Update on Phototherapy and Childhood Cancer in a Northern California Cohort.

OBJECTIVES: We aimed to reassess the relationship between phototherapy and cancer in an extended version of a previous cohort and to replicate a report from Quebec of increased cancer risk after phototherapy beginning at age 4 years. METHODS: This cohort study included 139 100 children born at ≥35 weeks' gestation from 1995 to 2017, followed through March 16, 2019, in Kaiser Permanente Northern California hospitals who had a qualifying bilirubin level from -3 mg/dL to +4.9 mg/dL from the American Academy of Pediatrics phototherapy threshold; an additional 40 780 children and 5 years of follow-up from our previous report. The exposure was inpatient phototherapy (yes or no), and the outcomes were various types of childhood cancer. We used Cox proportional hazard models, controlling for propensity-score quintiles, and allowed for time-dependent exposure effects to assess for the risk of cancer after a latent period. RESULTS: Over a mean (SD) follow-up of 8.2 (5.7) years, the crude incidence of cancer per 100 000 person-years was 25.1 among those exposed to phototherapy and 19.2 among those not exposed (233 cases of cancer). After propensity adjustment, phototherapy was not associated with any cancer (hazard ratio [HR]: 1.13, 95% confidence interval [CI]: 0.83-1.54), hematopoietic cancer (HR: 1.17, 95% CI: 0.74-1.83), or solid tumors (HR: 1.01, 95% CI: 0.65-1.58). We also found no association with cancer diagnoses at age ≥4 years. CONCLUSIONS: We did not confirm previous, concerning associations between phototherapy and adjusted risk of any cancer, nonlymphocytic leukemia, or brain and/or central nervous systems tumors in later childhood.

Easy clinical predictor for low BCAA to tyrosine ratio in chronic liver disease patients with hepatocellular carcinoma: Usefulness of ALBI score as nutritional prognostic marker.

BACKGROUND/AIM: Low branched-chain amino acid (BCAA) to tyrosine ratio (BTR) is known as an indicator of amino acid imbalance. We elucidated usefulness of newly developed albumin-bilirubin (ALBI) score as alternative methods of BTR in patients with naïve hepatocellular carcinoma (HCC) retrospectively. MATERIALS/METHODS: In 842 patients with HCC and without BCAA supplementation (71 years, male 614, Child-Pugh A:B:C = 689:116:37), relationships among BTR and clinical features were evaluated. Of those, 438 patients, with Milan criteria HCC, treated curatively were divided into the high-BTR (>4.4) (n = 293) and low-BTR (≤4.4) (n = 145) groups. The prognostic value of BTR was evaluated using inverse probability weighting (IPW) with propensity score. RESULTS: The low-BTR group showed worse prognosis than the other (3-, 5-, 10-year overall survival rates: 88.9% vs. 86.3%/70.5% vs. 78.1%/38.1% vs. 52.3%, respectively; p < 0.001). Multivariate Cox-hazard analysis adjusted for IPW showed elderly (≥65 years) HR 2.314, p = 0.001), female gender (HR 0.422, p < 0.001), ECOG PS ≥2 (HR 3.032, p = 0.002), low platelet count (HR 1.757, p = 0.010), and low BTR (≤4.4) (HR 1.852, p = 0.005) to be significant prognostic factors. Both serum albumin level (r = 0.370, p < 0.001) and ALBI score (r = -0.389, p < 0.001) showed a significant relationship with BTR. Child-Pugh class B, modified ALBI grade (mALBI) 2a, and mALBI 2b predictive values for BTR were 3.589, 4.509, and 4.155 (AUC range: 0.735-0.770), respectively, while the predictive value of ALBI score for low-BTR (≤4.4) was -2.588 (AUC 0.790). CONCLUSION: ALBI score -2.588 was a predictor for low-BTR (≤4.4), which was prognostic factors for early HCC patients, and at least patients with mALBI 2b might have an amino acid imbalance.

Epidemiology and reporting characteristics of preclinical systematic reviews.

In an effort to better utilize published evidence obtained from animal experiments, systematic reviews of preclinical studies are increasingly more common-along with the methods and tools to appraise them (e.g., SYstematic Review Center for Laboratory animal Experimentation [SYRCLE's] risk of bias tool). We performed a cross-sectional study of a sample of recent preclinical systematic reviews (2015-2018) and examined a range of epidemiological characteristics and used a 46-item checklist to assess reporting details. We identified 442 reviews published across 43 countries in 23 different disease domains that used 26 animal species. Reporting of key details to ensure transparency and reproducibility was inconsistent across reviews and within article sections. Items were most completely reported in the title, introduction, and results sections of the reviews, while least reported in the methods and discussion sections. Less than half of reviews reported that a risk of bias assessment for internal and external validity was undertaken, and none reported methods for evaluating construct validity. Our results demonstrate that a considerable number of preclinical systematic reviews investigating diverse topics have been conducted; however, their quality of reporting is inconsistent. Our study provides the justification and evidence to inform the development of guidelines for conducting and reporting preclinical systematic reviews.

Agreement of Risk-of -Bias varied in systematic reviews on acupuncture and was associated with methodological quality.

OBJECTIVES: The objective of the study was to evaluate the consistency of risk of bias assessments for overlapping randomized controlled trials (RCTs) included in systematic reviews (SRs) on acupuncture. STUDY DESIGN AND SETTING: Databases were searched for acupuncture SRs. A weighted kappa (κ) statistic was calculated, and logistic regression was used to explore the factors of disagreements. RESULTS: We included 241 RCTs from 109 SRs on acupuncture. The percentage disagreements ranged from 25% to 44%, with moderate agreement for random sequence generation (κ = 0.57), allocation concealment (κ = 0.50), and incomplete outcome data (κ = 0.50), besides fair agreement for blinding of participants and personnel (κ = 0.44), blinding of outcome assessment (κ = 0.31), and selective reporting (κ = 0.39). Only 19% RCTs were evaluated completely consistent. Methodological quality (random sequence generation, odds ratio (OR) = 3.46), international cooperation (allocation concealment, OR = 0.14; incomplete outcome data, OR = 0.14; selective reporting, OR = 0.05), and risk of bias reporting completeness score (selective reporting, OR = 0.53) significantly affected the relative odds of disagreements. CONCLUSION: The level of agreement varied from fair to moderate agreement depending on the risk of bias domain. Methodological quality appears to be an overarching factor to account for disagreements.

Evolution of epidemiological thought in medicine taking into account the evolution of Polish epidemiology in the 20th century.

Communicable diseases have accompanied humanity since the beginning of its existence. The first descriptions of diseases appeared in the 8th century B.C. in the Iliad, Homer. Epidemics of communicable diseases were often described in social context by poets, historians, and chroniclers. Medicine as a science until the 19th century could not provide answers concerning the aetiology of epidemic diseases or propose therapies with measurable benefits. For centuries the fight against epidemics was the duty of administrative services. Quarantine, isolation (including forced isolation), sanitary cordons, and disinfection procedures involving the moxibustion, burning of objects, clothing and bodies, etc. were introduced very early on. The knowledge of practical measures taken during repeated epidemics of various communicable diseases in Europe laid the foundations for the development of social medicine in the 18th century. In the 19th century, methods such as statistics, comparison of patient groups, mathematics and others were introduced to assess the effectiveness of prophylactic and therapeutic measures. In the 19th century it became possible to distinguish a new science - epidemiology. The missing element was the so-called "bacteriological breakthrough". After the discovery and description of bacteria, there was a tumultuous development of bacteriology, vaccines were created and huge financial resources were allocated to bacteriological institutes. After extensive use of chemotherapeutics and antibiotics, it turned out in the mid-20th century that the mortality from communicable diseasesis statistically lower in some countries than in others.In the 1940s, population-based cardiological studies using epidemiological patterns were introduced in the United States, and in the 1950s epidemiological congresses worldwide accepted that it was reasonable for epidemiology to investigate the occurrence and causes of communicable and non-communicable diseases. In Poland, in 1964, at the 4th Congress of the Polish Society of Epidemiologists and Doctors of Infectious Diseases in Cracow, a decision was made to extend epidemiological studies to non-communicable diseases.

Overall survival predictors in hepatocellular carcinoma patients treated with sorafenib.

OBJECTIVE: Malignant liver tumors are the fourth leading cause of cancer death worldwide. Hepatocellular carcinoma (HCC) accounts for 75-85% of these. Most patients are diagnosed at incurable stages. Palliative care is the appropriate treatment course in these circumstances (chemoembolization and sorafenib). There are few national studies on sorafenib. The objective is to evaluate survival predictors of HCC patients treated with sorafenib and evaluate the compliance of its indication in relation to BCLC recommendations. METHODS: A total of 88 patients with an indication of sorafenib from 2010 to 2017 at the ISCMSP were retrospectively analyzed. Univariate and multivariate analyzes were performed in the search for predictors of survival. RESULTS: The mean age was 61.2 years, 70.5% were men, most were classified as Child-Pugh A (69.3%), and BCLC C (94.3%). Cirrhosis was present in 84.6% and portal hypertension in 55.7%. Hepatitis C virus was the most common etiology (40.9%). Sixty-nine (78.4%) patients received the medication, with the average duration of treatment being 9.7 months. The mean overall survival was 16.8 months. Significant differences were observed in the multivariate analysis: ECOG PS (p = 0.024): Child-Pugh (p = 0.013), time of medication use (p <0.001), clinical worsening (p = 0.031) and portal thrombosis (p = 0.010). CONCLUSION: Absence of portal thrombosis, Child-Pugh A, longer time of medication use, ECOG PS 0, and absence of suspension due to clinical worsening were predictors of better overall survival in the study. The drug's indication complies with BCLC guidelines in 94% of patients.

La Eficacia de la Homeopatía en el Tratamiento Epidemiológico / The Efficacy of Homeopathy in the Epidemiological Treatment

Pandemia de consecuencias sanitarias, sociales y económicas incalculables, la enfermedad COVID-19 parece haber llegado para quedarse mucho tiempo entre nosotros, y cuando decimos "nosotros" nos referimos a los 7,700 millones de habitantes del planeta. (au)

Innovations in applied decision theory for health and safety.

OBJECTIVES: There are established methods for occupational epidemiological cohort analysis, such as proportional hazards regression, that are well suited to aetiological research and yield parameter estimates that allow for succinct communication among academics. However, these methods are not necessarily well suited for evaluation of health impacts of policy choices and communication to decision makers. An informed decision about a policy that impacts health and safety requires a valid estimate of the policy's potential impact. METHODS: We propose methods for data summarisation that may facilitate communication with managers, workers and their advocates. We calculate measures of effect in a framework for competing events, graphically display potential impacts on cause-specific mortality under policy alternatives and contrast these results to estimates obtained using standard Poisson regression methods. Methods are illustrated using a cohort mortality study of 28 546 Ontario uranium miners hired between 1950 and 1996 and followed through 2007. RESULTS: A standard regression analysis yields a positive association between cumulative radon progeny exposure and all-cause mortality (log(RR per 100 WLM)=0.09; SE=0.02). The proposed method yields an estimate of the expected gain in life expectancy (approximately 6 months per worker) and reduction of 261 lung cancer deaths under a policy that eliminated occupational radon progeny exposure. CONCLUSIONS: The proposed method shifts attention from covariate-adjusted risk ratios or rate ratios to estimates of deaths that are avoided or delayed under a potential policy. The approach may help inform decision-making and strengthen the connection of epidemiological approaches to data analysis with developments in decision theory and systems engineering to improve health and safety.

Religion, Spirituality, and Health: New Considerations for Epidemiology.

Religion and spirituality are important social determinants that drive public health practice. The field of epidemiology has played a vital role in answering long-standing questions about whether religion is causally associated with health and mortality. As epidemiologists spark new conversations (e.g., see Kawachi (Am J Epidemiol. (https://doi.org/10.1093/aje/kwz204)) and Chen and VanderWeele (Am J Epidemiol. 2018;187(11):2355-2364)) about methods (e.g., outcomes-wide analysis) used to establish causal inference between religion and health, epidemiologists need to engage with other aspects of the issue, such as emerging trends and historical predictors. Epidemiologists will need to address 2 key aspects. The first is changing patterns in religious and spiritual identification. Specifically, how do traditional mechanisms (e.g., social support) hold up as explanations for religion-health associations now that more people identify as spiritual but not religious and more people are not attending religious services in physical buildings? The second is incorporation of place into causal inference designs. Specifically, how do we establish causal inference for associations between area-level constructs of the religious environment (e.g., denomination-specific church membership/adherence rates) and individual- and population-level health outcomes?

Overall survival predictors in hepatocellular carcinoma patients treated with sorafenib

SUMMARY Malignant liver tumors are the fourth leading cause of cancer death worldwide. Hepatocellular carcinoma (HCC) accounts for 75-85% of these. Most patients are diagnosed at incurable stages. Palliative care is the appropriate treatment course in these circumstances (chemoembolization and sorafenib). There are few national studies on sorafenib. The objective is to evaluate survival predictors of HCC patients treated with sorafenib and evaluate the compliance of its indication in relation to BCLC recommendations. METHODS A total of 88 patients with an indication of sorafenib from 2010 to 2017 at the ISCMSP were retrospectively analyzed. Univariate and multivariate analyzes were performed in the search for predictors of survival. RESULTS The mean age was 61.2 years, 70.5% were men, most were classified as Child-Pugh A (69.3%), and BCLC C (94.3%). Cirrhosis was present in 84.6% and portal hypertension in 55.7%. Hepatitis C virus was the most common etiology (40.9%). Sixty-nine (78.4%) patients received the medication, with the average duration of treatment being 9.7 months. The mean overall survival was 16.8 months. Significant differences were observed in the multivariate analysis: ECOG PS (p = 0.024): Child-Pugh (p = 0.013), time of medication use (p <0.001), clinical worsening (p = 0.031) and portal thrombosis (p = 0.010). CONCLUSION Absence of portal thrombosis, Child-Pugh A, longer time of medication use, ECOG PS 0, and absence of suspension due to clinical worsening were predictors of better overall survival in the study. The drug's indication complies with BCLC guidelines in 94% of patients.

RESUMO Tumores malignos do fígado são a quarta maior causa de morte por câncer, sendo que o carcinoma hepatocelular (CHC) corresponde a 85-90% desses casos. A maioria dos doentes apresenta-se, ao diagnóstico, sem possibilidade de tratamento curativo, restando apenas as opções paliativas (quimioembolização e sorafenibe). Há poucos estudos nacionais acerca do sorafenibe. OBJETIVO Avaliar fatores preditivos de sobrevida em pacientes com CHC que tiveram indicação de tratamento com sorafenibe na Irmandade da Santa Casa de Misericórdia de São Paulo (ISCMSP) e avaliação da conformidade da indicação da medicação em relação às recomendações do BCLC. MÉTODOS Foram analisados retrospectivamente os dados de 88 pacientes que tiveram indicação de tratamento com sorafenibe no período de 2010 a 2017 na ISCMSP. Análises univariada e multivariada foram realizadas na busca de preditores de sobrevida global nos pacientes que receberam a medicação. RESULTADOS Idade média de 61,2 anos, sendo 70,5% homens. A maioria (69,3%) foi classificada como Child Pugh A e BCLC C (94,3%). A cirrose esteve presente em 84,6% e a hipertensão portal em 55,7% desses. O vírus da hepatite C foi a etiologia mais comum (40,9%) do CHC. Sessenta e nove (78,4%) pacientes receberam a medicação, sendo o tempo médio de duração do tratamento 9,7 meses e a sobrevida global média, 16,8 meses. Diferenças significativas foram observadas na análise multivariada: Ecog PS (p=0,024), CP (p=0,013), tempo de uso de medicação (p<0,001), suspensão por piora clínica (p=0,031) e trombose portal (p=0,010). CONCLUSÃO Ausência de trombose portal, Child Pugh A, Ecog PS 0, tempo maior de uso de medicação e ausência de suspensão por piora clínica foram fatores preditores de melhor sobrevida global e a indicação da medicação esteve em conformidade com as orientações do BCLC em 94% dos pacientes.

Systematic review of the introduction and evaluation of magnetic augmentation of the lower oesophageal sphincter for gastro-oesophageal reflux disease.

BACKGROUND: Magnetic sphincter augmentation (MSA) is reported to be an innovative alternative to antireflux surgery for patients with gastro-oesophageal reflux disease. Although used in practice, little is known about how it has been evaluated. This study aimed to systematically summarize and appraise the reporting of MSA and its introduction into clinical practice, in the context of guidelines (such as IDEAL) for evaluating innovative surgical devices. METHODS: Systematic searches were used to identify all published studies reporting MSA insertion. Data collected included patient selection, governance arrangements, surgeon expertise, technique description and outcome reporting. RESULTS: Searches identified 587 abstracts; 39 full-text papers were included (1 RCT 5 cohort, 3 case-control, 25 case series, 5 case reports). Twenty-one followed US Food and Drug Administration eligibility criteria for MSA insertion. Twenty-six documented that ethical approval was obtained. Two reported that participating surgeons received training in MSA; 18 provided information about how MSA insertion was performed, although techniques varied between studies. Follow-up ranged from 4 weeks to 5 years; in 14 studies, it was less than 1 year. CONCLUSION: Most studies on MSA lacked information about patient selection, governance, expertise, techniques and outcomes, or varied between studies. Currently, MSA is being used despite a lack of robust evidence for its effectiveness.

ANTECEDENTES: El aumento de esfínter con un dispositivo magnético (magnetic sphincter augmentation, MSA) se ha descrito como una alternativa innovadora a la cirugía antirreflujo para pacientes con enfermedad por reflujo gastroesofágico. Aunque este procedimiento se utiliza en la práctica, se sabe poco acerca de cómo ha sido evaluado. Este estudio se propuso resumir sistemáticamente y evaluar los trabajos sobre MSA y su introducción en la práctica clínica, en el contexto de las guías (como IDEAL) para la evaluación de dispositivos quirúrgicos innovadores. MÉTODOS: Se identificaron todos los estudios publicados que describían la colocación de MSA efectuando búsquedas sistemáticas. Los datos recogidos incluían la selección de los pacientes, disposiciones de gobernanza, experiencia del cirujano, descripción técnica, y descripción de resultados. RESULTADOS: Las búsquedas identificaron 587 resúmenes, incluyéndose 39 artículos completos (5 estudios de cohortes, 3 estudios de casos y controles, 26 series de casos, 5 casos clínicos). En 21 estudios se siguieron los criterios de elegibilidad de la FDA para la colocación de MSA. En 26 estudios se confirmaba que se había obtenido la aprobación ética. Dos estudios describieron que los cirujanos participantes habían recibido formación en MSA; 18 proporcionaron información sobre cómo se realizó la colocación de MSA, aunque las técnicas variaron entre los estudios. El seguimiento oscilaba entre 4 semanas y 5 años; en 14 estudios fue inferior a un año. CONCLUSIÓN: La mayoría de los estudios sobre MSA fueron casos aislados y series de casos, sin un incremento apreciable en la calidad de la evidencia sobre MSA. La información sobre la selección de los pacientes, gobernanza, experiencia, técnicas, y resultados estaba ausente o variaba entre los estudios, haciendo difíciles las comparaciones. En la actualidad, MSA se utiliza a pesar de la falta de evidencia robusta sobre su efectividad.

Statistical Approaches in the Studies Assessing Associations between Human Milk Immune Composition and Allergic Diseases: A Scoping Review.

A growing number of studies are focusing on the associations between human milk (HM) immunological composition and allergic diseases. This scoping review aims to identify statistical methods applied in the field and highlight pitfalls and unmet needs. A comprehensive literature search in MEDLINE and Embase retrieved 13,607 unique records. Following title/abstract screening, 29 studies met the selection criteria and were included in this review. We found that definitions of colostrum and mature milk varied across the studies. A total of 17 out of 29 (59%) studies collected samples longitudinally, but only 12% of these used serial (longitudinal) analyses. Multivariable analysis was used in 45% of the studies, but statistical approaches to modelling varied largely across the studies. Types of variables included as potential confounding factors differed considerably between models. Discrimination analysis was absent from all studies and only a single study reported classification measures. Outcomes of this scoping review highlight lack of standardization, both in data collection and handling, which remains one of the main challenges in the field. Improved standardization could be obtained by a consensus group of researchers and clinicians that could recommend appropriate methods to be applied in future prospective studies, as well as already existing datasets.

Intravenous iron supplementation does not increase infectious disease risk in hemodialysis patients: a nationwide cohort-based case-crossover study.

BACKGROUND: Studies have reported conflicting findings on the infection risk posed by intravenous iron supplementation among hemodialysis (HD) patients. We used a novel study design to assess associations between intravenous iron and infectious diseases. METHODS: Patients initiating HD between 1998 and 2008 were extracted from Taiwan's National Health Insurance Research Database. Their first infectious disease in the period between 1.5 years after dialysis initiation and 2010 was identified and defined as the index date. Through the case-crossover design, the odds of exposure to intravenous iron within the 1-month period immediately preceding the index date (i.e., the case period) were compared with iron exposure in three different matched control periods for the same enrollee, thus possibly reducing some unmeasured confounders. RESULTS: A total of 1410 patients who met our enrollment criteria were extracted from incident HD patients. The odds of intravenous iron exposure during the case period versus total control periods exhibited no significant difference (odds ratio: 1.000, 95% confidence interval: 0.75-1.33). In subgroup analyses, this association remained nonsignificant across patients with diabetes mellitus, heart failure, chronic lung disease, venous catheter for HD, and higher iron load. CONCLUSIONS: We found that intravenous iron supplementation did not increase short-term infection risk among HD patients.

Impact of Overactive Bladder-Wet Syndrome on Female Sexual Function: A Systematic Review and Meta-Analysis.

INTRODUCTION: Overactive bladder (OAB) is subtyped into OAB-wet and OAB-dry, based on the presence or absence, respectively, of urgency incontinence. Although women with OAB frequently have a higher risk for sexual dysfunction, a systematic review on the impact of OAB-wet on female sexuality is lacking. This may be evaluated by measuring the effect of the bladder condition on sexuality per se, or by the effect of OAB treatment on female sexual dysfunction. AIM: To assess the role of OAB-wet on female sexual function. METHODS: A systematic review of the literature was performed according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement recommendations. Research on PubMed, EMBASE, and SCOPUS was performed and concluded on October 15, 2018. A systematic computerized search was conducted on published literature from January 1, 2000-2018. Meta-analysis was performed with a meta-analysis program. MAIN OUTCOMES MEASURES: The following search terms were used: ((("female sexual function") OR ("female sexual dysfunction") OR ("female sexuality") OR ("dyspareunia")) AND (("overactive bladder") OR ("coital incontinence") OR ("detrusor instability") OR ("detrusor overactivity") OR ("urge urinary incontinence") OR (onabotulinumtoxinA) OR ("botulinum") OR ("sacral neuromodulation") OR (SNM) OR (PTNS) OR ("stoller afferent neuro-stimulation") OR ("SANS") OR ("antimuscarinic drugs") OR ("anticholinergic") OR ("peripheral neuromodulation") OR (beta-agonist))). RESULTS: 1,033 references were reviewed for inclusion and exclusion criteria. Final analysis identified 12 articles for systematic review. OAB-wet was reported as the most affecting factor on sexuality. OAB treatments showed improvement of both the OAB-wet and the sexual function. Results of the meta-analysis suggested that OAB therapies improving OAB-wet significantly reduced female sexual dysfunction (odds ratio 0.19; 95% CI 0.26-0.45). CONCLUSION: OAB-wet represents a risk for sexual dysfunction; however, data available show low-quality evidence of the impact of OAB-wet on sexual dysfunction. Balzarro M, Rubilotta E, Mancini V, et al. Impact of Overactive Bladder-Wet Syndrome on Female Sexual Function: A Systematic Review and Meta-Analysis. Sex Med Rev 2019;7:565-574.

[Investigation of acute poisoning event caused by carbofuran].

Objective: To analyze the epidemiological characteristics and response process of an acute poisoning event caused by carbofuran in buttered tea and provide scientific evidence for the investigation of similar events in the future. Methods: Field epidemiological survey, animal experiments and laboratory tests were conducted for an acute poisoning event occurred in Suopo township of Danba county of Sichuan province in 2018. Descriptive epidemiological method was used to analyze the epidemiological characteristics of the acute poisoning event. Results: A total of 26 poisoning cases occurred in 3 villages. The total attack rate was 41.27%. No death cases were reported. The 26 cases occurred in a few minutes after drinking buttered tea, the main symptoms were vomit, dizziness, miosis and nausea. A dog showed the same symptoms after drinking a sample of buttered tea. Carbofuran was detected in buttered tea, vomitus and zanba samples. Conclusions: The acute poisoning was caused by carbofuran in buttered tea, the transmission mode was point source spread. Effective epidemiological investigation and simple animal experiment can provide evidence for the rapid sample detection and clinical treatment of cases in emergency response. Timely case treatment and strict poisoning source control are the key measures to reduce casualty and prevent the spread of poisoning.

Explaining patient delay in healthcare seeking and loss to diagnostic follow-up among patients with presumptive tuberculosis in Tanzania: a mixed-methods study.

BACKGROUND: Delay in healthcare seeking and loss to diagnostic follow-up (LDFU) contribute to substantial increase in tuberculosis (TB) morbidity and mortality. We examined factors, including perceived causes and prior help seeking, contributing to delay and LDFU during referral to a TB clinic among patients with presumptive TB initially seeking help at the pharmacies in Dar es Salaam Tanzania. METHODS: In a TB clinic, a semi-structured interview based on the explanatory model interview catalogue (EMIC) framework for cultural epidemiology was administered to presumptive TB patients enrolled at pharmacies during an intervention study. We assessed delay in seeking care at any medical care provider for a period of ≥3 weeks after the onset of symptoms, LDFU during referral (not reaching the TB clinic), and LDFU for three required TB clinic visits among the presumptive and confirmed TB patients. Logistic regression models were used to assess factors associated with delay and LDFU. RESULTS: Among 136 interviewed patients, 86 (63.2%) were LDFU from pharmacies and TB clinic while 50 (36.8%) were non-LDFU. Out of 136 patients 88 (64.7%) delayed seeking care, of whom 59 (67%) were females. Among the 86 (63.2%) patients in LDFU group, 62 (72.1%) delayed seeking care, while among the 50 (36.8%) non-LDFU, 26 (52.0%) had also delayed seeking care. Prior consultation with a traditional healer (aOR 2.84, 95% CI 1.08-7.40), perceived causes as ingestion (water and food) (aOR 0.38 CI 0.16-0.89), and substance use (smoking and alcohol) (aOR 1.45 CI 0.98-2.14) were all associated with patient delay. Female gender was associated with LDFU (aOR 3.80, 95% CI 1.62-8.87) but not with delay. Other conditions as prior illness and heredity were also associated with LDFU but not delay (aOR 1.48 CI 1.01-2.17). CONCLUSION: Delay and LDFU after referral from the pharmacies were substantial. Notable effects of diagnosis and female gender indicate a need for more attention to women's health to promote timely and sustained TB treatment. Public awareness to counter misconceptions about the causes of TB is needed.

Hepatite C no sistema público de saúde brasileiro: impacto da doença / Hepatitis c in the brazilian public health care system: burden of disease

ABSTRACT BACKGROUND: Infection by hepatitis C virus is one of the leading causes of chronic hepatitis C and cause severe burden for patients, families and the health care system. OBJECTIVE: The aims of this research were to assess the severity of liver fibrosis, comorbidities and complications of hepatitis C virus; to examine health-related quality of life (HRQoL), productivity loss and resource use and costs in a sample of Brazilian chronic hepatitis C, genotype 1, patients. METHODS: This was a cross-sectional multicenter study performed in genotype-1 chronic hepatitis C patients to assess disease burden in the Brazilian public health care system between November 2014 and March 2015. Patients were submitted to a liver transient elastography (FibroScan) to assess liver fibrosis and answered an interview composed by a questionnaire specifically developed for the study and three standardized questionnaires: EQ-5D-3L, HCV-PRO and WPAI:HepC. RESULTS: There were 313 subjects enrolled, with predominance of women (50.8%), caucasian/white (55.9%) and employed individuals (39.9%). Mean age was 56 (SD=10.4) years old. Moreover, 42.8% of patients who underwent FibroScan were cirrhotic; the most frequent comorbidity was cardiovascular disease (62.6%) and the most frequent complication was esophageal varices (54.5%). The results also showed that "pain and discomfort" was the most affected HRQoL dimension (55.0% of patients reported some problems) and that the mean HCV-PRO overall score was 69.1 (SD=24.2). Regarding productivity loss, the most affected WPAI:HepC component was daily activity (23.5%) and among employed patients, presenteeism was more frequent than absenteeism (18.5% vs 6.5%). The direct medical costs in this chronic hepatitis C sample was 12,305.72USD per patient in the 2 years study period; drug treatment costs represented 95.9% of this total. CONCLUSION: This study showed that most patients are cirrhotic, present high prevalence of cardiometabolic diseases and esophageal varices, reduced HRQoL mainly in terms of pain/discomfort, and work productivity impairment, especially presenteeism. Additionally, we demonstrated that hepatitis C virus imposes an economic burden on Brazilian Health Care System and that most of this cost is due to drug treatment.

RESUMO CONTEXTO: A infecção pelo vírus da hepatite C (HCV) é uma das principais causas de hepatite C crônica e provoca implicações graves para pacientes, familiares e sistema de saúde. OBJETIVO: Os objetivos deste estudo foram: analisar a gravidade da fibrose hepática, comorbidades e complicações da hepatite C; examinar a qualidade de vida relacionada à saúde (QVRS), a perda de produtividade e o uso de recursos e custos no sistema público por pacientes brasileiros com hepatite C crônica, genótipo tipo 1. MÉTODOS: Foi realizado um estudo transversal, multicêntrico em pacientes com hepatite C crônica genótipo-1 para avaliar a carga da doença no sistema público de saúde brasileiro entre novembro de 2014 e março de 2015. Os pacientes foram submetidos a uma elastografia hepática transitória (FibroScan) para avaliar a fibrose e a uma entrevista composta por um questionário desenvolvido para o estudo e cinco questionários padronizados: EQ-5D-3L, HCV-PRO, e WPAI:HepC. RESULTADOS: Foram recrutados 313 pacientes. A amostra foi composta predominantemente por mulheres (50,8%), caucasianos/brancos (55,9%) e indivíduos empregados (39,9%). A média de idade foi 56 (DP=10,4) anos. Em média, os pacientes com HCV esperaram 40,6 (DP=49,6) meses entre o diagnóstico e o primeiro tratamento. Ademais, 42,8% dos pacientes que realizaram o FibroScan tinham cirrose; a comorbidade mais frequente foi doença cardiovascular (62,6%) e a complicação mais comum as varizes esofágicas (54,5%). Os resultados também mostraram que "dor e desconforto" foi a dimensão de QVRS mais afetada (55,0% dos pacientes relataram alguns problemas) e que a média do escore do HCV-PRO foi 69,1 (DP=24,2). Em relação à perda de produtividade, o componente do WPAI:HepC mais afetado foi atividade diária (23,5%) e entre os pacientes empregados, presenteísmo foi mais frequente do que absenteísmo (18,5% vs 6,5%). Os custos diretos médicos totais com essa amostra foi de 12.305,72USD por paciente em um período de dois anos; o tratamento medicamentoso representou 95% desse total. CONCLUSÃO Esse estudo mostrou a maioria dos pacientes possui cirrose, apresenta alta prevalência de doenças cardiometabolicas e varizes esofágicas, QVRS reduzida principalmente em termos de dor/desconforto e dano na produtividade, especialmente presenteísmo. Adicionalmente, nós demonstramos que o HCV impõe uma carga econômica no sistema de saúde brasileiro e que os medicamentos correspondem à maioria dos custos.

Tratamento cirúrgico de lesões císticas do pâncreas: uma experiência unicêntrica / Surgical management of cystic lesions of the pancreas: a single-centre experience

ABSTRACT BACKGROUND: Cystic lesions of the pancreas represent a group of pancreatic diseases with great histological heterogeneity, varying from benign lesions, some of them with malignant potential, to overt malignant lesions. OBJECTIVE: To describe the cases of cystic lesions of the pancreas which underwent surgical intervention at a tertiary university hospital. METHODS: This is a retrospective population-based study (historical cohort) which was carried out enrolling individuals attended at the Outpatient service of Pancreas Surgery of the Hospital de Clínicas of Unicamp. The individuals underwent surgical procedures performed from January 2012 through December 2016. RESULTS: In the period evaluated, 39 cases of cystic lesions of the pancreas which underwent surgery were identified, 26 (66.6%) of which were female. The average age at diagnosis was 47.4±16.4 years (range, 18-73). In regards to symptoms, 35 (89.7%) were symptomatic. The average length of hospital stay was 10 days (range 4-76). Surgeries performed to treat the lesions depended on the localization and type of the lesions: cystojejunostomy (41%), distal pancreatectomy (36%), pancreaticoduodenectomy (15.4%), drainage of ruptured and/or infected pseudocyst (5.2%) and central pancreatectomy (2.6%). CONCLUSION: Cystic lesions of the pancreas are a group of lesions with a highly varying presentation and diagnostic approach and may require an also highly variable surgical treatment. An appropriate preoperative imaging diagnosis is essential for their management.

RESUMO CONTEXTO: As lesões císticas do pâncreas representam um grupo de doenças pancreáticas com grande heterogeneidade histológica, variando desde lesões benignas, algumas com potencial pré-maligno, até outras degeneradas para formas malignas. OBJETIVO: Descrever os casos de LCPs submetidos à intervenção cirúrgica em um hospital universitário terciário. MÉTODOS: Trata-se de um estudo retrospectivo populacional (coorte histórica) realizado com a participação de indivíduos atendidos no Ambulatório de Cirurgia do Pâncreas do Hospital de Clínicas da Unicamp. Os indivíduos foram submetidos a procedimentos cirúrgicos realizados no período de janeiro de 2012 a dezembro de 2016. RESULTADOS: No período avaliado, foram identificados 39 casos de lesões císticas do pâncreas operados, sendo 26 (66,6%) do sexo feminino. A idade média no diagnóstico foi de 47,4±16,4 anos. Em relação aos sintomas, 35 (89,7%) eram sintomáticos. O tempo médio de internação foi de 10 dias (variação de 4-76). As cirurgias realizadas para o tratamento das lesões dependeram da localização e do tipo das lesões: derivação pseudocisto-jejunal (41%), pancreatectomia distal (36%), pancreaticoduodenectomia (15,4%), drenagem de pseudocistos rotos e/ou infectados (5,2%) e pancreatectomia central (2,6%). CONCLUSÃO: As lesões císticas do pâncreas são um grupo de lesões cuja apresentação e abordagem diagnóstica são altamente heterogêneas e que podem requerer um tratamento cirúrgico altamente complexo e variável. Um diagnóstico pré-operatório adequado é essencial para definir o seu tratamento.

[Factors associated with the involuntary pilgrimage for childbirth care in São Luís (Maranhão State) and Ribeirão Preto (São Paulo State), Brazil: a contribution from the BRISA cohort]. / Fatores associados à peregrinação para o parto em São Luís (Maranhão) e Ribeirão Preto (São Paulo), Brasil: uma contribuição da coorte BRISA.

The objectives of this study were to estimate the involuntary pilgrimage by women in labor in search of childbirth care and to identify factors associated with this endeavor in two Brazilian cities. This was a cross-sectional study nested in the BRISA birth cohort, whose sample consisted of 10,475 women admitted to the selected maternity hospitals for delivery in São Luís (Maranhão State) and Ribeirão Preto (São Paulo State). Interviews were held with questionnaires that contained sociodemographic and obstetric variables. Hierarchical modeling was used, and relative risk was calculated with Poisson regression. Involuntary pilgrimage during labor was more frequent in São Luís (35.8%) than in Ribeirão Preto (5.8%). In São Luís, factors associated with pilgrimage were: first pregnancy (RR = 1.19; 95%CI: 1.08-1.31) and schooling less than 12 complete years. However, age 35 years or older (RR = 0.65; 95%CI: 0.54-0.84) was associated with less pilgrimage. In Ribeirão Preto, such trekking for obstetric care was more frequent in women with high-risk pregnancies (RR = 2.45; 95%CI: 1.81-3.32) and those with gestational age less than 37 weeks (RR = 1.93; 95%CI: 1.50-2.50). Meanwhile, delivery with gestational age equal to or greater than 42 weeks was associated with less pilgrimage (RR = 0.57; 95%CI: 0.33-0.98). In both cities, poor women had to trek more in search of childbirth care and had no guarantee of care, even for those who had received prenatal care. The study revealed the lack of guarantee of universal and equitable access and highlighted the unequal access to childbirth care between Brazil's major geographic regions.

O objetivo deste trabalho foi estimar a peregrinação de gestantes no momento do parto e identificar os fatores associados a essa peregrinação em duas cidades brasileiras. Estudo seccional, aninhado à coorte de nascimento BRISA, cuja amostra foi composta por 10.475 gestantes admitidas nas maternidades selecionadas por ocasião do parto em São Luís (Maranhão) e Ribeirão Preto (São Paulo). Entrevistas foram realizadas utilizando-se questionários que continham variáveis sociodemográficas e relacionadas ao parto. Utilizou-se modelagem hierarquizada, e calculou-se o risco relativo utilizando regressão de Poisson. A peregrinação foi mais frequente em São Luís (35,8%) que em Ribeirão Preto (5,8%). Em São Luís, foram fatores associados à maior peregrinação: ser primípara (RR = 1,19; IC95%: 1,08-1,31) e ter escolaridade menor que 12 ou mais anos de estudo. Entretanto, ter 35 anos ou mais (RR = 0,65; IC95%: 0,54-0,84) foi fator associado à menor peregrinação. Em Ribeirão Preto, peregrinaram com maior frequência as gestantes cujos partos foram de alto risco (RR = 2,45; IC95%: 1,81-3,32) e com idade gestacional inferior a 37 semanas (RR = 1,93; IC95%: 1,50-2,50). No entanto, partos com idade gestacional igual ou acima de 42 semanas foi um fator associado à menor peregrinação (RR = 0,57; IC95%: 0,33-0,98). Nas duas cidades, gestantes pobres peregrinaram com maior frequência, e sem garantia de que seriam atendidas, mesmo dentre as que realizaram o pré-natal. O estudo evidenciou ausência da garantia de acesso universal e equânime e reafirmou a desigualdade de acesso à assistência ao parto entre as regiões brasileiras.

El objetivo de este trabajo fue estimar los desplazamientos largos de gestantes en el momento del parto e identificar los factores asociados a estos desplazamientos en dos ciudades brasileñas. Se trata de una investigación seccional, encajada en la cohorte de nacimiento BRISA, cuya muestra estuvo compuesta por 10.475 gestantes, admitidas en las maternidades seleccionadas para dar a luz en São Luís (Maranhão) y Ribeirão Preto (São Paulo). Las entrevistas se realizaron utilizando cuestionarios que contenían variables sociodemográficas y relacionadas con el parto. Se utilizó un modelado jerarquizado, y se calculó el riesgo relativo utilizando la regresión de Poisson. Los desplazamientos fueron más frecuentes en São Luís (35,8%) que en Ribeirão Preto (5,8%). En São Luís, los factores asociados a mayores desplazamientos fueron: ser primípara (RR = 1,19; IC95%: 1,08-1,31) y contar con una escolaridad menor a 12 o más años de estudio. Sin embargo, tener 35 años o más (RR = 0,65; IC95%: 0,54-0,84) fue un factor asociado a menores desplazamientos. En Ribeirão Preto, se desplazaron con mayor frecuencia las gestantes cuyos partos fueron de alto riesgo (RR = 2,45; IC95%: 1,81-3,32) y con una edad gestacional inferior a 37 semanas (RR = 1,93; IC95%: 1,50-2,50). Sin embargo, los partos con una edad gestacional igual o por encima de las 42 semanas fue un factor asociado a un menor desplazamiento (RR = 0,57; IC95%: 0,33-0,98). En las dos ciudades, las gestantes pobres se desplazaron con mayor frecuencia, y sin garantía de que serían atendidas, incluso entre quienes realizaron seguimiento prenatal. El estudio evidenció la inexistencia de garantías de acceso universal y ecuánime a la salud y reafirmó la desigualdad de acceso en la asistencia al parto entre regiones brasileñas.