RESUMO
BACKGROUND: The available data on anticoagulation therapy in real-world primary care settings for atrial fibrillation (AF) patients at high risk of stroke is limited. OBJECTIVE: To evaluate anticoagulation therapy and elucidate the factors associated with the selection between direct oral anticoagulants (DOACs) and warfarin. DESIGN AND PARTICIPANTS: This is a retrospective cohort study that included patients ≥ 18 years old at a large primary care outpatient group, a network of twenty clinics in the northeast United States between January 4, 2021 - January 4, 2023. MAIN MEASURES: Oral anticoagulation therapy in AF patients with high risk of stroke (CHA2DS2-VASc score of ≥ 2 in men or ≥ 3 in women). KEY RESULTS: Among the 3,118 adult patients with AF and high risk of stroke (median age 77.90, IQR 71.66-84.50 years; male 57.6%), we found that older age (aOR 1.40, p = 0.003), greater BMI (25-29.9: aOR 1.32, p = 0.048; ≥ 30 aOR 1.42, p = 0.010), and taking more than five medications (aOR 2.28, p < 0.001) were more likely to be on an oral anticoagulant. Among those taking an OAC, having Medicare as the sole coverage (aOR 0.53, p = 0.032), male gender (aOR 0.69, p = 0.011), worse renal function (aOR 0.80, p = 0.021), and higher CHA2DS2-VASc score (aOR 0.88, p = 0.024) are more likely to be on warfarin than a DOAC. Patients taking more than five medications daily (6-10 medications: aOR 1.92, p = 0.013; ≥ 16: aOR = 2.10, p = 0.006) were more likely to be on an anticoagulant and may receive a DOAC over warfarin. CONCLUSIONS: AF with high stroke risk adult patients are more likely to be on an oral anticoagulant if they are older, having BMI ≥ 25, or taking more than five medications. Medicare as the sole coverage, male gender, worse renal function, and higher CHA2DS2-VASc scores are factors associated with greater warfarin usage, while patients taking over five daily medications are more likely to be prescribed DOACs.
RESUMO
Hispanic/Latino populations are disproportionately impacted by coronavirus disease 2019 (COVID-19) in the United States. The impact of state reopening on COVID-19 in this population after stay-at-home orders is unknown. We evaluated the incidence, prevalence and trends during reopening of severe acute respiratory syndrome-coronavirus-2 (SARS-CoV-2) at a major federally qualified health centre in Providence, Rhode Island. A total of 14 505 patients were tested for SARS-CoV-2 from 19 March to 18 August 2020, of which, data on 13 318 (91.8%) patients were available; 70.0% were Hispanic/Latino, and 2905 were positive for SARS-CoV-2 infection. The urban Hispanic/Latino population was almost five times more likely to test positive for SARS-CoV-2 (risk ratio 4.97, 95% CI 2.59-9.53, P < 0.001) compared to non-Hispanic White. The positivity rates among the urban Hispanic/Latino population remained >10% during all phases of reopening. The trends of the incidence rates showed similar associations to those we observed for positivity rates. Public health interventions to address SARS-CoV-2 in Hispanic/Latino communities are urgently needed, even in latter phases of state reopening.
Assuntos
COVID-19/etnologia , Hispânico ou Latino , SARS-CoV-2 , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Criança , Pré-Escolar , Estudos de Coortes , Feminino , Acessibilidade aos Serviços de Saúde , Disparidades em Assistência à Saúde/etnologia , Habitação/classificação , Humanos , Incidência , Lactente , Seguro Saúde , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , População Urbana , Adulto JovemRESUMO
The real world COVID-19 vaccine effectiveness among the urban underserved Hispanic/Latino populations is unknown. We evaluated the mRNA vaccine effectiveness in preventing SARS-CoV-2 infections at a major federally qualified health center in Providence, Rhode Island, and a total of 38,602 patients were included. Time period was used as the SARS-CoV-2 variant proxy. Compared to the unvaccinated group, the adjusted vaccine effectiveness for 2 doses of BNT162b2 and mRNA-1273 were 94.6% and 97.5% respectively against the alpha variant/wild type, which dropped to 64.8% and 65.0% respectively against the delta variant and 31.6% and 25.6% respectively against the omicron variant. However, once received the booster dose (3rd dose) of BNT162b2 and mRNA-1273, the vaccine effectiveness against the omicron variant improved to 79.9% and 71.2% respectively. Improving the COVID-19 vaccine education and encouraging to receive a booster dose may help further reduce the burden of SARS-CoV-2 infection in this population.
Assuntos
Vacina BNT162 , COVID-19 , Humanos , Vacina de mRNA-1273 contra 2019-nCoV , SARS-CoV-2/genética , Vacinas contra COVID-19 , COVID-19/epidemiologia , COVID-19/prevenção & controle , Eficácia de Vacinas , Populações VulneráveisRESUMO
BACKGROUND AND OBJECTIVES: Dementia has been gaining attention in aging societies and is estimated to affect 50 million adults globally in 2020, and 12% of the US population may develop a thyroid disorder in their lifetime. There have been limited studies investigating the correlation between thyroid disorder and dementia in the Asian population. METHODS: Our large nationwide population-based case-control study used the Taiwanese National Health Insurance Research Database. A total of 7,843 adults with newly diagnosed dementia without a history of dementia or neurodegenerative disease between 2006 and 2013 were identified and included in our study. In addition, 7,843 adults without dementia diagnosis before the index date were age and sex-matched as controls. Diagnosis of hyperthyroidism or hypothyroidism before the diagnosis of dementia or the same index date was identified. Results were obtained from logistic regression models and adjusted for sex, age, history of hypertension, diabetes, coronary artery disease, depression, hyperlipidemia, alcohol dependence syndrome, tinnitus, hearing loss, and radioactive iodine treatment. RESULTS: A total of 15,686 patients were included in the study. Both case and control groups were slightly predominantly female (4,066 [51.8%]). The mean (SD) age for those with dementia was 74.9 (11.3) years and for those without dementia was 74.5 (11.3) years. Among patients aged 65 years or older, a history of hypothyroidism was associated with an increased risk of being diagnosed with dementia (adjusted odds ratio [aOR] 1.81; 95% CI 1.14-2.87; p = 0.011), which was an association not present in patients older than 50 years but younger than 65 years. We found that this association was most significant among patients aged 65 years or older with a history of hypothyroidism who received hypothyroidism medication (aOR 3.17; 95% CI 1.04-9.69; p = 0.043). DISCUSSION: Our large-scale case-control study found that among people aged 65 years or older, those with a history of hypothyroidism were associated with an 81% increased risk of having dementia and among those, there was a more than 3-fold increased dementia risk with thyroid conditions that required thyroid hormone replacement treatment. Future well-controlled prospective longitudinal studies should be conducted to elucidate these potential mechanisms and relationships. CLASSIFICATION OF EVIDENCE: This study provides Class III evidence that among patients aged 65 years or older, a history of hypothyroidism was associated with an increased risk of being diagnosed with dementia.
Assuntos
Demência , Hipotireoidismo , Doenças Neurodegenerativas , Neoplasias da Glândula Tireoide , Adulto , Estudos de Casos e Controles , Demência/complicações , Demência/epidemiologia , Feminino , Humanos , Hipotireoidismo/complicações , Hipotireoidismo/epidemiologia , Radioisótopos do Iodo , Masculino , Doenças Neurodegenerativas/complicações , Estudos Prospectivos , Fatores de Risco , Hormônios Tireóideos , Neoplasias da Glândula Tireoide/complicaçõesRESUMO
BACKGROUND: Castleman's disease (CD) is a rare, benign lymphoproliferative disorder that can involve single lymph node stations or can be systemic. Unicentric CD in patients with microcytic anemia is rarely described in the English literature. CASE REPORT: We describe the case of a 19-year-old Chinese woman with hyaline vascular type of unicentric CD presenting as severe non-iron deficiency microcytic anemia. We report the clinical course from the initial presentation to diagnosis and surgical cure, and discuss the most up-to-date information on CD. CONCLUSIONS: CD should be included in the differential diagnosis of microcytic anemia. Imaging tools and pathological studies should be considered in order to make a more accurate diagnosis and to avoid the use of ineffective treatments.
Assuntos
Anemia Hipocrômica/diagnóstico , Anemia Hipocrômica/cirurgia , Hiperplasia do Linfonodo Gigante/diagnóstico , Hiperplasia do Linfonodo Gigante/cirurgia , Diagnóstico Diferencial , Feminino , Hemoglobinometria , Humanos , Linfonodos/patologia , Tomografia Computadorizada por Raios X , Adulto JovemRESUMO
PURPOSE: To evaluate the diagnostic value of symptoms used by daycares and schools to screen children and adolescents for SARS-CoV-2 infection, we analyzed data from a primary care setting. METHODS: This cohort study included all patients ≤17 years old who were evaluated at Providence Community Health Centers (PCHC; Providence, U.S.), for COVID-19 symptoms and/or exposure, and received SARS-CoV-2 polymerase chain reaction (PCR) testing between March-June 2020. Participants were identified from PCHC electronic medical records. For three age groups- 0-4, 5-11, and 12-17 years-we estimated the sensitivity, specificity, and area under the receiver operating curve (AUC) of individual symptoms and three symptom combinations: a case definition published by the Rhode Island Department of Health (RIDOH), and two novel combinations generated by different statistical approaches to maximize sensitivity, specificity, and AUC. We evaluated symptom combinations both with and without consideration of COVID-19 exposure. Myalgia, headache, sore throat, abdominal pain, nausea, anosmia, and ageusia were not assessed in 0-4 year-olds due to the lower reliability of these symptoms in this group. RESULTS: Of 555 participants, 217 (39.1%) were SARS-CoV-2-infected. Fever was more common among 0-4 years-olds (p = 0.002); older children more frequently reported fatigue (p = 0.02). In children ≥5 years old, anosmia or ageusia had 94-98% specificity. In all ages, exposure history most accurately predicted infection. With respect to individual symptoms, cough most accurately predicted infection in <5 year-olds (AUC 0.69) and 12-17 year-olds (AUC 0.62), while headache was most accurate in 5-11 year-olds (AUC 0.62). In combination with exposure history, the novel symptom combinations generated statistically to maximize test characteristics had sensitivity >95% but specificity <30%. No symptom or symptom combination had AUC ≥0.70. CONCLUSIONS: Anosmia or ageusia in children ≥5 years old should raise providers' index of suspicion for COVID-19. However, our overall findings underscore the limited diagnostic value of symptoms.
Assuntos
Ageusia/diagnóstico , COVID-19/diagnóstico , Tosse/diagnóstico , Cefaleia/diagnóstico , Mialgia/diagnóstico , Faringite/diagnóstico , Adolescente , Distribuição por Idade , Área Sob a Curva , Criança , Pré-Escolar , Estudos de Coortes , Centros Comunitários de Saúde , Testes Diagnósticos de Rotina , Registros Eletrônicos de Saúde , Humanos , Lactente , Recém-Nascido , Atenção Primária à SaúdeRESUMO
Background: The association between thyroid disorders and breast cancer remains controversial, in part, due to small cohort sizes and inconsistent findings. We investigated this association in postmenopausal women to determine whether hyper- or hypothyroidism is associated with the risk of developing breast cancer and to determine whether menopausal hormone therapy (MHT) further modifies the risk. Methods: We conducted a prospective cohort study of multiethnic U.S. postmenopausal women aged 50 to 79 years enrolled in both clinical trial and observational study arms between 1993 and 1998 and followed up through February 28, 2017. Development of invasive breast cancer after enrollment was recorded and a history of hyper- or hypothyroidism before the diagnosis of breast cancer was identified. The effect modification by MHT in both study arms was analyzed. All statistical tests were two sided. Results: Among a total of 134,122 women who were included in our study, 8137 participants developed invasive breast cancer during the follow-up period. There was a significant inverse association of invasive breast cancer among women with a history of hypothyroidism (hazard ratio [HR] 0.91, confidence interval [95% CI] 0.86-0.97) and among women who had taken levothyroxine [HR 0.89, 95% CI 0.82-0.96]. Evaluating effect modification by MHT use, the inverse association between hypothyroidism treated with thyroid replacement medications and breast cancer risk was strongest in non-MHT users [HR 0.80, 95% CI 0.69-0.93]. The results did not significantly differ by race/ethnicity. Although a history of hyperthyroidism was associated with an increased risk of invasive breast cancer [HR 1.11, 95% CI 0.91-1.35], this finding did not reach statistical significance. We did not see significant differences in the breast cancer Surveillance, Epidemiology, and End Results stages, histologic types, morphologic grades, or receptor status (estrogen receptor, progesterone receptor, human epidermal growth factor receptor 2) according to thyroid disorder status. Conclusions: Compared with women with no history of thyroid disorder, hypothyroidism was associated with a lower risk of breast cancer. This was mainly seen among those who received thyroid replacement therapy and had never used MHT. Among the treatment options for hypothyroidism, levothyroxine had the strongest inverse association with breast cancer risk.
Assuntos
Neoplasias da Mama/epidemiologia , Terapia de Reposição Hormonal/efeitos adversos , Pós-Menopausa , Doenças da Glândula Tireoide/epidemiologia , Idoso , Neoplasias da Mama/etiologia , Feminino , Humanos , Incidência , Pessoa de Meia-Idade , Risco , Doenças da Glândula Tireoide/tratamento farmacológico , Saúde da MulherRESUMO
Importance: Thyroid hormones have been shown to affect several important pathways in cancer development, including colorectal cancer (CRC). Clinical studies examining the association between thyroid disorders and colorectal cancer have conflicting results and have predominantly involved white populations. Objective: To determine if a diagnosis of hyperthyroidism or hypothyroidism is associated with the risk of developing colorectal cancer in an East Asian population. Design, Setting, and Participants: This nationwide population-based case-control study was conducted from April 27, 2018, to November 8, 2018, using the Taiwanese National Health Insurance Research Database. Participants were adults (n = 139â¯426) either with a new diagnosis (between 2008 and 2013) of primary colorectal cancer without a history of cancer, or without cancer. Cases and controls were matched 1:1 by age, sex, and index date. Diagnosis of hyperthyroidism or hypothyroidism prior to the diagnosis of colorectal cancer (or the same index date in controls) was then determined. Main Outcomes and Measures: Risk differences in developing colorectal cancer among patients with a medical history of hyperthyroidism or hypothyroidism. Results: A total of 139â¯426 patients were included in the study, and 69â¯713 individuals made up each case and control group, which were both predominantly male (39 872 [57.2%]). The mean (SD) age for those with CRC was 65.8 (13.7) years and for those without CRC was 66.0 (13.6) years. Both hyperthyroidism (adjusted odds ratio [aOR], 0.77; 95% CI, 0.69-0.86; P < .001) and hypothyroidism (aOR, 0.78; 95% CI, 0.65-0.94; P = .008) were associated with a decreased risk of being diagnosed with colorectal cancer. An inverse association of rectal cancer was found among patients aged 50 years or older with a history of hypothyroidism despite treatment (aOR, 0.54; 95% CI, 0.39-0.74; P < .001). A history of hyperthyroidism in all age groups was associated with a lower risk of colon cancer (aOR, 0.74; 95% CI, 0.64-0.85; P < .001), with a stronger association seen among those younger than 50 years (aOR, 0.55; 95% CI, 0.36-0.85; P = .007). Conclusions and Relevance: In this study, hypothyroidism appeared to be associated with a lower risk of rectal cancer, whereas hyperthyroidism appeared to be associated with a lower risk of colon cancer. Because of this, biochemical in vivo research and epidemiologic studies appear to be needed to further clarify the nature of these associations.
Assuntos
Neoplasias Colorretais/epidemiologia , Hipertireoidismo/epidemiologia , Hipotireoidismo/epidemiologia , Idoso , Estudos de Casos e Controles , Estudos Transversais , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Sistema de Registros , Medição de Risco , Taiwan/epidemiologiaRESUMO
In an analysis of over 260 million emergency department visits across the United States from 2007 to 2017, inflammatory bowel disease conferred >10-fold risk for suicide deaths, self-harm, substance use, and psychiatric disorders, though the overall self-harm rates were low (<1% of all-cause inflammatory bowel disease emergency department visits; total 56 suicide deaths).
Assuntos
Doenças Inflamatórias Intestinais , Transtornos Mentais , Comportamento Autodestrutivo , Transtornos Relacionados ao Uso de Substâncias , Suicídio , Adulto , Humanos , Estados Unidos/epidemiologia , Suicídio/psicologia , Comportamento Autodestrutivo/epidemiologia , Comportamento Autodestrutivo/psicologia , Transtornos Mentais/epidemiologia , Transtornos Relacionados ao Uso de Substâncias/complicações , Transtornos Relacionados ao Uso de Substâncias/epidemiologia , Doenças Inflamatórias Intestinais/complicações , Doenças Inflamatórias Intestinais/epidemiologiaRESUMO
OBJECTIVE: To evaluate whether hyperthyroidism or hypothyroidism increases the risk of subsequent breast cancer in an Asian population. DESIGN: Nationwide population-based case-control study. SETTING: All healthcare facilities in Taiwan. PARTICIPANTS: A total of 103 466 women (mean age 53.3 years) were enrolled. METHODS: 51 733 adult women with newly diagnosed primary breast cancer without a previous cancer history between 2006 and 2011 were identified and included in our study. 51 733 women with no cancer diagnosis prior to the index date were age matched as controls. Diagnosis of hyperthyroidism or hypothyroidism prior to the diagnosis of breast cancer or the same index date was identified, age, histories of thyroid disease treatment, oestrogen use and radioactive iodine treatment were adjusted. MAIN OUTCOME MEASURES: To identify risk differences in developing breast cancer among patients with a medical history of hyperthyroidism or hypothyroidism. RESULTS: There was a significantly increased risk of breast cancer in women with hyperthyroidism under the age of 55 years (age <45: OR 1.16, P=0.049; age 45-55: OR 1.15, P=0.019). Patients with hypothyroidism also showed an increased risk of breast cancer (OR 1.19, P=0.029) without statistical significance after stratification by age group (age <45, 45-55, >55 years). Treatment for thyroid disorders did not alter the association in subgroup analyses (P=0.857; 0.262, respectively). CONCLUSIONS: Asian women under 55 years of age with history of hyperthyroidism have a significantly increased risk of breast cancer regardless of treatment. Women with history of hypothyroidism may also have an increased risk.
Assuntos
Neoplasias da Mama , Hipotireoidismo , Adulto , Neoplasias da Mama/epidemiologia , Estudos de Casos e Controles , Feminino , Humanos , Hipotireoidismo/epidemiologia , Pessoa de Meia-Idade , Fatores de Risco , Taiwan/epidemiologiaRESUMO
Health confidencean individual's belief in their ability and agency to affect disease outcomeshas bidirectional temporal correlations with inflammatory bowel disease activity. Low health confidence is associated with higher risks for future disease activity, and inflammatory bowel disease flares erode confidence.
Assuntos
Doenças Inflamatórias Intestinais , Humanos , Estudos Longitudinais , Doenças Inflamatórias Intestinais/epidemiologia , Estudos de CoortesRESUMO
BACKGROUND: Patent ductus arteriosus (PDA) is one of the most common cardiac conditions in preterm infants. Closure of the PDA in symptomatic patients can be achieved medically or surgically. Atropine is commonly administered in general anesthesia as a premedication in this age group but with limited evidence addressing the effect of its use. Our study examined the association of the use of atropine as a premedication in PDA ligation and the risk of post-operative respiratory complications. METHODS: This retrospective cohort study included 150 newborns who have failed medical treatment for PDA and received PDA ligation during 2008-2012 in a single tertiary medical center. Ninety-two of them (61.3%) received atropine as premedication for general anesthesia while 58 (38.7%) did not. Post-operative respiratory condition, the need of cardiopulmonary resuscitation and the presence of bradycardia were measured. RESULTS: Patients with atropine use were associated with increased odds of respiratory acidosis in both univariate analysis (22.9% vs 7.3%; OR = 3.785, 95% CI = 1.211-11.826, p = 0.022) and multivariate analysis (OR = 4.030, 95% CI = 1.230-13.202, p = 0.021), with an even higher odds of respiratory acidosis in patients receiving both atropine and ketamine. CONCLUSION: The use of atropine as premedication in general anesthesia for neonatal PDA ligation is associated with higher risk of respiratory acidosis, which worsens with the combined use of ketamine.
Assuntos
Acidose Respiratória/etiologia , Atropina/efeitos adversos , Permeabilidade do Canal Arterial/cirurgia , Complicações Pós-Operatórias/etiologia , Medicação Pré-Anestésica , Humanos , Recém-Nascido , Ketamina/efeitos adversos , Ligadura , Estudos RetrospectivosRESUMO
OBJECTIVE: To investigate the association between mid-upper arm circumference (MUAC), calf circumference (CC) and all-cause mortality in a Chinese population. DESIGN: Prospective cohort study. SETTING: Eight long-term care facilities in central Taiwan. PARTICIPANTS: A total of 329 residents age 60 years and older (median 79.0 years, range 60-101; 139 men, 190 women) were enrolled. METHODS: Anthropometrics and metabolic parameters were measured at the time of enrolment to the study. Mean MUAC and CC were 24.2±3.4 cm and 27.5±4.3 cm, respectively. Mortality data were obtained from the Department of Health in Taiwan. MAIN OUTCOME MEASURE: To identify the association between all-cause mortality and MUAC or CC. RESULTS: There were 255 deaths during the 7-year follow-up period. After adjusting for age, sex, cigarette smoking, betel nut chewing, alcohol use, Karnofsky Performance Status Scale score, serum albumin level, hypertension and diabetes mellitus, subjects in the highest tertile of MUAC (27.8±2.2 cm) and CC (32.1±2.6 cm) had a significantly lower mortality rate than did subjects in the lowest tertile (MUAC 20.6±1.7 cm; CC 22.8±1.9 cm). The adjusted HR for all-cause mortality in the highest versus lowest MUAC tertile was 0.64 (95% CI 0.45 to 0.90). The adjusted HR for all-cause mortality in the highest versus lowest CC tertile was 0.51 (95% CI 0.35 to 0.74). CONCLUSIONS: MUAC and CC are negative predictors for all-cause mortality in older Chinese adults living in long-term care facilities. Participants with higher MUAC and CC had lower all-cause mortality.
Assuntos
Braço , Pesos e Medidas Corporais/mortalidade , Pesos e Medidas Corporais/métodos , Perna (Membro) , Instituições Residenciais , Centros Médicos Acadêmicos , Idoso , Idoso de 80 Anos ou mais , Estudos de Coortes , Feminino , Seguimentos , Humanos , Assistência de Longa Duração , Masculino , Pessoa de Meia-Idade , Estudos Prospectivos , Fatores de Risco , Taiwan/epidemiologia , Centros de Atenção TerciáriaRESUMO
Gastric cancer is one of the leading causes of cancer-related mortality worldwide. The majority of gastric cancers are diagnosed at an advanced or metastatic stage, with a 5-year survival rate of ~5-20% and a median overall survival of <1 year. Synchronous occurrence of gastric adenocarcinoma and lymphoma is rare, and thus far there is no consensus regarding their management. We herein describe a case of synchronous gastric adenocarcinoma and diffuse large B-cell lymphoma in a patient with chronic hepatitis B and the treatment strategy. A literature review with the most up-to-date treatment options and their application in similar situations was also performed.