RESUMO
BACKGROUND: Policy is one of the levers for initiating structural change to foster the promotion of health-enhancing physical activity (HEPA). To this end, policy-makers have to deal with complex ecosystems embedded in specific contexts. However, limited research has been conducted on this topic at the local level. The purpose of this study was to identify the perceived barriers and levers of HEPA policies according to department heads and elected officials across various sectors in mid-size French municipalities. METHODS: This study used a mixed method primarily based on an adaptation of the concept mapping approach. A list of statements completing the sentence: 'In a mid-size municipal context, to develop HEPA policies, it is necessary to ' was submitted to key informants of 17 mid-sized French cities. Key informants in each municipality first rated the importance of each statement without considering their local context; they then rated the feasibility of each statement given their local context. In both cases, they used a Likert scale ranging from 1 to 6. RESULTS: A total of 23 municipal department heads and 10 elected officials from the sport (n = 14), health (n = 10) and social (n = 9) sectors in 11 mid-size French cities participated in this study. A list of 84 statements, sorted into 16 categories, was rated by participants according to their importance (M = 4.52, SD = 0.86) and their feasibility (M = 3.77, SD = 0.74). Potential barriers to (n = 10) and levers of (n = 38) HEPA policy development were identified. These results varied according to the position and sector of the participants. CONCLUSIONS: The results suggest that local contextual factors can affect the development of HEPA policies in mid-size French municipalities. The different perceptions of the potential levers and barriers according to sector might affect intersectoral collaboration. This study contributes by enhancing understanding of how local HEPA policies are developed in the French context.
Assuntos
Exercício Físico , Política de Saúde , Formulação de Políticas , Adulto , Idoso , Cidades , Feminino , França , Conhecimentos, Atitudes e Prática em Saúde , Promoção da Saúde , Humanos , Masculino , Pessoa de Meia-Idade , Inquéritos e QuestionáriosRESUMO
BACKGROUND: Disturbances in one carbon metabolism may contribute to carcinogenesis by affecting methylation and synthesis of DNA. Choline and its oxidation product betaine are involved in this metabolism and can serve as alternative methyl group donors when folate status is low. PATIENTS AND METHODS: We conducted a case-control study nested within the European Prospective Investigation into Cancer and Nutrition (EPIC), to investigate plasma concentrations of the methyl donors methionine, choline, betaine (trimethylglycine), and dimethylglycine (DMG) in relation to colorectal cancer (CRC) risk. Our study included 1367 incident CRC cases (965 colon and 402 rectum) and 2323 controls matched by gender, age group, and study center. Multivariate-adjusted odds ratios (ORs) and 95% confidence intervals (95% CIs) for CRC risk were estimated by conditional logistic regression, comparing the fifth to the first quintile of plasma concentrations. RESULTS: Overall, methionine (OR: 0.79, 95% CI: 0.63-0.99, P-trend = 0.05), choline (OR: 0.77, 95% CI: 0.60-0.99, P-trend = 0.07), and betaine (OR: 0.85, 95% CI: 0.66-1.09, P-trend = 0.06) concentrations were inversely associated with CRC risk of borderline significance. In participants with folate concentration below the median of 11.3 nmol/l, high betaine concentration was associated with reduced CRC risk (OR: 0.71, 95% CI: 0.50-1.00, P-trend = 0.02), which was not observed for those having a higher folate status. Among women, but not men, high choline concentration was associated with decreased CRC risk (OR: 0.62, 95% CI: 0.43-0.88, P-trend = 0.01). Plasma DMG was not associated with CRC risk. CONCLUSIONS: Individuals with high plasma concentrations of methionine, choline, and betaine may be at reduced risk of CRC.
Assuntos
Betaína/sangue , Colina/sangue , Neoplasias Colorretais/etiologia , Metionina/sangue , Estado Nutricional/fisiologia , Sarcosina/análogos & derivados , Idoso , Estudos de Casos e Controles , Neoplasias Colorretais/sangue , Neoplasias Colorretais/epidemiologia , Europa (Continente)/epidemiologia , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Prospectivos , Fatores de Risco , Sarcosina/sangueRESUMO
BACKGROUND: Evidence on associations between self-reported diabetes mellitus, diabetes duration, age at diabetes diagnosis, insulin treatment, and risk of biliary tract cancer (BTC) and hepatocellular carcinoma (HCC), independent of general and abdominal obesity is scarce. PATIENTS AND METHODS: We conducted a prospective analysis in the EPIC-cohort study among 363 426 participants with self-reported diabetes data. Multivariable adjusted relative risks and 95% confidence intervals were estimated from Cox regression models. In a nested case-control subset, analyses were carried out in HCV/HBV-negative individuals. RESULTS: During 8.5 years of follow-up, 204 BTC cases [including 75 gallbladder cancer (GBC) cases], and 176 HCC cases were identified. Independent of body mass index and waist-to-height ratio diabetes status was associated with higher risk of BTC and HCC [1.77 (1.00-3.13) and 2.17 (1.36-3.47)]. For BTC, the risk seemed to be higher in participants with shorter diabetes duration and those not treated with insulin. Regarding cancer subsites, diabetes was only associated with GBC [2.72 (1.17-6.31)]. The risk for HCC was particularly higher in participants treated with insulin. The results were not appreciably different in HCV/HBV-negative individuals. CONCLUSION(S): This study supports the hypothesis that diabetes is a risk factor for BTC (particularly GBC) and HCC. Further research is required to establish whether diabetes treatment or duration is associated with these cancers.
Assuntos
Neoplasias do Sistema Biliar/epidemiologia , Carcinoma Hepatocelular/epidemiologia , Diabetes Mellitus/tratamento farmacológico , Insulina/uso terapêutico , Neoplasias Hepáticas/epidemiologia , Neoplasias do Sistema Biliar/complicações , Composição Corporal , Índice de Massa Corporal , Carcinoma Hepatocelular/complicações , Estudos de Casos e Controles , Estudos de Coortes , Europa (Continente) , Feminino , Humanos , Neoplasias Hepáticas/complicações , Masculino , Pessoa de Meia-Idade , Obesidade Abdominal/epidemiologia , Estudos Prospectivos , Fatores de Risco , AutorrelatoRESUMO
BACKGROUND: The type and quantity of dietary carbohydrate as quantified by glycemic index (GI) and glycemic load (GL), and dietary fiber may influence the risk of liver and biliary tract cancers, but convincing evidence is lacking. PATIENTS AND METHODS: The association between dietary GI/GL and carbohydrate intake with hepatocellular carcinoma (HCC; N = 191), intrahepatic bile duct (IBD; N = 66), and biliary tract (N = 236) cancer risk was investigated in 477 206 participants of the European Prospective Investigation into Cancer and Nutrition cohort. Dietary intake was assessed by country-specific, validated dietary questionnaires. Hazard ratios and 95% confidence intervals were estimated from proportional hazard models. HBV/HCV status was measured in a nested case-control subset. RESULTS: Higher dietary GI, GL, or increased intake of total carbohydrate was not associated with liver or biliary tract cancer risk. For HCC, divergent risk estimates were observed for total sugar = 1.43 (1.17-1.74) per 50 g/day, total starch = 0.70 (0.55-0.90) per 50 g/day, and total dietary fiber = 0.70 (0.52-0.93) per 10 g/day. The findings for dietary fiber were confirmed among HBV/HCV-free participants [0.48 (0.23-1.01)]. Similar associations were observed for IBD [dietary fiber = 0.59 (0.37-0.99) per 10 g/day], but not biliary tract cancer. CONCLUSIONS: Findings suggest that higher consumption of dietary fiber and lower consumption of total sugars are associated with lower HCC risk. In addition, high dietary fiber intake could be associated with lower IBD cancer risk.
Assuntos
Neoplasias do Sistema Biliar/epidemiologia , Carboidratos da Dieta/administração & dosagem , Fibras na Dieta/administração & dosagem , Índice Glicêmico , Neoplasias Hepáticas/epidemiologia , Adulto , Idoso , Neoplasias do Sistema Biliar/mortalidade , Glicemia , Carcinoma Hepatocelular/epidemiologia , Carcinoma Hepatocelular/mortalidade , Estudos de Casos e Controles , Colangiocarcinoma/epidemiologia , Colangiocarcinoma/mortalidade , Estudos de Coortes , Dieta , Europa (Continente) , Feminino , Alimentos , Humanos , Fígado/patologia , Neoplasias Hepáticas/mortalidade , Masculino , Pessoa de Meia-Idade , Estado Nutricional , Estudos Prospectivos , Fatores de Risco , Inquéritos e QuestionáriosRESUMO
BACKGROUND: In 1994, acrylamide (AA) was classified as a probable human carcinogen by the International Agency for Research on Cancer. In 2002, AA was discovered at relatively high concentrations in some starchy, plant-based foods cooked at high temperatures. PATIENTS AND METHODS: A prospective analysis was conducted to evaluate the association between the dietary intake of AA and ductal adenocarcinoma of the exocrine pancreatic cancer (PC) risk in the European Prospective Investigation into Cancer and Nutrition (EPIC) cohort using Cox regression modeling. EPIC includes >500,000 men and women aged 35-75 at enrollment from 10 European countries. AA intake was estimated for each participant by combining questionnaire-based food consumption data with a harmonized AA database derived from the EU monitoring database of AA levels in foods, and evaluated in quintiles and continuously. RESULTS: After a mean follow-up of 11 years, 865 first incident adenocarcinomas of the exocrine pancreas were observed and included in the present analysis. At baseline, the mean dietary AA intake in EPIC was 26.22 µg/day. No overall association was found between continuous or quintiles of dietary AA intake and PC risk in EPIC (HR:0.95, 95%CI:0.89-1.01 per 10 µg/day). There was no effect measure modification by smoking status, sex, diabetes, alcohol intake or geographic region. However, there was an inverse association (HR: 0.73, 95% CI: 0.61-0.88 per 10 µg/day) between AA intake and PC risk in obese persons as defined using the body mass index (BMI, ≥ 30 kg/m(2)), but not when body fatness was defined using waist and hip circumference or their ratio. CONCLUSIONS: Dietary intake of AA was not associated with an increased risk of PC in the EPIC cohort.
Assuntos
Acrilamida/toxicidade , Carcinoma Ductal Pancreático/induzido quimicamente , Carcinoma Ductal Pancreático/epidemiologia , Dieta/efeitos adversos , Neoplasias Pancreáticas/induzido quimicamente , Neoplasias Pancreáticas/epidemiologia , Adulto , Idoso , Índice de Massa Corporal , Estudos de Coortes , Ingestão de Alimentos , Europa (Continente) , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Estado Nutricional , Obesidade , Estudos Prospectivos , Risco , Fatores de Risco , Inquéritos e Questionários , Circunferência da CinturaRESUMO
BACKGROUND: Established risk factors for pancreatic cancer include smoking, long-standing diabetes, high body fatness, and chronic pancreatitis, all of which can be characterised by aspects of inflammatory processes. However, prospective studies investigating the relation between inflammatory markers and pancreatic cancer risk are scarce. METHODS: We conducted a nested case-control study within the European Prospective Investigation into Cancer and Nutrition, measuring prediagnostic blood levels of C-reactive protein (CRP), interleukin-6 (IL-6), and soluble receptors of tumour necrosis factor-α (sTNF-R1, R2) in 455 pancreatic cancer cases and 455 matched controls. Odds ratios (ORs) were estimated using conditional logistic regression models. RESULTS: None of the inflammatory markers were significantly associated with risk of pancreatic cancer overall, although a borderline significant association was observed for higher circulating sTNF-R2 (crude OR=1.52 (95% confidence interval (CI) 0.97-2.39), highest vs lowest quartile). In women, however, higher sTNF-R1 levels were significantly associated with risk of pancreatic cancer (crude OR=1.97 (95% CI 1.02-3.79)). For sTNF-R2, risk associations seemed to be stronger for diabetic individuals and those with a higher BMI. CONCLUSION: Prospectively, CRP and IL-6 do not seem to have a role in our study with respect to risk of pancreatic cancer, whereas sTNF-R1 seemed to be a risk factor in women and sTNF-R2 might be a mediator in the risk relationship between overweight and diabetes with pancreatic cancer. Further large prospective studies are needed to clarify the role of proinflammatory proteins and cytokines in the pathogenesis of exocrine pancreatic cancer.
Assuntos
Biomarcadores Tumorais/sangue , Inflamação/sangue , Neoplasias Pancreáticas/sangue , Adulto , Idoso , Proteína C-Reativa/análise , Estudos de Casos e Controles , Estudos de Coortes , Feminino , Humanos , Interleucina-6/sangue , Masculino , Pessoa de Meia-Idade , Neoplasias Pancreáticas/imunologia , Receptores do Fator de Necrose Tumoral/sangue , Fatores de RiscoRESUMO
BACKGROUND: Insulin-like growth factors (IGFs) and their binding proteins (BPs) regulate cell differentiation, proliferation and apoptosis, and may have a role in the aetiology of various cancers. Information on their role in pancreatic cancer is limited and was examined here in a case-control study nested within the European Prospective Investigation into Cancer and Nutrition. METHODS: Serum concentrations of IGF-I and IGFBP-3 were measured using enzyme-linked immunosorbent assays in 422 cases and 422 controls matched on age, sex, study centre, recruitment date, and time since last meal. Conditional logistic regression was used to compute odds ratios (OR) and 95% confidence intervals (CI) adjusted for confounding variables. RESULTS: Neither circulating levels of IGF-I (OR=1.21, 95% CI 0.75-1.93 for top vs bottom quartile, P-trend 0.301), IGFBP-3 (OR=1.00, 95% CI 0.66-1.51, P-trend 0.79), nor the molar IGF-I/IGFBP-3 ratio, an indicator of free IGF-I level (OR=1.22, 95% CI 0.75-1.97, P-trend 0.27), were statistically significantly associated with the risk of pancreatic cancer. In a cross-classification, however, a high concentration of IGF-I with concurrently low levels of IGFBP-3 was related to an increased risk of pancreatic cancer (OR=1.72, 95% CI 1.05-2.83; P-interaction=0.154). CONCLUSION: On the basis of these results, circulating levels of components of the IGF axis do not appear to be the risk factors for pancreatic cancer. However, on the basis of the results of a subanalysis, it cannot be excluded that a relatively large amount of IGF-1 together with very low levels of IGFBP-3 might still be associated with an increase in pancreatic cancer risk.
Assuntos
Proteína 3 de Ligação a Fator de Crescimento Semelhante à Insulina/sangue , Fator de Crescimento Insulin-Like I/análise , Neoplasias Pancreáticas/epidemiologia , Adulto , Idoso , Idoso de 80 Anos ou mais , Estudos de Casos e Controles , Dieta , Europa (Continente)/epidemiologia , Feminino , Humanos , Estilo de Vida , Masculino , Pessoa de Meia-Idade , Razão de Chances , Fatores de RiscoRESUMO
BACKGROUND: Management of inflammatory bowel disease (IBD) has evolved in the last decade. AIM: To assess IBD therapeutic management, including treatment withdrawal and early treatment use in the current era of anti-TNF agents (anti-TNFs). METHODS: All patients affiliated to the French national health insurance diagnosed with IBD were included from 2009 to 2013 and followed up until 31 December 2014. Medication uses, treatment sequences after introduction of thiopurine or anti-TNF monotherapies or both (combination therapy), surgical procedures and hospitalisations were assessed. RESULTS: A total of 210 001 patients were diagnosed with IBD [Crohn's disease (CD), 100 112; ulcerative colitis (UC), 109 889]. Five years after diagnosis, cumulative probabilities of anti-TNF monotherapy and combination therapy exposures were 33.8% and 18.3% in CD patients and 12.9% and 7.4% in UC patients, respectively. Among incident patients who received thiopurines or anti-TNFs, the first treatment was thiopurine in 69.1% of CD and 78.2% of UC patients. Among patients treated with anti-TNFs, 45.2% and 54.5% of CD patients and 38.2% and 39.9% of UC patients started monotherapy and combination therapy within 3 months after diagnosis, respectively; 31.3% of CD and 27.1% of UC incident patients withdrew from thiopurine or anti-TNFs for more than 3 months after their first course of treatment. Five years after diagnosis, the cumulative risks of first intestinal resection in CD patients and colectomy in UC patients were 11.9% and 5.7%, respectively. CONCLUSIONS: Step-up approach remains the predominant strategy, while exposure to anti-TNFs is high. Surgery rates are low. Treatment withdrawal in IBD is more common than expected.
Assuntos
Demandas Administrativas em Assistência à Saúde , Bases de Dados Factuais , Fármacos Gastrointestinais/administração & dosagem , Doenças Inflamatórias Intestinais/tratamento farmacológico , Doenças Inflamatórias Intestinais/epidemiologia , Fator de Necrose Tumoral alfa/antagonistas & inibidores , Adulto , Colite Ulcerativa/diagnóstico , Colite Ulcerativa/tratamento farmacológico , Colite Ulcerativa/epidemiologia , Doença de Crohn/diagnóstico , Doença de Crohn/tratamento farmacológico , Doença de Crohn/epidemiologia , Bases de Dados Factuais/tendências , Gerenciamento Clínico , Feminino , Seguimentos , Hospitalização/tendências , Humanos , Doenças Inflamatórias Intestinais/diagnóstico , Masculino , Pessoa de Meia-Idade , Fatores de TempoRESUMO
BACKGROUND: Although infant mortality rates have declined gradually in New York City for many years, the rate of that decline began to accelerate dramatically at the end of the 1980s. OBJECTIVE: To analyze the recent accelerated decline in infant mortality for three race/ethnicity designations in New York City and to investigate whether shifts in birth weight distribution or changes in birth weight-specific death rates were more important in determining these declines between 1988 to 1989 and 1992 to 1993. METHODS: Two complete cohorts of linked birth-death certificate files consisting of all live births in New York City in 1988 to 1989 and 1992 to 1993 were examined. For each cohort, separate multinomial logistic regressions were estimated by race/ethnicity to analyze the probability of a neonatal or postneonatal death relative to survival as a function of a spectrum of covariates. The coefficients from these regressions were used to construct direct and indirect standardization exercises to predict changes in infant mortality holding characteristics of the cohort, including birth weight distribution, constant over time, or holding the influence of determinants, including birth weight-specific death rates, constant over time. RESULTS: For whites, Hispanics, and blacks, infant mortality rates declined by 27.4%, 24.8%, and 22.7%, respectively, between 1988 to 1989 and 1992 to 1993. For whites and blacks, the largest decreases occurred for neonatal mortality rates, whereas for Hispanics, postneonatal rates fell the greatest. Although infant mortality rates among very low birth weight infants (<1500 g) fell by 27.8%, 19.3%, and 16.6% for whites, Hispanics, and blacks, the greatest decreases in rates were seen among normal birth weight infants (>2500 g). Infant mortality rate declines for this category of infants reached 31%, 31.7%, and 31.3%, respectively, for whites, Hispanics, and blacks. Direct and indirect standardization exercises indicated that the most important factor in determining these declines were decreases in birth weight-specific death rates, not improvements in the birth weight distribution over time. CONCLUSIONS: We conclude that the large decreases in infant mortality rates witnessed in New York City between 1988 to 1989 and 1992 to 1993 were attributable not to improvements in birth weight distribution of the population but to declines in birth weight-specific death rates and that normal birth weight infants showed the greatest improvement.
Assuntos
Mortalidade Infantil/tendências , Negro ou Afro-Americano/estatística & dados numéricos , Peso ao Nascer , Estudos de Coortes , Hispânico ou Latino , Humanos , Lactente , Recém-Nascido de Baixo Peso , Recém-Nascido , Modelos Logísticos , Cidade de Nova Iorque/epidemiologia , População Branca/estatística & dados numéricosRESUMO
BACKGROUND: The combined effects of recent changes in health care financing and training priorities have compelled academic medical centers to develop innovative structures to maintain service commitments yet conform to health care marketplace demands. In 1992, a municipal hospital in the Bronx, New York, affiliated with a major academic medical center reorganized its pediatric service into a vertically integrated system of four interdependent practice teams that provided comprehensive care in the ambulatory as well as inpatient settings. One of the goals of the new system was to conserve inpatient resources. OBJECTIVE: To describe the development of a new vertically integrated pediatric service at an inner-city municipal hospital and to test whether its adoption was associated with the use of fewer inpatient resources. DESIGN: A descriptive analysis of the rationale, goals, implementation strategies, and structure of the vertically integrated pediatric service combined with a before-and-after comparison of in-hospital resource consumption. METHODS: A before-and-after comparison was conducted for two periods: the period before vertical integration, from January 1989 to December 1991, and the period after the adoption of vertical integration, from July 1992 to December 1994. Four measures of inpatient resource use were compared after adjustment for case mix index: mean certified length of stay per case, mean number of radiologic tests per case, mean number of ancillary tests per case, and mean number of laboratory tests per case. Difference-in-differences-in-differences estimators were used to control for institution-wide trends throughout the time period and regional trends in inpatient pediatric practice occurring across institutions. Results. In 1992, the Department of Pediatrics at the Albert Einstein College of Medicine reorganized the pediatric service at Jacobi Medical Center, one of its principal municipal hospital affiliates, into a vertically integrated pediatric service that combines ambulatory and inpatient activities into four interdependent practice teams composed of attending pediatricians, allied health professionals, house officers, and social workers. The new vertically integrated service was designed to improve continuity of care for patients, provide a model of practice for professional trainees, conserve scarce resources, and create a clinical research infrastructure. The vertically integrated pediatric service augmented the role of attending pediatricians, extended the use of allied health professionals from the ambulatory to the inpatient sites, established interdisciplinary practice teams that unified the care of pediatric patients and their families, and used less inpatient resources. Controlling for trends within the study institution and trends in the practice of pediatrics across institutions throughout the time period, the vertical integration was associated with a decline in 0.6 days per case, the use of 0.62 fewer radiologic tests per case, 0.21 fewer ancillary tests per case, and 2.68 fewer laboratory tests per case. CONCLUSIONS: We conclude that vertical integration of a pediatric service at an inner-city municipal hospital is achievable; conveys advantages of improved continuity of care, enhanced opportunities for primary care training, and increased participation of senior clinicians; and has the potential to conserve significant amounts of inpatient resources.
Assuntos
Centros Médicos Acadêmicos/organização & administração , Prestação Integrada de Cuidados de Saúde/organização & administração , Departamentos Hospitalares/organização & administração , Reestruturação Hospitalar/organização & administração , Ambulatório Hospitalar/organização & administração , Equipe de Assistência ao Paciente/organização & administração , Pediatria/organização & administração , Centros Médicos Acadêmicos/economia , Criança , Continuidade da Assistência ao Paciente/economia , Continuidade da Assistência ao Paciente/organização & administração , Redução de Custos , Prestação Integrada de Cuidados de Saúde/economia , Recursos em Saúde/economia , Recursos em Saúde/organização & administração , Departamentos Hospitalares/economia , Reestruturação Hospitalar/economia , Hospitais Municipais/economia , Hospitais Municipais/organização & administração , Hospitais Urbanos/economia , Hospitais Urbanos/organização & administração , Humanos , Cidade de Nova Iorque , Ambulatório Hospitalar/economia , Equipe de Assistência ao Paciente/economia , Pediatria/economiaRESUMO
Oral pretreatment with aldosterone or corticosterone blocked the memory-enhancing effects of the calcium antagonist nimodipine, the ACE inhibitor captopril, the NMDA blocker CGP 37,849, and the glycine antagonist strychnine in a passive-avoidance test in mice. The memory-disturbing effects of phenobarbitone, diazepam, CGP 37,849 and scopolamine were not influenced by the hormonal pretreatment. These findings could indicate the involvement of a steroid-sensitive mechanism in drug-induced improvement of memory. In the light of clinical observations showing elevated cortisol levels in Alzheimer patients, the results might also explain why only a limited number of these patients respond to therapy with memory enhancers.
Assuntos
Aldosterona/farmacologia , Corticosterona/farmacologia , Memória/efeitos dos fármacos , 2-Amino-5-fosfonovalerato/análogos & derivados , 2-Amino-5-fosfonovalerato/antagonistas & inibidores , 2-Amino-5-fosfonovalerato/farmacologia , Animais , Aprendizagem da Esquiva/efeitos dos fármacos , Captopril/antagonistas & inibidores , Captopril/farmacologia , Escuridão , Masculino , Camundongos , Nimodipina/antagonistas & inibidores , Nimodipina/farmacologia , Receptores de N-Metil-D-Aspartato/antagonistas & inibidores , Estricnina/antagonistas & inibidores , Estricnina/farmacologiaRESUMO
We use a pooled time-series cross-section of live births in New York City between 1980 and 1989 to investigate the dramatic rise in low birthweight, especially among Blacks, that occurred in the mid 1980s. After controlling for other risk factors, we estimate that the number of excess low birthweight births attributable to illicit substance abuse over this period ranged from approximately 1,482 to 3,359. The increase represents between 3.2 and 7.3% of all LBW over the period resulting in excess neonatal admission costs of between $18 and $41 million.
Assuntos
Custos de Cuidados de Saúde/estatística & dados numéricos , Recém-Nascido de Baixo Peso , Transtornos Relacionados ao Uso de Substâncias/epidemiologia , Negro ou Afro-Americano/estatística & dados numéricos , Distribuição de Qui-Quadrado , Estudos Transversais , Feminino , Hispânico ou Latino/estatística & dados numéricos , Hospitais Urbanos/economia , Humanos , Recém-Nascido , Unidades de Terapia Intensiva Neonatal/economia , Estudos Longitudinais , Modelos Estatísticos , Cidade de Nova Iorque/epidemiologia , Gravidez , Análise de Regressão , Fatores Socioeconômicos , Transtornos Relacionados ao Uso de Substâncias/complicações , Transtornos Relacionados ao Uso de Substâncias/economia , População Branca/estatística & dados numéricosRESUMO
OBJECTIVE: Our intention is to determine newborn costs and lengths of stay attributable to prenatal exposure to cocaine and other illicit drugs. DATA SOURCES AND STUDY SETTING: All parturients who delivered at a large municipal hospital in New York City between November 18, 1991 and April 11, 1992. STUDY DESIGN: A cross-sectional analysis used multivariate, loglinear regressions to analyze differences in costs and length of stay between infants exposed and unexposed prenatally to cocaine and other illicit drugs, adjusting for maternal race, age, prenatal care, tobacco, parity, type of delivery, birth weight, prematurity, and newborn infection. DATA COLLECTION/EXTRACTION METHODS: Urine specimens, with linked obstetric sheets and discharge abstracts, provided information on exposure, prenatal behaviors, costs, length of stay, and discharge disposition. PRINCIPAL FINDINGS: Infants exposed to cocaine or some other illicit drug stay approximately seven days longer at a cost of $7,731 more than infants unexposed. Approximately 60 percent of these costs are indirect, the result of adverse birth outcomes and newborn infection. Hospital screening as recorded on discharge abstracts substantially underestimates prevalence at delivery, but overestimates its impact on costs.
Assuntos
Cocaína/efeitos adversos , Recém-Nascido , Berçários Hospitalares/economia , Berçários Hospitalares/estatística & dados numéricos , Efeitos Tardios da Exposição Pré-Natal , Transtornos Relacionados ao Uso de Substâncias/economia , Adulto , Estudos Transversais , Feminino , Hospitais com mais de 500 Leitos , Custos Hospitalares/estatística & dados numéricos , Hospitais Municipais/economia , Hospitais Municipais/estatística & dados numéricos , Humanos , Terapia Intensiva Neonatal/economia , Terapia Intensiva Neonatal/estatística & dados numéricos , Tempo de Internação/estatística & dados numéricos , Cidade de Nova Iorque , Gravidez , Análise de RegressãoRESUMO
In this study we investigate the effect of Medicaid on children's health, as measured by the incidence of ambulatory care sensitive (ACS) hospitalizations in the USA. The use of ACS hospitalizations is a unique contribution of our study. ACS discharges are known to be sensitive to better primary care and greater medical intervention and are objective measures of children's health. The results of this analysis were mixed. We found relatively robust evidence that the Medicaid expansions decreased the incidence of ACS hospitalizations among children age 2-6 from very low-income areas. For other groups of children, our results were less consistent. There was some evidence, although not uniform, that the Medicaid expansions improved the health of children age 2-6 from what we refer to as near-poor areas, areas with a median family income between $25,000 and 30,000. For older children, age 7-9, we found little evidence that the Medicaid expansions improved their health.
Assuntos
Assistência Ambulatorial/estatística & dados numéricos , Proteção da Criança/tendências , Definição da Elegibilidade , Hospitalização/estatística & dados numéricos , Medicaid/estatística & dados numéricos , Assistência Ambulatorial/economia , Criança , Proteção da Criança/economia , Pré-Escolar , Acessibilidade aos Serviços de Saúde/economia , Humanos , Incidência , Cobertura do Seguro , Pobreza , Estados UnidosRESUMO
We report a case of a pregnant woman with a mitochondrial disorder affecting the energy-generating pathway of oxidative phosphorylation which was suggested when the patient presented the progressive clinical phenotype of a proximal tubular renal insufficiency, a muscular weakness of extremities, a bilateral optic neuropathy and a brain magnetic resonance imaging suggesting diffuse leucoencephalopathy. Her diagnosis was made on the basis of abnormal mitochondria on a muscle biopsy and of spectrophotometric deficiencies of the complexes I, II+III and IV of the respiratory chain. No specific molecular mutation could be detected. Her pregnancy was complicated by a severe preeclampsia, an insulin requiring gestational diabetes and a worrying renal failure which precipitated the premature delivery by cesarean section at 30 weeks gestation. The clinical course of the female neonate weighing 1030 grams was uneventful. At two Years of age she showed no sign of mitochondrial disease. But the postpartum course of the mother was complicated by seizures and a terminal renal failure leading presently to dialysis, but requiring a kidney transplantation in the near future.
Assuntos
Falência Renal Crônica/etiologia , Doenças Mitocondriais/complicações , Complicações na Gravidez , Resultado da Gravidez , Transtornos Puerperais/etiologia , Adulto , Cesárea , Diabetes Gestacional , Feminino , Humanos , Recém-Nascido , Recém-Nascido Prematuro , Falência Renal Crônica/terapia , Pré-Eclâmpsia/complicações , Gravidez , Transtornos Puerperais/terapia , Diálise Renal , Convulsões/etiologiaRESUMO
The recent demonstration that aromatase is expressed at higher levels in endometriosis implants than in normal endometrium has led to pilot studies using inhibitor aromatasis in patients with endometriosis. We conducted a systematic review of the literature and studied the efficacy of aromatase inhibitors on endometriosis. There were seventeen studies (case reports/series) evaluating outcomes of aromatase inhibitors. Studies suggest that aromatase inhibitors alone or co-administered with progestins, oral contraceptives or gonadotrophin releasing hormone (GnRH) agonist could reduce pain and endometriosis. There is only one randomized controlled trial comparing aromatase inhibitor+GnRH agonist and GnRH agonist and one study with eighty patients. Side-effects profiles of aromatase inhibitor regimens are favorable; it does not appear a significant bone loss. Aromatase inhibitors seem to have a promising effect on endometriosis but randomized controlled trials are needed to prove their effects and their safety.
Assuntos
Inibidores da Aromatase/efeitos adversos , Inibidores da Aromatase/uso terapêutico , Endometriose/tratamento farmacológico , Osteoporose/induzido quimicamente , Aromatase/fisiologia , Anticoncepcionais Orais/administração & dosagem , Quimioterapia Combinada , Endometriose/etiologia , Endometriose/fisiopatologia , Feminino , Hormônio Liberador de Gonadotropina/administração & dosagem , Hormônio Liberador de Gonadotropina/análogos & derivados , Humanos , Dor/tratamento farmacológico , Progestinas/administração & dosagem , Ensaios Clínicos Controlados Aleatórios como AssuntoRESUMO
OBJECTIVE: To test whether socioeconomic differences in the ratio of infant hospitalizations to births, a proxy for infant hospitalization rates, and hospital lengths of stay for infants narrowed between 1988 and 1992: a period of large increases in the numbers of low-income infants enrolled in Medicaid. RESEARCH DESIGN: Before and after comparison of socioeconomic differences in the ratio of infant hospitalizations to births (ie, infant hospitalization rates) and lengths of stay between 1988 and 1992. By use of ICD-9 codes, hospitalizations were categorized as mandatory or discretionary. The difference between the 2 is that discretionary hospitalizations are potentially avoidable with appropriate primary care. Difference-in-differences techniques were used to assess the differential change in the rates of hospitalizations and lengths of stay for infants from low-income, compared with high-income, zip codes. SETTING AND PARTICIPANTS: Discharges of infants <2 years of age at 326 nonfederal, short-term, general, and other specialty hospitals in 8 states. OUTCOME MEASURES: Ratios of discretionary and mandatory hospitalizations to births (ie, hospitalization rates) and hospital lengths of stay of infants <2 years of age. RESULTS: Infants from the poorest zip codes had ratios of discretionary hospitalizations to births (discretionary hospitalization rate) that were 3.1% points higher than infants from the wealthiest zip codes and ratios of mandatory hospitalizations to births (mandatory hospitalization rates) that were 0.2% points higher. Poor versus nonpoor differences in lengths of stay were 0.3 and 1.9 days for discretionary and mandatory hospitalizations, respectively. No narrowing in the socioeconomic gradients about ratios of hospitalizations to births (ie, rates of hospitalization) or lengths of stay was observed. CONCLUSIONS: Expansions in the Medicaid program from 1988 to 1992 did not result in a decrease in ratios of discretionary hospitalizations to births (ie, discretionary hospitalization rate) or hospital length of stay for infants from low-income areas.
Assuntos
Serviços de Saúde da Criança/estatística & dados numéricos , Acessibilidade aos Serviços de Saúde , Hospitalização/estatística & dados numéricos , Renda , Medicaid/estatística & dados numéricos , Humanos , Lactente , Recém-Nascido , Tempo de Internação , Modelos Econômicos , Análise de Regressão , Fatores Socioeconômicos , Estados UnidosRESUMO
OBJECTIVES: Although the association between antenatal cocaine use and adverse birth outcomes has been well documented, relatively little is known about interventions that may ameliorate these consequences. We therefore examined the relationship between prenatal care and birth weight among a population of prenatal cocaine users. DESIGN: Population-based retrospective analysis. PATIENTS: All single-gestation live births to white non-Hispanic, black non-Hispanic, and Hispanic residents of New York City who gave birth between 1988 and 1990 with a positive indication for cocaine recorded on birth certificates (N = 7923). MAIN OUTCOME MEASURES: We contrasted mean birth weight and rates of low birth weight (< 2500 g) among cocaine users with one to three prenatal care visits, four or more visits, and unknown numbers of visits with users who reported no prenatal care. We used ordinary least squares and logistic regression to control for age, parity, smoking, alcohol, other drugs, weight gain, prepregnancy weight, employment, marital status, participation in the Supplemental Food Program for Women, Infants and Children, and method of finance. MAIN RESULTS: Adjusted odds ratios of low birth weight for cocaine users with four prenatal care visits or more as compared with those who had none were 0.51 for blacks (95% confidence interval [CI], 0.44 to 0.59), 0.39 for whites (95% CI, 0.23 to 0.66), and 0.37 for Hispanics (95% CI, 0.28 to 0.48). Adjusted mean birth weight differences between users with four visits or more and those with none were 262 g for blacks (P < .001), 247 g for whites (P < .001), and 317 g for Hispanics (P < .001). CONCLUSIONS: The receipt of prenatal care among cocaine users is associated with significant improvements in birth weight. Enrollment of cocaine users in prenatal care may be an effective start to a more comprehensive approach to this problem.
Assuntos
Peso ao Nascer , Cocaína , Complicações na Gravidez , Cuidado Pré-Natal , Transtornos Relacionados ao Uso de Substâncias , Adulto , Feminino , Humanos , Recém-Nascido de Baixo Peso , Recém-Nascido , Modelos Logísticos , Análise Multivariada , Cidade de Nova Iorque/epidemiologia , Gravidez , Complicações na Gravidez/epidemiologia , Cuidado Pré-Natal/estatística & dados numéricos , Análise de Regressão , Estudos Retrospectivos , Transtornos Relacionados ao Uso de Substâncias/epidemiologiaRESUMO
Monthly time-series data on rates of low birthweight and very low birthweight in New York City from 1963 to 1990 indicate that the dramatic increase, particularly among Blacks beginning in 1984, appears to have peaked in 1988. Based on vital statistics records, the rate of low birthweight for Blacks fell from 13.1% in 1988 to 12.1% in 1990. The rate of low birthweight among Whites and Hispanics has fallen slightly since 1988.