Nutrient Patterns, Cognitive Function, and Decline in Older Persons: Results from the Three-City and NuAge Studies.

Dietary patterns, or the combination of foods and beverages intake, have been associated with better cognitive function in older persons. To date, no study has investigated the link between a posteriori nutrient patterns based on food intake, and cognitive decline in longitudinal analyses. The aim of this study was to evaluate the relationship between nutrient patterns and cognitive function and decline in two longitudinal cohorts of older persons from France and Canada. The study sample was composed of participants from the Three-City study (3C, France) and the Quebec Longitudinal Study on Nutrition and Successful Aging (NuAge, Quebec, Canada). Both studies estimated nutritional intakes at baseline, and carried out repeated measures of global cognitive function for 1,388 and 1,439 individuals, respectively. Nutrient patterns were determined using principal component analysis methodology in the two samples, and their relation with cognitive function and decline was estimated using linear mixed models. In 3C, a healthy nutrient pattern, characterized by higher intakes of plant-based foods, was associated with a higher global cognitive function at baseline, as opposed to a Western nutrient pattern, which was associated with lower cognitive performance. In NuAge, we also found a healthy nutrient pattern and a Western pattern, although no association was observed with either of these patterns in the Canadian cohort. No association between any of the nutrient patterns and cognitive decline was observed in either cohort. There is a need for longitudinal cohorts focusing on nutrient patterns with substantial follow-up, in order to evaluate more accurately associations between nutrition and cognition in older persons.

Dietary patterns and risk of self-reported activity limitation in older adults from the Three-City Bordeaux Study.

Few studies have been interested in the relationship between dietary patterns and activity limitation in older adults yet. We analysed the association between dietary patterns and the risk of self-reported activity limitation - that is mobility restriction, limitation in instrumental activities in daily living (IADL) and in activities in daily living (ADL) - in community-dwellers aged 67+ years initially free of activity limitation in 2001-2002 and re-examined at least once over 10 years - that is 583 participants for mobility restriction, 1114 for IADL limitation and 1267 for ADL limitation. At baseline, five sex-specific dietary clusters were derived by hybrid clustering method from weekly frequency of intake of twenty food and beverage items. Self-reported mobility restriction, limitations in IADL and in ADL were assessed using the Rosow-Breslau, the Lawton-Brody and the Katz scales, respectively. Associations between dietary clusters and the risk of each activity limitation were assessed using Cox proportional hazard models. In models adjusted for socio-demographic and health-related covariates, compared with the 'Healthy' cluster the 'Biscuits and snacking' cluster was associated with a higher risk of mobility restriction (hazard ratio (HR)=3·0; 95 % CI 1·6, 5·8) and limitation in IADL (HR=2·1; 95 % CI 1·1, 4·2) in men and limitation in ADL in women (HR=2·3; 95 % CI 1·3, 4·0). In this French cohort of community-dwellers aged 67+ years, some unhealthy dietary patterns may increase the risk of activity limitation all along the disablement process in older adults.

Reliable assessment of the incidence of childhood autoimmune hemolytic anemia.

BACKGROUND: Childhood autoimmune hemolytic anemia (AIHA) is a rare and severe disease characterized by hemolysis and positive direct antiglobulin test (DAT). Few epidemiologic indicators are available for the pediatric population. The objective of our study was to reliably estimate the number of AIHA cases in the French Aquitaine region and the incidence of AIHA in patients under 18 years old. PROCEDURE: In this retrospective study, the capture-recapture method and log-linear model were used for the period 2000-2008 in the Aquitaine region from the following three data sources for the diagnosis of AIHA: the OBS'CEREVANCE database cohort, positive DAT collected from the regional blood bank database, and the French medico-economic information system. RESULTS: A list of 281 different patients was obtained after cross-matching the three databases; 44 AIHA cases were identified in the period 2000-2008; and the total number of cases was estimated to be 48 (95% confidence interval [CI]: 45-55). The calculated incidence of the disease was 0.81/100,000 children under 18 years old per year (95% CI 0.76-0.92). CONCLUSION: Accurate methods are required for estimating the incidence of AIHA in children. Capture-recapture analysis corrects underreporting and provides optimal completeness. This study highlights a possible under diagnosis of this potentially severe disease in various pediatric settings. AIHA incidence may now be compared with the incidences of other hematological diseases and used for clinical or research purposes.

Dietary Patterns and 12-Year Risk of Frailty: Results From the Three-City Bordeaux Study.

OBJECTIVE: To analyze the association between dietary patterns and the 12-year risk of frailty and its components in community-dwelling elderly French adults. DESIGN: A prospective cohort study. SETTING: The Bordeaux sample of the Three-City Study. PARTICIPANTS: A total of 972 initially nonfrail nondemented participants (336 men and 636 women) aged 73 years on average, re-examined at least once over 12 years. MEASUREMENTS: Five sex-specific dietary clusters were previously derived at baseline. Frailty incident to the baseline visit was defined as having at least three out of the following 5 criteria: unintentional weight loss, exhaustion, low energy expenditure, slowness, and muscle weakness. Multivariate Cox proportional hazard models were used to assess the association between dietary clusters and the risk of frailty and its components. RESULTS: In total, 78 men for 3719 person-years and 221 women for 7027 person-years became frail over the follow-up. In multivariate analyses, men in the "pasta" pattern and women in the "biscuits and snacking" pattern had a significantly higher risk of frailty compared with those in the "healthy" pattern [hazard ratio (HR) 2.2; 95% confidence interval (CI) 1.1-4.4 and HR 1.8; 95% CI 1.2-2.8, respectively; P = .09 and P = .13 for the global test of significance of risk difference across clusters, respectively]. In men, "biscuits and snacking" and "pasta" patterns were significantly associated with higher risk for muscle weakness (HR 3.3; 95% CI 1.6-7.0 and HR 2.1; 95% CI 1.2-3.7, respectively; P = .003 for global test). CONCLUSIONS: This 12-year prospective population-based study suggests that some particular unhealthy dietary patterns may increase the risk of frailty in older adults.

Nutrient Patterns and Their Food Sources in Older Persons from France and Quebec: Dietary and Lifestyle Characteristics.

BACKGROUND: Dietary and nutrient patterns have been linked to health outcomes related to aging. Food intake is influenced by environmental and genetic factors. The aim of the present study was to compare nutrient patterns across two elderly populations sharing a common ancestral cultural background, but living in different environments. METHODS: The diet quality, lifestyle and socioeconomic characteristics of participants from the Three-City Study (3C, France, n = 1712) and the Québec Longitudinal Study on Nutrition and Successful Aging (NuAge, Quebec, Canada, n = 1596) were analyzed. Nutrient patterns and their food sources were identified in the two samples using principal component analysis. Diet quality was compared across sample-specific patterns by describing weekly food intake and associations with the Canadian Healthy Eating Index (C-HEI). RESULTS: Three nutrient patterns were retained in each study: a healthy, a Western and a more traditional pattern. These patterns accounted for 50.1% and 53.5% of the total variance in 3C and NuAge, respectively. Higher education and non-physical occupations over lifetime were associated with healthy patterns in both studies. Other characteristics such as living alone, having a body mass index lower than 25 and being an ex-smoker were associated with the healthy pattern in NuAge. No association between these characteristics and the nutrient patterns was noted in 3C. The healthy and Western patterns from each sample also showed an inverse association with C-HEI. CONCLUSION: The two healthy patterns showed important similarities: adequate food variety, consumption of healthy foods and associations with common sociodemographic factors. This work highlights that nutrient patterns derived using a posteriori methods may be useful to compare the nutritional quality of the diet of distinct populations.

Characterization of a French series of female cases of mesothelioma.

BACKGROUND: More than 80% of mesothelioma cases in men are attributable to occupational asbestos exposure compared to only 40% in women. The objective of the study was to characterize a series of female pleural mesotheliomas according to known and suspected risk factors. METHODS: From the exhaustive recording of 318 female mesothelioma cases in the French National Mesothelioma Surveillance Program between 1998 and 2009, multiple correspondence analysis and hybrid clustering were performed to characterize these cases according to expert assessed occupational and non-occupational exposure to asbestos and man-made vitreous fibers, X-ray exposure, and history of cancer and non-malignant respiratory diseases. RESULTS: Four clusters were identified: (1) occupational exposure to asbestos and man-made vitreous fibers (7.9% of subjects); (2) radiation exposure during radiotherapy (12.9%); (3) increased asbestos exposure (19.8%); and (4) "non-exposure" characteristics (59.4%). CONCLUSION: These results will allow hypotheses to be generated about associations between mesothelioma and non-occupational asbestos exposure, X-ray exposure and history of respiratory disease.

A qualitative study on knowledge, perceptions, and attitudes of mothers and health care providers toward pneumococcal conjugate vaccine in Bandung, West Java, Indonesia.

UNLABELLED: Due to the high burden of pneumonia in Indonesia, the inclusion of pneumococcal conjugate vaccine (PCV) into Indonesia's National Immunization Program (NIP) is recommended by World Health Organization. Prior to the introduction of new vaccines, it is imperative to assess the perceptions of the public and medical community about the disease and the vaccine. The purpose of this qualitative study was to explore the knowledge, perceptions, and attitudes of mothers and health care providers (HCPs) toward PCV in Bandung, West Java, Indonesia. METHODOLOGY: Fifty-five respondents (26 mothers and 29 HCPs) were interviewed at public and private health care facilities in Bandung using semi-structured interviews in May-June 2011. Data were analyzed manually according to pre-defined themes. RESULTS: Although most mothers had low knowledge about PCV, did not perceive themselves as susceptible to the disease, perceived that cost was the main barrier to PCV access, and obtained little information on PCV, they considered pneumonia as a severe disease and a priority health problem, perceived benefits of the vaccine, and were likely to adopt it. Similarly, knowledge about PCV among most HCPs was limited. Despite perceiving cost as the main barrier, most HCPs perceived benefits of the vaccine, susceptibility and severity of the disease, regarded pneumonia as a priority health problem, and were likely to suggest the new vaccination. DISCUSSION/CONCLUSIONS: Despite the poor knowledge of mothers and HCPs about PCV, they are aware of the high burden of pneumonia and the need for a vaccine in the NIP. Perceived severity and benefits among mothers, and, additionally, perceived susceptibility among HCPs were manifested in the willingness to accept PCV. The findings would contribute to better understanding the factors, which could support decision-making about vaccine introduction, and be utilized for developing suitable messages for mothers and HCPs.

Hepatic lesions observed in hepatitis C virus transgenic mice infected by Helicobacter hepaticus.

BACKGROUND: The heterogeneity of hepatitis C virus (HCV) infection cannot always be explained by HCV genotypes or host genetic factors, raising the issue of possible cofactors. A new form of hepatitis leading to liver cancer was discovered in 1992 in mice, owing to an infection by Helicobacter hepaticus. Moreover, several studies showed an association between the presence of HCV and Helicobacter in the liver of patients with severe liver diseases suggesting a possible synergism between the two pathogens. In an HCV transgenic mouse model with a B6C3F1 background, the combination of H. hepaticus infection and the HCV transgene resulted in a significantly greater incidence and multiplicity of preneoplastic and neoplastic liver foci in males. OBJECTIVES: Because the mouse genetic background is a major determinant in the development of liver disease, our aim was to test the synergism between HCV and H. hepaticus infection using transgenic mice with a more sensitive genetic background to H. hepaticus infection. METHODS: For this purpose, four groups of mice were followed up to 14 months, the presence of H. hepaticus was monitored by PCR and hepatic lesions were looked for. RESULTS: We found that H. hepaticus, but not the HCV transgene, increased the number of hepatic lesions. The presence of carcinoma was more likely to occur on a background of hepatitis, and the overall lesions were more frequent in the presence of steatosis. The effect of the mouse genetic background was greater than the effect of the HCV transgene and was sufficient to promote lesions particularly via its sensitivity to H. hepaticus infection. CONCLUSIONS: Genetic susceptibility may be a more important factor than expected. Indeed, the synergism between HCV and H. hepaticus infection involved in liver disease may be highly host dependent.

Feasibility and acceptability of rapid HIV screening in a labour ward in Togo.

BACKGROUND: HIV screening in a labour ward is the last opportunity to initiate an antiretroviral prophylaxis among pregnant women living with HIV to prevent mother-to-child HIV transmission. Little is known about the feasibility and acceptability of HIV screening during labour in West Africa. FINDINGS: A cross-sectional survey was conducted in the labour ward at the Tokoin Teaching Hospital in Lomé (Togo) between May and August 2010. Pregnant women admitted for labour were randomly selected to enter the study and were interviewed on the knowledge of their HIV status. Clinical and biological data were collected from the individual maternal health chart. HIV testing or re-testing was systematically proposed to all pregnant women. Among 1530 pregnant women admitted for labour, 508 (32.2%)were included in the study. Information on HIV screening was available in the charts of 359 women (71%). Overall, 467 women accepted HIV testing in the labour ward (92%). The HIV prevalence was 8.8% (95% confidence interval: 6.4 to 11.7%). Among the 41 women diagnosed as living with HIV during labour, 34% had not been tested for HIV during pregnancy and were missed opportunities. Antiretroviral prophylaxis had been initiated antenatally for 24 women living with HIV and 17 in the labour room. CONCLUSIONS: This study is the first to show in West Africa that HIV testing in a labour room is feasible and well accepted by pregnant women. HIV screening in labour rooms needs to be routinely implemented to reduce missed opportunities for intervention aimed at HIV care and prevention, especially PMTCT.

Adherence to a Mediterranean diet and plasma fatty acids: data from the Bordeaux sample of the Three-City study.

Higher adherence to a Mediterranean diet (MeDi) and n-3 PUFA may both contribute to decreased dementia risk, but the association between MeDi adherence and lipid status is unclear. The aim of the present study was to analyse the relationship between plasma fatty acids and MeDi adherence in French elderly community dwellers. The study population (mean age 75·9 years) consisted of 1050 subjects from Bordeaux (France) included in the Three-City cohort. Adherence to the MeDi (scored as 0-9) was computed from a FFQ and 24 h recall. The proportion of each plasma fatty acid was determined. Cross-sectional analysis of the association between plasma fatty acids and MeDi adherence was performed by multi-linear regression. After adjusting for age, sex, energy intake, physical activity, smoking status, BMI, plasma TAG and apoE-ɛ4 genotype, plasma palmitoleic acid was significantly inversely associated with MeDi adherence, whereas plasma DHA, the EPA+DHA index and total n-3 PUFA were positively associated with MeDi adherence. The n-6:n-3 PUFA, arachidonic acid (AA):EPA, AA:DHA and AA:(EPA+DHA) ratios were significantly inversely associated with MeDi adherence. Plasma EPA was positively associated with MeDi adherence only in apoE-ɛ4 non-carriers. There was no association between MeDi adherence and SFA and total MUFA. The present results suggest that the protective effect of the MeDi on cognitive functions might be mediated by higher plasma DHA and lower n-6:n-3 PUFA ratios.

Use of psychoactive substances and health care in response to anxiety and depressive disorders.

OBJECTIVES: The use of psychoactive substances in response to psychological distress is not well documented in the general population and has never been studied in combination with health care use. This study estimated the frequency of health care and substance use in response to anxiety or depressive disorders and determined factors associated with these behaviors. METHODS: From a large survey of adults from four French regions, the authors selected those with a 12-month probable anxiety or depressive disorder without a substance use disorder (N=4,071). These disorders were determined with the Composite International Diagnostic Interview Short Form, and participants were asked whether they used substances or health care in response to each disorder. RESULTS: The use of substances in response to anxiety or depressive disorders was 12.9% among men and 5.2% among women. Compared with those who used health care only, those who used substances (with or without health care) were more likely to be men, single, and young. Those who used both substances and health care were also less likely to have a depressive disorder. CONCLUSIONS: This study shows that a sizeable portion of the general population uses substances in response to anxiety or depressive disorders. It also shows that these substance users have distinctive sociodemographic characteristics and can thus be targeted by prevention programs. Strategies to reach substance users with depressive or anxiety disorders who do not use health care remain to be elaborated.

Undernutrition in geriatric institutions in South-West France: policies and risk factors.

OBJECTIVE: This study aimed to describe the nutritional status of geriatric home residents according to their place of dwelling and to identify institutional factors associated with higher rates of undernutrition. METHODS: All institutions (514) in the Aquitaine region were interviewed for staff ratio, nutritional procedures, staff training, and other procedures in the area of nutrition. A stratified random sample of 601 residents in a subsample of 42 institutions underwent Mini-Nutritional Assessment. RESULTS: The estimated prevalence of undernutrition was 19.1 (95% confidence interval [CI] 14.0-24.2), with a higher rate in long-term care (48.0%, 95% CI 15.9-80.2) than in nursing homes (14.5%, 95% CI 10.6-18.4, P < 0.0001). In univariate analyses the risk of undernutrition was higher in long-term care (P < 0.0001), in settings with better weighing equipment (P < 0.0001), with a higher staff ratio (P = 0.0001), and a higher rate of subjects needing help for eating (P < 0.0001) and was lower in settings with a higher rate of training in nutritional screening (P = 0.0001) and management (P < 0.0001). In nursing homes, each item of the Mini-Nutritional Assessment Short Form was independently predictive of undernutrition. In multivariate analyses in nursing homes only, better weighing equipment (adjusted odds ratio 2.34, 95% CI 1.39-4.12, P = 0.0017) and higher staff ratio (adjusted odds ratio 1.03, 95% CI 1.00-1.05, P = 0.0230) were associated with higher rates of undernutrition. CONCLUSION: Undernutrition in institutions was linked to the resident health problems, with little evidence in favor of the influence of institutional policies.

Dietary patterns derived by hybrid clustering method in older people: association with cognition, mood, and self-rated health.

BACKGROUND: Several nutritional factors, including dietary fatty acids, antioxidants, and folates, have been related to pathological brain aging. Dietary patterns that represent a combination of foods may better predict disease risk than single foods or nutrients. OBJECTIVE: To identify dietary patterns by a mixed clustering method and to analyze their relationship with cognitive function, depressive symptoms, and self-rated health in older people. DESIGN: Cross-sectional population-based study. SUBJECTS/SETTING: Subjects included 1,724 elderly community dwellers living in Bordeaux, France from 2001 to 2002. STATISTICAL ANALYSIS: Cluster analysis, combining hybrid clustering, and research for stable groups during the k-means step on mean number of weekly servings of 20 predetermined food groups, separately in men and women. RESULTS: Five dietary clusters were identified in each sex. A "healthy" cluster characterized by higher consumption of fish in men (n=157; 24.3%) and fruits and vegetables in women (n=267; 24.8%) had significantly lower mean number of errors to Mini Mental State score after adjustment for socio-demographic variables (beta=-0.11; 95% confidence interval [CI], -0.22 to -0.004 in men; beta=-0.13; 95% CI, -0.22 to -0.04 in women). The same cluster was associated with borderline significance with lower depressive symptoms in women (beta=-0.16; 95% CI, -0.33 to 0.007). Men in the "pasta eaters" cluster (n=136; 21%) had higher depressive symptoms (beta=0.26; 95% CI, 0.06 to 0.46) and higher risk to report poor health (polytomous regression, odds ratio [OR]=1.91; 95% CI, 1.21 to 3.01) than the "healthy" cluster. Women in the "biscuits and snacking" cluster (n=162; 15%) had greater risk of poor perceived health (OR=1.69; 95% CI, 1.15 to 2.48) compared to "healthy" eaters. Additional adjustment for body mass index and medication use strengthened these associations. CONCLUSIONS: Sex-specific dietary patterns derived by hybrid clustering method are associated with fewer cognitive and depressive symptoms and better perceived health in older people.

Co-occurrence of neuropsychiatric syndromes in demented and psychotic institutionalized elderly.

OBJECTIVES: To explore and determine the clinical figures of behavioral syndromes from the factor structure of the Neuropsychiatric Inventory-Nursing Home version (NPI-NH) in demented and psychotic patients. SETTING: Two nursing homes and two long-term care homes. DESIGN: Observational, cross-sectional. PARTICIPANTS: One hundred and sixty-three institutionalized elderly with dementia or psychosis (66.9% female), mean age 80.9 +/- 9.1 years. MEASUREMENTS: The NPI-NH includes 12 neuropsychiatric symptoms and a distress scale. The product score of frequency (F) and severity (S) ratings provides an overall score for each of the 12 items. An exploratory principal component analysis with Varimax rotation was performed on the F x S scores according to patients' diagnosis. RESULTS: High internal consistency of the NPI-NH was found (alpha = 0.8). In demented patients a 4-factor solution was found that explained 63.9% of the variance, with the syndromes: (a) 'hyperactivity'; (b) 'affective'; (c) 'psychosis'; and (d) 'Hallucinations'. A four-factor solution was also found in psychotic patients, explaining 61.3% of variance, with syndromes: (a) 'affective'; (b) 'frontal lobe symptoms'; (c) 'sundowning'; and (d) 'psychomotor agitation'. A syndrome was unlikely to appear alone but was most likely to occur with other syndromes. A specific pattern of syndrome co-occurrence were found in demented (a + b + c in 30.5% of cases) and psychotic patients (a + b + c + d in 35.2% of cases). CONCLUSION: The syndrome taxonomies are consistent with the diagnostic criteria. The clinical use of syndrome co-occurrence could help to further understand and evaluate behavioral changes in pharmacological and non-pharmacological treatments.

Do anxiety, body image, social support and coping strategies predict survival in breast cancer? A ten-year follow-up study.

A longitudinal study enrolled 75 women with primary breast cancer. Before the confirmation of diagnosis, authors measured trait-anxiety and body satisfaction. Three weeks after diagnosis, coping strategies and state-anxiety were evaluated. The number of days of survival was measured 10 years after diagnosis. In Cox proportional-hazards models adjusting for severity of disease and age, high social support and low state-anxiety predicted an increased risk of death from breast cancer. A significant increased risk of death in women with low scores on the Body Image Questionnaire appeared only in the univariate model.

Hepatitis B vaccination in HIV-infected patients: a survey of physicians and patients participating in the Aquitaine cohort.

UNLABELLED: In France, HIV-infected (HIV+) patients are frequently coinfected with hepatitis B virus (HBV) or at risk for this infection. Physicians and their patients should be more committed to HBV prevention than the average population. AIMS: To gain insight into the attitude towards HBV and its vaccination in HIV+ patients from the Aquitaine Cohort and their attending physicians in France. METHODS: A cross-sectional survey based on self-administered questionnaires was performed from November 2002 to June 2003. It targeted 198 physicians from the clinical group on AIDS epidemiology (Groupe d'Epidémiologie Clinique du SIDA en Aquitaine, GECSA) or participating in medical HIV networks in southwestern France; and 512 patients from the cohort. Questions concerned the following items for the physicians: HBV status, prescription of HBV serology and vaccination (frequency, type, schedule), risk factors assessed, reasons for non-vaccination; and for the patients: HBV status, information received, risk factors, attitude towards vaccination. RESULTS: 93% of physicians and 22% of patients stated they were vaccinated against HBV. HBV serological status was reported to be systematically ascertained by 75% of physicians, but post-vaccinal testing was only prescribed by 23% of them. The main reasons for not prescribing more often HBV vaccine were forgetting (79%), difficulty to identify subjects at risk (44%) and being afraid of post-vaccinal complications (32%). Thirty percent of patients reported not to have received any information on HBV vaccination. Overall, 44% considered not to be at risk of infection but 82% of them had been confronted with at least one risk. The main reasons for not having been vaccinated were mostly worry about AIDS (70%), not having been asked by physician (65%) or afraid of complications (58%); nonetheless, 42% of patients were willing to be vaccinated. CONCLUSIONS: Results from this survey underline the need for specific health actions to be undertaken concerning hepatitis B vaccination in HIV+ patients as well as their health care providers.

A multicenter cluster randomized controlled trial of strategies to improve thyroid function testing.

OBJECTIVES: This project aimed to compare the independent and combined effectiveness of two implementation interventions of guidelines for ordering thyroid function tests: a Memorandum Pocket Card (MPC) and a Test Request Form (TRF). RESEARCH DESIGN: Intervention groups were wards. The study used an experimental 2*2 factorial design with matching hospitals according to size and activity and wards according to preintervention appropriateness for test ordering. Four ward groups were established: the dual intervention group, the order form group, the pocket card group and the control group. Physicians in all groups received guidelines and were invited to a local information meeting. MEASURES: The main outcome measure of effectiveness was the Guideline Conformity Rate (GCR). RESULTS: Six hospitals participated in the study (two middle-sized hospitals, two small-sized hospitals and two psychiatric hospitals). A total of 1412 orders for thyroid function tests were collected. GCR was 78% in the dual intervention group, 83% in the order form group, 73% in the pocket card group and 62% in the control group. The interaction between TRF and MPC was not significant (beta = -0.70; P = 0.21). Compared with simple information, TRF was effective in increasing GCR (OR, 2.65; 95% CI, 1.52-4.62), unlike MPC (OR, 1.28; CI, 0.75-2.19). CONCLUSIONS: Using a robust design, our study shows the greater effectiveness of TRF than MPC and their association in implementing thyroid function test guidelines.