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1.
JAMA ; 331(18): 1565-1575, 2024 05 14.
Artículo en Inglés | MEDLINE | ID: mdl-38619832

RESUMEN

Importance: Diltiazem, a commonly prescribed ventricular rate-control medication for patients with atrial fibrillation, inhibits apixaban and rivaroxaban elimination, possibly causing overanticoagulation. Objective: To compare serious bleeding risk for new users of apixaban or rivaroxaban with atrial fibrillation treated with diltiazem or metoprolol. Design, Setting, and Participants: This retrospective cohort study included Medicare beneficiaries aged 65 years or older with atrial fibrillation who initiated apixaban or rivaroxaban use and also began treatment with diltiazem or metoprolol between January 1, 2012, and November 29, 2020. Patients were followed up to 365 days through November 30, 2020. Data were analyzed from August 2023 to February 2024. Exposures: Diltiazem and metoprolol. Main Outcomes and Measures: The primary outcome was a composite of bleeding-related hospitalization and death with recent evidence of bleeding. Secondary outcomes were ischemic stroke or systemic embolism, major ischemic or hemorrhagic events (ischemic stroke, systemic embolism, intracranial or fatal extracranial bleeding, or death with recent evidence of bleeding), and death without recent evidence of bleeding. Hazard ratios (HRs) and rate differences (RDs) were adjusted for covariate differences with overlap weighting. Results: The study included 204 155 US Medicare beneficiaries, of whom 53 275 received diltiazem and 150 880 received metoprolol. Study patients (mean [SD] age, 76.9 [7.0] years; 52.7% female) had 90 927 person-years (PY) of follow-up (median, 120 [IQR, 59-281] days). Patients receiving diltiazem treatment had increased risk for the primary outcome (RD, 10.6 [95% CI, 7.0-14.2] per 1000 PY; HR, 1.21 [95% CI, 1.13-1.29]) and its components of bleeding-related hospitalization (RD, 8.2 [95% CI, 5.1-11.4] per 1000 PY; HR, 1.22 [95% CI, 1.13-1.31]) and death with recent evidence of bleeding (RD, 2.4 [95% CI, 0.6-4.2] per 1000 PY; HR, 1.19 [95% CI, 1.05-1.34]) compared with patients receiving metoprolol. Risk for the primary outcome with initial diltiazem doses exceeding 120 mg/d (RD, 15.1 [95% CI, 10.2-20.1] per 1000 PY; HR, 1.29 [95% CI, 1.19-1.39]) was greater than that for lower doses (RD, 6.7 [95% CI, 2.0-11.4] per 1000 PY; HR, 1.13 [95% CI, 1.04-1.24]). For doses exceeding 120 mg/d, the risk of major ischemic or hemorrhagic events was increased (HR, 1.14 [95% CI, 1.02-1.27]). Neither dose group had significant changes in the risk for ischemic stroke or systemic embolism or death without recent evidence of bleeding. When patients receiving high- and low-dose diltiazem treatment were directly compared, the HR for the primary outcome was 1.14 (95% CI, 1.02-1.26). Conclusions and Relevance: In Medicare patients with atrial fibrillation receiving apixaban or rivaroxaban, diltiazem was associated with greater risk of serious bleeding than metoprolol, particularly for diltiazem doses exceeding 120 mg/d.


Asunto(s)
Fibrilación Atrial , Diltiazem , Inhibidores del Factor Xa , Hemorragia , Rivaroxabán , Anciano , Anciano de 80 o más Años , Femenino , Humanos , Masculino , Fibrilación Atrial/tratamiento farmacológico , Fibrilación Atrial/complicaciones , Diltiazem/efectos adversos , Diltiazem/uso terapéutico , Quimioterapia Combinada , Embolia/prevención & control , Inhibidores del Factor Xa/efectos adversos , Inhibidores del Factor Xa/uso terapéutico , Hemorragia/inducido químicamente , Hospitalización/estadística & datos numéricos , Medicare , Metoprolol/efectos adversos , Metoprolol/uso terapéutico , Metoprolol/administración & dosificación , Pirazoles/efectos adversos , Pirazoles/uso terapéutico , Piridonas/efectos adversos , Piridonas/uso terapéutico , Piridonas/administración & dosificación , Estudios Retrospectivos , Rivaroxabán/efectos adversos , Rivaroxabán/uso terapéutico , Estados Unidos
2.
Nutr Cancer ; 75(10): 1900-1910, 2023.
Artículo en Inglés | MEDLINE | ID: mdl-37791878

RESUMEN

Studies of dietary inflammation potential and risks of colorectal cancer precursors are limited, particularly for sessile serrated lesions (SSLs). This study examines the association using the energy-adjusted dietary inflammatory index (E-DIITM), a measure of anti- and/or pro-inflammatory diet, in a large US colonoscopy-based case-control study of 3246 controls, 1530 adenoma cases, 472 hyperplastic polyp cases, and 180 SSL cases. Odds ratios (ORs) and 95% confidence intervals (CIs) were derived from logistic regression models. Analyses were stratified by participant characteristics, and urinary prostaglandin E2 metabolite (PGE-M) and high-sensitivity plasma C-reactive protein (hs-CRP) levels, inflammation biomarkers. Highest E-DII™ intake was associated with significantly increased risks of colorectal adenomas (OR 1.36, 95% CI 1.11, 1.67), and hyperplastic polyps (OR 1.43, 95% CI 1.06, 1.98), compared with participants consuming the lowest E-DII™ quartile. A similar, but non-significant, increased risk was also observed for SSLs (OR 1.41, 95% CI 0.82, 2.41). The positive association was stronger in females (pinteraction <0.001), normal weight individuals (ptrend 0.01), and in individuals with lower inflammatory biomarkers (ptrend 0.02 and 0.01 for PGE-M and hs-CRP, respectively). A high E-DII™ is associated with colorectal polyp risk, therefore promoting an anti-inflammatory diet may aid in preventing colorectal polyps.


Asunto(s)
Adenoma , Pólipos Adenomatosos , Pólipos del Colon , Neoplasias Colorrectales , Neoplasias del Recto , Femenino , Humanos , Pólipos del Colon/patología , Estudios de Casos y Controles , Proteína C-Reactiva/metabolismo , Neoplasias Colorrectales/epidemiología , Neoplasias Colorrectales/etiología , Neoplasias Colorrectales/metabolismo , Adenoma/etiología , Colonoscopía , Dieta/efectos adversos , Inflamación , Biomarcadores , Factores de Riesgo
3.
Ann Intern Med ; 176(6): 769-778, 2023 06.
Artículo en Inglés | MEDLINE | ID: mdl-37216662

RESUMEN

BACKGROUND: Amiodarone, the most effective antiarrhythmic drug in atrial fibrillation, inhibits apixaban and rivaroxaban elimination, thus possibly increasing anticoagulant-related risk for bleeding. OBJECTIVE: For patients receiving apixaban or rivaroxaban, to compare risk for bleeding-related hospitalizations during treatment with amiodarone versus flecainide or sotalol, antiarrhythmic drugs that do not inhibit these anticoagulants' elimination. DESIGN: Retrospective cohort study. SETTING: U.S. Medicare beneficiaries aged 65 years or older. PATIENTS: Patients with atrial fibrillation began anticoagulant use between 1 January 2012 and 30 November 2018 and subsequently initiated treatment with study antiarrhythmic drugs. MEASUREMENTS: Time to event for bleeding-related hospitalizations (primary outcome) and ischemic stroke, systemic embolism, and death with or without recent (past 30 days) evidence of bleeding (secondary outcomes), adjusted with propensity score overlap weighting. RESULTS: There were 91 590 patients (mean age, 76.3 years; 52.5% female) initiating use of study anticoagulants and antiarrhythmic drugs, 54 977 with amiodarone and 36 613 with flecainide or sotalol. Risk for bleeding-related hospitalizations increased with amiodarone use (rate difference [RD], 17.5 events [95% CI, 12.0 to 23.0 events] per 1000 person-years; hazard ratio [HR], 1.44 [CI, 1.27 to 1.63]). Incidence of ischemic stroke or systemic embolism did not increase (RD, -2.1 events [CI, -4.7 to 0.4 events] per 1000 person-years; HR, 0.80 [CI, 0.62 to 1.03]). The risk for death with recent evidence of bleeding (RD, 9.1 events [CI, 5.8 to 12.3 events] per 1000 person-years; HR, 1.66 [CI, 1.35 to 2.03]) was greater than that for other deaths (RD, 5.6 events [CI, 0.5 to 10.6 events] per 1000 person-years; HR, 1.15 [CI, 1.00 to 1.31]) (HR comparison: P = 0.003). The increased incidence of bleeding-related hospitalizations for rivaroxaban (RD, 28.0 events [CI, 18.4 to 37.6 events] per 1000 person-years) was greater than that for apixaban (RD, 9.1 events [CI, 2.8 to 15.3 events] per 1000 person-years) (P = 0.001). LIMITATION: Possible residual confounding. CONCLUSION: In this retrospective cohort study, patients aged 65 years or older with atrial fibrillation treated with amiodarone during apixaban or rivaroxaban use had greater risk for bleeding-related hospitalizations than those treated with flecainide or sotalol. PRIMARY FUNDING SOURCE: National Heart, Lung, and Blood Institute.


Asunto(s)
Amiodarona , Fibrilación Atrial , Embolia , Accidente Cerebrovascular Isquémico , Accidente Cerebrovascular , Humanos , Anciano , Femenino , Estados Unidos/epidemiología , Masculino , Rivaroxabán/efectos adversos , Fibrilación Atrial/complicaciones , Fibrilación Atrial/tratamiento farmacológico , Amiodarona/efectos adversos , Flecainida/uso terapéutico , Sotalol/uso terapéutico , Antiarrítmicos/efectos adversos , Estudios Retrospectivos , Medicare , Hemorragia/inducido químicamente , Anticoagulantes/efectos adversos , Accidente Cerebrovascular Isquémico/tratamiento farmacológico , Hospitalización , Embolia/epidemiología , Embolia/prevención & control , Accidente Cerebrovascular/epidemiología , Accidente Cerebrovascular/prevención & control , Dabigatrán/efectos adversos
4.
Gastroenterology ; 163(1): 118-136, 2022 07.
Artículo en Inglés | MEDLINE | ID: mdl-35738724

RESUMEN

BACKGROUND & AIMS: Irritable bowel syndrome (IBS) is a common disorder of gut-brain interaction associated with significant disease burden. This American Gastroenterological Association guideline is intended to support practitioners in decisions about the use of medications for the pharmacological management of IBS-C and is an update of a prior technical review and guideline. METHODS: The Grading of Recommendations Assessment, Development and Evaluation framework was used to assess evidence and make recommendations. The technical review panel prioritized clinical questions and outcomes according to their importance for clinicians and patients and conducted an evidence review of the following agents: tenapanor, plecanatide, linaclotide, tegaserod, lubiprostone, polyethylene glycol laxatives, tricyclic antidepressants, selective serotonin reuptake inhibitors, and antispasmodics. The Guideline Panel reviewed the evidence and used the Evidence-to-Decision Framework to develop recommendations. CONCLUSIONS: The panel agreed on 9 recommendations for the management of patients with IBS-C. The panel made a strong recommendation for linaclotide (high certainty) and conditional recommendations for tenapanor, plecanatide, tegaserod, and lubiprostone (moderate certainty), polyethylene glycol laxatives, tricyclic antidepressants, and antispasmodics (low certainty). The panel made a conditional recommendation against the use of selective serotonin reuptake inhibitors (low certainty).


Asunto(s)
Síndrome del Colon Irritable , Antidepresivos Tricíclicos/uso terapéutico , Estreñimiento/diagnóstico , Estreñimiento/tratamiento farmacológico , Estreñimiento/etiología , Fármacos Gastrointestinales/efectos adversos , Humanos , Síndrome del Colon Irritable/complicaciones , Síndrome del Colon Irritable/diagnóstico , Síndrome del Colon Irritable/tratamiento farmacológico , Laxativos/uso terapéutico , Lubiprostona/uso terapéutico , Parasimpatolíticos/uso terapéutico , Polietilenglicoles/uso terapéutico , Inhibidores Selectivos de la Recaptación de Serotonina/uso terapéutico
5.
Gastroenterology ; 163(1): 137-151, 2022 07.
Artículo en Inglés | MEDLINE | ID: mdl-35738725

RESUMEN

BACKGROUND & AIMS: Irritable bowel syndrome (IBS) is a common functional gastrointestinal disorder associated with significant disease burden. This American Gastroenterological Association Guideline is intended to support practitioners in decisions about the use of medications for the pharmacological management of IBS with predominant diarrhea (IBS-D) and is an update of a prior technical review and guideline. METHODS: The Grading of Recommendations Assessment, Development and Evaluation framework was used to assess evidence and make recommendations. The technical review panel prioritized clinical questions and outcomes according to their importance for clinicians and patients and conducted an evidence review of the following agents: eluxadoline, rifaximin, alosetron, loperamide, tricyclic antidepressants, selective serotonin reuptake inhibitors, and antispasmodics. The guideline panel reviewed the evidence and used the Evidence-to-Decision Framework to develop recommendations. CONCLUSIONS: The panel agreed on 8 recommendations for the management of patients with IBS-D. The panel made conditional recommendations for eluxadoline, rifaximin, alosetron, (moderate certainty), loperamide (very low certainty), tricyclic antidepressants, and anstispasmodics (low certainty). The panel made a conditional recommendation against the use of selective serotonin reuptake inhibitors (low certainty).


Asunto(s)
Síndrome del Colon Irritable , Antidepresivos Tricíclicos/uso terapéutico , Diarrea/diagnóstico , Diarrea/tratamiento farmacológico , Diarrea/etiología , Fármacos Gastrointestinales/uso terapéutico , Humanos , Síndrome del Colon Irritable/complicaciones , Síndrome del Colon Irritable/diagnóstico , Síndrome del Colon Irritable/tratamiento farmacológico , Loperamida/efectos adversos , Rifaximina/uso terapéutico , Inhibidores Selectivos de la Recaptación de Serotonina/uso terapéutico
6.
JAMA ; 326(23): 2395-2404, 2021 12 21.
Artículo en Inglés | MEDLINE | ID: mdl-34932078

RESUMEN

Importance: The comparative effectiveness of rivaroxaban and apixaban, the most frequently prescribed oral anticoagulants for ischemic stroke prevention in patients with atrial fibrillation, is uncertain. Objective: To compare major ischemic and hemorrhagic outcomes in patients with atrial fibrillation treated with rivaroxaban or apixaban. Design, Setting, and Participants: Retrospective cohort study using computerized enrollment and claims files for US Medicare beneficiaries 65 years or older. Between January 1, 2013, and November 30, 2018, a total of 581 451 patients with atrial fibrillation began rivaroxaban or apixaban treatment and were followed up for 4 years, through November 30, 2018. Exposures: Rivaroxaban (n = 227 572) and apixaban (n = 353 879), either standard or reduced dose. Main Outcomes and Measures: The primary outcome was a composite of major ischemic (stroke/systemic embolism) and hemorrhagic (intracerebral hemorrhage/other intracranial bleeding/fatal extracranial bleeding) events. Secondary outcomes were nonfatal extracranial bleeding and total mortality (fatal ischemic/hemorrhagic event or other death during follow-up). Rates, hazard ratios (HRs), and rate differences (RDs) were adjusted for baseline differences in comorbidity with inverse probability of treatment weighting. Results: Study patients (mean age, 77.0 years; 291 966 [50.2%] women; 134 393 [23.1%] receiving reduced dose) had 474 605 person-years of follow-up (median [IQR] of 174 [62-397] days). The adjusted primary outcome rate for rivaroxaban was 16.1 per 1000 person-years vs 13.4 per 1000 person-years for apixaban (RD, 2.7 [95% CI, 1.9-3.5]; HR, 1.18 [95% CI, 1.12-1.24]). The rivaroxaban group had increased risk for both major ischemic events (8.6 vs 7.6 per 1000 person-years; RD, 1.1 [95% CI, 0.5-1.7]; HR, 1.12 [95% CI, 1.04-1.20]) and hemorrhagic events (7.5 vs 5.9 per 1000 person-years; RD, 1.6 [95% CI, 1.1-2.1]; HR, 1.26 [95% CI, 1.16-1.36]), including fatal extracranial bleeding (1.4 vs 1.0 per 1000 person-years; RD, 0.4 [95% CI, 0.2-0.7]; HR, 1.41 [95% CI, 1.18-1.70]). Patients receiving rivaroxaban had increased risk of nonfatal extracranial bleeding (39.7 vs 18.5 per 1000 person-years; RD, 21.1 [95% CI, 20.0-22.3]; HR, 2.07 [95% CI, 1.99-2.15]), fatal ischemic/hemorrhagic events (4.5 vs 3.3 per 1000 person-years; RD, 1.2 [95% CI, 0.8-1.6]; HR, 1.34 [95% CI, 1.21-1.48]), and total mortality (44.2 vs 41.0 per 1000 person-years; RD, 3.1 [95% CI, 1.8-4.5]; HR, 1.06 [95% CI, 1.02-1.09]). The risk of the primary outcome was increased for rivaroxaban in both those receiving the reduced dose (27.4 vs 21.0 per 1000 person-years; RD, 6.4 [95% CI, 4.1-8.7]; HR, 1.28 [95% CI, 1.16-1.40]) and the standard dose (13.2 vs 11.4 per 1000 person-years; RD, 1.8 [95% CI, 1.0-2.6]; HR, 1.13 [95% CI, 1.06-1.21]) groups. Conclusions and Relevance: Among Medicare beneficiaries 65 years or older with atrial fibrillation, treatment with rivaroxaban compared with apixaban was associated with a significantly increased risk of major ischemic or hemorrhagic events.


Asunto(s)
Anticoagulantes/efectos adversos , Fibrilación Atrial/tratamiento farmacológico , Inhibidores del Factor Xa/efectos adversos , Hemorragia/inducido químicamente , Pirazoles/efectos adversos , Piridonas/efectos adversos , Rivaroxabán/efectos adversos , Accidente Cerebrovascular/etiología , Anciano , Anticoagulantes/uso terapéutico , Fibrilación Atrial/complicaciones , Embolia/etiología , Embolia/prevención & control , Inhibidores del Factor Xa/uso terapéutico , Femenino , Hemorragia/mortalidad , Humanos , Hemorragias Intracraneales/inducido químicamente , Masculino , Pirazoles/uso terapéutico , Piridonas/uso terapéutico , Estudios Retrospectivos , Rivaroxabán/uso terapéutico , Accidente Cerebrovascular/prevención & control
7.
J Clin Gastroenterol ; 55(10): 876-883, 2021.
Artículo en Inglés | MEDLINE | ID: mdl-34049372

RESUMEN

GOAL: We sought to quantify the independent effects of age, sex, and race/ethnicity on risk of colorectal cancer (CRC) and advanced neoplasia (AN) in Veterans. STUDY: We conducted a retrospective, cross-sectional study of Veterans aged 40 to 80 years who had diagnostic or screening colonoscopy between 2002 and 2009 from 1 of 14 Veterans Affairs Medical Centers. Natural language processing identified the most advanced finding and location (proximal, distal). Logistic regression was used to examine the adjusted, independent effects of age, sex, and race, both overall and in screening and diagnostic subgroups. RESULTS: Among 90,598 Veterans [mean (SD) age 61.7 (9.4) y, 5.2% (n=4673) were women], CRC and AN prevalence was 1.3% (n=1171) and 8.9% (n=8081), respectively. Adjusted CRC risk was higher for diagnostic versus screening colonoscopy [odds ratio (OR)=3.79; 95% confidence interval (CI), 3.19-4.50], increased with age, was numerically (but not statistically) higher for men overall (OR=1.53; 95% CI, 0.97-2.39) and in the screening subgroup (OR=2.24; 95% CI, 0.71-7.05), and was higher overall for Blacks and Hispanics, but not in screening. AN prevalence increased with age, and was present in 9.2% of men and 3.9% of women [adjusted OR=1.90; 95% CI, 1.60-2.25]. AN risk was 11% higher in Blacks than in Whites overall (OR=1.11; 95% CI, 1.04-1.20), was no different in screening, and was lower in Hispanics (OR=0.74; 95% CI, 0.55-0.98). Women had more proximal CRC (63% vs. 39% for men; P=0.03), but there was no difference in proximal AN (38.3% for both genders). CONCLUSIONS: Age and race were associated with AN and CRC prevalence. Blacks had a higher overall prevalence of both CRC and AN, but not among screenings. Men had increased risk for AN, while women had a higher proportion of proximal CRC. These findings may be used to tailor when and how Veterans are screened for CRC.


Asunto(s)
Neoplasias Colorrectales , Veteranos , Neoplasias Colorrectales/diagnóstico , Neoplasias Colorrectales/epidemiología , Estudios Transversales , Etnicidad , Femenino , Humanos , Masculino , Persona de Mediana Edad , Prevalencia , Estudios Retrospectivos , Factores de Riesgo
8.
Endosc Int Open ; 8(12): E1804-E1810, 2020 Dec.
Artículo en Inglés | MEDLINE | ID: mdl-33269313

RESUMEN

Background and study aims Endoscopic mentoring requires active attention by the preceptor. Unfortunately, sources of distraction are abundant during endoscopic precepting. The impact of distraction minimization on endoscopic mentoring and performance is unknown. Methods Fellow and attending preceptors were paired and randomized in a prospective crossover design to perform esophagogastroduodenoscopy (EGD) and/or colonoscopy in either a "distraction minimization" (DM) or a "standard" (S) room. Cell phones, pagers, music, and computers were not permitted in DM rooms. S rooms operated under typical conditions. Fellows and attendings then completed a survey. The primary outcome was fellow satisfaction with mentoring experience (visual analogue scale: 0 = min,100 = max). Additional fellow outcomes included satisfaction of attending attentiveness, identifying landmarks, communication, and distractedness; attending outcomes included satisfaction with mentoring, attentiveness, communication, and distractedness. Endoscopic performance measures included completion of EGD, cecal intubation rate, cecal intubation time, withdrawal time, total procedure time, attending assistance, and polyp detection rate. A paired t -test was used to compare mean differences (MD) between rooms; significance set at P  < 0.05. Results Eight fellows and seven attendings completed 164 procedures. Despite a trend toward less distraction between rooms (DM = 12.5 v. S = 18.3, MD =  4.1, P  = 0.17), there was no difference in fellow satisfaction with training/mentoring (DM = 93, S = 93, MD = -0.04, P  = 0.97), attentiveness (DM = 95, S = 92, MD = 0.86, P  = 0.77), identifying pathology/landmarks (DM = 94, S = 94, MD = -1.72, P  = 0.56), or communication (DM = 95, S = 95,MD = 1.0, P  = 0.37). Similarly, there was no difference between rooms for any attending outcome measures or performance metrics. Conclusions DM did not improve perceived quality of endoscopic mentoring or performance for fellows or attendings; however, reduced distraction may improve attending engagement/availability.

9.
J Am Coll Surg ; 231(2): 257-266, 2020 08.
Artículo en Inglés | MEDLINE | ID: mdl-32454089

RESUMEN

BACKGROUND: Although endoscopy is recommended at 1 year after colorectal cancer (CRC) resection to detect locally recurrent CRC, earlier work at our Veterans Affairs (VA) facility demonstrated that 35% of patients achieve this metric. STUDY DESIGN: The interdisciplinary team used quality improvement methods to standardize processes and implement a gastroenterology-managed virtual surveillance clinic. The intervention clinic was implemented in August 2014. Veterans who underwent resection for stage I to III CRC at a single VA facility from January 2010 to December 2017 were included, with those undergoing resection between January 2010 and July 2014 considered pre-intervention and those undergoing resection between August 2014 and December 2017 considered post-intervention. The primary endpoint was the proportion of eligible patients for whom endoscopy was completed within 1 year of resection. Secondary outcomes were the proportion of patients who completed endoscopy within 18 months of resection or at any time post-resection and time to surveillance endoscopy. RESULTS: A total of 186 patients underwent resection for stage I to III CRC from 2010 to 2017; of these, 160 (86%) were eligible for endoscopy at 1-year post-resection (98 pre-intervention and 62 post-intervention). In the pre-intervention period, 30 of 98 patients (30.6%) underwent surveillance endoscopy within 1 year vs 31 of 62 (50.0%) post-intervention (p = 0.031). When evaluated at 18 months after resection, 56 of 98 patients (57.1%) in the pre-intervention group vs 52 of 62 (83.9%) in the post-intervention group underwent surveillance endoscopy (p = 0.001). Median time from resection to endoscopy decreased during the study period, from 1.19 years pre-intervention (interquartile range 0.93 to 1.74 years) to 1.0 years post-intervention (interquartile range 0.93 to 1.09 years) (p = 0.006). CONCLUSIONS: Implementation of a virtual surveillance clinic with standardized processes was associated with increased guideline-concordant endoscopic surveillance after CRC resection.


Asunto(s)
Colonoscopía/normas , Neoplasias Colorrectales/diagnóstico por imagen , Detección Precoz del Cáncer/normas , Hospitales de Veteranos/normas , Recurrencia Local de Neoplasia/diagnóstico por imagen , Cooperación del Paciente/estadística & datos numéricos , Mejoramiento de la Calidad , Adulto , Anciano , Anciano de 80 o más Años , Colonoscopía/estadística & datos numéricos , Neoplasias Colorrectales/cirugía , Detección Precoz del Cáncer/métodos , Detección Precoz del Cáncer/estadística & datos numéricos , Femenino , Hospitales de Veteranos/estadística & datos numéricos , Humanos , Masculino , Persona de Mediana Edad , Grupo de Atención al Paciente/organización & administración , Mejoramiento de la Calidad/organización & administración , Mejoramiento de la Calidad/estadística & datos numéricos , Telemedicina/métodos , Telemedicina/normas , Tennessee
10.
Br J Nutr ; 124(1): 80-91, 2020 07 14.
Artículo en Inglés | MEDLINE | ID: mdl-32077397

RESUMEN

Diet modifies the risk of colorectal cancer (CRC), and inconclusive evidence suggests that yogurt may protect against CRC. We analysed the data collected from two separate colonoscopy-based case-control studies. The Tennessee Colorectal Polyp Study (TCPS) and Johns Hopkins Biofilm Study included 5446 and 1061 participants, respectively, diagnosed with hyperplastic polyp (HP), sessile serrated polyp, adenomatous polyp (AP) or without any polyps. Multinomial logistic regression models were used to derive OR and 95 % CI to evaluate comparisons between cases and polyp-free controls and case-case comparisons between different polyp types. We evaluated the association between frequency of yogurt intake and probiotic use with the diagnosis of colorectal polyps. In the TCPS, daily yogurt intake v. no/rare intake was associated with decreased odds of HP (OR 0·54; 95 % CI 0·31, 0·95) and weekly yogurt intake was associated with decreased odds of AP among women (OR 0·73; 95 % CI 0·55, 0·98). In the Biofilm Study, both weekly yogurt intake and probiotic use were associated with a non-significant reduction in odds of overall AP (OR 0·75; 95 % CI 0·54, 1·04) and (OR 0·72; 95 % CI 0·49, 1·06) in comparison with no use, respectively. In summary, yogurt intake may be associated with decreased odds of HP and AP and probiotic use may be associated with decreased odds of AP. Further prospective studies are needed to verify these associations.


Asunto(s)
Pólipos del Colon/epidemiología , Dieta , Yogur , Pólipos Adenomatosos/epidemiología , Adulto , Anciano , Estudios de Casos y Controles , Pólipos del Colon/patología , Colonoscopía , Neoplasias Colorrectales/epidemiología , Neoplasias Colorrectales/patología , Femenino , Humanos , Masculino , Persona de Mediana Edad , Oportunidad Relativa , Probióticos/administración & dosificación , Factores de Riesgo , Factores Sexuales , Tennessee/epidemiología
11.
Am J Clin Nutr ; 111(6): 1244-1251, 2020 06 01.
Artículo en Inglés | MEDLINE | ID: mdl-32077920

RESUMEN

BACKGROUND: Red and processed meat, recognized carcinogens, are risk factors for colorectal neoplasia, including polyps, the precursor for colorectal cancer. The mechanism is unclear. One possible explanation is the mutagenic activity of these foods, perhaps due to generation during cooking [e.g., heterocyclic amine (HCA) intake]. Few studies have evaluated meat intake and sessile serrated lesion (SSL) risk, a recently recognized precursor, and no study has evaluated meat cooking methods and meat-derived mutagens with SSL risk. OBJECTIVE: We evaluated intakes of meat, meat cooking methods, and inferred meat mutagens with SSL risk and in comparison to risk of other polyps. METHODS: Meat, well-done meat, and inferred meat mutagen intakes were evaluated. Polytomous logistic regression models were used to estimate ORs and 95% CIs among cases (556 hyperplastic polyp, 1753 adenoma, and 208 SSL) and controls (3804) in the large colonoscopy-based, case-control study, the Tennessee Colorectal Polyp Study. RESULTS: The highest quartile intakes of red meat (OR: 2.38; 95% CI: 1.44, 3.93), processed meat (OR: 2.03; 95% CI: 1.30, 3.17), well-done red meat (OR: 2.19; 95% CI: 1.34, 3.60), and the HCA 2-amino-3,8-dimethylimidazo[4,5-f]quinoxaline (MeIQX; OR: 2.48; 95% CI: 1.49, 4.16) were associated with increased risk of SSLs in comparison to the lowest quartile intake. CONCLUSIONS: High intakes of red and processed meats are strongly and especially associated with SSL risk and part of the association may be due to HCA intake. Future studies should evaluate other mechanism(s) and the potential for primary prevention.


Asunto(s)
Neoplasias Colorrectales/metabolismo , Neoplasias Colorrectales/patología , Culinaria/métodos , Exposición Dietética/efectos adversos , Carne/análisis , Mutágenos/efectos adversos , Aminas/efectos adversos , Aminas/análisis , Aminas/metabolismo , Estudios de Casos y Controles , Neoplasias Colorrectales/epidemiología , Exposición Dietética/análisis , Femenino , Calor , Humanos , Masculino , Persona de Mediana Edad , Mutágenos/análisis , Mutágenos/metabolismo , Factores de Riesgo , Tennessee/epidemiología
12.
Int J Cancer ; 146(11): 2999-3010, 2020 06 01.
Artículo en Inglés | MEDLINE | ID: mdl-31472027

RESUMEN

Gastric cancer remains a leading cause of cancer-related mortality. Identifying dietary and other modifiable disease determinants has important implications for risk attenuation in susceptible individuals. Our primary aim was to estimate the association between dietary and supplemental intakes of calcium and magnesium and the risk of incident gastric cancer. We conducted a prospective cohort analysis of the National Institutes of Health-American Association of Retired Persons Diet and Health Study. We used Cox proportional hazard modeling to estimate the association between calcium and magnesium intakes with risk of incident gastric adenocarcinoma (GA) overall and by anatomic location, noncardia GA (NCGA) and cardia GA (CGA). A total of 536,403 respondents (59% males, 41% females) were included for analysis, among whom 1,518 incident GAs (797 NCGA and 721 CGA) occurred. Increasing calcium intake was associated with lower risk of GA overall (p-trend = 0.05), driven primarily by the association with NCGA, where the above median calcium intakes were associated with a 23% reduction in risk compared to the lowest quartile (p-trend = 0.05). This magnitude of NCGA risk reduction was greater among nonwhite ethnic group and Hispanics (hazard ratio [HR] 0.51, 95% confidence interval [CI]: 0.24-1.07, p-trend = 0.04), current/former smokers (HR 0.58, 95% CI: 0.41-0.81), obese individuals (HR 0.54, 95% CI: 0.31-0.96) and those with high NCGA risk scores (HR 0.50, 95% CI: 0.31-0.80). Among men only, increasing magnesium intake was associated with 22-27% reduced risk of NCGA (p-trend = 0.05), while for the cohort, dietary magnesium intake in the highest vs. lowest quartile was associated with a 34% reduced risk of NCGA (HR 0.66, 95% CI: 0.48-0.90). These findings have important implications for risk factor modification. Future investigations are needed not only to confirm our results, but to define mechanisms underlying these associations.


Asunto(s)
Adenocarcinoma/prevención & control , Calcio de la Dieta/farmacología , Magnesio/farmacología , Neoplasias Gástricas/prevención & control , Adenocarcinoma/epidemiología , Cardias/patología , Estudios de Cohortes , Dieta , Suplementos Dietéticos , Femenino , Humanos , Masculino , Persona de Mediana Edad , Estado Nutricional/fisiología , Estudios Prospectivos , Neoplasias Gástricas/dietoterapia , Neoplasias Gástricas/epidemiología , Encuestas y Cuestionarios , Estados Unidos/epidemiología
15.
Clin Epidemiol ; 11: 17-22, 2019.
Artículo en Inglés | MEDLINE | ID: mdl-30588120

RESUMEN

BACKGROUND: Previous studies have shown a link between increased dietary intake of arachidonic acid (ARA) and colorectal neoplasms. It has been shown that erythrocyte phospholipid membrane concentrations of ARA are strongly determined by genetic variation. Fatty acid desaturase (FADS) controls the rate limiting step in ARA production, and FADS variant rs174537 has been shown to be responsible for up to 18.6% of the variation seen. To determine if a causal association exists between erythrocyte membrane ARA concentrations and colorectal adenomas, we conducted a Mendelian randomization (MR) analysis using rs174537 as an instrumental variable (IV). MR analysis was chosen because it is less susceptible to bias and confounding. PATIENTS AND METHODS: A case-control study was performed using the Tennessee Colorectal Polyps Study. Patients were matched on age, gender, race, facility site, and year of colonoscopy. Cases were defined as any colorectal adenoma on colonoscopy (n=909) and controls were polyp free (n=855). A two-stage logistic regression was conducted using rs174537 as the IV with the dependent variable being the presence of a colorectal adenoma on colonoscopy. RESULTS: Cases were older (59 vs 57 years of age, P<0.0001), and more likely to use alcohol (47.4% vs 19.8%, P=0.001) and to smoke (77.0% vs 66.9%, P<0.0001). There was no statistically significant difference in: age, sex, alcohol use, body mass index (BMI), or NSAID use when stratified by the rs174537 alleles. Genotype was strongly associated with erythrocyte membrane ARA concentrations (P<0.0001). We found no evidence of an association between our IV (rs174537) and colorectal adenomas (P=0.41). CONCLUSION: In our MR study increased erythrocyte ARA concentrations were not associated with the risk of colorectal adenomas.

16.
JAMA ; 320(21): 2221-2230, 2018 12 04.
Artículo en Inglés | MEDLINE | ID: mdl-30512099

RESUMEN

Importance: Anticoagulant choice and proton pump inhibitor (PPI) cotherapy could affect the risk of upper gastrointestinal tract bleeding, a frequent and potentially serious complication of oral anticoagulant treatment. Objectives: To compare the incidence of hospitalization for upper gastrointestinal tract bleeding in patients using individual anticoagulants with and without PPI cotherapy, and to determine variation according to underlying gastrointestinal bleeding risk. Design, Setting, and Participants: Retrospective cohort study in Medicare beneficiaries between January 1, 2011, and September 30, 2015. Exposures: Apixaban, dabigatran, rivaroxaban, or warfarin with or without PPI cotherapy. Main Outcomes and Measures: Hospitalizations for upper gastrointestinal tract bleeding: adjusted incidence and risk difference (RD) per 10 000 person-years of anticoagulant treatment, incidence rate ratios (IRRs). Results: There were 1 643 123 patients with 1 713 183 new episodes of oral anticoagulant treatment included in the cohort (mean [SD] age, 76.4 [2.4] years, 651 427 person-years of follow-up [56.1%] were for women, and the indication was atrial fibrillation for 870 330 person-years [74.9%]). During 754 389 treatment person-years without PPI cotherapy, the adjusted incidence of hospitalization for upper gastrointestinal tract bleeding (n = 7119) was 115 per 10 000 person-years (95% CI, 112-118). The incidence for rivaroxaban (n = 1278) was 144 per 10 000 person-years (95% CI, 136-152), which was significantly greater than the incidence of hospitalizations for apixaban (n = 279; 73 per 10 000 person-years; IRR, 1.97 [95% CI, 1.73-2.25]; RD, 70.9 [95% CI, 59.1-82.7]), dabigatran (n = 629; 120 per 10 000 person-years; IRR, 1.19 [95% CI, 1.08-1.32]; RD, 23.4 [95% CI, 10.6-36.2]), and warfarin (n = 4933; 113 per 10 000 person-years; IRR, 1.27 [95% CI, 1.19-1.35]; RD, 30.4 [95% CI, 20.3-40.6]). The incidence for apixaban was significantly lower than that for dabigatran (IRR, 0.61 [95% CI, 0.52-0.70]; RD, -47.5 [95% CI,-60.6 to -34.3]) and warfarin (IRR, 0.64 [95% CI, 0.57-0.73]; RD, -40.5 [95% CI, -50.0 to -31.0]). When anticoagulant treatment with PPI cotherapy (264 447 person-years; 76 per 10 000 person-years) was compared with treatment without PPI cotherapy, risk of upper gastrointestinal tract bleeding hospitalizations (n = 2245) was lower overall (IRR, 0.66 [95% CI, 0.62-0.69]) and for apixaban (IRR, 0.66 [95% CI, 0.52-0.85]; RD, -24 [95% CI, -38 to -11]), dabigatran (IRR, 0.49 [95% CI, 0.41-0.59]; RD, -61.1 [95% CI, -74.8 to -47.4]), rivaroxaban (IRR, 0.75 [95% CI, 0.68-0.84]; RD, -35.5 [95% CI, -48.6 to -22.4]), and warfarin (IRR, 0.65 [95% CI, 0.62-0.69]; RD, -39.3 [95% CI, -44.5 to -34.2]). Conclusions and Relevance: Among patients initiating oral anticoagulant treatment, incidence of hospitalization for upper gastrointestinal tract bleeding was the highest in patients prescribed rivaroxaban, and the lowest for patients prescribed apixaban. For each anticoagulant, the incidence of hospitalization for upper gastrointestinal tract bleeding was lower among patients who were receiving PPI cotherapy. These findings may inform assessment of risks and benefits when choosing anticoagulant agents.


Asunto(s)
Anticoagulantes/efectos adversos , Hemorragia Gastrointestinal/inducido químicamente , Hospitalización/estadística & datos numéricos , Inhibidores de la Bomba de Protones/uso terapéutico , Administración Oral , Anciano , Anciano de 80 o más Años , Anticoagulantes/uso terapéutico , Dabigatrán/efectos adversos , Quimioterapia Combinada , Femenino , Hemorragia Gastrointestinal/epidemiología , Humanos , Masculino , Persona de Mediana Edad , Pirazoles/efectos adversos , Piridonas/efectos adversos , Estudios Retrospectivos , Rivaroxabán/efectos adversos , Tracto Gastrointestinal Superior/efectos de los fármacos , Warfarina/efectos adversos
17.
Gut ; 67(3): 456-465, 2018 03.
Artículo en Inglés | MEDLINE | ID: mdl-27852795

RESUMEN

OBJECTIVE: To identify modifiable factors associated with sessile serrated polyps (SSPs) and compare the association of these factors with conventional adenomas (ADs) and hyperplastic polyps (HPs). DESIGN: We used data from the Tennessee Colorectal Polyp Study, a colonoscopy-based case-control study. Included were 214 SSP cases, 1779 AD cases, 560 HP cases and 3851 polyp-free controls. RESULTS: Cigarette smoking was associated with increased risk for all polyps and was stronger for SSPs than for ADs (OR 1.74, 95% CI 1.16 to 2.62, for current vs never, ptrend=0.008). Current regular use of non-steroidal anti-inflammatory drugs was associated with a 40% reduction in SSP risk in comparison with never users (OR 0.68, 95% CI 0.48 to 0.96, ptrend=0.03), similar to the association with AD. Red meat intake was strongly associated with SSP risk (OR 2.59, 95% CI 1.41 to 4.74 for highest vs lowest intake, ptrend<0.001) and the association with SSP was stronger than with AD (ptrend=0.003). Obesity, folate intake, fibre intake and fat intake were not associated with SSP risk after adjustment for other factors. Exercise, alcohol use and calcium intake were not associated with risk for SSPs. CONCLUSIONS: SSPs share some modifiable risk factors for ADs, some of which are more strongly associated with SSPs than ADs. Thus, preventive efforts to reduce risk for ADs may also be applicable to SSPs. Additionally, SSPs have some distinctive risk factors. Future studies should evaluate the preventive strategies for these factors. The findings from this study also contribute to an understanding of the aetiology and biology of SSPs.


Asunto(s)
Adenoma/epidemiología , Neoplasias del Colon/epidemiología , Pólipos del Colon/epidemiología , Pólipos del Colon/patología , Dieta , Estilo de Vida , Adenoma/patología , Anciano , Antiinflamatorios no Esteroideos/uso terapéutico , Estudios de Casos y Controles , Fumar Cigarrillos/epidemiología , Neoplasias del Colon/patología , Colonoscopía , Femenino , Humanos , Hiperplasia/epidemiología , Hiperplasia/patología , Masculino , Persona de Mediana Edad , Factores Protectores , Carne Roja , Factores de Riesgo , Conducta de Reducción del Riesgo , Tennessee/epidemiología
18.
Br J Nutr ; 117(11): 1615-1622, 2017 Jun.
Artículo en Inglés | MEDLINE | ID: mdl-28660850

RESUMEN

Dietary intake of PUFA has been associated with colorectal neoplasm risk; however, results from observational studies have been inconsistent. Most prior studies have utilised self-reported dietary measures to assess fatty acid exposure which might be more susceptible to measurement error and biases compared with biomarkers. The purpose of this study was to determine whether erythrocyte phospholipid membrane PUFA percentages are associated with colorectal adenoma risk. We included data from 904 adenoma cases and 835 polyp-free controls who participated in the Tennessee Colorectal Polyp Study, a large colonoscopy-based case-control study. Erythrocyte membrane PUFA percentages were measured using GC. Conditional logistic regression was used to calculate adjusted OR for risk of colorectal adenomas with erythrocyte membrane PUFA. Higher erythrocyte membrane percentages of arachidonic acid was associated with an increased risk of colorectal adenomas (adjusted OR 1·66; 95 % CI 1·05, 2·62, P trend=0·02) comparing the highest tertile to the lowest tertile. The effect size for arachidonic acid was more pronounced when restricting the analysis to advanced adenomas only. Higher erythrocyte membrane EPA percentages were associated with a trend towards a reduced risk of advanced colorectal adenomas (P trend=0·05). Erythrocyte membrane arachidonic acid percentages are associated with an increased risk of colorectal adenomas.


Asunto(s)
Adenoma/sangre , Ácido Araquidónico/sangre , Neoplasias Colorrectales/sangre , Ácido Eicosapentaenoico/sangre , Membrana Eritrocítica/metabolismo , Fosfolípidos/química , Adenoma/etiología , Adenoma/prevención & control , Biomarcadores/sangre , Estudios de Casos y Controles , Neoplasias Colorrectales/etiología , Neoplasias Colorrectales/prevención & control , Dieta , Femenino , Humanos , Modelos Logísticos , Masculino , Persona de Mediana Edad , Oportunidad Relativa , Fosfolípidos/sangre , Factores de Riesgo , Tennessee
19.
J Nutr Biochem ; 47: 35-40, 2017 09.
Artículo en Inglés | MEDLINE | ID: mdl-28501704

RESUMEN

Solute carrier family 7, member 2 (SLC7A2) gene encodes a protein called cationic amino acid transporter 2, which mediates the transport of arginine, lysine and ornithine. l-Arginine is necessary for cancer development and progression, including an important role in colorectal cancer pathogenesis. Furthermore, previous studies found that both calcium and magnesium inhibit the transport of arginine. Thus, calcium, magnesium or calcium:magnesium intake ratio may interact with polymorphisms in the SLC7A2 gene in association with colorectal cancer. We conducted a two-phase case-control study within the Tennessee Colorectal Polyps Study. In the first phase, 23 tagging single-nucleotide polymorphisms in the SLC7A2 gene were included for 725 colorectal adenoma cases and 755 controls. In the second phase conducted in an independent set of 607 cases and 2113 controls, we replicated the significant findings in the first phase. We observed that rs2720574 significantly interacted with calcium:magnesium intake ratio in association with odds of adenoma, particularly multiple/advanced adenoma. In the combined analysis, among those with a calcium:magnesium intake ratio below 2.78, individuals who carried GC/CC genotypes demonstrated higher odds of adenoma [OR (95% CI):1.36 (1.11-1.68)] and multiple/advanced adenoma [OR (95% CI): 1.68 (1.28, 2.20)] than those who carried the GG genotype. The P values for interactions between calcium:magnesium intake ratio and rs2720574 were .002 for all adenomas and <.001 for multiple/advanced adenoma. Among those with the GG genotype, a high calcium:magnesium ratio was associated with increased odds of colorectal adenoma [OR (95% CI): 1.73 (1.27-2.36)] and advanced/multiple adenomas [1.62 (1.05-2.50)], whereas among those with the GC/CC genotypes, high calcium:magnesium ratio was related to reduced odds of colorectal adenoma [0.64 (0.42-0.99)] and advanced/multiple adenomas [0.55 (0.31-1.00)].


Asunto(s)
Sistemas de Transporte de Aminoácidos Básicos/genética , Calcio de la Dieta/uso terapéutico , Pólipos del Colon/prevención & control , Dieta Saludable , Suplementos Dietéticos , Magnesio/uso terapéutico , Polimorfismo de Nucleótido Simple , Adenoma/diagnóstico , Adenoma/genética , Adenoma/patología , Adenoma/prevención & control , Estudios de Casos y Controles , Pólipos del Colon/diagnóstico , Pólipos del Colon/genética , Pólipos del Colon/patología , Colonoscopía , Neoplasias Colorrectales/diagnóstico , Neoplasias Colorrectales/genética , Neoplasias Colorrectales/patología , Neoplasias Colorrectales/prevención & control , Femenino , Estudios de Asociación Genética , Predisposición Genética a la Enfermedad , Humanos , Masculino , Persona de Mediana Edad , Clasificación del Tumor , Cooperación del Paciente , Autoinforme , Tennessee , Carga Tumoral
20.
Mol Carcinog ; 56(10): 2258-2266, 2017 10.
Artículo en Inglés | MEDLINE | ID: mdl-28544176

RESUMEN

The SLC8A1 (solute carrier family 8, member 1) gene, encoding Na+ /Ca2+ exchanger, is essential in regulating calcium reabsorption and homeostasis. Calcium homeostasis plays a key role in cell proliferation and apoptosis. We hypothesized that polymorphisms in five calcium-regulating genes (SLC8A1, ATP2B1, CALB1, CALB2, and CABP1) interact with calcium intake in relation to the risk of colorectal neoplasia. A two-phase (discovery and replication) study was conducted within the Tennessee Colorectal Polyp Study, including a total of 1275 cases and 2811 controls. In Phase I, we identified six out of 135 SNPs that significantly interacted with calcium intake in relation to adenoma risk. In Phase II, the calcium intake by rs4952490 (SLC8A1) interaction was replicated (Pinteraction = 0.048). We found an inverse association between calcium intake (1000-2000 mg/day) and colorectal adenomas, particularly for multiple/advanced adenomas, among the G-allele carriers but not among homozygous carriers of the common variant (A) in rs4952490. In the joint analysis of SLC8A1, KCNJ1, and SLC12A1 SNPs, carriers of variant alleles in at least two genes and with calcium intake above the DRI (1000 mg/day) were approximately 30-57% less likely to have adenomas than those whose calcium intake was below the DRI. The association was stronger for multiple/advanced adenomas. No association was found among those who did not carry any variant alleles in these genes when calcium intake was below 2500 mg/day. These findings, if confirmed, may provide a new avenue for the personalized prevention of colorectal adenoma and cancer.


Asunto(s)
Calbindina 1/genética , Calbindina 2/genética , Calcio de la Dieta/administración & dosificación , Neoplasias Colorrectales/genética , ATPasas Transportadoras de Calcio de la Membrana Plasmática/genética , Intercambiador de Sodio-Calcio/genética , Adulto , Anciano , Femenino , Humanos , Masculino , Persona de Mediana Edad , Variantes Farmacogenómicas , Polimorfismo de Nucleótido Simple , Factores de Riesgo
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