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1.
Medicine (Baltimore) ; 100(10): e24430, 2021 Mar 12.
Artigo em Inglês | MEDLINE | ID: mdl-33725821

RESUMO

OBJECTIVE: It remains unclear whether transfusion strategies during orthopedic surgery and infection are related. The purpose of this study is to evaluate whether liberal blood transfusion strategies contribute to infection risk in orthopedic patients by analyzing randomized controlled trials (RCTs). METHODS: RCTs with liberal versus restrictive red blood cell (RBC) transfusion strategies were identified by searching PubMed, Embase, the Cochrane Central Register of Controlled Trials from their inception to July 2019. Ten studies with infections as outcomes were included in the final analysis. According to the Jadad scale, all studies were considered to be of high quality. RESULTS: Ten trials involving 3938 participants were included in this study. The pooled risk ratio (RR) for the association between liberal transfusion strategy and infection was 1.34 (95% confidence intervals [CI], 0.94-1.90; P = .106). The sensitivity analysis indicated unstable results, and no significant publication bias was observed. CONCLUSION: This pooled analysis of RCTs demonstrates that liberal transfusion strategies in orthopedic patients result in a nonsignificant increase in infections compared with more restrictive strategies. The conclusions are mainly based on retrospective studies and should not be considered as recommendation before they are supported by larger scale and well-designed RCTs.


Assuntos
Transfusão de Sangue/estatística & dados numéricos , Infecções/epidemiologia , Cuidados Intraoperatórios/efeitos adversos , Procedimentos Ortopédicos/efeitos adversos , Complicações Pós-Operatórias/epidemiologia , Perda Sanguínea Cirúrgica/prevenção & controle , Humanos , Infecções/etiologia , Cuidados Intraoperatórios/métodos , Cuidados Intraoperatórios/estatística & dados numéricos , Complicações Pós-Operatórias/etiologia , Ensaios Clínicos Controlados Aleatórios como Assunto , Medição de Risco/estatística & dados numéricos , Fatores de Risco
2.
Evol Psychol ; 19(1): 14747049211000714, 2021.
Artigo em Inglês | MEDLINE | ID: mdl-33752457

RESUMO

It is puzzling why countries do not all implement stringent behavioral control measures to prevent the spread of COVID-19 even though preventive behaviors have been proven to be the only effective means to stop the pandemic. We provide a novel evolutionary life history explanation whereby pathogenic and parasitic prevalence represents intrinsic rather than extrinsic mortality risk that drives slower life history strategies and the related disease control motivation in all animals but especially humans. Our theory was tested and supported based on publicly available data involving over 150 countries. Countries having a higher historical prevalence of infectious diseases are found to adopt slower life history strategies that are related to prompter COVID-19 containment actions by the government and greater compliance by the population. Findings could afford governments novel insight into the design of more effective COVID-19 strategies that are based on enhancing a sense of control, vigilance, and compliance in the general population.


Assuntos
Controle Comportamental , Controle de Doenças Transmissíveis , Infecções , Traços de História de Vida , Comportamento de Redução do Risco , Controle Comportamental/legislação & jurisprudência , Controle Comportamental/métodos , Controle Comportamental/psicologia , /prevenção & controle , Controle de Doenças Transmissíveis/métodos , Controle de Doenças Transmissíveis/tendências , Comportamento Cooperativo , Saúde Global , Regulamentação Governamental , Humanos , Infecções/epidemiologia , Infecções/psicologia , Infecções/transmissão , Prevalência
3.
Ann Hematol ; 100(4): 969-978, 2021 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-33594448

RESUMO

A head-to-head comparison of outcomes of unrelated donor allogeneic peripheral blood stem cell transplantation for AML between reduced intensity conditioning (RIC) and myeloablative conditioning (MAC) regimens using thymoglobulin for GVHD prophylaxis is limited. We evaluated outcomes of 122 AML patients who received either busulfan (Bu)/fludarabine (Flu)/low-dose total body irradiation (TBI) as RIC (n = 64, 52%) or Bu/Flu as MAC (n = 58, 48%), and thymoglobulin 4.5 mg/kg total dose between day - 3 to - 1 for GVHD prophylaxis. Grades III-IV acute GVHD (aGVHD) was lower with Bu/Flu/TBI compared with Bu/Flu (6.2% vs 26.1%, p = 0.009). At 1 year, Bu/Flu/TBI was associated with similar chronic GVHD (41.2% vs 44.8%, p = 0.75), OS (61.9% vs 56.9%, p = 0.69), relapse rate (29.9% vs 20.7%, p = 0.24), relapse-free survival (52.8% vs 50%, p = 0.80), non-relapse mortality (17.4% vs 29.3%, p = 0.41), and GVHD-free relapse-free survival (24.2% vs 27.5%, p = 0.80) compared with Bu/Flu. Multivariable analysis did not reveal any difference in outcomes between both regimens. In summary, thymoglobulin at 4.5 mg/kg did not have any adverse impact on survival when used with RIC regimen. Both Bu/Flu/TBI and Bu/Flu conditioning regimens yielded similar survival.


Assuntos
Soro Antilinfocitário/uso terapêutico , Bussulfano/uso terapêutico , Doença Enxerto-Hospedeiro/prevenção & controle , Imunossupressores/uso terapêutico , Leucemia Mieloide Aguda/terapia , Agonistas Mieloablativos/uso terapêutico , Transplante de Células-Tronco de Sangue Periférico , Condicionamento Pré-Transplante/métodos , Vidarabina/análogos & derivados , Idoso , Aloenxertos , Bussulfano/efeitos adversos , Feminino , Doença Enxerto-Hospedeiro/etiologia , Humanos , Infecções/epidemiologia , Depleção Linfocítica , Masculino , Pessoa de Meia-Idade , Ácido Micofenólico/uso terapêutico , Agonistas Mieloablativos/efeitos adversos , Intervalo Livre de Progressão , Estudos Retrospectivos , Linfócitos T , Tacrolimo/uso terapêutico , Resultado do Tratamento , Doadores não Relacionados , Vidarabina/efeitos adversos , Vidarabina/uso terapêutico , Irradiação Corporal Total
4.
JAMA Netw Open ; 4(2): e2036321, 2021 02 01.
Artigo em Inglês | MEDLINE | ID: mdl-33533931

RESUMO

Importance: Rituximab is among the most frequently used immunotherapies in pediatrics. Few studies have reported long-term adverse events associated with its use for children. Objective: To describe the use of rituximab and to assess whether its use is associated with short- or long-term adverse events, infections, or time to immune reconstitution in a diverse group of young people. Design, Setting, and Participants: This retrospective cohort study included 468 patients aged younger than 21 years who received rituximab for diverse indications between October 1, 2010, and December 31, 2017, at Texas Children's Hospital, a large pediatric referral hospital. Patterns of adverse events, infections, and immune recovery are described. Data analyses were conducted from December 2019 to June 2020. Exposure: One or more doses of rituximab. Main Outcomes and Measures: Adverse drug events (eg, anaphylaxis), incidence of mild and severe infections, and time to recovery of B lymphocyte subset counts and immunoglobulin levels. Survival models and logistic regression analyses and were used to identify associated risk factors of infectious and noninfectious adverse drug events. Results: We identified 468 patients receiving at least 1 dose of rituximab. The total follow-up time was 11 713 person-months. Of the 468 patients, 293 (62.6%) were female, the median (interquartile range) age at receipt of dose was 14.3 (9.9-16.8) years, and 209 (44.7%) were self-reported White Hispanic. Adverse events associated with rituximab infusion occurred in 72 patients (15.4%), and anaphylaxis occurred in 17 patients (3.6%). Long-term adverse events, such as prolonged neutropenia and leukoencephalopathy, were absent. Infections occurred in 224 patients (47.9%); 84 patients (17.9%) had severe infections, and 3 patients (0.6%) had lethal infections. Concurrent use of intravenous chemotherapy, treatment of systemic lupus erythematosus, neutropenia, and use of intravenous immunoglobulin were associated with increased risk of infection. Among 135 patients (28.8%) followed up to B cell count recovery, CD19+ or CD20+ cell numbers normalized in a median of 9.0 months (interquartile range, 5.9-14.4 months) following rituximab use; 48 of 95 patients (51%) evaluated beyond a year had low-for-age B cell counts. Recovery of CD27+ memory B cell number occurred in a median of 15.7 months (interquartile range, 6.0-22.7 months). Among patients with normal baseline values, low immunoglobulin G (IgG) levels developed in 67 of 289 patients (23.2%) and low IgM levels in 118 of 255 patients (40.8%); of these patients evaluated beyond 12 months from rituximab, 16 of 117 (13.7%) had persistently low IgG and 37 (33.9%) of 109 had persistently low IgM. Conclusions and Relevance: Rituximab is well tolerated among young people and is associated with few serious adverse events, but infections are common, corresponding to a prolonged period of B cell count recovery often lasting for longer than a year. Further examination of strategies to prevent infections following rituximab should be pursued.


Assuntos
Anafilaxia/epidemiologia , Fatores Imunológicos/efeitos adversos , Infecções/epidemiologia , Reação no Local da Injeção/epidemiologia , Neutropenia/epidemiologia , Rituximab/efeitos adversos , Adolescente , Agamaglobulinemia/induzido quimicamente , Agamaglobulinemia/epidemiologia , Anafilaxia/induzido quimicamente , Doenças Autoimunes do Sistema Nervoso/tratamento farmacológico , Linfócitos B , Criança , Pré-Escolar , Estudos de Coortes , Encefalite/tratamento farmacológico , Feminino , Humanos , Imunoglobulinas Intravenosas/uso terapêutico , Lactente , Infecções/induzido quimicamente , Leucoencefalopatia Multifocal Progressiva/epidemiologia , Efeitos Adversos de Longa Duração/induzido quimicamente , Efeitos Adversos de Longa Duração/epidemiologia , Lúpus Eritematoso Sistêmico/tratamento farmacológico , Contagem de Linfócitos , Linfoma/tratamento farmacológico , Masculino , Esclerose Múltipla/tratamento farmacológico , Síndrome Nefrótica/tratamento farmacológico , Neutropenia/induzido quimicamente , Razão de Chances , Modelos de Riscos Proporcionais , Púrpura Trombocitopênica Idiopática/tratamento farmacológico , Índice de Gravidade de Doença , Fatores de Tempo , Adulto Jovem
5.
Ann Hematol ; 100(4): 855-863, 2021 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-33416902

RESUMO

Monoclonal gammopathy of undetermined significance (MGUS), precursor of multiple myeloma, is an asymptomatic plasma cell disorder that overproduces serum monoclonal protein. Older age, male sex, black race, and family history of MGUS increase the risk of MGUS, yet other risk factors are known. We systematically reviewed observational epidemiological studies that examined sociodemographic, clinical, and behavioral risk factors for the development of MGUS. The protocol for this study was registered on the PROSPERO registry for systematic reviews. We identified epidemiological studies from PubMed and Scopus. Articles were limited to those written in English and published before February 2019. Five case-control and three cohort studies were eligible for data extraction. Studies evaluating factors associated with MGUS risk are limited, with conflicting conclusions regarding risk associated with obesity. Despite the limited research, a significant elevated risk for being diagnosed with MGUS was associated with several specific prior infections, inflammatory disorders, and smoking. The sparse existing literature suggests an increased risk of MGUS associated with several risk factors related to immune function. Further research is needed to explore the potential mechanisms underlying the development of MGUS and to confirm risk factors, both modifiable and non-modifiable.


Assuntos
Gamopatia Monoclonal de Significância Indeterminada/epidemiologia , Fatores Etários , Idoso , Antígenos/imunologia , Doenças Autoimunes/epidemiologia , Estudos de Casos e Controles , Comorbidade , Dieta , Europa (Continente)/epidemiologia , Feminino , Humanos , Hipersensibilidade/epidemiologia , Infecções/epidemiologia , Inflamação/epidemiologia , Masculino , Pessoa de Meia-Idade , Gamopatia Monoclonal de Significância Indeterminada/imunologia , Obesidade/epidemiologia , Estudos Observacionais como Assunto , Fatores de Risco , Fatores Sexuais , Fumar/epidemiologia , Fatores Socioeconômicos , Estados Unidos/epidemiologia
6.
Neurology ; 96(11): e1574-e1584, 2021 03 16.
Artigo em Inglês | MEDLINE | ID: mdl-33514645

RESUMO

OBJECTIVE: To assess safety outcomes for the induction therapies alemtuzumab and autologous hematopoietic stem cell transplantation (AHSCT) compared to noninduction disease-modifying therapies. METHODS: We performed a population-based cohort study linking the Swedish Multiple Sclerosis Register to national health care registers. Alemtuzumab, AHSCT, and a matched reference group of noninduction therapies (natalizumab, dimethyl fumarate, rituximab, fingolimod) were included if started between 2008 and 2017. Main outcomes were death, thyroid disease, nonthyroid autoimmune disease, and infection. RESULTS: We identified 132 alemtuzumab-treated and 139 AHSCT-treated (68% high-dose cyclophosphamide and anti-thymocyte globulin [ATG], 32% BCNU, etoposide, cytosine-arabinoside, and melphalan/ATG) patients, together with 2,486 matched patients treated with noninduction therapies. Four patients in the alemtuzumab group died (incidence rate [IR] per 1,000 person-years 8.6, 95% confidence interval [CI] 2.3-22.0) compared to 1 patient in the AHSCT group (IR 1.7, 95% CI 0.0-9.6), and the mortality rate in the reference group was 0.7 (95% CI 0.3-1.3). Thyroid disease was most frequent in the alemtuzumab group (IR 109, 95% CI 75-154) but also occurred more often for AHSCT (IR 34, 95% CI 18-56) compared to the reference (IR 5.3 95% CI 3.9-7.1). The incidence of nonthyroid autoimmune disease was similar in all groups. IR for infection diagnosed ≥6 months from therapy initiation was 53 (95% CI 30-87) for alemtuzumab, 108 (95% CI 75-150) for AHSCT, and 51 (95% CI 46-57) for the reference. CONCLUSION: We confirmed a high incidence of thyroid disease in alemtuzumab- and, to a smaller extent, AHSCT-treated patients and found a higher incidence of infection for AHSCT compared to both alemtuzumab and noninduction therapies. The incidence of nonthyroid autoimmune disease was low for both therapies. CLASSIFICATION OF EVIDENCE: This study provides Class III evidence of an increased risk of thyroid disease with alemtuzumab and an increased risk of infection with AHSCT treatment.


Assuntos
Alemtuzumab/efeitos adversos , Transplante de Células-Tronco Hematopoéticas/efeitos adversos , Fatores Imunológicos/efeitos adversos , Esclerose Múltipla Recidivante-Remitente/terapia , Adulto , Estudos de Coortes , Feminino , Humanos , Infecções/epidemiologia , Infecções/etiologia , Masculino , Pessoa de Meia-Idade , Sistema de Registros , Suécia/epidemiologia , Doenças da Glândula Tireoide/induzido quimicamente , Doenças da Glândula Tireoide/epidemiologia , Transplante Autólogo/efeitos adversos
7.
BMC Infect Dis ; 21(1): 105, 2021 Jan 22.
Artigo em Inglês | MEDLINE | ID: mdl-33482752

RESUMO

BACKGROUND: Better information on the typical course and management of acute common infections in the community could inform antibiotic stewardship campaigns. We aimed to investigate the incidence, management, and natural history of a range of infection syndromes (respiratory, gastrointestinal, mouth/dental, skin/soft tissue, urinary tract, and eye). METHODS: Bug Watch was an online prospective community cohort study of the general population in England (2018-2019) with weekly symptom reporting for 6 months. We combined symptom reports into infection syndromes, calculated incidence rates, described the proportion leading to healthcare-seeking behaviours and antibiotic use, and estimated duration and severity. RESULTS: The cohort comprised 873 individuals with 23,111 person-weeks follow-up. The mean age was 54 years and 528 (60%) were female. We identified 1422 infection syndromes, comprising 40,590 symptom reports. The incidence of respiratory tract infection syndromes was two per person year; for all other categories it was less than one. 194/1422 (14%) syndromes led to GP (or dentist) consultation and 136/1422 (10%) to antibiotic use. Symptoms usually resolved within a week and the third day was the most severe. CONCLUSIONS: Most people reported managing their symptoms without medical consultation. Interventions encouraging safe self-management across a range of acute infection syndromes could decrease pressure on primary healthcare services and support targets for reducing antibiotic prescribing.


Assuntos
Antibacterianos/uso terapêutico , Infecções/tratamento farmacológico , Infecções/patologia , Encaminhamento e Consulta/estatística & dados numéricos , Gestão de Antimicrobianos , Estudos de Coortes , Assistência à Saúde , Inglaterra/epidemiologia , Feminino , Humanos , Incidência , Infecções/epidemiologia , Masculino , Pessoa de Meia-Idade , Inquéritos e Questionários , Síndrome
8.
Ann Hematol ; 100(3): 645-651, 2021 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-33515047

RESUMO

Management of adult patients with immune thrombocytopenia (ITP) is often unsatisfactory, due to variable efficacy of treatment, risk of life-threatening bleeding if disease control is poor, and side effects associated with treatment. Lack of data on the platelet count threshold associated with bleeding and infection risk associated with ITP treatment limits risk/benefit clinical decision making. We reviewed medical records of all ITP patients who were admitted to our hospital between 2012 and 2017 to evaluate the platelet count threshold for bleeding, infection burden associated with treatment, and real-world efficacy of second-line treatment. We demonstrated fair discrimination between platelet count and occurrence of bleeding, with 15 × 109/L being the optimal cut-off for predicting any bleeding while 20 × 109/L had the highest negative predictive value for severe bleeding. In multivariable analyses, patients who were treated with corticosteroids for at least 2 months were 5.3 times as likely to have an infection. In addition, rituximab response was strongly associated with response to frontline corticosteroids and infection was associated with older age ≥ 65 years and corticosteroid dependence. If corticosteroids are initiated, physicians should aim for the shortest duration of treatment before switching to effective second-line agents for hemostatic platelet counts.


Assuntos
Efeitos Colaterais e Reações Adversas Relacionados a Medicamentos , Púrpura Trombocitopênica Idiopática/complicações , Púrpura Trombocitopênica Idiopática/diagnóstico , Púrpura Trombocitopênica Idiopática/terapia , Corticosteroides/uso terapêutico , Adulto , Idoso , Idoso de 80 Anos ou mais , Plaquetas/patologia , Estudos de Coortes , Efeitos Colaterais e Reações Adversas Relacionados a Medicamentos/diagnóstico , Efeitos Colaterais e Reações Adversas Relacionados a Medicamentos/epidemiologia , Efeitos Colaterais e Reações Adversas Relacionados a Medicamentos/etiologia , Feminino , Seguimentos , Hemorragia/sangue , Hemorragia/diagnóstico , Hemorragia/epidemiologia , Hemorragia/etiologia , Hospitalização/estatística & dados numéricos , Humanos , Imunoglobulinas Intravenosas/uso terapêutico , Infecções/epidemiologia , Infecções/etiologia , Masculino , Pessoa de Meia-Idade , Contagem de Plaquetas , Prognóstico , Púrpura Trombocitopênica Idiopática/epidemiologia , Estudos Retrospectivos , Fatores de Risco , Rituximab/uso terapêutico , Singapura/epidemiologia , Esplenectomia/estatística & dados numéricos , Resultado do Tratamento
9.
Neurology ; 96(6): e831-e839, 2021 02 09.
Artigo em Inglês | MEDLINE | ID: mdl-33318166

RESUMO

OBJECTIVE: To determine whether hospital-diagnosed and community-treated infections are important Guillain-Barré syndrome (GBS) risk factors, we investigated the magnitude and duration of associated GBS risk. METHODS: We conducted a nationwide population-based case-control study of all patients with first-time hospital-diagnosed GBS in Denmark between 1987 and 2016 and 10 matched population controls per case. Hospital-diagnosed infections were determined in the 1987-2016 period and community antibiotic prescriptions in the 2004-2016 period. We used conditional logistic regression to examine the relative risk of GBS associated with having a recent infection. RESULTS: Hospital-diagnosed infections within 60 days were observed in 4.3% of 2,414 GBS cases vs 0.3% of 23,909 controls, with a matched odds ratio (OR) of 13.7 (95% confidence interval [CI], 10.2-18.5). The strongest association with subsequent GBS was observed for lower respiratory tract infection, gastrointestinal tract infection, and septicemia. Community antibiotic prescriptions within 60 days were observed in 22.4% of 1,086 GBS cases and 7.8% of 10,747 controls, with a matched OR of 3.5 (95% CI, 3.0-4.1). The risk of GBS declined considerably with time since infection, with high ORs of 21.3 (95% CI, 14.5-31.2) and 4.7 (95% CI, 3.9-5.7) observed within the first month after a hospital-diagnosed infection and a community antibiotic prescription, respectively. However, GBS risk remained increased 2.4-fold (95% CI, 1.1-5.5) and 1.5-fold (95% CI, 1.2-2.0) even in the fifth month after infection. CONCLUSION: There is a strong, temporal association between community antibiotic use and especially infections necessitating hospitalization and risk of subsequent GBS.


Assuntos
Antibacterianos/uso terapêutico , Prescrições de Medicamentos/estatística & dados numéricos , Síndrome de Guillain-Barré/epidemiologia , Hospitalização/estatística & dados numéricos , Infecções/tratamento farmacológico , Infecções/epidemiologia , Sistema de Registros , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Estudos de Casos e Controles , Criança , Pré-Escolar , Dinamarca/epidemiologia , Feminino , Humanos , Lactente , Masculino , Pessoa de Meia-Idade , Infecções Respiratórias/tratamento farmacológico , Infecções Respiratórias/epidemiologia , Fatores de Risco , Sepse/tratamento farmacológico , Sepse/epidemiologia , Adulto Jovem
11.
Medicina (Kaunas) ; 56(11)2020 Nov 06.
Artigo em Inglês | MEDLINE | ID: mdl-33172013

RESUMO

Pathogens are various organisms, such as viruses, bacteria, fungi, and protozoa, which can cause severe illnesses to their hosts. Throughout history, pathogens have accompanied human populations and caused various epidemics. One of the most significant outbreaks was the Black Death, which occurred in the 14th century and caused the death of one-third of Europe's population. Pathogens have also been studied for their use as biological warfare agents by the former Soviet Union, Japan, and the USA. Among bacteria and viruses, there are high priority agents that have a significant impact on public health. Bacillus anthracis, Francisella tularensis, Yersinia pestis, Variola virus, Filoviruses (Ebola, Marburg), Arenoviruses (Lassa), and influenza viruses are included in this group of agents. Outbreaks and infections caused by them might result in social disruption and panic, which is why special operations are needed for public health preparedness. Antibiotic-resistant bacteria that significantly impede treatment and recovery of patients are also valid threats. Furthermore, recent events related to the massive spread of Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) are an example of how virus-induced diseases cannot be ignored. The impact of outbreaks, such as SARS-CoV-2, have had far-reaching consequences beyond public health. The economic losses due to lockdowns are difficult to estimate, but it would take years to restore countries to pre-outbreak status. For countries affected by the 2019 coronavirus disease (COVID-19), their health systems have been overwhelmed, resulting in an increase in the mortality rate caused by diseases or injuries. Furthermore, outbreaks, such as SARS-CoV-2, will induce serious, wide-ranging (and possibly long-lasting) psychological problems among, not only health workers, but ordinary citizens (this is due to isolation, quarantine, etc.). The aim of this paper is to present the most dangerous pathogens, as well as general characterizations, mechanisms of action, and treatments.


Assuntos
Infecções por Coronavirus , Infecções , Pandemias , Pneumonia Viral , Saúde Pública , Betacoronavirus , Guerra Biológica/métodos , Guerra Biológica/prevenção & controle , Infecções por Coronavirus/economia , Infecções por Coronavirus/epidemiologia , Infecções por Coronavirus/psicologia , Infecções por Coronavirus/terapia , Humanos , Infecções/epidemiologia , Infecções/microbiologia , Infecções/terapia , Pandemias/economia , Pandemias/prevenção & controle , Pandemias/estatística & dados numéricos , Pneumonia Viral/economia , Pneumonia Viral/epidemiologia , Pneumonia Viral/psicologia , Pneumonia Viral/terapia , Psicologia
12.
Pediatrics ; 146(5)2020 11.
Artigo em Inglês | MEDLINE | ID: mdl-33097658

RESUMO

BACKGROUND: Studies on the association between breastfeeding and infections in children beyond the first year of life reveal conflicting results. In a population-based birth cohort, we investigated whether the duration of breastfeeding was associated with the number of hospitalizations due to infection and symptoms of infection at home. METHODS: In the Odense Child Cohort, text message questionnaires were used to register information on breastfeeding (weekly until end of weaning) and symptoms of infection (biweekly; 12-36 months of age). Hospitalization data were obtained from the Danish National Patient Registry. RESULTS: Of the 1087 invited, 815 mother-infant pairs were included. The median duration of any breastfeeding was 7.6 (interquartile range: 3.5-10.4) months and of exclusive breastfeeding was 2.1 (interquartile range: 0.7-4.4) months. Hospitalization due to infection was seen in 207 (25.4%) infants during the first 3 years of life. The adjusted incidence rate ratio (IRR) for hospitalization due to any infection decreased with a longer duration of any breastfeeding (adjusted IRR: 0.96; 95% confidence interval 0.93-0.99; P < .001). The strongest associations between the duration of any breastfeeding and hospitalizations due to infection were found within the first year of life, for lower respiratory tract infections, and other infections (P ≤ .05). For infants exclusively breastfed, the adjusted IRR for hospitalization was 0.88 (95% confidence interval: 0.80-0.96; P = .006). No protective associations were present between breastfeeding and infection symptoms registered at home from ages 12 to 36 months. CONCLUSIONS: The results suggest that increased duration of breastfeeding, especially exclusive breastfeeding, protects against infections requiring hospitalization in the first year of life but not hospitalizations or symptoms of infection at home beyond the first year.


Assuntos
Aleitamento Materno/estatística & dados numéricos , Hospitalização/estatística & dados numéricos , Infecções/epidemiologia , Fatores Etários , Pré-Escolar , Estudos de Coortes , Intervalos de Confiança , Feminino , Humanos , Incidência , Lactente , Recém-Nascido , Masculino , Análise de Regressão , Infecções Respiratórias/epidemiologia , Infecções Respiratórias/prevenção & controle , Envio de Mensagens de Texto/estatística & dados numéricos , Fatores de Tempo , Desmame
13.
Cochrane Database Syst Rev ; 10: CD013256, 2020 Oct 24.
Artigo em Inglês | MEDLINE | ID: mdl-33098570

RESUMO

BACKGROUND: Medications used to treat inflammatory bowel disease (IBD) have significantly improved patient outcomes and delayed time to surgery. However, some of these therapies are recognized to increase the general risk of infection and have an unclear impact on postoperative infection risk. OBJECTIVES: To assess the impact of perioperative IBD medications on the risk of postoperative infections within 30 days of surgery. SEARCH METHODS: We searched the Cochrane IBD Group's Specialized Register (29 October 2019), MEDLINE (January 1966 to October 2019), Embase (January 1985 to October 2019), the Cochrane Library, ClinicalTrials.gov and the WHO International Clinical Trials Registry Platform from inception up to October 2019, and reference lists of articles. SELECTION CRITERIA: Randomized controlled trials, quasi-randomized controlled trials, non-randomized controlled trials, prospective cohort studies, retrospective cohort studies, case-control studies and cross-sectional studies comparing participants treated with an IBD medication preoperatively or within 30 days postoperatively to those who were not taking that medication (either another active medication, placebo, or no treatment). We included published study reports and abstracts. DATA COLLECTION AND ANALYSIS: Two review authors independently screened titles and abstracts and extracted data. The primary outcome was postoperative infection within 30 days of surgery. Secondary outcomes included incisional infections and wound dehiscence, intra-abdominal infectious complications and extra-abdominal infections. Three review authors assessed risks of bias using the Newcastle-Ottawa Scale. We contacted authors for additional information when data were missing. For the primary and secondary outcomes, we calculated odds ratios (ORs) and corresponding 95% confidence intervals (95% CIs) using the generic inverse variance method. When applicable, we analyzed adjusted and unadjusted data separately. We evaluated the certainty of the evidence using GRADE. MAIN RESULTS: We included 68 observational cohort studies (total number of participants unknown because some studies did not report the number of participants). Of these, 48 studies reported including participants with Crohn's disease, 36 reported including participants with ulcerative colitis and five reported including participants with indeterminate colitis. All 42 studies that reported urgency of surgery included elective surgeries, with 31 (74%) of those also including emergency surgeries. Twenty-four studies had low risk of bias while the rest had very high risk. Based on pooling of adjusted data, we calculated ORs for postoperative total infection rates in participants who received corticosteroids (OR 1.70, 95% CI 1.38 to 2.09; low-certainty evidence), immunomodulators (OR 1.29, 95% CI 0.95 to 1.76; low-certainty evidence), anti-TNF agents (OR 1.60, 95% CI 1.20 to 2.13; very low-certainty evidence) and anti-integrin agents (OR 1.04, 95% CI 0.79 to 1.36; low-certainty evidence). We pooled unadjusted data to assess postoperative total infection rates for the use of aminosalicylates (5-ASA) (OR 0.76, 95% CI 0.51 to 1.14; very low-certainty evidence). One secondary outcome examined was wound-related complications in participants using: corticosteroids (OR 1.41, 95% CI 0.72 to 2.74; very low-certainty evidence), immunomodulators (OR 1.35, 95% CI 0.96 to 1.89; very low-certainty evidence), anti-TNF agents (OR 1.18, 95% CI 0.83 to 1.68; very low-certainty evidence) and anti-integrin agents (OR 1.64, 95% CI 0.77 to 3.50; very low-certainty evidence) compared to controls. Another secondary outcome examined the odds of postoperative intra-abdominal infections in participants using: corticosteroids (OR 1.53, 95% CI 1.28 to 1.84; very low-certainty evidence), 5-ASA (OR 0.77, 95% CI 0.45 to 1.33; very low-certainty evidence), immunomodulators (OR 0.86, 95% CI 0.66 to 1.12; very low-certainty evidence), anti-TNF agents (OR 1.38, 95% CI 1.04 to 1.82; very low-certainty evidence) and anti-integrin agents (OR 0.40, 95% CI 0.14 to 1.20; very low-certainty evidence) compared to controls. Lastly we checked the odds for extra-abdominal infections in participants using: corticosteroids (OR 1.23, 95% CI 0.97 to 1.55; very low-certainty evidence), immunomodulators (OR 1.17, 95% CI 0.80 to 1.71; very low-certainty evidence), anti-TNF agents (OR 1.34, 95% CI 0.96 to 1.87; very low-certainty evidence) and anti-integrin agents (OR 1.15, 95% CI 0.43 to 3.08; very low-certainty evidence) compared to controls. AUTHORS' CONCLUSIONS: The evidence for corticosteroids, 5-ASA, immunomodulators, anti-TNF medications and anti-integrin medications was of low or very low certainty. The impact of these medications on postoperative infectious complications is uncertain and we can draw no firm conclusions about their safety in the perioperative period. Decisions on preoperative IBD medications should be tailored to each person's unique circumstances. Future studies should focus on controlling for potential confounding factors to generate higher-quality evidence.


Assuntos
Infecções/induzido quimicamente , Doenças Inflamatórias Intestinais/tratamento farmacológico , Complicações Pós-Operatórias/induzido quimicamente , Corticosteroides/efeitos adversos , Adulto , Ácidos Aminossalicílicos/efeitos adversos , Viés , Colite Ulcerativa/tratamento farmacológico , Intervalos de Confiança , Doença de Crohn/tratamento farmacológico , Feminino , Humanos , Fatores Imunológicos/efeitos adversos , Infecções/epidemiologia , Integrinas/antagonistas & inibidores , Masculino , Estudos Observacionais como Assunto/estatística & dados numéricos , Razão de Chances , Complicações Pós-Operatórias/epidemiologia , Deiscência da Ferida Operatória/induzido quimicamente , Deiscência da Ferida Operatória/epidemiologia , Infecção da Ferida Cirúrgica/induzido quimicamente , Infecção da Ferida Cirúrgica/epidemiologia , Fatores de Tempo , Fator de Necrose Tumoral alfa/antagonistas & inibidores
14.
JAMA ; 324(16): 1629-1639, 2020 10 27.
Artigo em Inglês | MEDLINE | ID: mdl-33095849

RESUMO

Importance: Although current guidelines suggest the use of regional citrate anticoagulation (which involves the addition of a citrate solution to the blood before the filter of the extracorporeal dialysis circuit) as first-line treatment for continuous kidney replacement therapy in critically ill patients, the evidence for this recommendation is based on few clinical trials and meta-analyses. Objective: To determine the effect of regional citrate anticoagulation, compared with systemic heparin anticoagulation, on filter life span and mortality. Design, Setting, and Participants: A parallel-group, randomized multicenter clinical trial in 26 centers across Germany was conducted between March 2016 and December 2018 (final date of follow-up, January 21, 2020). The trial was terminated early after 596 critically ill patients with severe acute kidney injury or clinical indications for initiation of kidney replacement therapy had been enrolled. Interventions: Patients were randomized to receive either regional citrate anticoagulation (n = 300), which consisted of a target ionized calcium level of 1.0 to 1.40 mg/dL, or systemic heparin anticoagulation (n = 296), which consisted of a target activated partial thromboplastin time of 45 to 60 seconds, for continuous kidney replacement therapy. Main Outcomes and Measures: Coprimary outcomes were filter life span and 90-day mortality. Secondary end points included bleeding complications and new infections. Results: Among 638 patients randomized, 596 (93.4%) (mean age, 67.5 years; 183 [30.7%] women) completed the trial. In the regional citrate group vs systemic heparin group, median filter life span was 47 hours (interquartile range [IQR], 19-70 hours) vs 26 hours (IQR, 12-51 hours) (difference, 15 hours [95% CI, 11 to 20 hours]; P < .001). Ninety-day all-cause mortality occurred in 150 of 300 patients vs 156 of 296 patients (Kaplan-Meier estimator percentages, 51.2% vs 53.6%; unadjusted difference, -2.4% [95% CI, -10.5% to 5.8%]; unadjusted hazard ratio, 0.91 [95% CI, 0.72 to 1.13]; unadjusted P = .38; adjusted difference, -6.1% [95% CI, -12.6% to 0.4%]; primary adjusted hazard ratio, 0.79 [95% CI, 0.63 to 1.004]; primary adjusted P = .054). Of 38 prespecified secondary end points, 34 showed no significant difference. Compared with the systemic heparin group, the regional citrate group had significantly fewer bleeding complications (15/300 [5.1%] vs 49/296 [16.9%]; difference, -11.8% [95% CI, -16.8% to -6.8%]; P < .001) and significantly more new infections (204/300 [68.0%] vs 164/296 [55.4%]; difference, 12.6% [95% CI, 4.9% to 20.3%]; P = .002). Conclusions and Relevance: Among critically ill patients with acute kidney injury receiving continuous kidney replacement therapy, anticoagulation with regional citrate, compared with systemic heparin anticoagulation, resulted in significantly longer filter life span. The trial was terminated early and was therefore underpowered to reach conclusions about the effect of anticoagulation strategy on mortality. Trial Registration: ClinicalTrials.gov Identifier: NCT02669589.


Assuntos
Lesão Renal Aguda/terapia , Anticoagulantes/administração & dosagem , Ácido Cítrico/administração & dosagem , Terapia de Substituição Renal Contínua/instrumentação , Heparina/administração & dosagem , Lesão Renal Aguda/sangue , Lesão Renal Aguda/mortalidade , Idoso , Anticoagulantes/efeitos adversos , Cálcio/sangue , Ácido Cítrico/efeitos adversos , Terapia de Substituição Renal Contínua/mortalidade , Estado Terminal , Término Precoce de Ensaios Clínicos , Feminino , Filtração/instrumentação , Alemanha , Hemorragia/induzido quimicamente , Hemorragia/epidemiologia , Heparina/efeitos adversos , Humanos , Infecções/epidemiologia , Estimativa de Kaplan-Meier , Masculino , Tempo de Tromboplastina Parcial , Modelos de Riscos Proporcionais , Fatores de Tempo
15.
Medicine (Baltimore) ; 99(39): e22284, 2020 Sep 25.
Artigo em Inglês | MEDLINE | ID: mdl-32991430

RESUMO

BACKGROUND: Plate fixation and intramedullary nail/Knowles pin fixation methods are commonly used to treat displaced midshaft clavicle fractures. However, the differences between these 2 methods are unclear. OBJECTIVE: This meta-analysis aimed to compare plate fixation and intramedullary nail/Knowles pin fixation for displaced midshaft clavicle fractures. METHODS: We searched PubMed, EBM reviews, and Ovid Medline online for studies related to comparison of plate fixation versus intramedullary nail/Knowles pin fixation for displaced midshaft clavicle fracture from inception to June 30, 2019. Relevant literature search, data extraction, and quality assessment will be performed by 2 researchers independently. The methodological quality of all included studies was appraised using the Cochrane system for randomized trials. The RevMan 5.2 software was used for heterogeneity assessment, generating funnel-plots, data synthesis, sensitivity analysis, and determining publication bias. The fixed-effects or random-effects model was used to calculate mean difference (MD)/relative risks (RRs) and 95% confidence intervals (CIs). RESULTS: This meta-analysis included 839 patients from 12 randomized controlled trials. We found that compared to plate fixation, intramedullary nail/Knowles pin fixation yielded a higher shoulder constant score [MD = -2.43, 95% CI (-3.46 to -1.41), P < .00001] and lower disabilities of the arm, shoulder and hand (DASH) score [MD = 2.98, 95% CI (0.16-5.81), P = .04], and lower infection rates [RR = 2.05, 95% CI (1.36-3.09), P = .003], operation time [MD = 20.20, 95% CI (10.80-29.60), P < .0001], incision size [MD = 6.09, 95% CI (4.54-7.65), P < .00001], and hospital stay [MD = 1.10, 95% CI (0.56-1.64), P < .00001] but with a higher removal rate [RR = 0.52, 95% CI (0.41-0.65), P < .00001] compared to plate fixation. There were no significant differences in nonunion, reintervention, or revision and refracture between these two methods. The limitation is that many studies did not demonstrate the random generated details, and only English articles were enrolled in this meta-analysis. CONCLUSIONS: Intramedullary nail/Knowles pin fixation might be an optimum choice for treating displaced midshaft clavicle fractures, with similar performance in terms of the nonunion, reintervention, or revision and refracture, and better shoulder constant and DASH scores, infection rates, and operative parameters.


Assuntos
Placas Ósseas/efeitos adversos , Clavícula/patologia , Fixação Intramedular de Fraturas/efeitos adversos , Fraturas Ósseas/cirurgia , Adulto , Pinos Ortopédicos/efeitos adversos , Avaliação da Deficiência , Feminino , Fixação Intramedular de Fraturas/instrumentação , Fraturas Ósseas/classificação , Fraturas não Consolidadas/epidemiologia , Humanos , Infecções/epidemiologia , Tempo de Internação/estatística & dados numéricos , Masculino , Pessoa de Meia-Idade , Duração da Cirurgia , Avaliação de Resultados em Cuidados de Saúde , Garantia da Qualidade dos Cuidados de Saúde/métodos , Ensaios Clínicos Controlados Aleatórios como Assunto , Reoperação/estatística & dados numéricos , Risco , Sensibilidade e Especificidade , Ferida Cirúrgica/classificação , Ferida Cirúrgica/epidemiologia
16.
Intern Med J ; 50(8): 924-930, 2020 08.
Artigo em Inglês | MEDLINE | ID: mdl-32881266

RESUMO

BACKGROUND: Infectious diseases (ID) physicians perform a pivotal role in directing the response to severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). AIM: To assess the impact of SARS-CoV-2 on workload and the perceptions of ID physicians regarding the national response in Australia and New Zealand in the pre-pandemic. METHODS: A survey of ID physicians in Australia and New Zealand was undertaken from 3 to 10 March 2020. Respondents were asked to estimate time spent on SARS-CoV-2-related activities in February and report their agreement with statements on a 5-point Likert scale ranging from 'strongly agree' to 'strongly disagree'. We also asked about the intended use of investigational agents. RESULTS: There were 214 respondents (36% of 600 eligible participants). The median workload due to SARS-CoV-2-related activities was 34% of one full-time equivalent (interquartile range 18-68%). Less than a quarter (50, 23%) of respondents had experience managing cases, while 33% (70) had experience preparing during similar pandemics. Nevertheless, 88% (188/213) believed they were well informed when giving testing and management advice, and 45% (95/212) believed their national response was well coordinated. Additionally, 41% (88/214) were worried about becoming infected through occupational exposure. Over half (116, 54%) the respondents intended to use lopinavir/ritonavir in confirmed cases of COVID-19 with severe disease. CONCLUSIONS: ID physicians spent a large proportion of time on SARS-CoV-2-related activities. Increased staffing is required to avoid burnout. Importantly, ID physicians feel well informed when giving advice. A national body should be established to co-ordinate response. Treatment efficacy trials are needed to clarify the utility of unproven treatments.


Assuntos
Infecções por Coronavirus , Pandemias , Médicos , Pneumonia Viral , Austrália/epidemiologia , Betacoronavirus , Esgotamento Profissional/prevenção & controle , Infecções por Coronavirus/epidemiologia , Infecções por Coronavirus/prevenção & controle , Humanos , Infecções/epidemiologia , Nova Zelândia/epidemiologia , Pandemias/prevenção & controle , Papel do Médico , Médicos/psicologia , Médicos/provisão & distribução , Pneumonia Viral/epidemiologia , Pneumonia Viral/prevenção & controle , Psicologia , Inquéritos e Questionários , Carga de Trabalho
17.
Stroke ; 51(10): 3156-3168, 2020 10.
Artigo em Inglês | MEDLINE | ID: mdl-32897811

RESUMO

Understanding the relationship between infection and stroke has taken on new urgency in the era of the coronavirus disease 2019 (COVID-19) pandemic. This association is not a new concept, as several infections have long been recognized to contribute to stroke risk. The association of infection and stroke is also bidirectional. Although infection can lead to stroke, stroke also induces immune suppression which increases risk of infection. Apart from their short-term effects, emerging evidence suggests that poststroke immune changes may also adversely affect long-term cognitive outcomes in patients with stroke, increasing the risk of poststroke neurodegeneration and dementia. Infections at the time of stroke may also increase immune dysregulation after the stroke, further exacerbating the risk of cognitive decline. This review will cover the role of acute infections, including respiratory infections such as COVID-19, as a trigger for stroke; the role of infectious burden, or the cumulative number of infections throughout life, as a contributor to long-term risk of atherosclerotic disease and stroke; immune dysregulation after stroke and its effect on the risk of stroke-associated infection; and the impact of infection at the time of a stroke on the immune reaction to brain injury and subsequent long-term cognitive and functional outcomes. Finally, we will present a model to conceptualize the many relationships among chronic and acute infections and their short- and long-term neurological consequences. This model will suggest several directions for future research.


Assuntos
Aterosclerose/epidemiologia , Infecções/epidemiologia , Acidente Vascular Cerebral/epidemiologia , Arritmias Cardíacas/epidemiologia , Arritmias Cardíacas/fisiopatologia , Aterosclerose/imunologia , Aterosclerose/fisiopatologia , Bacteriemia/epidemiologia , Bacteriemia/imunologia , Bacteriemia/fisiopatologia , Betacoronavirus , Doença Crônica , Infecções por Coronavirus/epidemiologia , Infecções por Coronavirus/imunologia , Infecções por Coronavirus/fisiopatologia , Infecções por Citomegalovirus/epidemiologia , Infecções por Citomegalovirus/imunologia , Infecções por Citomegalovirus/fisiopatologia , Endotélio/fisiopatologia , Infecções por HIV/epidemiologia , Infecções por HIV/imunologia , Infecções por HIV/fisiopatologia , Humanos , Hospedeiro Imunocomprometido/imunologia , Infecções/imunologia , Infecções/fisiopatologia , Inflamação/imunologia , Influenza Humana/epidemiologia , Influenza Humana/imunologia , Influenza Humana/fisiopatologia , Pandemias , Ativação Plaquetária , Agregação Plaquetária , Pneumonia/epidemiologia , Pneumonia/imunologia , Pneumonia/fisiopatologia , Pneumonia Viral/epidemiologia , Pneumonia Viral/imunologia , Pneumonia Viral/fisiopatologia , Prognóstico , Fatores de Risco , Acidente Vascular Cerebral/imunologia , Trombose/epidemiologia , Trombose/imunologia , Infecção pelo Vírus da Varicela-Zoster/epidemiologia , Infecção pelo Vírus da Varicela-Zoster/imunologia , Infecção pelo Vírus da Varicela-Zoster/fisiopatologia
18.
Zhonghua Wei Zhong Bing Ji Jiu Yi Xue ; 32(7): 792-796, 2020 Jul.
Artigo em Chinês | MEDLINE | ID: mdl-32788011

RESUMO

OBJECTIVE: To study the clinical characteristics of patients with severe abdominal infection and the epidemiological characteristics of pathogenic bacteria in a hospital, to provide a basis for rational use of antibiotics and reduce the drug resistance rate of pathogens. METHODS: A retrospective analysis was performed on 237 patients with abdominal disease as the primary disease admitted to the surgical intensive care unit (ICU) of the First Affiliated Hospital of Guangxi Medical University from January 1st, 2017 to December 31st, 2019. They were divided into two groups according to whether abdominal infection occurred or not. The clinical features of patients in both groups were analyzed, including gender, age, acute physiology and chronic health evaluation II (APACHE II) score, chronic underlying diseases, primary abdominal site, abdominal trauma or bleeding, multiple organ dysfunction syndrome (MODS) involving organs and surgical treatment. At the same time, the bacterial origin, bacterial distribution and antibiotics sensitivity test results of patients with abdominal infection were recorded. RESULTS: Abdominal infection occurred in 141 of the 237 patients and did not occur in the remaining 96 patients. There were no statistically significant differences between the abdominal infection group and the non-abdominal infection group in terms of gender, age, chronic underlying diseases, etiology and trauma. The APACHE II score in the abdominal infection group was obviously higher than that of the non-abdominal infection group (24.0±8.1 vs. 17.1±5.8, P < 0.01). Incidences of abdominal bleeding, MODS involving four or more organs, surgery and the times of surgery ≥ 3 in the abdominal infection group were significantly higher than those in the non-abdominal infection group (36.2% vs. 17.7%, 20.6% vs. 1.0%, 84.4% vs. 21.9%, 9.3% vs. 0%, all P < 0.05). Among the 141 patients with abdominal infection, 107 obtained positive microbial culture results, and a total of 133 pathogenic strains were detected, including 115 strains of bacteria (86.5%) and 18 strains of fungi (13.5%). The main source of bacteria was abdominal drainage (46.1% of non-bloody specimens and 13.9% of bloody specimens). Among the 115 bacteria, Gram-negative (G-) bacteria were the most common (72.2%) and Gram-positive (G+) bacteria accounted for 27.8%. Escherichia coli and Acinetobacter baumannii were the top two G- bacteria (40.9% and 13.9%, respectively), and enterococcus faecalis accounted for the largest proportion of G+ bacteria (7.8%). The pathogenic bacteria of abdominal infection were sensitive to tigacycline. CONCLUSIONS: The patients with abdominal infection in our hospital had high APACHE II score, more organs failure and were easily complicated with intraperitoneal hemorrhage and required surgical intervention and even repeated surgery. The pathogenic bacteria in patients with abdominal infection in ICU were mainly G- bacteria, and the rate of multi-drug resistance of Acinetobacter baumannii was high. Empirical anti-infective treatment should be started as soon as possible according to the microbial spectrum of the region until the pathogenic bacteria results are obtained. Broad-spectrum antimicrobial therapy and combined antimicrobial therapy are recommended for the healthcare acquired abdominal infection in hospital.


Assuntos
Abdome/microbiologia , Infecções/epidemiologia , Unidades de Terapia Intensiva , Bactérias , China/epidemiologia , Cuidados Críticos , Humanos , Estudos Retrospectivos
19.
Ann Rheum Dis ; 79(10): 1290-1297, 2020 10.
Artigo em Inglês | MEDLINE | ID: mdl-32788396

RESUMO

OBJECTIVES: To evaluate the incidence of infection in patients with active rheumatoid arthritis (RA) treated with baricitinib, an oral selective Janus kinase (JAK)1 and JAK2 inhibitor. METHODS: Infections are summarised from an integrated database (8 phase 3/2/1b clinical trials and 1 long-term extension (LTE)) with data to 1 April 2017. The 'all-bari-RA' analysis set included patients who received any baricitinib dose. Placebo comparison was based on six studies with 4 mg and placebo to week 24, including four trials with 2 mg (placebo-controlled set). Dose-response assessment was based on four studies with 2 mg and 4 mg, including LTE data (2-4 mg extended set). RESULTS: There were 3492 patients who received baricitinib for 7860 patient-years (PY) of exposure (median 2.6 years, maximum 6.1 years). Treatment-emergent infections were higher for baricitinib versus placebo (exposure-adjusted incidence rate (IR)/100 PY: placebo 75.9, 2 mg 84.0 (p not significant), 4 mg 88.4 (p≤0.001)). The IR of serious infection was similar for baricitinib versus placebo and stable over time (all-bari-RA IR 3.0/100 PY). There were 11 cases of tuberculosis (all-bari-RA IR 0.1/100 PY); all occurred with 4 mg in endemic regions. Herpes zoster (HZ) IR/100 PY was higher for baricitinib versus placebo (placebo 1.0, 2 mg 3.1 (p not significant), 4 mg 4.3 (p≤0.01)); rates remained elevated and stable over time (all-bari-RA 3.3). Opportunistic infections, including multidermatomal HZ, were infrequent in the baricitinib programme (all-bari-RA IR 0.5/100 PY). CONCLUSIONS: Increased rates of treatment-emergent infections including HZ were observed in patients with RA treated with baricitinib, consistent with baricitinib's immunomodulatory mode of action.


Assuntos
Antirreumáticos/efeitos adversos , Artrite Reumatoide/tratamento farmacológico , Azetidinas/efeitos adversos , Hospedeiro Imunocomprometido , Infecções/imunologia , Sulfonamidas/efeitos adversos , Método Duplo-Cego , Humanos , Incidência , Infecções/epidemiologia , Ensaios Clínicos Controlados Aleatórios como Assunto , Estudos Retrospectivos
20.
PLoS Med ; 17(8): e1003247, 2020 08.
Artigo em Inglês | MEDLINE | ID: mdl-32764761

RESUMO

BACKGROUND: Patients with opioid use disorder (OUD) who are hospitalized for serious infections requiring prolonged intravenous antibiotics may face barriers to discharge, which could prolong hospital length of stay (LOS) and increase financial burden. We investigated differences in LOS, discharge disposition, and charges between hospitalizations for serious infections in patients with and without OUD. METHODS AND FINDINGS: We utilized the 2016 National Inpatient Sample-a nationally representative database of all discharges from US acute care hospitals. The population of interest was all hospitalizations for infective endocarditis, epidural abscess, septic arthritis, or osteomyelitis. The exposure was OUD, and the primary outcome was LOS until discharge, assessed by using a competing risks analysis to estimate adjusted hazard ratios (aHRs). Adjusted odds ratio (aOR) of discharge disposition and adjusted differences in hospital charges were also reported. Of 95,470 estimated hospitalizations for serious infections (infective endocarditis, epidural abscess, septic arthritis, and osteomyelitis), the mean age was 49 years and 35% were female. 46% had Medicare (government-based insurance coverage for people age 65+ years), and 70% were non-Hispanic white. After adjustment for potential confounders, OUD was associated with a lower probability of discharge at any given LOS (aHR 0.61; 95% CI 0.59-0.63; p < 0.001). OUD was also associated with lower odds of discharge to home (aOR 0.38; 95% CI 0.33-0.43; p < 0.001) and higher odds of discharge to a post-acute care facility (aOR 1.85; 95% CI 1.57-2.17; p < 0.001) or patient-directed discharge (also referred to as "discharge against medical advice") (aOR 3.47; 95% CI 2.80-4.29; p < 0.001). There was no significant difference in average total hospital charges, though daily hospital charges were significantly lower for patients with OUD. Limitations include the potential for unmeasured confounders and the use of billing codes to identify cohorts. CONCLUSIONS: Our findings suggest that among hospitalizations for some serious infections, those involving patients with OUD were associated with longer LOS, higher odds of discharge to post-acute care facilities or patient-directed discharge, and similar total hospital charges, despite lower daily charges. These findings highlight opportunities to improve care for patients with OUD hospitalized with serious infections, and to reduce the growing associated costs.


Assuntos
Disparidades em Assistência à Saúde/tendências , Hospitalização/tendências , Infecções/epidemiologia , Transtornos Relacionados ao Uso de Opioides/epidemiologia , Índice de Gravidade de Doença , Adulto , Idoso , Estudos Transversais , Feminino , Disparidades em Assistência à Saúde/economia , Hospitalização/economia , Humanos , Infecções/economia , Infecções/terapia , Cobertura do Seguro/economia , Cobertura do Seguro/tendências , Masculino , Medicare/economia , Medicare/tendências , Pessoa de Meia-Idade , Transtornos Relacionados ao Uso de Opioides/economia , Transtornos Relacionados ao Uso de Opioides/terapia , Estados Unidos/epidemiologia
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