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1.
Cardiovasc Diabetol ; 19(1): 164, 2020 10 01.
Artículo en Inglés | MEDLINE | ID: mdl-33004045

RESUMEN

BACKGROUND: Cardiometabolic disorders may worsen Covid-19 outcomes. We investigated features and Covid-19 outcomes for patients with or without diabetes, and with or without cardiometabolic multimorbidity. METHODS: We collected and compared data retrospectively from patients hospitalized for Covid-19 with and without diabetes, and with and without cardiometabolic multimorbidity (defined as ≥ two of three risk factors of diabetes, hypertension or dyslipidaemia). Multivariate logistic regression was used to assess the risk of the primary composite outcome (any of mechanical ventilation, admission to an intensive care unit [ICU] or death) in patients with diabetes and in those with cardiometabolic multimorbidity, adjusting for confounders. RESULTS: Of 354 patients enrolled, those with diabetes (n = 81), compared with those without diabetes (n = 273), had characteristics associated with the primary composite outcome that included older age, higher prevalence of hypertension and chronic obstructive pulmonary disease (COPD), higher levels of inflammatory markers and a lower PaO2/FIO2 ratio. The risk of the primary composite outcome in the 277 patients who completed the study as of May 15th, 2020, was higher in those with diabetes (Adjusted Odds Ratio (adjOR) 2.04, 95%CI 1.12-3.73, p = 0.020), hypertension (adjOR 2.31, 95%CI: 1.37-3.92, p = 0.002) and COPD (adjOR 2.67, 95%CI 1.23-5.80, p = 0.013). Patients with cardiometabolic multimorbidity were at higher risk compared to patients with no cardiometabolic conditions (adjOR 3.19 95%CI 1.61-6.34, p = 0.001). The risk for patients with a single cardiometabolic risk factor did not differ with that for patients with no cardiometabolic risk factors (adjOR 1.66, 0.90-3.06, adjp = 0.10). CONCLUSIONS: Patients with diabetes hospitalized for Covid-19 present with high-risk features. They are at increased risk of adverse outcomes, likely because diabetes clusters with other cardiometabolic conditions.


Asunto(s)
Betacoronavirus , Enfermedades Cardiovasculares/diagnóstico , Enfermedades Cardiovasculares/epidemiología , Infecciones por Coronavirus/diagnóstico , Infecciones por Coronavirus/epidemiología , Diabetes Mellitus/diagnóstico , Diabetes Mellitus/epidemiología , Neumonía Viral/diagnóstico , Neumonía Viral/epidemiología , Anciano , Anciano de 80 o más Años , Enfermedades Cardiovasculares/metabolismo , Infecciones por Coronavirus/metabolismo , Diabetes Mellitus/metabolismo , Femenino , Estudios de Seguimiento , Humanos , Masculino , Enfermedades Metabólicas/diagnóstico , Enfermedades Metabólicas/epidemiología , Enfermedades Metabólicas/metabolismo , Persona de Mediana Edad , Multimorbilidad/tendencias , Pandemias , Neumonía Viral/metabolismo , Pronóstico , Estudios Retrospectivos , Factores de Riesgo
5.
Am J Case Rep ; 21: e926886, 2020 Oct 01.
Artículo en Inglés | MEDLINE | ID: mdl-32999267

RESUMEN

BACKGROUND Coronavirus disease 2019 (COVID-19) is caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), which originated in Wuhan, China, in late 2019 and has led to an ongoing pandemic. COVID-19 typically affects the respiratory tract and mucous membranes, leading to pathological involvement of various organ systems. Although patients usually present with fever, cough, and fatigue, less common manifestations have been reported including symptoms arising from thrombosis and thromboembolism. A spectrum of dermatologic changes is becoming recognized in patients with COVID-19 who initially present with respiratory symptoms. The mechanism behind these manifestations remains unclear. This report presents the case of a 47-year-old Hispanic man who developed cutaneous vasculitic lesions and gangrene of the toes following admission to hospital with COVID-19 pneumonia. CASE REPORT COVID-19 has been associated with cardiovascular disease entities including stroke, acute coronary syndrome, venous thromboembolism, and peripheral vascular disease. We present a case in which a 47-year-old Hispanic man arrived at the Emergency Department with COVID-19 and was admitted for respiratory failure. Despite anticoagulation initiated on admission in the presence of an elevated D-dimer, the patient developed gangrene of all his toes, which required bilateral transmetatarsal amputation. CONCLUSIONS This case shows that dermatologic manifestations may develop in patients who initially present with COVID-19 pneumonia. These symptoms may be due to venous thrombosis following SARS-CoV-2 vasculitis, leading to challenging decisions regarding anticoagulation therapy. Randomized controlled trials are needed to evaluate the efficacy of anticoagulation, to choose appropriate anticoagulants and dosing, and to assess bleeding risk.


Asunto(s)
Infecciones por Coronavirus/complicaciones , Gangrena/etiología , Gangrena/cirugía , Neumonía Viral/complicaciones , Síndrome Respiratorio Agudo Grave/complicaciones , Dedos del Pie/cirugía , Vasculitis/etiología , Amputación/métodos , Infecciones por Coronavirus/diagnóstico , Servicio de Urgencia en Hospital , Estudios de Seguimiento , Gangrena/fisiopatología , Hispanoamericanos , Humanos , Masculino , Huesos Metatarsianos/cirugía , Persona de Mediana Edad , Multimorbilidad , Pandemias , Admisión del Paciente , Neumonía Viral/diagnóstico , Insuficiencia Respiratoria/diagnóstico , Insuficiencia Respiratoria/etnología , Insuficiencia Respiratoria/etiología , Medición de Riesgo , Síndrome Respiratorio Agudo Grave/diagnóstico , Dedos del Pie/irrigación sanguínea , Dedos del Pie/fisiopatología , Resultado del Tratamiento , Vasculitis/fisiopatología
6.
BMC Infect Dis ; 20(1): 720, 2020 Oct 01.
Artículo en Inglés | MEDLINE | ID: mdl-33004004

RESUMEN

BACKGROUND: Children living with sputum smear-positive adult tuberculosis (TB) patients are vulnerable to acquire tubercular infection. Contact tracing is an important strategy to control tubercular infection in the community. This study was done to find out prevalence of tuberculosis and tubercular infection in children living with sputum smear-positive adult patients receiving DOTS at recruitment and to find out incidence of tubercular infection and disease in these children on follow up. METHOD: Children (< 15 years) living in contact with adults on DOTS were grouped as < 6 years and 6-14 years. They were further sub grouped as being - uninfected, infected, diseased and on prophylaxis and were followed at 3, 6 and 9 months. Tuberculin skin test (TST) and chest X-ray were done. RESULTS: At recruitment 152 children were enrolled and 21.1% (n = 32) had TB. On follow up, 4.3% (n = 5), 5.8% (n = 6) and 11.6% (n = 11) children developed TB after 3, 6 and 9 months respectively.9 children did not come for the last follow up so the overall prevalence of TB disease at 9 months was 37.7% (n = 54). Out of the 128 children with TST reading 23.4% (n = 30) child contacts were found to be infected already at recruitment. The incidence of TST conversion was 20.7% (n = 18), 26.9% (n = 18) and 16.3% (n = 7) respectively. The overall prevalence of tubercular infection in the children, who were in contact with TB patients for 9 months was 74.5% (n = 73). CONCLUSION: About half the children were either suffering from TB or tubercular infection on recruitment. During 9 months follow up 22 unaffected children developed disease and 43acquired infection.


Asunto(s)
Tuberculosis/tratamiento farmacológico , Tuberculosis/epidemiología , Adolescente , Adulto , Anciano , Niño , Preescolar , Composición Familiar , Femenino , Estudios de Seguimiento , Humanos , Incidencia , Lactante , Masculino , Persona de Mediana Edad , Prevalencia , Esputo/microbiología , Prueba de Tuberculina , Tuberculosis Pulmonar/diagnóstico por imagen , Tuberculosis Pulmonar/tratamiento farmacológico , Tuberculosis Pulmonar/epidemiología , Adulto Joven
7.
Am J Case Rep ; 21: e927812, 2020 Oct 03.
Artículo en Inglés | MEDLINE | ID: mdl-33009361

RESUMEN

BACKGROUND This is a case report of an immunocompromised patient with a history of non-Hodgkin lymphoma and persistent severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection who was seronegative and successfully treated with convalescent plasma. CASE REPORT A 63-year-old woman with a past medical history of non-Hodgkin lymphoma in remission while on maintenance therapy with the anti-CD20 monoclonal antibody, obinutuzumab, tested positive for SARS-CoV-2 via nasopharyngeal reverse transcription polymerase chain reaction (RT-PCR) testing over 12 weeks and persistently tested seronegative for immunoglobulin G (IgG) antibodies using SARS-CoV-2 IgG chemiluminescent microparticle immunoassay technology. During this time, the patient experienced waxing and waning of symptoms, which included fever, myalgia, and non-productive cough, but never acquired severe respiratory distress. She was admitted to our hospital on illness day 88, and her symptoms resolved after the administration of convalescent plasma. CONCLUSIONS As the understanding of the pathogenesis of SARS-CoV-2 continues to evolve, we can currently only speculate about the occurrence of chronic infection vs. reinfection. The protective role of antibodies and their longevity against SARS-CoV-2 remain unclear. Since humoral immunity has an integral role in SARS-CoV-2 infection, various phase 3 vaccine trials are underway. In the context of this pandemic, the present case demonstrates the challenges in our understanding of testing and treating immunocompromised patients.


Asunto(s)
Anticuerpos Monoclonales Humanizados/administración & dosificación , Infecciones por Coronavirus/complicaciones , Infecciones por Coronavirus/diagnóstico , Huésped Inmunocomprometido , Linfoma no Hodgkin/inmunología , Neumonía Viral/complicaciones , Neumonía Viral/diagnóstico , Antineoplásicos Inmunológicos/administración & dosificación , Técnicas de Laboratorio Clínico/métodos , Infecciones por Coronavirus/terapia , Femenino , Estudios de Seguimiento , Humanos , Inmunización Pasiva/métodos , Linfoma no Hodgkin/complicaciones , Linfoma no Hodgkin/tratamiento farmacológico , Persona de Mediana Edad , Pandemias , Reacción en Cadena en Tiempo Real de la Polimerasa/métodos , Pruebas Serológicas/métodos , Índice de Severidad de la Enfermedad , Resultado del Tratamiento
8.
Ann Hematol ; 99(11): 2529-2538, 2020 Nov.
Artículo en Inglés | MEDLINE | ID: mdl-32948913

RESUMEN

INTRODUCTION: Since the 1970s outcome of aplastic anemia (AA) patients has improved significantly due to the introduction of immunosuppressive therapy (IST) and allogeneic hematopoietic transplantation (HCT). However, patients may suffer from persistent disease, relapse, clonal evolution, graft-versus-host disease and other late effects. Here, we analyse very long-term outcome of all AA patients at our institution comparing not only survival, but also response status and complications. METHODS: Patient charts of all 302 AA patients treated between 1973 and 2017 at the University Hospital Basel, Switzerland, were retrospectively analysed. RESULTS: First line treatment was IST in 226 (75%) and HCT in 76 (25%) patients. Overall survival at 30 years was similar in patients treated initially by HCT and IST (44% (±14%), and 40% (± 9%) respectively, with better results in more recent years. Partial and no response occurred more frequently after IST, relapse incidence after IST was 24 %, whereas non-engraftment and graft failure was documented in 15 patients (19 %) after HCT. Clonal evolution to myelodysplastic syndrome / acute myeloid leukemia was 16 % at 25 years in IST patients, 1.3 % in HCT patients, iron overload (18 versus 4 %, p = 0.002) and cardiovascular events (11 versus 1 %, p=0.011) occured significantly more often in IST than HCT treated patients. The majority of long-term survivors, 96% of those alive at 25 years, were in complete remission at last follow up, irrespective of the initial treatment modality. CONCLUSION: Very long term survivors after AA are those with stable hematopoietic recovery.


Asunto(s)
Anemia Aplásica , Hematopoyesis , Trasplante de Células Madre Hematopoyéticas , Inmunosupresión , Recuperación de la Función , Adolescente , Adulto , Anciano , Anciano de 80 o más Años , Aloinjertos , Anemia Aplásica/mortalidad , Anemia Aplásica/terapia , Niño , Preescolar , Femenino , Estudios de Seguimiento , Humanos , Lactante , Masculino , Persona de Mediana Edad , Estudios Retrospectivos
9.
Am J Case Rep ; 21: e926781, 2020 Sep 21.
Artículo en Inglés | MEDLINE | ID: mdl-32952147

RESUMEN

BACKGROUND Coronavirus disease 2019 (COVID-19) is caused by a novel coronavirus, SARS-CoV-2, and is associated with severe respiratory disease. There are extensive publications on the chest computed tomography (CT) findings of COVID-19 pneumonia, with ground-glass opacities (GGO) and mixed GGO and consolidation being the most common findings. Those with interstitial thickening manifesting as reticular opacities typically show superimposed ground-glass opacities, giving a crazy-paving pattern. CASE REPORT We report the case of a 77-year-old man with a background of asthma-chronic obstructive pulmonary disease (COPD) overlap syndrome (ACOS) who presented with progressive cough and shortness of breath for 2 days. He was in close contact with a confirmed COVID-19 case. Reverse-transcription polymerase chain reaction analysis of a nasopharyngeal swab was positive for SARS-CoV-2. The initial chest radiograph was negative for lung consolidation and ground-glass opacities. During admission, he had worsening shortness of breath with desaturation, prompting a chest CT examination, which was performed on day 14 of illness. The chest CT revealed an atypical finding of predominant focal subpleural interstitial thickening in the right lower lobe. He was provided supportive treatment along with steroid and antibiotics. He recovered well and subsequently tested negative for 2 consecutive swabs. He was discharged after 34 days. CONCLUSIONS Interstitial thickening or reticular pattern on CT has been described in COVID-19 pneumonia, but largely in association with ground-glass opacity or consolidation. This case demonstrates an atypical predominance of interstitial thickening on chest CT in COVID-19 pneumonia on day 14 of illness, which is the expected time of greatest severity of the disease.


Asunto(s)
Infecciones por Coronavirus/diagnóstico , Enfermedades Pulmonares Intersticiales/diagnóstico por imagen , Tomografía Computarizada Multidetector/métodos , Neumonía Viral/diagnóstico , Intensificación de Imagen Radiográfica , Síndrome Respiratorio Agudo Grave/diagnóstico por imagen , Corticoesteroides/administración & dosificación , Anciano , Antibacterianos/administración & dosificación , Técnicas de Laboratorio Clínico , Medios de Contraste , Infecciones por Coronavirus/complicaciones , Tos/diagnóstico , Tos/etiología , Progresión de la Enfermedad , Disnea/diagnóstico , Disnea/etiología , Estudios de Seguimiento , Humanos , Unidades de Cuidados Intensivos , Tiempo de Internación , Enfermedades Pulmonares Intersticiales/complicaciones , Enfermedades Pulmonares Intersticiales/terapia , Masculino , Pandemias , Neumonía Viral/complicaciones , Neumonía Viral/diagnóstico por imagen , Medición de Riesgo , Síndrome Respiratorio Agudo Grave/virología , Resultado del Tratamiento
10.
Am J Case Rep ; 21: e926915, 2020 Sep 23.
Artículo en Inglés | MEDLINE | ID: mdl-32963216

RESUMEN

BACKGROUND Recent studies demonstrated evidence of coagulation dysfunction in hospitalized patients with severe coronavirus disease 2019 (COVID-19) due to excessive inflammation, hypoxia, platelet activation, endothelial dysfunction, and stasis. Effective anticoagulation therapy may play a dominant role in the management of severe COVID-19 cases. CASE REPORT A 73-year-old man with a 6-day history of fever up to 38.5°C, dyspnea, cough, and fatigue was diagnosed with COVID-19. He had a past medical history significant for hypertension and coronary artery bypass grafting. Two days after hospital admission, the patient developed acute respiratory failure, requiring intubation, mechanical ventilation, and transfer to the intensive care unit (ICU). He received treatment including antibiotics, hydroxychloroquine, tocilizumab, vasopressors, prone positioning, and anticoagulation with enoxaparin at a prophylactic dose. After a 15-day ICU stay, the patient was hemodynamically stable but still hypoxemic; a transthoracic echocardiogram at that time, followed by a transesophageal echocardiogram for better evaluation, revealed the presence of a right atrium thrombus without signs of acute right ventricular dilatation and impaired systolic function. Since the patient was hemodynamically stable, we decided to treat him with conventional anticoagulation under close monitoring for signs of hemodynamic deterioration; thus, the prophylactic dose of enoxaparin was replaced by therapeutic dosing, which was a key component of the patient's successful outcome. Over the next few days he showed significant clinical improvement. The follow-up transesophageal echocardiogram 3 weeks after effective therapeutic anticoagulation revealed no signs of right heart thrombus. CONCLUSIONS The presented COVID-19 case, one of the first reported cases with evidence of right heart thrombus by transesophageal echocardiography, highlights the central role of diagnostic imaging strategies and the importance of adequate anticoagulation therapy in the management of severe COVID-19 cases in the ICU.


Asunto(s)
Infecciones por Coronavirus/complicaciones , Ecocardiografía Transesofágica/métodos , Atrios Cardíacos/diagnóstico por imagen , Cardiopatías/terapia , Neumonía Viral/complicaciones , Síndrome Respiratorio Agudo Grave/complicaciones , Trombosis/terapia , Anciano , Terapia Combinada , Infecciones por Coronavirus/diagnóstico , Infecciones por Coronavirus/terapia , Tos/diagnóstico , Tos/etiología , Cuidados Críticos/métodos , Progresión de la Enfermedad , Servicio de Urgencia en Hospital , Fiebre/diagnóstico , Fiebre/etiología , Estudios de Seguimiento , Grecia , Atrios Cardíacos/patología , Cardiopatías/diagnóstico por imagen , Cardiopatías/etiología , Humanos , Unidades de Cuidados Intensivos , Tiempo de Internación , Masculino , Pandemias , Neumonía Viral/diagnóstico , Neumonía Viral/terapia , Síndrome Respiratorio Agudo Grave/diagnóstico , Síndrome Respiratorio Agudo Grave/terapia , Índice de Severidad de la Enfermedad , Trombosis/diagnóstico por imagen , Trombosis/etiología , Resultado del Tratamiento
11.
Indian J Ophthalmol ; 68(10): 2199-2201, 2020 Oct.
Artículo en Inglés | MEDLINE | ID: mdl-32971640

RESUMEN

To describe a smartphone-based telemedicine tool for monitoring of corneal ulcer size during the corona pandemic, a simple "U"-shaped tool was constructed using three Schirmer's strips that were provided to the patients with small to medium-sized corneal ulcers. The patient and the attendant were trained to use this simple U-shaped tool at home and send digital images to the treating ophthalmologist, to monitor the course of the ulcer. The tool was used in five eyes of five patients with active microbial keratitis. Patients were followed up regularly with the use of telemedicine facility every 48 h for an average duration of 7.6 days (range 6-9 days). In all the five eyes, assessment of the serial images with U-shaped tool showed decrease in size of corneal ulcer, which corroborated with subjective improvement in symptoms. Hence, the novel "'U'-shaped tool" may provide an effective measure in following-up of corneal ulcer patients in times of the COVID-19 pandemic, obviating frequent hospital visits and risk of contracting COVID.


Asunto(s)
Betacoronavirus , Úlcera de la Córnea/diagnóstico , Infecciones por Coronavirus/epidemiología , Técnicas de Diagnóstico Oftalmológico/instrumentación , Infecciones Bacterianas del Ojo/diagnóstico , Neumonía Viral/epidemiología , Teléfono Inteligente/instrumentación , Telemedicina/métodos , Adulto , Anciano , Preescolar , Úlcera de la Córnea/microbiología , Infecciones Bacterianas del Ojo/microbiología , Femenino , Estudios de Seguimiento , Humanos , India/epidemiología , Masculino , Pandemias , Proyectos Piloto , Microscopía con Lámpara de Hendidura
12.
Pediatrics ; 146(4)2020 10.
Artículo en Inglés | MEDLINE | ID: mdl-32934151

RESUMEN

OBJECTIVES: Although the airway microbiota is a highly dynamic ecology, the role of longitudinal changes in airway microbiota during early childhood in asthma development is unclear. We aimed to investigate the association of longitudinal changes in early nasal microbiota with the risk of developing asthma. METHODS: In this prospective, population-based birth cohort study, we followed children from birth to age 7 years. The nasal microbiota was tested by using 16S ribosomal RNA gene sequencing at ages 2, 13, and 24 months. We applied an unsupervised machine learning approach to identify longitudinal nasal microbiota profiles during age 2 to 13 months (the primary exposure) and during age 2 to 24 months (the secondary exposure) and examined the association of these profiles with the risk of physician-diagnosed asthma at age 7 years. RESULTS: Of the analytic cohort of 704 children, 57 (8%) later developed asthma. We identified 4 distinct longitudinal nasal microbiota profiles during age 2 to 13 months. In the multivariable analysis, compared with the persistent Moraxella dominance profile during age 2 to 13 months, the persistent Moraxella sparsity profile was associated with a significantly higher risk of asthma (adjusted odds ratio, 2.74; 95% confidence interval, 1.20-6.27). Similar associations were observed between the longitudinal changes in nasal microbiota during age 2 to 24 months and risk of asthma. CONCLUSIONS: Children with an altered longitudinal pattern in the nasal microbiota during early childhood had a high risk of developing asthma. Our data guide the development of primary prevention strategies (eg, early identification of children at high risk and modification of microbiota) for childhood asthma. These observations present a new avenue for risk modification for asthma (eg, microbiota modification).


Asunto(s)
Asma/etiología , Microbiota , Nariz/microbiología , Aerococcaceae/aislamiento & purificación , Factores de Edad , Asma/diagnóstico , Asma/microbiología , Niño , Preescolar , Femenino , Finlandia , Estudios de Seguimiento , Perfilación de la Expresión Génica/métodos , Haemophilus/aislamiento & purificación , Humanos , Incidencia , Lactante , Recién Nacido , Aprendizaje Automático , Masculino , Microbiota/genética , Moraxella/aislamiento & purificación , Análisis Multivariante , Estudios Prospectivos , ARN Ribosómico 16S/genética , Infecciones del Sistema Respiratorio/complicaciones , Infecciones del Sistema Respiratorio/epidemiología , Infecciones del Sistema Respiratorio/microbiología , Riesgo , Streptococcus/aislamiento & purificación
13.
Lancet Diabetes Endocrinol ; 8(10): 834-844, 2020 10.
Artículo en Inglés | MEDLINE | ID: mdl-32946820

RESUMEN

BACKGROUND: Although metformin is increasingly being used in women with type 2 diabetes during pregnancy, little data exist on the benefits and harms of metformin use on pregnancy outcomes in these women. We aimed to investigate the effects of the addition of metformin to a standard regimen of insulin on neonatal morbidity and mortality in pregnant women with type 2 diabetes. METHODS: In this prospective, multicentre, international, randomised, parallel, double-masked, placebo-controlled trial, women with type 2 diabetes during pregnancy were randomly assigned from 25 centres in Canada and four in Australia to receive either metformin 1000 mg twice daily or placebo, added to insulin. Randomisation was done via a web-based computerised randomisation service and stratified by centre and pre-pregnancy BMI (<30 kg/m2 or ≥30 kg/m2) in a ratio of 1:1 using random block sizes of 4 and 6. Women were eligible if they had type 2 diabetes, were on insulin, had a singleton viable pregnancy, and were between 6 and 22 weeks plus 6 days' gestation. Participants were asked to check their fasting blood glucose level before the first meal of the day, before the last meal of the day, and 2 h after each meal. Insulin doses were adjusted aiming for identical glucose targets (fasting glucose <5·3 mmol/L [95 mg/dL], 2-h postprandial glucose <6·7 mmol/L [120 mg/dL]). Study visits were done monthly and patients were seen every 1-4 weeks as was needed for standard clinical care. At study visits blood pressure and bodyweight were measured; patients were asked about tolerance to their pills, any hospitalisations, insulin doses, and severe hypoglycaemia events; and glucometer readings were downloaded to the central coordinating centre. Participants, caregivers, and outcome assessors were masked to the intervention. The primary outcome was a composite of fetal and neonatal outcomes, for which we calculated the relative risk and 95% CI between groups, stratifying by site and BMI using a log-binomial regression model with an intention-to-treat analysis. Secondary outcomes included several relevant maternal and neonatal outcomes. The trial was registered with ClinicalTrials.gov, NCT01353391. FINDINGS: Between May 25, 2011, and Oct 11, 2018, we randomly assigned 502 women, 253 (50%) to metformin and 249 (50%) to placebo. Complete data were available for 233 (92%) participants in the metformin group and 240 (96%) in the placebo group for the primary outcome. We found no significant difference in the primary composite neonatal outcome between the two groups (40% vs 40%; p=0·86; relative risk [RR] 1·02 [0·83 to 1·26]). Compared with women in the placebo group, metformin-treated women achieved better glycaemic control (HbA1c at 34 weeks' gestation 41·0 mmol/mol [SD 8·5] vs 43·2 mmol/mol [-10]; 5·90% vs 6·10%; p=0·015; mean glucose 6·05 [0·93] vs 6·27 [0·90]; difference -0·2 [-0·4 to 0·0]), required less insulin (1·1 units per kg per day vs 1·5 units per kg per day; difference -0·4 [95% CI -0·5 to -0·2]; p<0·0001), gained less weight (7·2 kg vs 9·0 kg; difference -1·8 [-2·7 to -0·9]; p<0·0001) and had fewer caesarean births (125 [53%] of 234 in the metformin group vs 148 [63%] of 236 in the placebo group; relative risk [RR] 0·85 [95% CI 0·73 to 0·99]; p=0·031). We found no significant difference between the groups in hypertensive disorders (55 [23%] in the metformin group vs 56 [23%] in the placebo group; p=0·93; RR 0·99 [0·72 to 1·35]). Compared with those in the placebo group, metformin-exposed infants weighed less (mean birthweight 3156 g [SD 742] vs 3375 g [742]; difference -218 [-353 to -82]; p=0·002), fewer were above the 97th centile for birthweight (20 [9%] in the metformin group vs 34 [15%] in the placebo group; RR 0·58 [0·34 to 0·97]; p=0·041), fewer weighed 4000 g or more at birth (28 [12%] in the metformin group vs 44 [19%] in the placebo group; RR 0·65 [0·43 to 0·99]; p=0·046), and metformin-exposed infants had reduced adiposity measures (mean sum of skinfolds 16·0 mm [SD 5·0] vs 17·4 [6·2] mm; difference -1·41 [-2·6 to -0·2]; p=0·024; mean neonatal fat mass 13·2 [SD 6·2] vs 14·6 [5·0]; p=0·017). 30 (13%) infants in the metformin group and 15 (7%) in the placebo group were small for gestational age (RR 1·96 [1·10 to 3·64]; p=0·026). We found no significant difference in the cord c-peptide between groups (673 pmol/L [435] in the metformin group vs 758 pmol/L [595] in the placebo group; p=0·10; ratio of means 0·88 [0·72 to 1·02]). The most common adverse event reported was gastrointestinal (38 events in the metformin group and 38 events in the placebo group). INTERPRETATION: We found several maternal glycaemic and neonatal adiposity benefits in the metformin group. Along with reduced maternal weight gain and insulin dosage and improved glycaemic control, the lower adiposity and infant size measurements resulted in fewer large infants but a higher proportion of small-for-gestational-age infants. Understanding the implications of these effects on infants will be important to properly advise patients who are contemplating the use of metformin during pregnancy. FUNDING: Canadian Institutes of Health Research, Lunenfeld-Tanenbaum Research Institute, University of Toronto.


Asunto(s)
Biomarcadores/análisis , Diabetes Mellitus Tipo 2/tratamiento farmacológico , Hipoglucemiantes/uso terapéutico , Metformina/uso terapéutico , Adolescente , Adulto , Glucemia/análisis , Diabetes Mellitus Tipo 2/metabolismo , Diabetes Mellitus Tipo 2/patología , Método Doble Ciego , Femenino , Estudios de Seguimiento , Hemoglobina A Glucada/análisis , Humanos , Agencias Internacionales , Persona de Mediana Edad , Embarazo , Resultado del Embarazo , Estudios Prospectivos , Adulto Joven
14.
Am J Case Rep ; 21: e926101, 2020 Sep 28.
Artículo en Inglés | MEDLINE | ID: mdl-32981926

RESUMEN

BACKGROUND The novel coronavirus disease (COVID-19) has been declared a pandemic. With the ever-increasing number of COVID-19 patients, it is imperative to explore the factors related to the disease to aid patient management until a definitive vaccine is ready, as the disease is not limited to the respiratory system alone. COVID-19 has been associated with various cardiovascular complications including acute myocardial injury, myocarditis, arrhythmias, and venous thromboembolism. The infection is severe in patients with pre-existing cardiovascular disease, and a systemic inflammatory response due to a cytokine storm in severe COVID-19 cases can lead to acute myocardial infarction. CASE REPORT We present the case of a 56-year-old man with cardiovascular risk factors including coronary artery disease, hypertension, ischemic cardiomyopathy, and hyperlipidemia, who had COVID-19-induced pneumonia complicated with acute respiratory distress syndrome. He subsequently developed myocardial infarction during his hospitalization at our facility. He had a significant contact history for COVID-19. He was managed with emergent cardiac revascularization after COVID-19 was confirmed by real-time reverse transcription-polymerase chain reaction testing from a nasopharyngeal swab as per hospital policy for admitted patients. Apart from dual antiplatelet therapy, tocilizumab therapy was initiated due to the high interleukin-6 levels. His hospitalization was complicated by hemodialysis and failed extubation and intubation, resulting in a tracheostomy. Upon improvement, he was discharged to a long-term facility with a plan for outpatient follow-up. CONCLUSIONS In high-risk patients with COVID-19-induced pneumonia and cardiovascular risk factors, a severe systemic inflammatory response can lead to atherosclerotic plaque rupture, which can manifest as acute coronary syndrome.


Asunto(s)
Infecciones por Coronavirus/complicaciones , Infarto de la Pared Inferior del Miocardio/complicaciones , Infarto de la Pared Inferior del Miocardio/terapia , Intervención Coronaria Percutánea/métodos , Neumonía Viral/complicaciones , Síndrome Respiratorio Agudo Grave/complicaciones , Técnicas de Laboratorio Clínico/métodos , Angiografía Coronaria/métodos , Infecciones por Coronavirus/diagnóstico , Enfermedad Crítica , Estudios de Seguimiento , Humanos , Infarto de la Pared Inferior del Miocardio/diagnóstico por imagen , Cuidados a Largo Plazo/métodos , Masculino , Persona de Mediana Edad , Multimorbilidad , Pandemias , Neumonía Viral/diagnóstico , Respiración Artificial/métodos , Medición de Riesgo , Síndrome Respiratorio Agudo Grave/diagnóstico , Síndrome Respiratorio Agudo Grave/terapia , Factores de Tiempo , Traqueostomía/métodos , Resultado del Tratamiento
15.
Am J Case Rep ; 21: e927662, 2020 Sep 29.
Artículo en Inglés | MEDLINE | ID: mdl-32991573

RESUMEN

BACKGROUND There is no evidence-based treatment for coronavirus disease 2019 (COVID-19). We report the case of a 63-year-old woman with SARS-CoV-2 infection who developed severe COVID-19 pneumonia and was treated with convalescent plasma. CASE REPORT A 63-year-old woman who presented with severe and prolonged course of COVID-19 disease (fever up to 39.4°C, persistent cough, and dyspnea) received a convalescent plasma transfusion, which led to complete recovery. The diagnosis was confirmed by RT-PCR testing using the CFX96 Real-Time System (Bio-Rad, USA) from nasopharyngeal swabs. In laboratory tests, an increase in acute-phase parameters was observed. Chest computed tomography (CT) showed abnormalities typical for COVID-19. On days 9 and 11 of the disease, she received the convalescent plasma prepared from a single plasmapheresis donation from a male donor. This male donor was qualified as a convalescent plasma donor according to Polish guidelines, which are compliant with European guidelines. He donated plasma at the Regional Centre for Transfusion Medicine in Bialystok, Poland. The therapy with convalescent plasma led to clinical improvement and normalization of inflammatory parameters. CONCLUSIONS This report presents a case of severe COVID-19 pneumonia in a 63-year-old woman who was given supportive treatment with convalescent plasma. Ongoing clinical trials will determine whether convalescent plasma therapy is an effective treatment for SARS-CoV-2 infection.


Asunto(s)
Transfusión de Componentes Sanguíneos/métodos , Infecciones por Coronavirus/diagnóstico , Infecciones por Coronavirus/terapia , Neumonía Viral/terapia , Síndrome Respiratorio Agudo Grave/terapia , Femenino , Estudios de Seguimiento , Humanos , Persona de Mediana Edad , Pandemias , Neumonía Viral/diagnóstico , Neumonía Viral/diagnóstico por imagen , ARN Viral/análisis , Reacción en Cadena en Tiempo Real de la Polimerasa/métodos , Medición de Riesgo , Síndrome Respiratorio Agudo Grave/diagnóstico , Resultado del Tratamiento
16.
N Engl J Med ; 383(14): 1340-1348, 2020 10 01.
Artículo en Inglés | MEDLINE | ID: mdl-32997908

RESUMEN

BACKGROUND: The efficacy and effectiveness of the quadrivalent human papillomavirus (HPV) vaccine in preventing high-grade cervical lesions have been shown. However, data to inform the relationship between quadrivalent HPV vaccination and the subsequent risk of invasive cervical cancer are lacking. METHODS: We used nationwide Swedish demographic and health registers to follow an open population of 1,672,983 girls and women who were 10 to 30 years of age from 2006 through 2017. We assessed the association between HPV vaccination and the risk of invasive cervical cancer, controlling for age at follow-up, calendar year, county of residence, and parental characteristics, including education, household income, mother's country of birth, and maternal disease history. RESULTS: During the study period, we evaluated girls and women for cervical cancer until their 31st birthday. Cervical cancer was diagnosed in 19 women who had received the quadrivalent HPV vaccine and in 538 women who had not received the vaccine. The cumulative incidence of cervical cancer was 47 cases per 100,000 persons among women who had been vaccinated and 94 cases per 100,000 persons among those who had not been vaccinated. After adjustment for age at follow-up, the incidence rate ratio for the comparison of the vaccinated population with the unvaccinated population was 0.51 (95% confidence interval [CI], 0.32 to 0.82). After additional adjustment for other covariates, the incidence rate ratio was 0.37 (95% CI, 0.21 to 0.57). After adjustment for all covariates, the incidence rate ratio was 0.12 (95% CI, 0.00 to 0.34) among women who had been vaccinated before the age of 17 years and 0.47 (95% CI, 0.27 to 0.75) among women who had been vaccinated at the age of 17 to 30 years. CONCLUSIONS: Among Swedish girls and women 10 to 30 years old, quadrivalent HPV vaccination was associated with a substantially reduced risk of invasive cervical cancer at the population level. (Funded by the Swedish Foundation for Strategic Research and others.).


Asunto(s)
Vacuna Tetravalente Recombinante contra el Virus del Papiloma Humano Tipos 6, 11 , 16, 18 , Neoplasias del Cuello Uterino/prevención & control , Adolescente , Adulto , Niño , Estudios de Cohortes , Femenino , Estudios de Seguimiento , Humanos , Programas de Inmunización , Incidencia , Invasividad Neoplásica , Sistema de Registros , Suecia/epidemiología , Neoplasias del Cuello Uterino/epidemiología , Neoplasias del Cuello Uterino/patología , Vacunación , Adulto Joven
17.
N Engl J Med ; 383(14): 1305-1316, 2020 10 01.
Artículo en Inglés | MEDLINE | ID: mdl-32865375

RESUMEN

BACKGROUND: Despite improvements in the management of atrial fibrillation, patients with this condition remain at increased risk for cardiovascular complications. It is unclear whether early rhythm-control therapy can reduce this risk. METHODS: In this international, investigator-initiated, parallel-group, open, blinded-outcome-assessment trial, we randomly assigned patients who had early atrial fibrillation (diagnosed ≤1 year before enrollment) and cardiovascular conditions to receive either early rhythm control or usual care. Early rhythm control included treatment with antiarrhythmic drugs or atrial fibrillation ablation after randomization. Usual care limited rhythm control to the management of atrial fibrillation-related symptoms. The first primary outcome was a composite of death from cardiovascular causes, stroke, or hospitalization with worsening of heart failure or acute coronary syndrome; the second primary outcome was the number of nights spent in the hospital per year. The primary safety outcome was a composite of death, stroke, or serious adverse events related to rhythm-control therapy. Secondary outcomes, including symptoms and left ventricular function, were also evaluated. RESULTS: In 135 centers, 2789 patients with early atrial fibrillation (median time since diagnosis, 36 days) underwent randomization. The trial was stopped for efficacy at the third interim analysis after a median of 5.1 years of follow-up per patient. A first-primary-outcome event occurred in 249 of the patients assigned to early rhythm control (3.9 per 100 person-years) and in 316 patients assigned to usual care (5.0 per 100 person-years) (hazard ratio, 0.79; 96% confidence interval, 0.66 to 0.94; P = 0.005). The mean (±SD) number of nights spent in the hospital did not differ significantly between the groups (5.8±21.9 and 5.1±15.5 days per year, respectively; P = 0.23). The percentage of patients with a primary safety outcome event did not differ significantly between the groups; serious adverse events related to rhythm-control therapy occurred in 4.9% of the patients assigned to early rhythm control and 1.4% of the patients assigned to usual care. Symptoms and left ventricular function at 2 years did not differ significantly between the groups. CONCLUSIONS: Early rhythm-control therapy was associated with a lower risk of adverse cardiovascular outcomes than usual care among patients with early atrial fibrillation and cardiovascular conditions. (Funded by the German Ministry of Education and Research and others; EAST-AFNET 4 ISRCTN number, ISRCTN04708680; ClinicalTrials.gov number, NCT01288352; EudraCT number, 2010-021258-20.).


Asunto(s)
Antiarrítmicos/uso terapéutico , Fibrilación Atrial/tratamiento farmacológico , Fibrilación Atrial/cirugía , Enfermedades Cardiovasculares/prevención & control , Ablación por Catéter , Síndrome Coronario Agudo/epidemiología , Anciano , Antiarrítmicos/efectos adversos , Fibrilación Atrial/complicaciones , Enfermedades Cardiovasculares/mortalidad , Femenino , Estudios de Seguimiento , Insuficiencia Cardíaca/epidemiología , Hospitalización/estadística & datos numéricos , Humanos , Incidencia , Tiempo de Internación , Masculino , Riesgo , Prevención Secundaria , Método Simple Ciego , Función Ventricular Izquierda/efectos de los fármacos
18.
Pediatrics ; 146(4)2020 10.
Artículo en Inglés | MEDLINE | ID: mdl-32883808

RESUMEN

BACKGROUND: Children with isolated neutropenia (absolute neutrophil count [ANC] <1500/µL) are frequently referred to pediatric hematology and oncology clinics for further diagnostic evaluation. Scant literature exists on interventions and outcomes for isolated neutropenia. We hypothesized that children will have resolution of their neutropenia without the need for intervention(s) by a pediatric hematologist and oncologist. METHODS: We performed a 5.5-year institutional review board-approved retrospective chart review of children referred to our pediatric hematology and oncology clinics for isolated neutropenia. Neutropenia was categorized as mild (ANC of 1001-1500/µL), moderate (ANC of 500-1000 µL), severe (ANC of 201-500/µL), or very severe (ANC of ≤200/µL). RESULTS: Among 155 children referred with isolated neutropenia, 45 (29%) had mild neutropenia, 65 (42%) had moderate neutropenia, 30 (19%) had severe neutropenia, and 15 (10%) had very severe neutropenia. Only 29 (19%) children changed to an ANC category lower than their initial referral category. At a median follow-up of 12 months, 101 children had resolution of neutropenia, 40 children had mild neutropenia, 10 children had moderate neutropenia, 3 children had severe neutropenia, and 1 patient had very severe neutropenia. A specific diagnosis was not identified in most (54%) children. The most common etiologies were viral suppression (16%), autoimmune neutropenia (14%), and drug-induced neutropenia (8%). Black children had a 3.5 higher odds of having persistent mild neutropenia. Six (4%) children received granulocyte colony-stimulating factor therapy. CONCLUSIONS: Most children referred for isolated neutropenia do not progress in severity and do not require subspecialty interventions or hospitalizations.


Asunto(s)
Neutropenia/epidemiología , Derivación y Consulta/estadística & datos numéricos , Adolescente , Afroamericanos/estadística & datos numéricos , Anticuerpos Antinucleares/análisis , Americanos Asiáticos/estadística & datos numéricos , Enfermedades Autoinmunes/complicaciones , Neutropenia Febril Inducida por Quimioterapia/epidemiología , Niño , Preescolar , Progresión de la Enfermedad , Grupo de Ascendencia Continental Europea/estadística & datos numéricos , Femenino , Estudios de Seguimiento , Factor Estimulante de Colonias de Granulocitos/uso terapéutico , Hematología , Hospitalización/estadística & datos numéricos , Humanos , Lactante , Recién Nacido , Masculino , Oncología Médica , Neutropenia/diagnóstico , Neutropenia/tratamiento farmacológico , Neutropenia/etiología , Remisión Espontánea , Estudios Retrospectivos , Virosis/complicaciones
19.
Pediatrics ; 146(4)2020 10.
Artículo en Inglés | MEDLINE | ID: mdl-32900877

RESUMEN

BACKGROUND: Children born preterm are at high risk for autism spectrum disorder (ASD). However, there is still a lack of appropriate developmental markers. In this study, we aim to examine whether early mental performance trajectory is related to ASD outcome in the preterm population. METHODS: The population-based cohort included 414 very preterm survivors born between 2008 and 2014. After excluding children with severe neurosensory impairment, 319 children with available records of developmental quotients before age 2 years were enrolled. The trajectory of mental performance evaluated by using the Bayley Scales of Infant Development across 6, 12, and 24 months of age was analyzed with group-based trajectory modeling. At 5 years of age, the ASD diagnosis was established by using the Autism Diagnostic Observation Schedule and the Autism Diagnostic Interview-Revised. RESULTS: There were 29 children with ASD and 290 children without ASD. The mental performances from age 6 to 24 months could be classified into 3 trajectory patterns: low declining, high declining, and high stable, which corresponded to ASD prevalence at age 5 years of 35%, 9%, and 3%, respectively. ASD odds was 15 times higher in the low-declining group than in the high-stable group (odds ratio 15; 95% confidence interval 3.8-59; P < .001). Through the analysis of multinomial logistic regression, we found that male infants with longer exposure to oxygen therapy whose mothers had lower maternal education levels tended to follow the low-declining trajectory. CONCLUSIONS: The early-life mental trajectory patterns, by using the Bayley Scales of Infant Development, may lead to identification of vulnerable children born preterm for early ASD diagnosis and targeted intervention.


Asunto(s)
Trastorno del Espectro Autista , Desarrollo Infantil , Recien Nacido Extremadamente Prematuro , Factores de Edad , Trastorno del Espectro Autista/clasificación , Trastorno del Espectro Autista/diagnóstico , Trastorno del Espectro Autista/epidemiología , Trastorno del Espectro Autista/fisiopatología , Preescolar , Intervalos de Confianza , Diagnóstico Precoz , Escolaridad , Femenino , Estudios de Seguimiento , Humanos , Lactante , Recién Nacido , Modelos Logísticos , Masculino , Oportunidad Relativa , Oxígeno/uso terapéutico , Prevalencia , Factores Sexuales
20.
Braz Oral Res ; 34: e104, 2020 Sep 04.
Artículo en Inglés | MEDLINE | ID: mdl-32901728

RESUMEN

The aim of the study was to investigate the influence of clinical and socioeconomic factors on social capital throughout adolescence. A cohort study was performed in 2012 (T1) with a random sample of 1,134 12-year-old adolescents from Santa Maria, Brazil. Questions on socioeconomic factors (maternal education, household income, household crowding) were answered by the parents. Clinicians evaluated their dental caries (decayed, missing, and filled status of permanent teeth) and gingival bleeding (using the Community Periodontal Index). Contextual variables including the mean income of the neighborhood in which the school was located were used (T1). The adolescents were revaluated in 2018 (T2) and answered questions regarding social capital (social trust, social control, empowerment, neighborhood security, and political effectiveness). A path analysis was used to test the relationship between the predictor variables (T1) and social capital (T2). A total of 768 adolescents were reevaluated at a 6-year follow-up (cohort retention rate of 67.7%). Most of the adolescents were girls, with a low household income, about 40% had caries experience (T1), and about 64% had high social capital (T2). The highest neighborhood's mean income was related to a lower household income in T1 (p < 0.01), and this was directly related to a low social capital in T2 (p = 0.04). Furthermore, caries experience at T1 was directly associated with low social capital at T2 (p = 0.03). Socioeconomic factors were also related to caries experience. Individuals who lived in neighborhoods with greater inequality such as families with a low household income and those with untreated dental caries in early adolescence, had a low social capital after follow-up.


Asunto(s)
Caries Dental , Capital Social , Brasil , Niño , Estudios de Cohortes , Estudios Transversales , Femenino , Estudios de Seguimiento , Humanos , Masculino , Clase Social
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