , Transtornos Cognitivos/diagnóstico , Transtornos Cognitivos/etnologia , Transtornos Cognitivos/psicologia , Feminino , Frequência do Gene , Predisposição Genética para Doença , Humanos , Modelos Lineares , Masculino , Testes de Estado Mental e Demência , Pessoa de Meia-Idade , Análise Multivariada , Fenótipo , Fatores de Risco , Fatores SexuaisRESUMO
OBJECTIVES: To evaluate growth patterns of ambulatory males with Duchenne muscular dystrophy (DMD) treated with corticosteroids compared with ambulatory, steroid-naïve males with DMD and age-matched unaffected general-population males and to test associations between growth and steroid treatment patterns among treated males. STUDY DESIGN: Using data from the Muscular Dystrophy Surveillance, Tracking, and Research Network, we identified a total of 1768 height, 2246 weight, and 1755 body mass index (BMI) measurements between age 2 and 12 years for 324 ambulatory males who were treated with corticosteroids for at least 6 months. Growth curve comparisons and linear mixed-effects modeling, adjusted for race/ethnicity and birth year, were used to evaluate growth and steroid treatment patterns (age at initiation, dosing interval, duration, cumulative dose). RESULTS: Growth curves for ambulatory males treated with corticosteroids showed significantly shorter stature, heavier weight, and greater BMI compared with ambulatory, steroid-naïve males with DMD and general-population US males. Adjusted linear mixed-effects models for ambulatory males treated with corticosteroids showed that earlier initiation, daily dosing, longer duration, and greater dosages predicted shorter stature with prednisone. Longer duration and greater dosages predicted shorter stature for deflazacort. Daily prednisone dosing predicted lighter weight, but longer duration, and greater dosages predicted heavier weight. Early initiation, less than daily dosing, longer duration, and greater doses predicted greater BMIs. Deflazacort predicted shorter stature, but lighter weight, compared with prednisone. CONCLUSION: Prolonged steroid use is significantly associated with short stature and heavier weight. Growth alterations associated with steroid treatment should be considered when making treatment decisions for males with DMD.
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Estatura/efeitos dos fármacos , Peso Corporal/efeitos dos fármacos , Glucocorticoides/efeitos adversos , Distrofia Muscular de Duchenne/tratamento farmacológico , Prednisona/efeitos adversos , Pregnenodionas/efeitos adversos , Adolescente , Índice de Massa Corporal , Estudos de Casos e Controles , Criança , Pré-Escolar , Relação Dose-Resposta a Droga , Glucocorticoides/administração & dosagem , Humanos , Masculino , Prednisona/administração & dosagem , Pregnenodionas/administração & dosagemRESUMO
PURPOSE: A high prevalence of chronic pain and high rates of polypharmacy among older adults suggest that this age group may be particularly susceptible to unintentional misuse of prescription opioids. We examined recent trends in misuse of prescription opioids and associated medical outcomes among older-aged adults (60+ years) and compared the patterns with trends among younger-aged adults (20-59 years). METHODS: Linear regression trend analysis was used to analyze 57 681 misuse cases reported to participating US poison centers during 2006-2014. RESULTS: Population rates of misuse of prescription opioids were higher for older adults than for younger adults, and this disparity increased over time. Rates among the older ages increased each year, although the rate of increase slowed over time (p < 0.0001 for negative quadratic trend). In contrast, among the younger adults, there was a significant negative quadratic trend in population rates (p < 0.0001) with a rise in rates during 2006-2010 followed by a decline during 2011-2014. Rates of serious medical outcomes among the older ages followed an increasing linear trend (p < 0.0001); in contrast, rates among younger adults rose and fell during the period, with recent rates trending downward (p < 0.0001 for quadratic trend). CONCLUSIONS: Recent increases in rates of misuse of prescription opioids and associated unfavorable medical outcomes among older adults have important implications as the USA undergoes a rapid expansion of its elderly population. Copyright © 2015 John Wiley & Sons, Ltd.
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Analgésicos Opioides/intoxicação , Transtornos Relacionados ao Uso de Opioides/epidemiologia , Uso Indevido de Medicamentos sob Prescrição/estatística & dados numéricos , Adulto , Fatores Etários , Idoso , Analgésicos Opioides/administração & dosagem , Dor Crônica/tratamento farmacológico , Feminino , Humanos , Modelos Lineares , Masculino , Pessoa de Meia-Idade , Centros de Controle de Intoxicações , Polimedicação , Prevalência , Fatores de Tempo , Estados Unidos/epidemiologia , Adulto JovemRESUMO
OBJECTIVES: The gestation-adjusted projection method extrapolates birth weight using third-trimester sonography. This technique is shown to be more accurate for sonographic examinations from 34 weeks to 36 weeks 6 days than 37 weeks to 38 weeks 6 days. Our objective was to determine whether even earlier sonographic examinations (31 weeks-33 weeks 6 days) further improves birth weight prediction in patients with diabetes. METHODS: We conducted a retrospective cohort analysis of 388 pregnant women with pregestational or gestational diabetes who delivered at 37 weeks or later and had a sonographic examination performed between 31 weeks and 36 weeks 6 days. Sonographic examinations were categorized as "early" if performed at 31 weeks to 33 weeks 6 days or "late" if performed at 34 weeks to 36 weeks 6 days. We estimated birth weight using the gestation-adjusted projection method, compared errors in prediction of birth weight using the t test and Mann-Whitney U test, and performed a 2-sample test of proportions to compare prediction of macrosomia (birth weight >4000 g). RESULTS: The early and late groups had similar mean gestational ages at birth (38 weeks 4 days versus 38 weeks 5 days; P = .13) and rates of macrosomia (10.7% versus 12.4%; P = .63). The early group had a greater mean absolute error (336 versus 297 g; P = .03) and percent error (9.9% versus 7.9%; P = .01) in birth weight prediction but a lower mean birth weight (3303 versus 3426 g; P = .02). Sensitivity for prediction of macrosomia was 19% in the early group versus 45% in the late group (P = .07), whereas specificity was similar (98% versus 96%; P = .27). CONCLUSIONS: Using the gestation-adjusted projection method in our patients with diabetes, we found that sonographic examinations performed at 34 weeks to 36 weeks 6 days better predicted birth weight than those performed at 31 weeks to 33 weeks 6 days.
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Diabetes Gestacional/diagnóstico por imagem , Peso Fetal , Ultrassonografia Pré-Natal/métodos , Adulto , Peso ao Nascer , Estudos de Coortes , Feminino , Humanos , Gravidez , Complicações na Gravidez , Terceiro Trimestre da Gravidez , Estudos Retrospectivos , Fatores de TempoRESUMO
OBJECTIVE: The purpose of this study was to examine associations between the prepregnancy maternal body mass index (BMI) across the 3 clinical presentations of preterm birth (PTB). STUDY DESIGN: We conducted a retrospective cohort study of the records of 11,726 women. The World Health Organization International Classification was used to categorize BMI. The primary outcome of the study was PTB (<37 weeks' gestation) presenting as spontaneous preterm labor, preterm premature rupture of the membranes, or a medical indication. We used univariable and multivariable logistic regression analysis to analyze the data (P < .05). RESULTS: We found (1) a significant increase in the overall incidence of PTB at the extremes of BMI, (2) a higher risk for PTB from spontaneous preterm labor at the lower extremes (low plus moderate thinness) of BMI (adjusted odds ratio [aOR], 2.4; 95% confidence interval [CI], 1.4-4.2; P = .003), (3) a higher risk for preterm premature rupture of the membranes at the upper extremes (obese class II plus III) of BMI (aOR, 1.6; 95% CI, 1.1-2.3; P = .02), and (4) a higher risk for a medically indicated PTB at the lower (aOR, 2.8; 95% CI, 1.4-5.6; P = .004) and upper (aOR, 1.5; 95% CI, 1.1-2.2; P = .02) extreme of BMI. CONCLUSION: Women at the extremes of prepregnancy BMI are at risk for PTB.
Assuntos
Índice de Massa Corporal , Resultado da Gravidez , Nascimento Prematuro/epidemiologia , Adulto , Feminino , Ruptura Prematura de Membranas Fetais/epidemiologia , Humanos , Incidência , Modelos Logísticos , Trabalho de Parto Prematuro/epidemiologia , Gravidez , Estudos Retrospectivos , Fatores de RiscoRESUMO
OBJECTIVE: To provide weight-for-age, height-for-age, and body mass index-for-age growth reference standards for ambulatory, steroid-naïve males, ages 2-12 years, with Duchenne muscular dystrophy (DMD) and to compare these growth curves to the 2000 Centers for Disease Control and Prevention growth charts for boys, which serve as references of physical size and growth for the general male pediatric population in the US. STUDY DESIGN: Through a multi-state population-based surveillance of individuals with muscular dystrophy, a total of 1877 weight and 1544 height measurements ascertained during 1985-2010 from 513 males with DMD were obtained retrospectively from medical record review. Cases were classified as DMD if loss of ambulation occurred before the 12th birthday or, if younger than 12 years and still ambulating, the earliest symptoms of dystrophinopathy occurred before the 6th birthday. Each growth chart was constructed using 5 percentiles: 10th, 25th, 50th, 75th, and 90th. Smoothing procedures were applied in 2 stages to the irregular plots of the empirical percentile values. RESULTS: A set of growth curves, derived from a large cohort of male youth with DMD, are presented. These curves demonstrate that DMD males are shorter and tend to the extremes of weight and body mass index compared with the general male pediatric population in the US. CONCLUSION: Charts representing the pattern of growth in ambulatory, steroid-naïve males with DMD can facilitate monitoring of growth and early detection of unusual growth patterns. Use of these growth standards also will assist in monitoring responses to corticosteroid treatment.
Assuntos
Crescimento , Distrofia Muscular de Duchenne/fisiopatologia , Estatura , Índice de Massa Corporal , Peso Corporal , Criança , Pré-Escolar , Humanos , Masculino , Estudos RetrospectivosRESUMO
OBJECTIVE: To estimate the age when cardiomyopathy develops in boys with Duchenne muscular dystrophy (DMD) and to analyze the effect of corticosteroid treatment on the age of cardiomyopathy onset. STUDY DESIGN: We identified a population-based sample of 462 boys with DMD, born between 1982 and 2005, in 5 surveillance sites in the US. Echocardiographic and corticosteroid treatment data were collected. Cardiomyopathy was defined by a reduced fractional shortening (<28%) or ejection fraction (<55%). The age of cardiomyopathy onset was determined. Survival analysis was performed to determine the effects of corticosteroid treatment on cardiomyopathy onset. RESULTS: The mean (SD) age of cardiomyopathy onset was 14.3 (4.2) years for the entire population and 15.2 (3.4) years in corticosteroid-treated vs 13.1 (4.8) in non-treated boys. Survival analysis described a significant delay of cardiomyopathy onset for boys treated with corticosteroids (P < .02). By 14.3 years of age, 63% of non-treated boys had developed cardiomyopathy vs only 36% of those treated. Among boys treated with corticosteroids, there is a significant positive effect of duration of corticosteroid treatment on cardiomyopathy onset (P < .0001). For every year of corticosteroid treatment, the probability of developing cardiomyopathy decreased by 4%. CONCLUSIONS: Oral corticosteroid treatment was associated with delayed cardiomyopathy onset. The duration of corticosteroid treatment also correlated positively with delayed cardiomyopathy onset. Our analysis suggests that a boy with DMD treated for 5 years with corticosteroids might experience a 20% decrease in the likelihood of developing cardiomyopathy compared with untreated boys.
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Corticosteroides/uso terapêutico , Cardiomiopatias/epidemiologia , Distrofia Muscular de Duchenne/complicações , Distrofia Muscular de Duchenne/tratamento farmacológico , Administração Oral , Adolescente , Corticosteroides/administração & dosagem , Idade de Início , Cardiomiopatias/complicações , Cardiomiopatias/tratamento farmacológico , Criança , Pré-Escolar , Ecocardiografia , Humanos , Masculino , Análise de Regressão , Fatores de Tempo , Resultado do TratamentoRESUMO
OBJECTIVE: We hypothesized that women who are obese before they become pregnant and also have elevations of complement Bb and C3a in the top quartile in early pregnancy would have the highest risk of preeclampsia compared with a referent group of women who were not obese and had levels of complement less than the top quartile. STUDY DESIGN: This was a prospective study of 1013 women recruited at less than 20 weeks' gestation. An EDTA-plasma sample was obtained, and complement fragments were measured using enzyme-linked immunosorbent assays. The data were analyzed using univariable and multivariable logistic regression analysis. RESULTS: Women who were obese with levels of Bb or C3a in the top quartile were 10.0 (95% confidence interval, 3.3-30) and 8.8 (95% confidence interval, 3-24) times, respectively, more likely to develop preeclampsia compared with the referent group. CONCLUSION: We demonstrate a combined impact of obesity and elevated complement on the development of preeclampsia.
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Ativação do Complemento , Complemento C3a/metabolismo , Fator B do Complemento/metabolismo , Obesidade/complicações , Pré-Eclâmpsia/etiologia , Adulto , Biomarcadores/sangue , Índice de Massa Corporal , Ensaio de Imunoadsorção Enzimática , Feminino , Humanos , Modelos Logísticos , Análise Multivariada , Obesidade/sangue , Obesidade/imunologia , Pré-Eclâmpsia/sangue , Pré-Eclâmpsia/imunologia , Gravidez , Estudos ProspectivosRESUMO
INTRODUCTION: There is a paucity of data exploring the extent that preclinical cognitive changes are predictive of subsequent sleep outcomes. METHODS: Logistic regression models were used to evaluate data from a cohort of 196 African American adults who had measures of cognitive function assessed at 2 time points during a 20-year period across the mid- to late-life transition. Cognitive testing included the Delayed Word Recall, the Digit Symbol Substitution, and the Word Fluency tests, which were summarized as a composite cognitive z-score. Sleep apnea was measured by in-home sleep apnea testing and sleep duration and quality were derived from 7-day wrist actigraphy at the end of the study period. RESULTS: A one standard deviation (SD) lower composite cognitive z-score at baseline was significantly associated with greater odds of low sleep efficiency (<85%) (odds ratio [OR] = 1.85, 95% confidence interval [CI] = 1.13, 3.04) and greater odds of increased wakefulness after sleep onset time (WASO; >60 minutes) (OR = 1.65, 95% CI = 1.05, 2.60) in adjusted models. A one SD faster rate of cognitive decline over the study period was significantly associated with greater odds of low sleep efficiency (OR = 1.68, 95% CI = 1.04, 2.73), greater odds of sleep fragmentation (>35%); (OR = 1.73, 95% CI = 1.05, 2.85), and greater odds of increased WASO (OR = 1.85, 95% CI = 1.15, 2.95) in adjusted models. Neither baseline cognitive z-score nor rate of cognitive decline was associated with sleep apnea or the total average sleep duration. CONCLUSION: Cognition at baseline and change over time predicts sleep quality and may reflect common neural mechanisms and vulnerabilities.
Assuntos
Transtornos do Sono-Vigília , Actigrafia , Adulto , Cognição , Humanos , Testes Neuropsicológicos , Sono , Transtornos do Sono-Vigília/psicologiaRESUMO
CONTEXT: The independent contribution of young adult exposure to overweight and obesity to later-life incident diabetes is not well studied. OBJECTIVE: To assess the associations of exposures to elevated body mass index (BMI) and waist circumference (WC) in young adulthood (ages 18-39 years) with incident diabetes later in life (≥40 years). DESIGN: Pooled data from 6 US prospective cohorts (Atherosclerosis Risk in Communities Study, Cardiovascular Risk Development in Young Adults Study, Cardiovascular Health Study, (4) Framingham Heart Study Offspring Cohort, (5) Health, Aging and Body Composition Study, and (6) Multi-Ethnic Study of Atherosclerosis. SETTING: Population-based cohort studies. PARTICIPANTS: 30 780 participants (56.1% female, 69.8% non-Hispanic white) without a diagnosis of diabetes by age 40. INTERVENTIONS: We imputed BMI and WC trajectories from age 18 for every participant and estimated time-weighted average exposures to BMI or WC during young adulthood and later life. MAIN OUTCOME MEASURE(S): Incident diabetes defined as fasting glucose ≥126 mg/dL, nonfasting glucose ≥200 mg/dL, or use of diabetes medications. RESULTS: During a 9-year median follow-up, 4323 participants developed incident diabetes. Young adult BMI and WC were associated with later-life incident diabetes after controlling for later-life exposures [hazard ratios (HR) 1.99 for BMIâ ≥â 30 kg/m2 and 2.13 for WCâ >â 88cm (women)/>102cm (men) compared to normal ranges]. Young adult homeostatic model of insulin resistance mediated 49% and 44% of the association between BMI and WC with later-life incident diabetes. High-density lipoproteins and triglycerides mediated a smaller proportion of these associations. CONCLUSIONS: Elevated BMI and WC during young adulthood were independently associated with later-life incident diabetes. Insulin resistance may be a key mediator.
Assuntos
Biomarcadores/sangue , Índice de Massa Corporal , Diabetes Mellitus/epidemiologia , Obesidade/fisiopatologia , Sobrepeso/fisiopatologia , Circunferência da Cintura , Adolescente , Adulto , Diabetes Mellitus/sangue , Diabetes Mellitus/patologia , Feminino , Seguimentos , Humanos , Masculino , Prognóstico , Estudos Prospectivos , Fatores de Risco , Estados Unidos/epidemiologia , Adulto JovemRESUMO
BACKGROUND/OBJECTIVE: Inflammation is implicated in cognitive decline; however, there is a paucity of data for African American populations and for sex-specific associations. DESIGN: Prospective cohort study. SETTING: Genetic Epidemiology Network of Arteriopathy/Genetics of Microangiopathic Brain Injury studies. PARTICIPANTS: African-American sibships (N = 1010). MEASUREMENTS: Neurocognitive tests assessed global cognition and four cognitive domains: processing speed, memory, language, and executive function at two time points over seven years. Circulating levels of C-reactive protein (CRP), interleukin-6 (IL-6), and tumor necrosis factor receptor (TNFR)-1 and TNFR2 were measured at study baseline. Linear mixed models were used to investigate the association between inflammation markers and cognitive decline. RESULTS: Among men, a one SD increase in CRP was associated with an increased rate of decline over 7 years in global cognitive Z-score (adjusted difference in slopes = -0.31, p = 0.006) and in processing speed Z-score (adjusted difference in slopes = -0.10, p = 0.02), but not declines in memory, language, or executive function Z-scores. Also among men, a one SD increase in IL-6 was associated with an increased decline rate in global cognitive Z-score (adjusted difference in slopes = -0.33, p = 0.002) and in processing speed Z-score (adjusted difference in slopes = -0.12, p = 0.007). There was no difference in decline rates by CRP or IL-6 level in adjusted analyses among women for any cognitive scores. Among men and women combined, a one SD increase in baseline sTNFR1 was associated with a faster rate of decline in memory Z-score (adjusted difference in slopes = -0.09, p = 0.02). Baseline sTNFR2 levels did not significantly predict rate of cognitive decline in any cognitive domains. CONCLUSIONS: Circulating markers of CRP and IL-6 may be differential risk factors for men and women in relation to cognitive decline. A novel inflammation marker, sTNFR1, may be a useful predictor of memory decline in older adults.
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Disfunção Cognitiva , Idoso , Biomarcadores , Proteína C-Reativa/análise , Cognição , Disfunção Cognitiva/diagnóstico , Feminino , Humanos , Inflamação , Masculino , Testes Neuropsicológicos , Estudos ProspectivosRESUMO
INTRODUCTION: Elevated serum uric acid (SUA) is associated with cardiovascular risk factors, which often contribute to dementia and dementia-like morbidity, yet several cross-sectional studies have shown protective associations with cognition, which would be consistent with other work showing benefits of elevated SUA through its antioxidant properties. METHODS: We studied 11,169 participants free of dementia and cardiovascular disease from the Atherosclerosis Risk in Communities (ARIC) cohort. SUA was measured in blood samples collected in 1990-92, baseline for this study (age range 47-70â¯years). Incident dementia was ascertained based on clinical assessments in 2011-13 and 2016-17, surveillance based on dementia screeners conducted over telephone interviews, hospitalization discharge codes, and death certificates. Cognitive function was assessed up to four times between 1990 and 92 and 2016-17. We estimated the association of SUA, categorized into quartiles, with incidence of dementia using Cox regression models adjusting for potential confounders. The association between cognitive decline and SUA was assessed using generalized estimating equations. RESULTS: Over a median follow-up period of 24.1â¯years, 2005 cases of dementia were identified. High baseline SUA was associated with incident dementia (HR, 1.29; 95% CI, 1.12, 1.47) when adjusted for sociodemographic variables. However, after further adjustment including cardiovascular risk factors, this relationship disappeared (HR, 1.03; 95% CI, 0.88, 1.21). Elevated baseline SUA was associated with faster cognitive decline even after further adjustment (25-year global z-score difference, -0.149; 95% CI, -0.246, -0.052). CONCLUSION: Higher levels of mid-life SUA were associated with faster cognitive decline, but not necessarily with higher risk of dementia.
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Aterosclerose , Disfunção Cognitiva , Demência , Idoso , Disfunção Cognitiva/epidemiologia , Estudos Transversais , Demência/epidemiologia , Humanos , Pessoa de Meia-Idade , Fatores de Risco , Ácido ÚricoRESUMO
OBJECTIVE: To examine the association between neuroimaging features in a predominantly middle-aged cohort and risk of late-life dementia. METHODS: Cerebral MRI was performed on 1,881 individuals with no history of stroke from the Atherosclerosis Risk in Communities Study cohort in 1993 to 1995. White matter hyperintensities (WMH), ventricular size, and sulcal size were graded on a semiquantitative scale, and presence of silent cerebral infarcts was identified. In 2011 to 2013, dementia was determined from neuropsychological testing, informant interview, hospital ICD-9 codes, and death certificate dementia codes. Cox regression was used to evaluate associations between MRI findings and dementia. RESULTS: Over 20 years of follow-up, dementia developed in 279 participants (14.8%). High-grade WMH and high-grade ventricular size were independently associated with increased dementia risk (hazard ratio [HR] for WMH 1.62, 95% confidence interval [CI] 1.14-2.30; HR for ventricular size 1.46, 95% CI 1.06-2.03). There was an increased risk of dementia for diabetic participants with silent infarcts (HR 2.56, 95% CI 1.23-5.31) but not among nondiabetic participants (HR 0.87, 95% CI 0.56-1.37). Each 1-unit increase in the total number of high-grade cerebral abnormalities at baseline (count values range 0-4) showed increased dementia risk, with a considerably higher risk among diabetic participants (HR for diabetes mellitus 1.97, 95% CI 1.44-2.69; HR for no diabetes mellitus 1.20, 95% CI 1.03-1.39). CONCLUSION: In adults without evidence of clinical stroke, MRI-detected WMH and ventricular enlargement in midlife may represent markers of brain injury that increase risk for later-life cognitive impairment. The presence of diabetes mellitus may modify the association between silent infarcts and dementia.
Assuntos
Encéfalo/diagnóstico por imagem , Infarto Cerebral/diagnóstico por imagem , Demência/epidemiologia , Idoso , Idoso de 80 Anos ou mais , Encéfalo/patologia , Infarto Cerebral/epidemiologia , Ventrículos Cerebrais/diagnóstico por imagem , Ventrículos Cerebrais/patologia , Estudos de Coortes , Diabetes Mellitus/epidemiologia , Feminino , Humanos , Imageamento por Ressonância Magnética , Masculino , Pessoa de Meia-Idade , Neuroimagem , Tamanho do Órgão , Modelos de Riscos Proporcionais , Fatores de Risco , Substância Branca/diagnóstico por imagem , Substância Branca/patologiaRESUMO
BACKGROUND: The metabolic syndrome (MetS) is highly prevalent in the growing U.S. Latino population. We hypothesize that MetS, with or without diabetes, is associated with progressive disability in older Mexican Americans. METHODS: Data from Mexican Americans 60-98 years old participating in the Sacramento Area Latino Study on Aging (SALSA) were analyzed from baseline through 3 years (3 years of follow-up). Disability was assessed by self-reported limitations in activities of daily living (ADLs), instrumental ADLs (IADLs), and mobility/strength tasks. MetS (46% of sample) was defined by National Cholesterol Education Program (NCEP) Adult Treatment Panel III criteria. Diabetes (DM, 33%) was defined by fasting blood sugar>125 mg/dL, physician diagnosis, and/or medication use. Four metabolic groups were defined: MetS with diabetes (MetS+DM+, n=402); MetS without diabetes (MetS+DM-, n=330); diabetes without MetS (MetS-DM+, n=125); and neither (MetS-DM-, n=749). Generalized estimating equation (GEE) regression models were used to evaluate the effect of metabolic group on physical limitations and disability changes over time. RESULTS: Diabetes, with or without MetS, was associated with a higher percent rate of increase over 3 years in ADL and IADL disability than was no diabetes, even after controlling for demographics, body mass index (BMI), and incident disease. The mean ADL score had a 35% higher rate of increase (higher = more impairment) for the MetS+DM+ group and 68% higher for the MetS-DM+ group. Results for IADL were similar. The baseline MetS, without or with diabetes, was associated with a significantly higher rate of increase in mobility/strength limitations (8% and 36.5%, respectively). CONCLUSIONS: In older Mexican Americans, MetS is associated with progressive limitations in mobility and strength. Preventing progressive mobility/strength limitations may require assessing and treating these impairments in people with MetS regardless of the presence of diabetes. However, preventing the progression of MetS without to MetS with diabetes may be important to limit the progression of ADL and IADL disability found in people with MetS and diabetes.
Assuntos
Diabetes Mellitus Tipo 2/complicações , Pessoas com Deficiência , Síndrome Metabólica/complicações , Americanos Mexicanos , Atividades Cotidianas , Idoso , Idoso de 80 Anos ou mais , Índice de Massa Corporal , Feminino , Humanos , Masculino , Pessoa de Meia-IdadeRESUMO
OBJECTIVE: To evaluate whether fetal brain lateral ventricle measurements differ between ultrasound (US) and MRI. METHODS: We evaluated 115 fetuses with US and MRI performed within 24 h of each other. Ventricular measurements were performed in the axial plane at the level of the atria for both modalities and the right and left ventricles were evaluated separately. We compared mean measurements; mean differences, association with gestational age (GA), association with the presence of a brain anomaly, and agreement between MRI and US. RESULTS: The LV and RV were measured in 65 and 64 cases, respectively. LV and RV size estimates were significantly greater when measured by MRI compared with US (p < 0.001). Therefore, LV and RV were 0.87 mm and 0.89 mm larger in MRI versus US, respectively. Neither GA at measurement or presence/absence of a brain anomaly was significantly associated with differences in measurements. When comparing the agreement between the US and MRI measurements for ventriculomegaly; the kappa level of agreement for the LV and RV was 0.74 for each. CONCLUSION: MRI measurements of ventricles are significantly larger than the measurements by US by â¼1 mm. There is a good level of agreement when categorizing by normal, mild and severe ventriculomegaly.
Assuntos
Hidrocefalia/diagnóstico por imagem , Ventrículos Laterais/diagnóstico por imagem , Imageamento por Ressonância Magnética , Ultrassonografia Pré-Natal , Feminino , Humanos , Hidrocefalia/embriologia , Ventrículos Laterais/embriologia , Gravidez , Estudos RetrospectivosRESUMO
OBJECTIVES: To examine associations between adiposity and adiposity change (loss, stable, gain) and subsequent longitudinal cognitive performance in African Americans in mid and late life. DESIGN: Cohort study using linear mixed models. SETTING: Genetic Epidemiology Network of Arteriopathy. PARTICIPANTS: African-American sibships with hypertension in Jackson, Mississippi (N = 1,108). MEASUREMENTS: Waist circumference and body mass index (BMI) were measured at two examinations 5 years apart. Stable adiposity was defined as values within 5% of the first measure. A composite cognitive Z-score was derived from individual cognitive test Z-scores at two study visits 6 years apart. RESULTS: Larger waist circumference was associated with greater rate of cognitive decline during follow-up (beta = -0.0009 per year, P = .001); BMI, change in waist circumference, and change in BMI were not associated with rate of decline. Loss of adiposity in midlife was associated with higher cognitive Z-scores in middle-aged individuals, and loss of adiposity in late life was associated with lower Z-scores in older adults (P = .01 for interaction between waist circumference and age; P = .04 for interaction between BMI and age). Simultaneous inclusion of waist circumference and BMI in the cross-sectional model suggested an association between larger waist circumference and poorer cognitive performance (beta = -0.009, P = .006) and between higher BMI and better cognitive performance (beta = 0.014, P = .06). CONCLUSION: The results suggested a differential pattern of the relationship between adiposity and cognition according to age (mid- or late life) and regional distribution of adiposity.
Assuntos
Adiposidade , Disfunção Cognitiva/epidemiologia , Aumento de Peso , Redução de Peso , Negro ou Afro-Americano/estatística & dados numéricos , Índice de Massa Corporal , Disfunção Cognitiva/etnologia , Estudos de Coortes , Estudos Transversais , Feminino , Humanos , Hipertensão/diagnóstico , Estudos Longitudinais , Masculino , Pessoa de Meia-Idade , Mississippi , Testes Neuropsicológicos , Circunferência da Cintura/fisiologiaRESUMO
PROBLEM: To determine the understudied relationship between complement Bb during pregnancy in subjects with preeclampsia compared with normotensive controls. METHOD OF STUDY: Nested case-control study. RESULTS: Average Bb levels significantly decreased over time in pregnancy [weekly slope (S.E.): -0.0094 (0.0005), P < 0.01]. Cross-sectionally, at less than 10 weeks, Bb levels decreased with increasing gestational age in women who remained normotensive [weekly slope (S.E.): -0.007 (0.02) and for women who developed preeclampsia (weekly slope (S.E.): -0.059 (0.03) P = 0.12]. Among women who developed preeclampsia, Bb levels were greatest when samples were drawn in the gestational window of 15-20 weeks [(weekly slope (S.E.): 0.06 (0.02)], while levels among normotensive women were inversely related with gestational age [weekly slope (S.E.): -0.02 (0.01)]. The differences in slopes between cases and controls between 10 and 21 weeks' gestation were statistically significant (P = 0.003). CONCLUSIONS: We suggest dysregulation of Bb activation between 10 and 20 weeks' gestation in women who develop preeclampsia.
Assuntos
Fator B do Complemento/análise , Pré-Eclâmpsia/sangue , Adulto , Estudos de Casos e Controles , Feminino , Humanos , Pré-Eclâmpsia/epidemiologia , Gravidez , Adulto JovemRESUMO
This study examines trends in corticosteroid use for males with Duchenne muscular dystrophy by birth year, race/ethnicity, and knowledge of Duchenne muscular dystrophy family history. Firstborn males (n = 521) selected from a population-based surveillance system of Duchenne muscular dystrophy were analyzed using Kaplan Meier and regression methods. Comparing males born 1982 to 1986 with males born 1997 to 2001, steroid use increased from 54% to 72% and mean age at steroid initiation decreased from 8.2 to 7.1 years. Hispanics and non-Hispanic Black males used steroids less frequently and delayed initiation compared to white males. Compared to males without a Duchenne muscular dystrophy family history, males with known family history were half as likely to use steroids. Duration of steroid use increased over time and age at initiation decreased. Racial/ethnic disparities exist for steroid use and should be addressed to improve outcome and quality of life for boys with Duchenne muscular dystrophy.