Occurrence of Aliarcobacter spp. in fresh and pre-cut vegetables of common use in San José, Costa Rica.

Aliarcobacter is a Gram-negative rod that can cause disease in both animals and humans. Several studies have evidenced its presence in a wide variety of foods. Given that the number of foodborne illness outbreaks linked to the consumption of vegetables has increased worldwide and that there is a lack of information about the occurrence of Aliarcobacter spp. in these, the aim of this study was to evaluate its presence and the occurrence of virulence factors in both fresh and ready-to-eat vegetable samples. 180 vegetable samples from Costa Rica were analyzed for the presence of Aliarcobacter spp., including 90 pre-cut vegetable packages and 90 fresh vegetables. Two (2.2%) of the isolates from pre-cut vegetables and 19 (21.1%) of the isolates obtained from fresh vegetables were confirmed as Aliarcobacter spp. One of the isolates from the pre-cut vegetable samples was identified as A. butzleri. For the fresh vegetables, 11 isolates were identified as A. skirrowii, one as A. butzleri, and the 7 remaining isolates could not be identified at a species level. There is an 87.5% positivity for hecA and 93.8% for pldA, virulence genes in strains isolated from fresh produce, contrasting with an absolute absence from pre-cut vegetable-isolated strains. These results evidence the presence of Aliarcobacter on fresh and pre-cut vegetables from Costa Rica and the potential hazard it might represent for public health.

A predictive algorithm to identify ever smoking in medical claims-based epidemiologic studies.

PURPOSE: To develop and validate an algorithm to estimate probability of ever smoking using administrative claims. METHODS: Using population-based samples of Medicare-aged individuals (121,278 Behavioral Risk Factor Surveillance System survey respondents and 207,885 Medicare beneficiaries), we developed a logistic regression model to predict probability of ever smoking from demographic and claims data. We applied the model in 1,657,266 additional Medicare beneficiaries and calculated area under the receiver operating characteristic curve (AUC) using presence or absence of a tobacco-specific diagnosis or procedure code as our "gold standard." We used these "gold standard" and lung/laryngeal cancer codes to over-ride predicted probability as 100%. We calculated Spearman's rho between probability from this full algorithm and smoking assessed in prior Parkinson disease studies, by substituting our observed and prior ("true") smoking-Parkinson disease odds ratios into the attenuation equation. RESULTS: The predictive model contained 23 variables, including basic demographics, high alcohol consumption, asthma, cardiovascular disease and associated risk factors, selected cancers, and indicators of routine medical usage. The AUC was 67.6% (95% confidence interval 67.5%-67.7%) comparing smoking probability to tobacco-specific diagnosis or procedure codes. Spearman's rho for the full algorithm was 0.82. CONCLUSIONS: Ever smoking might be approximated in administrative data for use as a continuous, probabilistic variable in epidemiologic analyses.

Biologic targets of prescription medications and risk of neurodegenerative disease in United States Medicare beneficiaries.

OBJECTIVE: To identify prescription medications associated with a lower risk of three neurodegenerative diseases: Parkinson disease, Alzheimer disease, and amyotrophic lateral sclerosis. METHODS: We conducted a population-based, case-control study of U.S. Medicare beneficiaries in 2009 (42,885 incident neurodegenerative disease cases, 334,387 randomly selected controls). Using medication data from 2006-2007, we categorized all filled medications according to their biological targets and mechanisms of action on those targets. We used multinomial logistic regression models, while accounting for demographics, indicators of smoking, and health care utilization, to estimate odds ratios (ORs) and 95% confidence intervals (CIs) for 141 target-action pairs and each neurodegenerative disease. For target-action pairs inversely associated with all three diseases, we attempted replication in a cohort study that included an active comparator group. We constructed the cohort by following controls forward for incident neurodegenerative disease from the beginning of 2010 until death or end of 2014, i.e., up to five years after the two-year exposure lag. We used Cox proportional hazards regression while accounting for the same covariates. RESULTS: The most consistent inverse association across both studies and all three neurodegenerative diseases was for xanthine dehydrogenase/oxidase blockers, represented by the gout medication, allopurinol. Allopurinol was associated with a 13-34% lower risk for each neurodegenerative disease group in multinomial regression, and a mean reduction of 23% overall, as compared to individuals who did not use allopurinol. In the replication cohort we observed a significant 23% reduction for neurodegenerative disease in the fifth year of follow-up, when comparing allopurinol users to non-users, and more marked associations with an active comparator group. We observed parallel associations for a related target-action pair unique to carvedilol. DISCUSSION/CONCLUSION: Xanthine dehydrogenase/oxidase blockade might reduce risk of neurodegenerative disease. However, further research will be necessary to confirm that the associations related to this pathway are causal or to examine whether this mechanism slows progression.

Resultados de la implementación de una guía de recomendaciones en el cuidado de las personas con ostomías digestivas / Results in the Application of a Recommendation Guide for the Care of People with Digestive Ostomy / Resultados da implementação de diretrizes de recomendações no cuidado de pessoas com ostomias digestivas

Introducción. La instauración de una ostomía digestiva tiene una importante repercusión física y emocional en las personas. El objetivo de este estudio es analizar la adherencia de las enfermeras a las buenas prácticas en el manejo de las ostomías, la disminución de complicaciones y la adquisición de destrezas de los pacientes en su propio autocuidado tras la implementación de la Guía de Buenas Prácticas de la asociación de enfermeras de Ontario. Metodología. Estudio cuasiexperimental prospectivo en una unidad de cirugía digestiva desde 2017 hasta 2022. La intervención ha consistido en la implementación de las recomendaciones de cuidados de una Guía de Buenas Prácticas, analizando variables de proceso y de resultados en la salud a lo largo del proceso. Resultados. Se han encontrado diferencias significativas (p<0.05) en las variables de adherencia: educación sanitaria preoperatoria, marcaje del estoma, evaluación integral posoperatoria y educación sanitaria posoperatoria. No se han encontrado diferencias significativas en las variables de complicaciones del estoma (del 37.5% al 27.8%), ni en las complicaciones de la piel periestomal (del 12.5% al 10.2%). Sí se han encontrado diferencias en la variable de adquisición de destrezas del paciente en su autocuidado (del 44.44% al 98%). Discusión. Implantar recomendaciones de buenas prácticas mejora la calidad de los cuidados y disminuye las complicaciones. Conclusiones. La implementación de la guía ha aumentado la adherencia de las enfermeras a las buenas prácticas basadas en la evidencia y ha mejorado la adquisición de destrezas de los pacientes en su autocuidado, disminuyendo las complicaciones (aunque sin significación). Palabras clave: Estomía; Autocuidado; Guía de Práctica Clínica; Enfermería Basada en la Evidencia; Evaluación de Resultado en la Atención de Salud

Introduction. The establishment of a digestive ostomy has an essential physical and emotional repercussion. This study aims to analyze nurses' adherence to the good practice of management in ostomy, the decrease of complications, and the acquisition of patients' ability in self-care after implementing the Ontario Nurses' Good Practices guide. Methodology. A quasi-experimental prospective study in a digestive surgery unit from 2017 to 2022. The intervention consists of implementing the recommendations made in the Good Practices Guide and analyzing variables of process and health throughout the process. Results. Significative differences have been found (p<0.05) in the adherence variables: preoperatory sanitary education, marking of stoma, post-operatory integral evaluation, and sanitary post-operatory education. The investigators did not find significant differences in the variable of stoma complications (from 37.5% to 27.8%) or the peristoma skin complications (from 12.5% to 10.2%). A difference in the acquisition of abilities of the patient self-care was found (from 44.4% to 98%). Discussion. To make good practice recommendations improves the quality of the care and reduces complications. Conclusions. Implementing the guide has increased the nurses' adherence to the good practices based on the evidence and the acquisition of abilities in the patient's self-care, decreasing the complications (even though it didn't show significance). Keywords: Ostomy; Self Care; Practice Guideline; Evidence-Based Nursing; Outcome Assessment, Health Care

Introdução. A realização de uma ostomia digestiva tem um importante impacto físico e emocional nas pessoas. O objetivo deste estudo é analisar a adesão das enfermeiras às boas práticas no manejo de ostomias, a redução de complicações e a aquisição de habilidades dos pacientes no seu próprio autocuidado após a implementação das diretrizes de boas práticas dos Associação de Enfermeiras de Ontário. Metodologia. Estudo prospectivo quase-experimental numa unidade de cirurgia digestiva de 2017 a 2022. A intervenção consistiu na implementação das recomendações de cuidados das Diretrizes de Boas Práticas, analisando variáveis de processo e resultados de saúde ao longo do processo. Resultados. Foram encontradas diferenças significativas (p<0.05) nas variáveis de adesão: educação em saúde préoperatória, marcação do estoma, avaliação pós-operatória abrangente e educação em saúde pós-operatória. Não foram encontradas diferenças significativas nas variáveis de complicações do estoma (de 37.5% para 27.8%), nem nas complicações da pele periestomal (de 12.5% para 10.2%). Foram encontradas diferenças na variável aquisição de habilidades de autocuidado pelo paciente (de 44.44% para 98%). Discussão. A implementação de recomendações de boas práticas melhora a qualidade dos cuidados e reduz complicações. Conclusões. A implementação das diretrizes aumentou a adesão das enfermeiras às boas práticas baseadas em evidências e melhorou a aquisição de habilidades de autocuidado pelos pacientes, diminuindo complicações (embora não significativamente). Palavras-chave: Estomia; Autocuidado; Guia de Prática Clínica; Enfermagem Baseada em Evidências; Avaliação de Resultados em Cuidados de Saúde

Incidence of amyotrophic lateral sclerosis in older adults.

INTRODUCTION/AIMS: We investigated the age- and sex-specific incidence and survival of Medicare beneficiaries with amyotrophic lateral sclerosis (ALS) in patients 66 to 90 years of age. METHODS: We identified all incident ALS cases within a population-based sample of Medicare beneficiaries in 2009 (total: 22 000 177 person-years at risk for ALS). We calculated age- and sex-specific incidence in 2009 according to multiple, progressively more stringent case definitions. Our most inclusive definition required one ALS code, whereas the most restrictive definition required at least one additional ALS code more than 6 months after the first code, including one from a neurologist. We identified associated imaging studies and electrodiagnostic testing and followed all cases through the end of 2014 to determine survival. RESULTS: The overall incidence for our most inclusive definition was 22.84 per 100 000 person-years for men and 16.05 per 100 000 person-years for women. The overall incidence was 5.72 per 100 000 person-years for men and 3.99 per 100 000 person-years for women for our most restrictive definition. For our most inclusive definition, fewer than 39.7% of cases ever had an ALS diagnosis from a neurologist, more than 50% had an electrodiagnostic test or imaging study, and 40.1% survived less than 1 year after diagnosis, with 25.5% of these cases surviving no more than 6 months. Cases not meeting the most restrictive definition were more likely than those who did meet the restrictive definition to be older, black, or Asian. DISCUSSION: The oldest and marginalized Medicare beneficiaries diagnosed with ALS are less likely to be included in epidemiological studies with restrictive definitions, but future studies will need to assess the accuracy of diagnosis.

Climate Mitigation through Biological Conservation: Extensive and Valuable Blue Carbon Natural Capital in Tristan da Cunha's Giant Marine Protected Zone.

Carbon-rich habitats can provide powerful climate mitigation if meaningful protection is put in place. We attempted to quantify this around the Tristan da Cunha archipelago Marine Protected Area. Its shallows (<1000 m depth) are varied and productive. The 5.4 km2 of kelp stores ~60 tonnes of carbon (tC) and may export ~240 tC into surrounding depths. In deep-waters we analysed seabed data collected from three research cruises, including seabed mapping, camera imagery, seabed oceanography and benthic samples from mini-Agassiz trawl. Rich biological assemblages on seamounts significantly differed to the islands and carbon storage had complex drivers. We estimate ~2.3 million tC are stored in benthic biodiversity of waters <1000 m, which includes >0.22 million tC that can be sequestered (the proportion of the carbon captured that is expected to become buried in sediment or locked away in skeletal tissue for at least 100 years). Much of this carbon is captured by cold-water coral reefs as a mixture of inorganic (largely calcium carbonate) and organic compounds. As part of its 2020 Marine Protection Strategy, these deep-water reef systems are now protected by a full bottom-trawling ban throughout Tristan da Cunha and representative no take areas on its seamounts. This small United Kingdom Overseas Territory's reef systems represent approximately 0.8 Mt CO2 equivalent sequestered carbon; valued at >£24 Million GBP (at the UN shadow price of carbon). Annual productivity of this protected standing stock generates an estimated £3 million worth of sequestered carbon a year, making it an unrecognized and potentially major component of the economy of small island nations like Tristan da Cunha. Conservation of near intact habitats are expected to provide strong climate and biodiversity returns, which are exemplified by this MPA.

A comparison of prediction approaches for identifying prodromal Parkinson disease.

Identifying people with Parkinson disease during the prodromal period, including via algorithms in administrative claims data, is an important research and clinical priority. We sought to improve upon an existing penalized logistic regression model, based on diagnosis and procedure codes, by adding prescription medication data or using machine learning. Using Medicare Part D beneficiaries age 66-90 from a population-based case-control study of incident Parkinson disease, we fit a penalized logistic regression both with and without Part D data. We also built a predictive algorithm using a random forest classifier for comparison. In a combined approach, we introduced the probability of Parkinson disease from the random forest, as a predictor in the penalized regression model. We calculated the receiver operator characteristic area under the curve (AUC) for each model. All models performed well, with AUCs ranging from 0.824 (simplest model) to 0.835 (combined approach). We conclude that medication data and random forests improve Parkinson disease prediction, but are not essential.

Modelling the Effect of Salt Concentration on the Fate of Listeria monocytogenes Isolated from Costa Rican Fresh Cheeses.

"Turrialba cheese" is a Costa Rican fresh cheese highly appreciated due to its sensory characteristics and artisanal production. As a ready-to-eat dairy product, its formulation could support Listeria monocytogenes growth. L. monocytogenes was isolated from 14.06% of the samples and the pathogen was able to grow under all tested conditions. Due to the increasing demand for low-salt products, the objective of this study was to determine the effect of salt concentration on the growth of pathogen isolates obtained from local cheese. Products from retail outlets in Costa Rica were analyzed for L. monocytogenes. These isolates were used to determine growth at 4 °C for different salt concentration (0.5-5.2%). Kinetic curves were built and primary and secondary models developed. Finally, a validation study was performed using literature data. The R2 and Standard Error of fit of primary models were ranked from 0.964-0.993, and 0.197-0.443, respectively. An inverse relationship was observed between growth rate and salt concentration. A secondary model was obtained, with R2 = 0.962. The model was validated, and all values were Bf > 1, thus providing fail-safe estimations. These data were added to the free and easy-to-use predictive microbiology software "microHibro" which is used by food producers and regulators to assist in decision-making.

Presence of Listeria monocytogenes in Ready-to-Eat Meat Products Sold at Retail Stores in Costa Rica and Analysis of Contributing Factors.

ABSTRACT: Listeria monocytogenes is a pathogenic bacterium associated with ready-to-eat (RTE) meat products sold at the retail level. The objective of this research was to determine the prevalence of L. monocytogenes in RTE meat products sold at retail in Costa Rica and to study the factors associated with the levels of contamination; analyzed factors include hygienic practices within stores (cutting techniques and microbial contamination of products) and the behavior of the isolates (persistence against antimicrobials and transfer potential). A total of 190 samples of RTE meat products were collected and analyzed for the presence of coliforms and Listeria spp. Isolates of L. monocytogenes were then evaluated in terms of resistance to disinfectants (quaternary ammonium compound [QAC] and chlorine) and their transfer potential from food contact surfaces (knife and cutting boards). Overall Listeria spp. prevalence was 37.4% (71 of 190); Listeria innocua was present in 32.1% (61 of 190) of the products, and L. monocytogenes was found in just 2.6% (5 of 190) of the samples. Most contaminated samples were cut with a knife at the moment of purchase (44.2%). When analyzing practices within the stores, it was observed that L. monocytogenes transfer from inoculated knife to salchichón was higher for samples cut at the beginning of the experiment. In addition, L. monocytogenes transfer from inoculated cutting boards was independent of the number of slices but contamination from plastic was higher than wood. Regarding L. monocytogenes resistance to disinfectants, average reductions of 2.6 ± 1.1 log CFU/mL were detected after 6 min of exposure to 200 ppm of chlorine; however, chlorine resistance varied among the strains. Prevalence of L. monocytogenes in RTE meat products sold at retail could be associated with handling practices within the stores; further studies are necessary to estimate the impact of these practices on the overall risk for consumers.

Fractures in the prodromal period of Parkinson disease.

OBJECTIVE: To examine the association between fractures and Parkinson disease (PD) during the 5-year prodromal phase as compared to controls. METHODS: We performed a population-based case-control study of Medicare beneficiaries in the United States from 2004 to 2009. We identified 89,632 incident PD cases and 117,760 comparable controls 66-90 years of age in 2009. PD case status was the outcome, and noncranial fracture the independent variable. We used logistic regression models to estimate odds ratios (ORs) and 95% confidence intervals (CIs) for association between fracture and PD in yearly time intervals prior to PD diagnosis/control reference date, after adjusting for covariates. RESULTS: There were 39,606 total fractures (25.4% cases, 14.3% controls) over the 5 years prior to the PD diagnosis/control reference date. PD was positively associated with fractures even after adjusting for age, sex, race/ethnicity, Charlson comorbidity index, alcohol use, tobacco use, and osteoporosis. The association between PD and fracture was evident at yearly time windows prior to PD diagnosis/control reference date. The association between PD and each type of fracture strengthened as the PD diagnosis/control reference date approached (all time interaction p values ≤0.02). Among beneficiaries with a mechanism of injury, the majority were attributed to falls (74.6% cases, 72.8% controls). CONCLUSION: Fractures occur more commonly during the prodromal period of PD compared to controls, especially as diagnosis date approached, suggesting that patients with PD may experience unrecognized motor and nonmotor symptoms.

Herpesvirus Infections and Risk of Parkinson's Disease.

INTRODUCTION: Herpesviruses might play a role in the pathogenesis of neurodegenerative disorders. We sought to examine a possible association between alpha herpesvirus infections and Parkinson's disease. METHODS: We conducted a population-based case-control study of incident Parkinson's disease in 2009 Medicare beneficiaries age 66-90 years (89,790 cases, 118,095 randomly selected comparable controls). We classified beneficiaries with any diagnosis code for "herpes simplex" and/or "herpes zoster" in the previous 5 years as having had the respective alpha herpesviruses. In beneficiaries with Part D prescription coverage, we also identified those prescribed anti-herpetic medications. We calculated odds ratios (OR) and 95% CI between alpha herpesvirus diagnosis/treatment and Parkinson's disease with logistic regression, with adjustment for age, sex, race/ethnicity, smoking, and use of medical care. RESULTS: Parkinson's disease risk was inversely associated with herpes simplex (OR 0.79, 95% CI 0.74-0.84), herpes zoster (OR 0.88, 95% CI 0.85-0.91), and anti-herpetic medications (OR 0.87, 95% CI 0.80-0.96). CONCLUSION: Herpesvirus infection or treatment might reduce risk of Parkinson's disease, but future studies will be required to explore whether this inverse association is causal.

Usos y actitudes de los pacientes ostomizados en España (Estudio U&A en Ostomía) / Uses and attitudes of ostomy patients in Spain (U&A Study on Ostomy)

Objetivo: conocer la práctica habitual de los profesionales expertos en ostomías en España. Explorar los usos y las actitudes del paciente ostomizado, así como su calidad de vida (CdV). Método: estudio retrospectivo nacional (U&A en Ostomía) con 148 participantes que recogieron datos clínicos sobre pacientes ostomizados. El estudio estuvo abierto al empleo de cualquier dispositivo comercial. Los profesionales registraron datos demográficos, características de ostomía y dispositivo, escala DET para evaluación de la piel periestomal (0-15), estado anímico del paciente (0-10), escala Stoma-QoL (0-100) y cambios de hábitos. También se evaluaron las características más valoradas del dispositivo, así como la atención recibida y las sugerencias de mejora por los pacientes. Resultados: se incluyeron 871 pacientes (64% hombres, 36% mujeres; 57,5% colostomía, 28,6% ileostomía y 13,9% urostomía; 68,5% definitiva, 31,5% temporal; 75% neoplasia, 13,2% enfermedad inflamatoria intestinal y 11,8% causa no filiada). En el 55,35% se realizó y respetó el marcado preoperatorio. La puntuación media DET fue 1,7±2,7 (rango 0-13), la satisfacción global con el dispositivo 8,1±1,3 (rango 1-10) y la puntuación Stoma-QoL 57,8±10,3 (rango 11,5-100). El uso de dispositivos Coloplast se asoció a menor frecuencia de fugas (p< 0,036). El 89% de los pacientes acudió regularmente a la consulta de Enfermería experta en ostomía y valoró con 9,4 (0-10) la atención recibida. Conclusiones: U&A en Ostomía es el primer estudio a gran escala que evalúa la realidad clínica del paciente con ostomía en España. Se describen los usos y las actitudes de los pacientes hacia su condición. Se confirma la importancia del marcado preoperatorio y sus repercusiones en la CdV

Objectives: to understand the daily practice of those professionals who are ostomy experts in Spain. To explore the uses and attitudes of the ostomy patients and their quality of life (QoL). Method: a national retrospective study (U&A on Ostomy), with 148 participants who collected clinical data about ostomy patients. The study was open for the use of any marketed device. Professionals collected demographical data, characteristics of ostomy and device, the DET score for evaluating the peristomal skin (0-15), the mood of the patient (0-10), the Stoma-QoL scale (0-100), and changes of habits. There was also an assessment of the most highly valued characteristics of the device, care received and improvement suggestions by patients. Results: the study included 871 patients (64% male, 36% female; 57.5% with colostomy, 28.6% with ileostomy and 13.9% with urostomy; 68.5% were permanent and 31.5% temporary; 75% for neoplasia, 13.2% for inflammatory bowel disease, and 11.8% with undetermined causes). Pre-surgical markings were conducted and observed in 55.35% of cases. The mean DET score was 1.7±2.7 (range 0-13), overall satisfaction with the device was of 8.1±1.3 (range 1-10), and the Stoma-QoL score was 57.8±10.3 (range 11.5-100).The use of Coloplast devices was associated with a lower frequency of leaks (p< 0.036). Overall, 89% of patients attended regularly their appointments with the Ostomy Nurse, and their score for the care received was 9.4 (0-10). Conclusions: U&A in Ostomy is the first large-scale study evaluating the clinical reality of the ostomy patient in Spain. It describes the uses and patients attitudes towards their condition. The importance of pre-surgical marking was confirmed, as well as its impact on QoL

C677T and A1298C methylenetetrahydrofolate reductase polymorphisms and breast cancer susceptibility among Latinos: a meta-analysis.

BACKGROUND: Previous meta-analyses have shown an ethnic dependency of the C677T and the A1298C methylenetetrahydrofolate reductase (MTHFR) polymorphisms, with no focus on the Latino population. For Latinos, many studies have examined these polymorphisms and breast cancer susceptibility, yielding no concise result. Therefore, we undertook this meta-analysis to determine the effect these polymorphisms have on breast cancer risk for Latinos. METHODS: PubMed, EBSCO, LILACS, Scopus, and Latin American-specific databases were searched for studies exploring the association between the MTHFR polymorphisms and breast cancer susceptibility in Latinos until January 2019. Genotype distributions were extracted and, depending on the level heterogeneity determined by the ψ2-based Q test and the I2 test, fixed-effects or random-effects models were used to calculate pooled odds ratios (ORs) with 95% confidence intervals (95% CIs) for the heterozygous, homozygous, dominant, recessive, and allelic genetic models. No publication bias was detected by the Begg-Mazumdar's test and Egger's test. RESULTS: Of the 280 retrieved publications, 9 studies were included: 9 for the C677T polymorphism and 5 for the A1298C polymorphism. For the C677T polymorphism, there was an elevated risk for the homozygous (OR 1.42, 95% CI 1.05-1.92), the dominant (OR 1.16, 95% CI 1.02-1.31), the recessive (OR 1.33, 95% CI 1.01-1.75), and the allelic model (OR 1.17, 95% CI 1.03-1.33, p < 0.01). No association between the A1298C polymorphism and the risk to develop breast cancer was determined. CONCLUSION: The results indicated that, for Latinos, the C677T polymorphism is associated with a significant risk for developing breast cancer, whereas the A1289C polymorphism does not.

ß2-adrenoreceptor medications and risk of Parkinson disease.

OBJECTIVE: A recent study observed a 2-fold greater risk of Parkinson disease (PD) in relation to the ß2-adrenoreceptor antagonist propranolol and a markedly lower risk of PD for the ß2-adrenoreceptor agonist salbutamol. We examined whether confounding by clinical indication for these medications, that is, tremor and smoking-related pulmonary conditions, explained these associations. METHODS: In a large, population-based case-control study of United States Medicare beneficiaries in 2009 with diagnosis codes, procedure codes, and prescription data (48,295 incident PD cases, 52,324 controls), we examined the risk of PD in relation to use of selected ß antagonists (propranolol, carvedilol, metoprolol), the ß2 agonist salbutamol, and other medications used for the same clinical indications (primidone, inhaled corticosteroids). We adjusted for demographics, smoking, and overall use of medical care. We then examined the effect of also adjusting for clinical indication and applying medication exposure lagging. RESULTS: Propranolol appeared to increase PD risk (odds ratio [OR] = 3.62, 95% confidence interval [CI] = 3.31-3.96). When we adjusted for tremor or abnormal involuntary movement prior to the PD diagnosis/reference date and lagged propranolol exposure, the association was 0.97 (95% CI = 0.80-1.18). Primidone, also used for tremor, was similarly sensitive to this adjustment and lagging. ß Antagonists not indicated for tremor appeared to reduce PD risk (carvedilol: OR = 0.77, 95% CI = 0.73-0.81; metoprolol: OR = 0.94, 95% CI = 0.91-0.97) and were insensitive to adjustment for indications and lagging. Neither salbutamol nor inhaled corticosteroids were consistently associated with PD risk. INTERPRETATION: ß2-adrenoreceptor agonists and antagonists do not appear to alter PD risk. Ann Neurol 2018;84:691-701.

Immunosuppressants and risk of Parkinson disease.

We performed a population-based case-control study of United States Medicare beneficiaries age 60-90 in 2009 with prescription data (48,295 incident Parkinson disease cases and 52,324 controls) to examine the risk of Parkinson disease in relation to use of immunosuppressants. Inosine monophosphate dehydrogenase inhibitors (relative risk = 0.64; 95% confidence interval 0.51-0.79) and corticosteroids (relative risk = 0.80; 95% confidence interval 0.77-0.83) were both associated with a lower risk of Parkinson disease. Inverse associations for both remained after applying a 12-month exposure lag. Overall, this study provides evidence that use of corticosteroids and inosine monophosphate dehydrogenase inhibitors might lower the risk of Parkinson disease.

Use of medical care biases associations between Parkinson disease and other medical conditions.

OBJECTIVE: To examine how use of medical care biases the well-established associations between Parkinson disease (PD) and smoking, smoking-related cancers, and selected positively associated comorbidities. METHODS: We conducted a population-based, case-control study of 89,790 incident PD cases and 118,095 randomly selected controls, all Medicare beneficiaries aged 66 to 90 years. We ascertained PD and other medical conditions using ICD-9-CM codes from comprehensive claims data for the 5 years before PD diagnosis/reference. We used logistic regression to estimate age-, sex-, and race-adjusted odds ratios (ORs) between PD and each other medical condition of interest. We then examined the effect of also adjusting for selected geographic- or individual-level indicators of use of care. RESULTS: Models without adjustment for use of care and those that adjusted for geographic-level indicators produced similar ORs. However, adjustment for individual-level indicators consistently decreased ORs: Relative to ORs without adjustment for use of care, all ORs were between 8% and 58% lower, depending on the medical condition and the individual-level indicator of use of care added to the model. ORs decreased regardless of whether the established association is known to be positive or inverse. Most notably, smoking and smoking-related cancers were positively associated with PD without adjustment for use of care, but appropriately became inversely associated with PD with adjustment for use of care. CONCLUSION: Use of care should be considered when evaluating associations between PD and other medical conditions to ensure that positive associations are not attributable to bias and that inverse associations are not masked.

Inflammatory bowel disease and risk of Parkinson's disease in Medicare beneficiaries.

INTRODUCTION: Gastrointestinal (GI) dysfunction precedes the motor symptoms of Parkinson's disease (PD) by several years. PD patients have abnormal aggregation of intestinal α-synuclein, the accumulation of which may be promoted by inflammation. The relationship between intestinal α-synuclein aggregates and central nervous system neuropathology is unknown. Recently, we observed a possible inverse association between inflammatory bowel disease (IBD) and PD as part of a predictive model of PD. Therefore, the objective of this study was to examine the relationship between PD risk and IBD and IBD-associated conditions and treatment. METHODS: Using a case-control design, we identified 89,790 newly diagnosed PD cases and 118,095 population-based controls >65 years of age using comprehensive Medicare data from 2004-2009 including detailed claims data. We classified IBD using International Classification of Diseases version 9 (ICD-9) diagnosis codes. We used logistic regression to calculate odds ratios (ORs) and 95% confidence intervals (CIs) to evaluate the association between PD and IBD. Covariates included age, sex, race/ethnicity, smoking, Elixhauser comorbidities, and health care use. RESULTS: PD was inversely associated with IBD overall (OR = 0.85, 95% CI 0.80-0.91) and with both Crohn's disease (OR = 0.83, 95% CI 0.74-0.93) and ulcerative colitis (OR = 0.88, 95% CI 0.82-0.96). Among beneficiaries with ≥2 ICD-9 codes for IBD, there was an inverse dose-response association between number of IBD ICD-9 codes, as a potential proxy for IBD severity, and PD (p-for-trend = 0.006). CONCLUSION: IBD is associated with a lower risk of developing PD.

Traumatic brain injury in the prodromal period of Parkinson's disease: A large epidemiological study using medicare data.

OBJECTIVE: Studies suggest a greater risk of Parkinson's disease (PD) after traumatic brain injury (TBI), but it is possible that the risk of TBI is greater in the prodromal period of PD. We aimed to examine the time-to-TBI in PD patients in their prodromal period compared to population-based controls. METHODS: We identified 89,790 incident PD cases and 118,095 comparable controls aged > 65 years in 2009 using Medicare claims data. Using data from the preceding 5 years, we compared time-to-TBI in PD patients in their prodromal period to controls. We estimated hazard ratios (HRs) and 95% confidence intervals (CIs) for TBI in a Cox regression, while adjusting for age, sex, race/ethnicity, modified Charlson comorbidity index, smoking, and alcohol use. RESULTS: Risk of TBI was greater in PD patients in their prodromal period across all age and sex groups, with HRs consistently increasing with proximity to PD diagnosis. HRs ranged from 1.64 (95% CI, 1.52, 1.77) 5 years preceding diagnosis to 3.93 (95% CI, 3.74, 4.13) in the year before. The interaction between PD, TBI, and time was primarily observed for TBI attributed to falls. Motor dysfunction and cognitive impairment, suggested by corresponding International Classification of Diseases, Ninth Revision codes, partially mediated the PD-TBI association. INTERPRETATION: There is a strong association between PD and a recent TBI in the prodromal period of PD. This association strengthens as PD diagnosis approaches and may be a result of undetected nonmotor and motor symptoms, but confirmation will be required. Ann Neurol 2017;82:744-754.

A predictive model to identify Parkinson disease from administrative claims data.

OBJECTIVE: To use administrative medical claims data to identify patients with incident Parkinson disease (PD) prior to diagnosis. METHODS: Using a population-based case-control study of incident PD in 2009 among Medicare beneficiaries aged 66-90 years (89,790 cases, 118,095 controls) and the elastic net algorithm, we developed a cross-validated model for predicting PD using only demographic data and 2004-2009 Medicare claims data. We then compared this model to more basic models containing only demographic data and diagnosis codes for constipation, taste/smell disturbance, and REM sleep behavior disorder, using each model's receiver operator characteristic area under the curve (AUC). RESULTS: We observed all established associations between PD and age, sex, race/ethnicity, tobacco smoking, and the above medical conditions. A model with those predictors had an AUC of only 0.670 (95% confidence interval [CI] 0.668-0.673). In contrast, the AUC for a predictive model with 536 diagnosis and procedure codes was 0.857 (95% CI 0.855-0.859). At the optimal cut point, sensitivity was 73.5% and specificity was 83.2%. CONCLUSIONS: Using only demographic data and selected diagnosis and procedure codes readily available in administrative claims data, it is possible to identify individuals with a high probability of eventually being diagnosed with PD.