Efeitos do D-limoneno no metabolismo energético de camundongos C57/Bl6 com obesidade induzida pela dieta / Effects of D-limonene on the energy metabolism of C57/Bl6 mice with diet-induced obesity

A obesidade está associada ao desenvolvimento de doenças crônicas não transmissíveis como hipertensão, resistência insulínica, dislipidemia e esteatose hepática. O consumo de compostos bioativos impacta na manutenção da saúde e na prevenção de risco de desenvolvimento dessas doenças. Entre os compostos bioativos, os monoterpenos são pouco investigados, apesar da literatura demonstrar efeitos promissores desses compostos sobre o metabolismo. O D-limoneno, o principal monoterpeno encontrado na laranja, é caracterizado por possuir efeitos hipolipemiantes, anti-inflamatórios e anti-obesogênicos. Estudos in vitro e in vivo descrevem sua capacidade de promover a ß-oxidação de ácidos graxos em adipócitos e redução da inflamação. Este estudo teve como objetivo investigar o efeito do D-limoneno no metabolismo e inflamação em um modelo de obesidade induzida por dieta. Para isso, quarenta camundongos machos (C57/Bl6) de 11 semanas de idade, foram distribuídos em 4 grupos, sendo que um dos grupos recebeu ração normolipídica e os demais, ração hiperlipídica. O D-limoneno foi suplementado na ração de dois grupos que receberam dieta hiperlipídica nas concentrações de 0,1%, e 0,8%. Considerando-se a ingestão alimentar dos animais, a ração suplementada com 0,1% D-limoneno correspondeu à ingestão de 0,15 g/kg/dia e ração com 0,8% de D-limoneno correspondeu a 1,3 g/kg/dia. Os animais tiveram o peso e a ingestão alimentar monitorados ao longo da intervenção com duração de 7 semanas. Os camundongos que receberam D-limoneno a 0,1% apresentaram menor ganho de peso e de acúmulo de tecido adiposo, comparado com os animais sem suplementação alimentados com a dieta hiperlipídica. Além disso, o D-limoneno promoveu a diminuição da concentração plasmática de marcadores inflamatórios incluindo TNF-α, INF-γ e IL-6 nos animais dos grupos que foram suplementados com D-limoneno. Entretanto, não houve diferença nos marcadores bioquímicos e metabólicos. Uma limitação do estudo foi o fato das complicações metabólicas associadas ao modelo de obesidade não terem sido plenamente estabelecidas, dados o alojamento individual, à curta duração da exposição à ração hiperlipídica e idade dos animais no início da suplementação. Esse fato pode ter dificultado a observação dos efeitos do D-limoneno na reversão dos parâmetros que seriam normalmente deteriorados pelo desenvolvimento da obesidade. Concluímos que o D-limoneno pode interferir no metabolismo energético, com possível efeito anti-obesogênico e anti-inflamatório. Devido às limitações do modelo, são necessários mais estudos para confirmar esses resultados

Obesity is associated with the development of chronic non-communicable diseases such as hypertension, insulin resistance, dyslipidemia, and hepatic steatosis. The intake of dietary bioactive compounds is associated with the maintenance of health and the prevention of chronic diseases. Among the group of bioactive compounds, monoterpenes are poorly investigated, in spite of several reports of their promising effects on metabolism. D-limonene is the main monoterpene found in oranges, known for its hypolipemic, anti-inflammatory, and anti-obesogenic effects. in vitro and in vivo studies associate D-limonene to increased ß-oxidation of fatty acids in adipocytes and reduced inflammation. This study aimed at investigating the effects of D-limonene on metabolism and inflammation in a diet-induced obesity model. For this purpose, forty male mice (C57/Bl6) were distributed in 4 groups, with one group receiving a normolipidic diet and the others, a high-fat diet. D-limonene was supplemented in the diets of two groups that received high-fat diet at the concentrations of 0.1% and 0.8%. Considering the feed intake, mice receiving D-limonene supplementation at 0.1% ingested in average 0.15 g/kg/day, while the mice receiving the supplemmentation at 0.8%, ingested approximately 1.3 g of D-limonene /kg/day. The animals had their weight and food intake monitored throughout the intervention. Mice that received Dlimonene supplementation at 0.1% showed reduced weight gain and accumulation of adipose tissue compared to the non-supplemented mice fed the high-fat diet. In addition, D-limonene promoted a decrease in hepatic inflammatory markers including TNF-α, INF-γ, and IL-6. However, there was no difference in biochemical and metabolic markers. A limitation of the study was that the metabolic complications associated with the obesity model were not fully established, probably due to the age at the start of the protocol (11 weeks), individual housing and short duration of the exposure to the high-fat feed. This fact may have prevented the observation of the positive effects of D-limonene in reversing parameters that would normally be impaired by the development of obesity. We conclude that D-limonene may interfere in energy metabolism, with a possible anti-obesogenic and anti-inflammatory effect. Due to the limitations of the model, further studies are needed to confirm these findings

Links Between Mortality and Socioeconomic Characteristics, Disease Burden, and Biological and Physical Functioning in the Aging Chinese Population.

OBJECTIVES: Determinants of mortality may depend on the time and place where they are examined. China provides an important context in which to study the determinants of mortality at older ages because of its unique social, economic, and epidemiological circumstances. This study uses a nationally representative sample of persons in China to determine how socioeconomic characteristics, early-life conditions, biological and physical functioning, and disease burden predict 4-year mortality after age 60. METHODS: We used data from the China Health and Retirement Longitudinal Study. We employed a series of Cox proportional hazard models based on exact survival time to predict 4-year all-cause mortality between the 2011 baseline interview and the 2015 interview. RESULTS: We found that rural residence, poor physical functioning ability, uncontrolled hypertension, diabetes, cancer, a high level of systemic inflammation, and poor kidney functioning are strong predictors of mortality among older Chinese. DISCUSSION: The results show that the objectively measured indicators of physical functioning and biomarkers are independent and strong predictors of mortality risk after accounting for several additional self-reported health measures, confirming the value of incorporating biological and performance measurements in population health surveys to help understand health changes and aging processes that lead to mortality. This study also highlights the importance of social and historical context in the study of old-age mortality.

Cross-sectional study on the prevalence of influenza and pneumococcal vaccination and its association with health conditions and risk factors among hospitalized multimorbid older patients.

BACKGROUND: Older adults with chronic conditions are at high risk of complications from influenza and pneumococcal infections. Evidence about factors associated with influenza and pneumococcal vaccination among older multimorbid persons in Europe is limited. The aim of this study was to investigate the prevalence and determinants of these vaccinations in this population. METHODS: Multimorbid patients aged ≥70 years with polypharmacy were enrolled in 4 European centers in Switzerland, Belgium, the Netherlands, and Ireland. Data on vaccinations, demographics, health care contacts, and comorbidities were obtained from self-report, general practitioners and medical records. The association of comorbidities or medical contacts with vaccination status was assessed using multivariable adjusted log-binomial regression models. RESULTS: Among 1956 participants with available influenza vaccination data (median age 79 years, 45% women), 1314 (67%) received an influenza vaccination within the last year. Of 1400 patients with available pneumococcal vaccination data (median age 79 years, 46% women), prevalence of pneumococcal vaccination was 21% (n = 291). The prevalence of vaccination remained low in high-risk populations with chronic respiratory disease (34%) or diabetes (24%), but increased with an increasing number of outpatient medical contacts. Chronic respiratory disease was independently associated with the receipt of both influenza and pneumococcal vaccinations (prevalence ratio [PR] 1.09, 95% confidence interval [CI] 1.03-1.16; and PR 2.03, 95%CI 1.22-3.40, respectively), as was diabetes (PR 1.06, 95%CI 1.03-1.08; PR 1.24, 95%CI 1.16-1.34, respectively). An independent association was found between number of general practitioner visits and higher prevalence of pneumococcal vaccination (p for linear trend <0.001). CONCLUSION: Uptake of influenza and particularly of pneumococcal vaccination in this population of European multimorbid older inpatients remains insufficient and is determined by comorbidities and number and type of health care contacts, especially outpatient medical visits. Hospitalization may be an opportunity to promote vaccination, particularly targeting patients with few outpatient physician contacts.

The Binary Model of Chronic Diseases Applied to COVID-19.

A binary model for the classification of chronic diseases has formerly been proposed. The model classifies chronic diseases as "high Treg" or "low Treg" diseases according to the extent of regulatory T cells (Treg) activity (frequency or function) observed. The present paper applies this model to severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection. The model correctly predicts the efficacy or inefficacy of several immune-modulating drugs in the treatment of severe coronavirus disease 2019 (COVID-19) disease. It also correctly predicts the class of pathogens mostly associated with SARS-CoV-2 infection. The clinical implications are the following: (a) any search for new immune-modulating drugs for the treatment of COVID-19 should exclude candidates that do not induce "high Treg" immune reaction or those that do not spare CD8+ T cells; (b) immune-modulating drugs, which are effective against SARS-CoV-2, may not be effective against any variant of the virus that does not induce "low Treg" reaction; (c) any immune-modulating drug, which is effective in treating COVID-19, will also alleviate most coinfections; and (d) severe COVID-19 patients should avoid contact with carriers of "low Treg" pathogens.

The prevalence and evidence-based management of needle fear in adults with chronic disease: A scoping review.

BACKGROUND: Little is known about the prevalence and best management of needle fear in adults with chronic disease, who may experience frequent and long-term exposure to needles for lifesaving therapies such as renal dialysis and cancer treatment. Identifying interventions that assist in management of needle fear and associated distress is essential to support these patients with repeated needle and cannula exposure. METHOD: We followed the PRISMA methodology for scoping reviews and systematically searched PsychINFO, PubMed (MEDLINE), ProQuest, Embase and grey literature and reference lists between 1989 and October 2020 for articles related to needle discomfort, distress, anxiety, fear or phobia. The following chronic diseases were included: arthritis, asthma, chronic back pain, cancer, cardiovascular disease, chronic obstructive pulmonary disease, diabetes, and mental illness, or kidney failure. Literature concerning dentistry, vaccination, intravenous drug users and paediatric populations were excluded. RESULTS: We identified 32 papers reporting prevalence (n = 24), management (n = 5) or both (n = 3). Needle fear prevalence varied in disease cohorts: 17-52% (cancer), 25-47% (chronic kidney disease) and 0.2-80% (diabetes). Assessment methods varied across studies. Management strategies had poor evidence-base, but included needle-specific education, decorated devices, cognitive-behavioural stress management techniques, distraction, and changing the therapy environment or modality. CONCLUSION: Although needle fear is common there is a paucity of evidence regarding interventions to address it among adults living with chronic disease. This scoping review has highlighted the need for improved identification of needle fear in adults and development of interventions are required for these cohorts.

Intervención educativa para elevar el nivel de conocimiento sobre hipertensión arterial en adolescentes / Educational intervention to raise the level of knowledge on arterial hypertension in adolescents

RESUMEN Introducción: la hipertensión arterial del adulto tiene sus inicios en la niñez, por lo que la percepción de riesgo debe aumentar en las edades pediátricas. Objetivo: elevar el nivel de conocimiento sobre hipertensión arterial en adolescentes de la Escuela Secundaria Básica Antonio Rodríguez, del municipio Colón, provincia de Matanzas. Materiales y métodos: se realizó un estudio de intervención educativa en 80 estudiantes de 8vo grado, en el período de febrero de 2017 a junio de 2018. Se aplicó un cuestionario para medir percepción de riesgo de enfermar, conocimientos sobre factores de riesgo y síntomas de hipertensión arterial antes y después de la intervención. Se crearon cuatro grupos de 20 adolescentes, que tuvieron una sesión semanal durante 6 semanas. Se desarrollaron seis temas relacionados con la enfermedad, en los que se utilizaron técnicas participativas de educación para la salud. Resultados: el 96,1 % de los adolescentes no percibían el riesgo de enfermar de hipertensión arterial antes de la intervención. Luego de esta, la percepción de riesgo se presentó en el 65,4 %. Un 43,6 % de los participantes desconocían los factores de riesgo, y el 69,2 % no conocían los síntomas. Después de la intervención, el 73 % de la muestra tenían un conocimiento parcial sobre los factores de riesgo; el 57,7 % conocían los síntomas, y el 37,2 % los conocían parcialmente. Conclusiones: la intervención educativa sobre hipertensión arterial contribuyó a elevar los conocimientos y la percepción de riesgo en los adolescentes. Se aportaron elementos para modificar estilos de vida poco saludables (AU).

ABSTRACT Introduction: the adults' arterial hypertension begins in childhood, therefore the risk perception must increase in pediatric ages. Objective: to raise knowledge level on arterial hypertension in adolescents from the high school Antonio Rodriguez, municipality of Colon, province of Matanzas. Materials and methods: an educational interventional study was carried out in 80 8th-grade students, in the period from February 2017 to June 2018. A survey was applied to measure risk perception of developing the disease, knowledge on risk factors and symptoms of arterial hypertension before and after intervention. Four groups of 20 teenagers were created, having a weekly session during six weeks. Six themes related to the disease were developed, using different participatory techniques of health education. Results: 96.1% of adolescents did not perceive the risk of developing hypertension before the intervention. After it, risk perception was present in 65.4% of them. 43.6% of participants did not know the risk factors, and 69.2 % did not know the symptoms. After the intervention, 73% of the sample had partial knowledge on risk factors; 57.7% knew the symptoms, and 37.2% knew them partially. Conclusions: the educational intervention on arterial hypertension contributed to raise knowledge and risk perception in adolescents. Elements were given to modify unhealthy lifestyles (AU).

Mapping three versions of the international classification of diseases to categories of chronic conditions.

INTRODUCTION: Administrative health data capture diagnoses using the International Classification of Diseases (ICD), which has multiple versions over time. To facilitate longitudinal investigations using these data, we aimed to map diagnoses identified in three ICD versions - ICD-8 with adaptations (ICDA-8), ICD-9 with clinical modifications (ICD-9-CM), and ICD-10 with Canadian adaptations (ICD-10-CA) - to mutually exclusive chronic health condition categories adapted from the open source Clinical Classifications Software (CCS). METHODS: We adapted the CCS crosswalk to 3-digit ICD-9-CM codes for chronic conditions and resolved the one-to-many mappings in ICD-9-CM codes. Using this adapted CCS crosswalk as the reference and referring to existing crosswalks between ICD versions, we extended the mapping to ICDA-8 and ICD-10-CA. Each mapping step was conducted independently by two reviewers and discrepancies were resolved by consensus through deliberation and reference to prior research. We report the frequencies, agreement percentages and 95% confidence intervals (CI) from each step. RESULTS: We identified 354 3-digit ICD-9-CM codes for chronic conditions. Of those, 77 (22%) codes had one-to-many mappings; 36 (10%) codes were mapped to a single CCS category and 41 (12%) codes were mapped to combined CCS categories. In total, the codes were mapped to 130 adapted CCS categories with an agreement percentage of 92% (95% CI: 86%-98%). Then, 321 3-digit ICDA-8 codes were mapped to CCS categories with an agreement percentage of 92% (95% CI: 89%-95%). Finally, 3583 ICD-10-CA codes were mapped to CCS categories; 111 (3%) had a fair or poor mapping quality; these were reviewed to keep or move to another category (agreement percentage = 77% [95% CI: 69%-85%]). CONCLUSIONS: We developed crosswalks for three ICD versions (ICDA-8, ICD-9-CM, and ICD-10-CA) to 130 clinically meaningful categories of chronic health conditions by adapting the CCS classification. These crosswalks will benefit chronic disease studies spanning multiple decades of administrative health data.

Childhood hunger experiences and chronic health conditions later in life among Brazilian older adults / Experiencias de hambre en la niñez y enfermedades crónicas en etapas posteriores de la vida en adultos mayores de Brasil / Experiência de passar fome na infância e problemas crônicos de saúde posteriores em idosos no Brasil

ABSTRACT Objectives. To assess the association between childhood hunger experiences and the prevalence of chronic diseases later in life. Methods. A cross-sectional study was conducted using baseline data from the Brazilian Longitudinal Study of Aging (ELSI-Brazil), a nationally representative study of persons aged 50 years and older (n = 9 412). Univariate and bivariate analyses were used to describe the sample, and multivariate logistic regressions to examine the association between childhood hunger and hypertension, diabetes, arthritis and osteoporosis. Adjusted odds ratios and predicted probabilities were calculated. Results. 24.7% of Brazilians aged 50 and over experienced hunger during childhood. This harmful exposure was significantly more common among non-white people, individuals with lower educational attainment, lower household income and heavy manual laborers. Regional variation was also observed, as the prevalence of individuals reporting childhood hunger was higher in the North and Northeast regions. The multivariate analysis revealed that older adults who reported having experienced hunger during childhood had 20% higher odds of developing diabetes in adulthood (aOR = 1.20, 95% CI: 1.02 - 1.41) and 38% higher odds of developing osteoporosis (aOR = 1.38, 95% CI: 1.15 - 1.64) than adults who did not experience hunger during childhood, after controlling for covariates. Conclusions. The study showed an association between childhood hunger and two chronic diseases in later life: diabetes and osteoporosis. This work restates that investing in childhood conditions is a cost-effective way to have a healthy society and provides evidence on relationships that deserve further investigation to elucidate underlying mechanisms.

RESUMEN Objetivos. Evaluar la asociación entre las experiencias de hambre en la niñez y la prevalencia de enfermedades crónicas en las etapas posteriores de la vida. Métodos. Se realizó un estudio transversal utilizando como línea de base los datos del Estudio Longitudinal del Envejecimiento en Brasil (ELSI-Brasil), un estudio nacional representativo de personas de 50 años o más (n = 9 412). Se emplearon análisis univariado y bivariado para describir la muestra, y regresión logística multivariada para examinar la asociación entre el hambre en la niñez y la hipertensión, la diabetes, la artritis y la osteoporosis. Se calcularon las razones de posibilidades ajustadas y las probabilidades previstas. Resultados. El 24,7% de los brasileños de 50 años o más pasó hambre en la niñez. Esta experiencia perjudicial fue considerablemente más común en las personas no blancas, las personas con menor nivel de instrucción, las personas con ingresos familiares bajos y los trabajadores de mano de obra pesada. También se observó una variación regional, puesto que la prevalencia de individuos que expresaron haber pasado hambre en la niñez fue mayor en las regiones Norte y Nordeste. Luego de controlar las covariables, el análisis multifactorial reveló que los adultos mayores que dijeron haber pasado hambre en la niñez tenían una probabilidad 20% mayor de tener diabetes en la edad adulta (aOR = 1,20, IC 95%: 1,02 - 1,41) y 38% mayor de tener osteoporosis (aOR = 1,38, IC 95%: 1,15 - 1,64) que los adultos que no habían pasado hambre en la niñez. Conclusiones. El estudio reveló una asociación entre el hambre en la niñez y dos enfermedades crónicas en las etapas posteriores de la vida: la diabetes y la osteoporosis. Este trabajo reafirma que invertir en las condiciones de vida de las personas en la niñez es una manera costoeficaz de tener una sociedad saludable, al tiempo que aporta evidencia acerca de relaciones que merecen investigarse más a fin de esclarecer los mecanismos subyacentes.

RESUMO Objetivos. Avaliar a associação entre a experiência de passar fome na infância e a prevalência posterior de doenças crônicas. Métodos. Um estudo transversal foi realizado a partir de dados básicos do Estudo Longitudinal da Saúde dos Idosos Brasileiros (ELSI-Brasil), uma pesquisa com representatividade nacional realizada com pessoas de 50 anos ou mais (n = 9.412). Análises univariadas e bivariadas foram usadas para descrever a amostra e a regressão logística multivariada foi aplicada para examinar a associação entre passar fome na infância e hipertensão, diabetes, artrite e osteoporose. Foram calculadas razões de chances (odds ratio, OR) ajustadas e probabilidades previstas. Resultados. Verificou-se que 24,7% dos brasileiros com 50 anos ou mais passaram fome na infância. Esta exposição prejudicial foi significativamente mais frequente em pessoas não brancas, com nível de instrução menor e renda familiar mais baixa e em trabalhadores braçais. Observou-se também uma variação regional, com uma maior prevalência de pessoas que relataram ter passado fome na infância nas Regiões Norte e Nordeste. Na análise multivariada, nos idosos que informaram ter passado fome na infância, a probabilidade foi 20% maior de ter diabetes na idade adulta (ORaj 1,20; IC 95% 1,02-1,41) e 38% maior de ter osteoporose (ORaj 1,38, IC 95% 1,15-1,64) em comparação aos adultos que não passaram fome na infância, após o controle de covariáveis. Conclusões. O estudo demonstrou associação entre passar fome na infância e duas doenças crônicas na vida adulta: diabetes e osteoporose. Este trabalho reitera que investir na infância é uma maneira custo-efetiva de se criar uma sociedade saudável e fornece evidências sobre relações que devem ser pesquisadas mais a fundo para esclarecer os processos subjacentes.

Comorbidities associated with mortality in 31,461 adults with COVID-19 in the United States: A federated electronic medical record analysis.

BACKGROUND: At the beginning of June 2020, there were nearly 7 million reported cases of coronavirus disease 2019 (COVID-19) worldwide and over 400,000 deaths in people with COVID-19. The objective of this study was to determine associations between comorbidities listed in the Charlson comorbidity index and mortality among patients in the United States with COVID-19. METHODS AND FINDINGS: A retrospective cohort study of adults with COVID-19 from 24 healthcare organizations in the US was conducted. The study included adults aged 18-90 years with COVID-19 coded in their electronic medical records between January 20, 2020, and May 26, 2020. Results were also stratified by age groups (<50 years, 50-69 years, or 70-90 years). A total of 31,461 patients were included. Median age was 50 years (interquartile range [IQR], 35-63) and 54.5% (n = 17,155) were female. The most common comorbidities listed in the Charlson comorbidity index were chronic pulmonary disease (17.5%, n = 5,513) and diabetes mellitus (15.0%, n = 4,710). Multivariate logistic regression analyses showed older age (odds ratio [OR] per year 1.06; 95% confidence interval [CI] 1.06-1.07; p < 0.001), male sex (OR 1.75; 95% CI 1.55-1.98; p < 0.001), being black or African American compared to white (OR 1.50; 95% CI 1.31-1.71; p < 0.001), myocardial infarction (OR 1.97; 95% CI 1.64-2.35; p < 0.001), congestive heart failure (OR 1.42; 95% CI 1.21-1.67; p < 0.001), dementia (OR 1.29; 95% CI 1.07-1.56; p = 0.008), chronic pulmonary disease (OR 1.24; 95% CI 1.08-1.43; p = 0.003), mild liver disease (OR 1.26; 95% CI 1.00-1.59; p = 0.046), moderate/severe liver disease (OR 2.62; 95% CI 1.53-4.47; p < 0.001), renal disease (OR 2.13; 95% CI 1.84-2.46; p < 0.001), and metastatic solid tumor (OR 1.70; 95% CI 1.19-2.43; p = 0.004) were associated with higher odds of mortality with COVID-19. Older age, male sex, and being black or African American (compared to being white) remained significantly associated with higher odds of death in age-stratified analyses. There were differences in which comorbidities were significantly associated with mortality between age groups. Limitations include that the data were collected from the healthcare organization electronic medical record databases and some comorbidities may be underreported and ethnicity was unknown for 24% of participants. Deaths during an inpatient or outpatient visit at the participating healthcare organizations were recorded; however, deaths occurring outside of the hospital setting are not well captured. CONCLUSIONS: Identifying patient characteristics and conditions associated with mortality with COVID-19 is important for hypothesis generating for clinical trials and to develop targeted intervention strategies.

Association of Diagnosis Coding With Differences in Risk-Adjusted Short-term Mortality Between Critical Access and Non-Critical Access Hospitals.

Importance: Critical access hospitals (CAHs) provide care to rural communities. Increasing mortality rates have been reported for CAHs relative to non-CAHs. Because Medicare reimburses CAHs at cost, CAHs may report fewer diagnoses than non-CAHs, which may affect risk-adjusted comparisons of outcomes. Objective: To assess serial differences in risk-adjusted mortality rates between CAHs and non-CAHs after accounting for differences in diagnosis coding. Design, Setting, and Participants: Serial cross-sectional study of rural Medicare Fee-for-Service beneficiaries admitted to US CAHs and non-CAHs for pneumonia, heart failure, chronic obstructive pulmonary disease, arrhythmia, urinary tract infection, septicemia, and stroke from 2007 to 2017. The final date of follow-up was December 31, 2017. Exposure: Admission to a CAH vs non-CAH. Main Outcomes and Measures: Discharge diagnosis count including trends from 2010 to 2011 when Medicare expanded the allowable number of billing codes for hospitalizations, and combined in-hospital and 30-day postdischarge mortality adjusted for demographics, primary diagnosis, preexisting conditions, and with vs without further adjustment for Hierarchical Condition Category (HCC) score to understand the contribution of in-hospital secondary diagnoses. Results: There were 4 094 720 hospitalizations (17% CAH) for 2 850 194 unique Medicare beneficiaries (mean [SD] age, 76.3 [11.7] years; 55.5% women). Patients in CAHs were older (median age, 80.1 vs 76.8 years) and more likely to be female (58% vs 55%). In 2010, the adjusted mean discharge diagnosis count was 7.52 for CAHs vs 8.53 for non-CAHs (difference, -0.99 [95% CI, -1.08 to -0.90]; P < .001). In 2011, the CAH vs non-CAH difference in diagnoses coded increased (P < .001 for interaction between CAH and year) to 9.27 vs 12.23 (difference, -2.96 [95% CI, -3.19 to -2.73]; P < .001). Adjusted mortality rates from the model with HCC were 13.52% for CAHs vs 11.44% for non-CAHs (percentage point difference, 2.08 [95% CI, 1.74 to 2.42]; P < .001) in 2007 and increased to 15.97% vs 12.46% (difference, 3.52 [95% CI, 3.09 to 3.94]; P < .001) in 2017 (P < .001 for interaction). Adjusted mortality rates from the model without HCC were not significantly different between CAHs and non-CAHs in all years except 2007 (12.19% vs 11.74%; difference, 0.45 [95% CI, 0.12 to 0.79]; P = .008) and 2010 (12.71% vs 12.28%; difference, 0.42 [95% CI, 0.07 to 0.77]; P = .02). Conclusions and Relevance: For rural Medicare beneficiaries hospitalized from 2007 to 2017, CAHs submitted significantly fewer hospital diagnosis codes than non-CAHs, and short-term mortality rates adjusted for preexisting conditions but not in-hospital comorbidity measures were not significantly different by hospital type in most years. The findings suggest that short-term mortality outcomes at CAHs may not differ from those of non-CAHs after accounting for different coding practices for in-hospital comorbidities.

Implicaciones de la microbiota intestinal en las enfermedades crónicas del hígado / Implications of the intestinal microbiota in the chronic liver diseases

RESUMEN La microbiota se refiere al conjunto de todos los de microorganismos que se localizan de manera normal en distintos sitios de los cuerpos de los seres vivos pluricelulares, tales como el cuerpo humano. Las modificaciones del eje intestino-hígado se ha convertido en la actualidad en un grave problema científico al haberse encontrado en diversas investigaciones, que esta microbiota está relacionada con el daño hepático con independencia de la causa de la lesión hepática. Se realizó una revisión sistemática sobre las implicaciones demamicrobiota intestinal en las enfermedades hepáticas. Se realizó una revisión de artículos científicos publicados entre 2012 y 2018 en diversas bases de datos en línea. Se presenta el conocimiento existente hasta el momento sobre la microbiota intestinal en pacientes portadores de enfermedades hepáticas, con hincapié en las hepatitis C y la cirrosis hepática. La composición de microbiota de intestino estuvo asociada con el perfil inflamatorio y marcadores de fibrosis hepática, las que mejoraron con el tratamiento de antivirales de acción directa aunque las medidas de permeabilidad intestinal e inflamación permanecían inalteradas. Se reporta mejoría de los pacientes portadores de hepatitis viral tipo C, con antivirales de acción directa la cual estuvo asociada con modificaciones de la microbiota intestinal, que se correlacionó con mejoría en la fibrosis e inflamación hepática, los avances en este campo abren nuevas perspectivas en la biomedicina (AU).

SUMMARY Microbiota refers to the whole of microorganisms located in a normal way in different places of the bodies of pluricelular living beings, like the human body. The modifications of the axis intestine-liver have become a serious scientific problem, because in different researches researchers have found that this microbiota is related to hepatic damage depending on the cause of this hepatic lesion. To carry out a systematic review on the implication of intestinal macrobiota in liver diseases. The scientific articles published in the period 2012-2018 in different databases on line were reviewed. A total of 26 bibliographic sources were used, original articles and reviews. The authors present knowledge existent up to the moment on intestinal microbiota in patients who have liver diseases, making emphasis on hepatitis C and hepatic cirrhosis. The composition of the intestine microbiota was associated to an inflammatory and markers of hepatic fibrosis that improved with the treatment of direct action antivirals although the measures of intestinal permeability and inflammation remained inalterably. It is reported an improvement of patients carriers of viral hepatitis type C with the use direct action retrovirals, what was linked to modifications in the intestinal microbiota, and correlated to an improvement of fibrosis and liver inflammation; the advances obtained in this field open new perspectives in biomedicine (AU).

Women and evaluation of inequalities in the distribution of risk factors for Chronic non-communicable diseases (NCD), Vigitel 2016-2017. / Mulheres e avaliação das desigualdades na distribuição de fatores de risco de doenças crônicas, Vigitel 2016-2017.

OBJECTIVE: To compare the distribution of chronic non-communicable diseases (CNCD) indicators among adult female beneficiaries and non-beneficiaries of the Bolsa Família Program (BFP) in Brazilian capitals. METHODS: Analysis of Vigitel telephone survey data in 2016 and 2017. Gross and adjusted prevalence ratios (PR) and their respective confidence intervals were estimated using Poisson Regression model. RESULTS: Women with BF have lower schooling, are young people, live more frequently in the Northeast and North of the country. Higher prevalence of risk factors were found in woman receiving BF. The adjusted PR of the BF women were: smokers (PR = 1.98), overweight (PR = 1.21), obesity (PR = 1.63), fruits and vegetables (PR = 0.63), consumption of soft drinks (PR = 1.68), bean consumption (PR = 1.25), physical activity at leisure (PR = 0.65), physical activity at home (PR = 1.35), time watching TV (PR = 1.37), self-assessment of poor health status (PR =2.04), mammography (PR = 0.86), Pap smears (PR = 0.91), hypertension (PR = 1.46) and diabetes (PR = 1,66). When women were compared among strata of the same schooling, these differences were reduced. CONCLUSION: Worst indicators among women receiving BF reflect social inequalities inherent in this most vulnerable group. The study also shows that BF is being targeted at the most vulnerable women.

OBJETIVO: Comparar a distribuição de indicadores de doenças crônicas não transmissíveis (DCNT) entre mulheres adultas beneficiárias e não beneficiárias do Programa Bolsa Família (PBF) nas capitais brasileiras. MÉTODOS: Análise de dados do Sistema de Vigilância de Fatores de Risco e Proteção para Doenças Crônicas por Inquérito Telefônico (Vigitel) em 2016 e 2017. Foram estimados as razões de prevalência (RP) brutas e ajustadas e seus respectivos intervalos de confiança usando o modelo de regressão de Poisson. RESULTADOS: Mulheres do PBF tem menor escolaridade, são mais jovens e vivem com maior frequência nas regiões Nordeste e Norte do país. Prevalências mais elevadas de fatores de risco foram encontradas nas mulheres beneficiárias do PBF. A RP ajustada por idade das mulheres com BF foram: fumantes (RP = 1,98), excesso de peso (RP = 1,21), obesidade (RP = 1,63), frutas e hortaliças (RP = 0,63), consumo de refrigerantes (RP = 1,68), consumo de feijão (RP = 1,25), prática de atividade física no lazer (RP = 0,65), atividade física no domicílio (RP = 1,35), tempo assistindo à TV (RP = 1,37), autoavaliação do estado de saúde ruim (RP = 2,04), mamografia (RP = 0,86), Papanicolau (RP = 0,91), hipertensão (RP = 1,46) e diabetes (RP = 1,66). Quando comparadas as mulheres entre estratos de mesma escolaridade, as diferenças entre os fatores de risco foram reduzidas. CONCLUSÃO: Piores indicadores entre mulheres que recebem BF refletem desigualdades sociais inerentes a esse grupo mais vulnerável. O estudo evidencia também que o PBF está sendo destinado às mulheres mais vulneráveis.

Towards an indigenous definition of health: an explorative study to understand the indigenous Ecuadorian people's health and illness concepts.

BACKGROUNDS: An intercultural society facilitates equitable and respectful interrelations. Knowing and understanding each other's sociocultural and linguitic contexts is a prerequisite for an intercultural society. This study explores the concepts of health and illness among healers of indigenous ethnicities in Southern Ecuador. METHODS: A qualitative observational study with eleven focus groups was conducted in three locations in Southern Ecuador; a total of 110 participants the Shuar, Kichwa and Mestizo ethnic groups were included. A phenomenological and hermeneutic analysis was conducted. RESULTS: Fourteen main subtopics around of two predefined themes, i.e., "Health" and "Illness" were identified: 1) four bodies, 2) religiosity, 3) health as a good diet, 4) health as god's blessing or a gift, 5) health as balance/ harmony, 6) health as community and social welfare, 7) health as potentiality or a skill, 8) health as peacefulness, 9) heath as individual will, 10) illness as an imbalance, 11) illness as bad energy, 12) illness as a bad diet, 13) illness as suffering or worry, and 14) illness from God, Nature and People illness. By analysing all the topics' and subtopics' narratives, a health and illness definition was developed. The principal evidence for this new framework is the presence of interculturality as a horizontal axis in health. The indigenous perspective of health and illness focus on a balance between 4 bodies: the physical, spiritual, social and mental bodies. Additionally, "good health" is obtained through of the good diet and balanced/harmony. CONCLUSION: Indigenous healers in Southern Ecuador have views on health and illness that differ from the Western biomedical model of care. These different views must be recognized and valued in order to build an intercultural (health) system that empowers both ancestral and modern medical knowledge and healing.

Chronic oedema and lymphoedema: what is the difference?

Chronic oedema is a term that encompasses several causes that lead to oedema formation in any part of the body. This includes lymphoedema and its subcategories. Despite the assumption that these are different, there are more commonalities amongst them. This makes the transfer of knowledge and experience, from chronic oedema conditions to lymphoedema, and vice versa easier to achieve. However, this takes both time and support, to achieve the ultimate patient outcome of self-care, with generalist able to support this process and journey.

Systematic identification of critically ill and dying patients in primary care using the German version of the Supportive and Palliative Care Indicators Tool (SPICT-DE).

Objective: The systematic identification of patients who are at risk of deteriorating and dying is the prerequisite for the provision of palliative care (PC). This study aimed to investigate the feasibility and practicability of the German version of the Supportive and Palliative Care Indicators Tool (SPICT-DE) for the systematic identification of these patients in general practice. Methods: In the beginning of 2017, twelve general practitioners (GPs; female n=6) were invited to take part in the study. GPs were asked to apply the SPICT-DE in everyday practice over a period of two months in patients with chronic progressive diseases. Six months after initial assessment, a follow-up survey revealed how the clinical situation of the initially identified patients had changed and which PC actions had been initiated by GPs. In addition, GPs gave feedback on the practicability of SPICT-DE in daily routine. Results: 10 of the 12 GPs (female n=5, median age 46 years, range 38-68) participated in both the two-month assessment period and the follow-up survey. A total of 79 patients (female n=40, median age 79 years, range 44-94) was assessed with the SPICT-DE. Main diagnoses were predominately of cardio-vascular (n=28) or oncological (n=26) origin. Follow-up after six months showed that 38 patients (48%) went through at least one crisis during the course of disease and almost one third (n=26) had died. The majority of GPs (n=7) considered the SPICT-DE to be practical in daily routine and helpful in identifying patients who might benefit from PC. Seven GPs indicated that they would use the SPICT-DE as part of everyday practice. Conclusions: The SPICT-DE seems to be a practical tool supporting the systematic identification of critically ill and dying patients in general practice.

Multimorbidity and Hospital Admissions in High-Need, High-Cost Elderly Patients.

Objective: The aim was to clarify which pairs or clusters of diseases predict the hospital-related events and death in a population of patients with complex health care needs (PCHCN). Method: Subjects classified in 2012 as PCHCN in a local health unit by ACG® (Adjusted Clinical Groups) System were linked with hospital discharge records in 2013 to identify those who experienced any of a series of hospital admission events and death. Number of comorbidities, comorbidities dyads, and latent classes were used as exposure variable. Regression analyses were applied to examine the associations between dependent and exposure variables. Results: Besides the fact that larger number of chronic conditions is associated with higher odds of hospital admission or death, we showed that certain dyads and classes of diseases have a particularly strong association with these outcomes. Discussion: Unlike morbidity counts, analyzing morbidity clusters and dyads reveals which combinations of morbidities are associated with the highest hospitalization rates or death.

Pediatric Complex Chronic Conditions: Evaluating Two Versions of the Classification System.

The original pediatric complex chronic conditions (CCC) classification system developed in 2000/2001 is the gold standard in classifying children with life-limiting illnesses. It was significantly modified in 2014; yet the two systems have not been evaluated. The objective of this study was to evaluate the agreement and validity of the original versus the modified CCC classification systems. Healthcare Cost and Utilization Project (HCUP) Kids' Inpatient Database (KID) data from 2012 was used with a sample of infant decedents less than 1 years. The agreement (i.e., Cohen's Kappa Statistic) and validity (i.e., sensitivity, specificity, and positive predictive value [PPV]) statistics were calculated. Among the 10,175 infants that were classified, the modified system performed well in identifying infants who had a CCC, and it captured infants that the original classification did not. The modified system represents an improvement over the original, but additional testing is warranted.