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1.
Br J Anaesth ; 124(3): 271-280, 2020 03.
Artigo em Inglês | MEDLINE | ID: mdl-31902588

RESUMO

BACKGROUND: Preclinical data suggest suppression of cancer proliferation by propofol, and retrospective studies suggest improved survival after cancer surgery with propofol-based anaesthesia. METHODS: To determine whether propofol dose administered for anaesthesia is associated with 1-yr mortality in patients with and without a diagnosis of solid cancer, we analysed adult patients undergoing monitored anaesthesia care or general anaesthesia at two academic medical centres in Boston, MA, USA. Logistic regression with interaction term analysis was applied with propofol dose (mg kg-1) as primary and diagnosis of solid cancer as co-primary exposure, and 1-yr mortality as the primary outcome. RESULTS: Of 280 081 patient cases, 10 744 (3.8%) died within 1 yr. Increasing propofol dose was associated with reduced odds of 1-yr mortality (adjusted odds ratio [aOR] 0.93 per 10 mg kg-1; 95% confidence interval [CI]: 0.89-0.98; absolute risk reduction fifth vs first quintile 0.5%; 95% CI: 0.2-0.7). This association was modified by a diagnosis of solid cancer (P<0.001 for interaction). Increasing propofol dose was associated with reduced odds of 1-yr mortality in patients without solid cancer (aOR: 0.78; 95% CI: 0.71-0.85), but not in patients with solid cancer (0.99; 0.94-1.04), a finding that was replicated when examining 5-yr mortality. CONCLUSIONS: Increasing propofol dose is associated with lower 1-yr mortality in patients without, but not in patients with, a diagnosis of solid cancer. We found evidence for competing effects, modifying the association between propofol dose and mortality.


Assuntos
Anestesia Geral/métodos , Anestésicos Intravenosos/administração & dosagem , Neoplasias/mortalidade , Complicações Pós-Operatórias/prevenção & controle , Propofol/administração & dosagem , Adulto , Idoso , Relação Dose-Resposta a Droga , Feminino , Seguimentos , Humanos , Masculino , Massachusetts/epidemiologia , Pessoa de Meia-Idade , Complicações Pós-Operatórias/mortalidade , Estudos Retrospectivos , Análise de Sobrevida
2.
Dis Colon Rectum ; 62(11): 1283-1293, 2019 11.
Artigo em Inglês | MEDLINE | ID: mdl-31567917

RESUMO

BACKGROUND: Extramammary Paget's disease is an uncommon intraepidermal adenocarcinoma with poorly defined clinical implications. OBJECTIVE: The purpose of this research was to estimate the risk of second primary neoplasms in patients with extramammary Paget's disease. DESIGN: This was a retrospective analysis of the Surveillance, Epidemiology, and End Results Registry (1973-2014). SETTINGS: The study included population-based cancer registries from the United States. PATIENTS: Patients who were diagnosed with anogenital Paget's disease were included. MAIN OUTCOME MEASURES: Risk of second primary development was measured. RESULTS: We identified 108 patients with anal Paget's disease, 421 patients with male genital (scrotum or penis) Paget's, and 1677 patients with female genital (vagina or vulva) Paget's. Median follow-up time was 5.9 years. The risk of developing colorectal adenocarcinoma was 18.5% for patients with anal Paget's disease. Eighty percent of colorectal adenocarcinoma diagnoses were synchronous (within 2 mo) to anal Paget's diagnoses, whereas metachronous tumors occurred at a median time of 2.4 years. Of patients with anal Paget's disease, 8.3% developed an anal adenocarcinoma or nonsmall cell cancer. In male patients with genital Paget's, the risk of proximal genitourinary malignancy was 9.7%, scrotal or testicular adenocarcinoma was 0.4%, and penile or scrotal squamous carcinoma was 1.7%. In female patients with genital Paget's, the risk of proximal genitourinary malignancy was 3.0%, vaginal or vulvar adenocarcinoma was 1.4%, and vaginal or vulvar squamous neoplasm was 1.0%. Five-year overall survival was 59.7%, 73.5%, and 80.7% in patients with anal, male genital, and female genital Paget's (p < 0.001). LIMITATIONS: The registry did not record surveillance schedule, provider specialty, or nonprocedural therapies for extramammary Paget's disease. CONCLUSIONS: In the largest published cohort of patients with extramammary Paget's disease, patients with anal Paget's had a much higher risk of both proximal and local neoplasms as compared with patients with genital Paget's. Patients with anal Paget's also experienced worse survival as compared with those with purely genital Paget's. See Video Abstract at http://links.lww.com/DCR/B20. ALTO RIESGO DE NEOPLASIAS PROXIMALES Y LOCALES EN 2206 PACIENTES CON ENFERMEDAD DE PAGET EXTRAMAMARIA ANOGENITAL:: La enfermedad de Paget extramamaria es un adenocarcinoma intraepidérmico poco frecuente con implicaciones clínicas poco definidas.Estimar el riesgo de segundas neoplasias primarias en pacientes con enfermedad de Paget extramamaria.Análisis retrospectivo del Registro de Vigilancia, Epidemiología y Resultados Finales (1973-2014).Registros de base poblacional en cáncer de los Estados Unidos.Pacientes que fueron diagnosticados con enfermedad de Paget anogenital.Riesgo de desarrollo un cáncer primario adicional.Se identificaron 108 pacientes con Paget anal, 421 pacientes con Paget genital masculino (escroto o pene) y 1677 pacientes con Paget genital femenino (vagina o vulva). Tiempo mediano de seguimiento fue de 5,9 años. El riesgo de desarrollar adenocarcinoma colorrectal fue del 18,5% para los pacientes con Paget anal. El ochenta por ciento de los diagnósticos de adenocarcinoma colorrectal fueron sincrónicos (dentro de los 2 meses) a los diagnósticos de Paget anal, mientras que los tumores metacrónicos ocurrieron en un tiempo promedio de 2,4 años. De los pacientes con Paget anal, el 8.3% desarrolló un adenocarcinoma anal o cáncer de células no pequeñas. En los pacientes masculinos con Paget genital, el riesgo de malignidad genitourinaria proximal fue del 9,7%, el adenocarcinoma escrotal o testicular fue del 0,4% y el carcinoma escamoso del pene o escroto fue del 1,7%. En pacientes femeninas con Paget genital, el riesgo de malignidad genitourinaria proximal fue de 3.0%, el adenocarcinoma vaginal o vulvar fue de 1.4% y la neoplasia escamosa vaginal o vulvar fue de 1.0%. La supervivencia general a cinco años fue del 59.7%, 73.5% y 80.7% en pacientes con anal, genital masculino y genital femenino, respectivamente (p <0.001).El registro no señalo el cronograma de vigilancia, la especialidad del proveedor o las terapias sin procedimiento para la enfermedad de Paget extramamaria.En la cohorte más grande publicada de pacientes con enfermedad de Paget extramamaria, los pacientes con Paget anal demostraron un riesgo mucho mayor de neoplasias proximales y locales en comparación con los pacientes con Paget genital. Los pacientes con Paget anal además demostraron una peor supervivencia en comparación con aquellos con Paget aislada genital. Vea el Resumen del Video en http://links.lww.com/DCR/B20.


Assuntos
Adenocarcinoma , Neoplasias do Ânus , Neoplasias dos Genitais Femininos , Neoplasias dos Genitais Masculinos , Segunda Neoplasia Primária , Doença de Paget Extramamária , Adenocarcinoma/epidemiologia , Adenocarcinoma/patologia , Assistência ao Convalescente/estatística & dados numéricos , Idoso de 80 Anos ou mais , Neoplasias do Ânus/epidemiologia , Neoplasias do Ânus/patologia , Epiderme/patologia , Feminino , Neoplasias dos Genitais Femininos/epidemiologia , Neoplasias dos Genitais Femininos/patologia , Neoplasias dos Genitais Masculinos/epidemiologia , Neoplasias dos Genitais Masculinos/patologia , Humanos , Masculino , Massachusetts/epidemiologia , Estadiamento de Neoplasias , Segunda Neoplasia Primária/epidemiologia , Segunda Neoplasia Primária/patologia , Doença de Paget Extramamária/epidemiologia , Doença de Paget Extramamária/patologia , Sistema de Registros/estatística & dados numéricos , Estudos Retrospectivos , Medição de Risco , Análise de Sobrevida
3.
Public Health Rep ; 134(6): 608-616, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-31539488

RESUMO

OBJECTIVES: Refugee children are known to have a high prevalence of elevated blood lead levels (EBLLs). We sought to determine trends in EBLLs among refugee children during an 18-year period and examine relationships between descriptive characteristics and EBLLs by using 10 µg/dL and 5 µg/dL levels of concern. METHODS: We retrospectively evaluated refugee health screening data from Massachusetts for 1998 through 2015 for refugee children aged <7 years. We performed bivariate and multivariate analyses of variables including sex, age, region of origin, anemia, intestinal parasites, tuberculosis test results, and anthropometric measurements and used both 5 µg/dL and 10 µg/dL levels of concern for EBLLs. RESULTS: Of 3421 eligible refugee children, 3054 (88.2%) were tested. Using 5 µg/dL and 10 µg/dL levels of concern, 1279 (41.9%) and 241 (7.9%) children, respectively, had EBLLs. Mean BLLs declined steadily from 7.58 µg/dL in 2004 to 4.03 µg/dL in 2015. African (adjusted odds ratio [aOR] = 2.49; 95% confidence interval [CI], 1.81-3.43), East Asian and Pacific (aOR = 1.98; 95% CI, 1.35-2.91), and South-Central Asian (aOR = 2.47; 95% CI, 1.53-4.01) regions of origin and anemia (aOR = 1.50; 95% CI, 1.14 -1.97) were significantly associated with BLLs ≥5 µg/dL. CONCLUSIONS: The prevalence of EBLLs among refugees compared with US-born children is high. Because EBBLs increase the risk for neurocognitive impairment in children, public health professionals, policy makers, researchers, refugee resettlement staff members, and health care providers must remain vigilant in screening for lead poisoning and educating refugees about the hazards posed to young children by lead.


Assuntos
Intoxicação por Chumbo/epidemiologia , Chumbo/sangue , Programas de Rastreamento , Refugiados/estatística & dados numéricos , África/etnologia , Ásia/etnologia , Criança , Pré-Escolar , Feminino , Humanos , Lactente , Chumbo/efeitos adversos , Masculino , Programas de Rastreamento/estatística & dados numéricos , Programas de Rastreamento/tendências , Massachusetts/epidemiologia , Oriente Médio/etnologia , Prevalência , Estudos Retrospectivos
4.
Pediatrics ; 144(4)2019 10.
Artigo em Inglês | MEDLINE | ID: mdl-31554667

RESUMO

BACKGROUND AND OBJECTIVES: Asthma is responsible for ∼1.7 million emergency department (ED) visits annually in the United States. Studies in adults have shown that anxiety and depression are associated with increased asthma-related ED use. Our objective was to assess this association in pediatric patients with asthma. METHODS: We identified patients aged 6 to 21 years with asthma in the Massachusetts All-Payer Claims Database for 2014 to 2015 using International Classification of Diseases, Ninth and 10th Revision codes. We examined the association between the presence of anxiety, depression, or comorbid anxiety and depression and the rate of asthma-related ED visits per 100 child-years using bivariate and multivariable analyses with negative binomial regression. RESULTS: Of 65 342 patients with asthma, 24.7% had a diagnosis of anxiety, depression, or both (11.2% anxiety only, 5.8% depression only, and 7.7% both). The overall rate of asthma-related ED use was 17.1 ED visits per 100 child-years (95% confidence interval [CI]: 16.7-17.5). Controlling for age, sex, insurance type, and other chronic illness, patients with anxiety had a rate of 18.9 (95% CI: 17.0-20.8) ED visits per 100 child-years, patients with depression had a rate of 21.7 (95% CI: 18.3-25.0), and patients with both depression and anxiety had a rate of 27.6 (95% CI: 24.8-30.3). These rates were higher than those of patients who had no diagnosis of anxiety or depression (15.5 visits per 100 child-years; 95% CI: 14.5-16.4; P < .001). CONCLUSIONS: Children with asthma and anxiety or depression alone, or comorbid anxiety and depression, have higher rates of asthma-related ED use compared with those without either diagnosis.


Assuntos
Ansiedade/epidemiologia , Asma/epidemiologia , Depressão/epidemiologia , Serviço Hospitalar de Emergência/estatística & dados numéricos , Adolescente , Algoritmos , Criança , Comorbidade , Intervalos de Confiança , Feminino , Hospitalização/estatística & dados numéricos , Humanos , Cobertura do Seguro/estatística & dados numéricos , Masculino , Massachusetts/epidemiologia , Prevalência , Análise de Regressão , Adulto Jovem
5.
Rev Fac Cien Med Univ Nac Cordoba ; 76(3): 142-147, 2019 08 29.
Artigo em Espanhol | MEDLINE | ID: mdl-31465180

RESUMO

Introduction: The analysis of injuries caused by traffic from a physical and mathematical perspective can help improve road safety strategies. Objective: Predict the dynamics of traffic fatalities in the states of Maryland and Massachusetts for the years 2004 and 2014 in the context of probabilistic random walk. Methods: An analysis was made of the number of total fatalities caused by traffic per year, in the states of Maryland and Massachusetts between the years 1994-2003 and 1994-2013. The behavior of these values was analyzed as a probabilistic random walk; for this, the probabilistic lengths were found for each year, during the period studied and four probability spaces were analyzed, with which it was possible to analyze their behavior, to establish a prediction of the number of total fatalities caused by traffic for the years 2004 and 2014. Results: The predictions for the years 2014 and 2004 for Maryland and Massachusetts when compared with the real values, the percentage of success was 98%. Main conclusion: The predictions for the years 2014 and 2004 for Maryland and Massachusetts when compared with the real values, the percentage of success was 98%. Conclusions: the behavior of traffic fatalities in Maryland and Massachusetts presented a predictable self-organization from the context of probabilistic random walk, constituting a useful tool for analyzing the operation of road safety strategies.


Assuntos
Acidentes de Trânsito/mortalidade , Acidentes de Trânsito/tendências , Humanos , Maryland/epidemiologia , Massachusetts/epidemiologia , Teoria da Probabilidade
6.
Matern Child Health J ; 23(9): 1152-1158, 2019 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-31267339

RESUMO

OBJECTIVES: The rate of severe maternal morbidity in the United States increased approximately 200% during 1993-2014. Few studies have reported on the health of the entire pregnant population, including women at low risk for maternal morbidity. This information might be useful for interventions aimed at primary prevention of pregnancy complications. To better understand this, we sought to describe the distribution of comorbid risk among all delivery hospitalizations in Massachusetts and its association with the distribution of severe maternal morbidity. METHODS: Using an existing algorithm, we assigned an obstetric comorbidity index (OCI) score to delivery hospitalizations contained in the Massachusetts pregnancy to early life longitudinal (PELL) data system during 1998-2013. We identified which hospitalizations included severe maternal morbidity and calculated the rate and frequency of these hospitalizations by OCI score. RESULTS: During 1998-2013, PELL contained 1,185,182 delivery hospitalizations; of these 5325 included severe maternal morbidity. Fifty-eight percent of delivery hospitalizations had an OCI score of zero. The mean OCI score increased from 0.60 in 1998 to 0.82 in 2013. Hospitalizations with an OCI score of zero comprised approximately one-third of all deliveries complicated by severe maternal morbidity, but had the lowest rate of severe maternal morbidity (22.8/10,000 delivery hospitalizations). CONCLUSIONS: The mean OCI score increased during the study period, suggesting that an overall increase in risk factors has occurred in the pregnant population in Massachusetts. Interventions that can make small decreases to the mean OCI score could have a substantial impact on the number of deliveries complicated by severe maternal morbidity. Additionally, all delivery facilities should be prepared for severe complications during low-risk deliveries.


Assuntos
Comorbidade , Mães/estatística & dados numéricos , Complicações na Gravidez/mortalidade , Adolescente , Adulto , Feminino , Hospitalização/estatística & dados numéricos , Humanos , Massachusetts/epidemiologia , Pessoa de Meia-Idade , Gravidez , Complicações na Gravidez/epidemiologia , Fatores de Risco , Índice de Gravidade de Doença
7.
Int J Soc Psychiatry ; 65(6): 496-506, 2019 09.
Artigo em Inglês | MEDLINE | ID: mdl-31288604

RESUMO

BACKGROUND: Resilience, or an individual's positive response in managing life's adversities, is of increasing interest in addressing the mental health disparities in refugees. Although the link between stressful life events and poor mental health is established, research on the role of resilience on the mental health of refugees is limited. AIMS: This study assessed the association between resilience and anxiety or depression in resettled Bhutanese adults in Western Massachusetts. METHODS: A cross-sectional survey was conducted among 225 Bhutanese (men: 113, women: 112) refugees aged 20-65 residing in Massachusetts. Resilience was measured with the 25-item Wagnild and Young's Resilience Scale including two constructs as follows: a 17-item 'personal competence' that measures self-reliance, independence, determination, resourcefulness, mastery and perseverance and an 8-item 'acceptance of self and life' that measures adaptability, flexibility and a balanced perspective of life. Higher total scores indicate greater resilience. The Hopkins Symptom Checklist-25 was used to measure anxiety (10-item) and depression (15-item) with a cutoff mean score of ⩾1.75 for moderate to severe symptoms. Associations of resilience with anxiety or depression scores were assessed using multiple-linear and logistic regression analyses. RESULTS: The proportion of participants with above threshold anxiety and depression were 34.2% and 24%, respectively. Resilience was inversely associated with both anxiety (beta for 1 unit change in resilience scores: ß = -0.026; p = .037) and depression (ß = -0.036, p = .041). 'Personal competence' resilience was inversely associated with both anxiety (ß = -0.041 p = .017) and depression (ß = -0.058, p = .019), but 'acceptance of self and life' resilience was not. Participants with the highest tertile of resilience scores had a significantly decreased risk of anxiety (ORs (95% CI): 0.13 (0.04-0.40)) and depression (0.16 (0.04-0.60)). CONCLUSION: Higher resilience was associated with reduced anxiety and depression among Bhutanese with personal competence resilience accounting for most of the effects. These findings suggest the potential targets for mental-health intervention to improve resilience in refugees.


Assuntos
Ansiedade/etnologia , Depressão/etnologia , Saúde Mental/etnologia , Refugiados/psicologia , Resiliência Psicológica , Adulto , Butão/etnologia , Estudos Transversais , Feminino , Humanos , Modelos Lineares , Modelos Logísticos , Masculino , Massachusetts/epidemiologia , Pessoa de Meia-Idade , Análise Multivariada , Escalas de Graduação Psiquiátrica , Apoio Social , Transtornos de Estresse Pós-Traumáticos/etnologia , Adulto Jovem
8.
Am J Public Health ; 109(9): 1205-1211, 2019 09.
Artigo em Inglês | MEDLINE | ID: mdl-31318595

RESUMO

Objectives. To evaluate the risk of death and injury in residential fires started on upholstered furniture, with a focus on open flame and cigarette-related heat sources.Methods. We used civilian death and injury data from 34 081 residential fires in the Massachusetts Fire Incident Reporting System from 2003 to 2016. We compared outcomes associated with fires that started on upholstered furniture ignited by smoking materials versus open flames.Results. Although fires starting on upholstered furniture were not common (2.2% of total fires), odds of death and injury were significantly higher in these fires than in fires started on other substrates. Among furniture fires, odds of death were 3 times greater when those fires were ignited by smoking materials than when ignited by open flames (odds ratio = 3.4; 95% confidence interval = 1.3, 10.9).Conclusions. Furniture fires started by smoking materials were associated with more deaths than were furniture fires started by open flames.Public Health Implications. Historically, furniture flammability regulations have focused on open flame heat sources, resulting in the addition of toxic flame retardants to furniture. Interventions to reduce deaths should instead focus on smoking materials.


Assuntos
Fogo/estatística & dados numéricos , Retardadores de Chama , Decoração de Interiores e Mobiliário/estatística & dados numéricos , Queimaduras/etiologia , Queimaduras/mortalidade , Humanos , Massachusetts/epidemiologia , Medição de Risco , Produtos do Tabaco
9.
Am J Public Health ; 109(9): 1273-1279, 2019 09.
Artigo em Inglês | MEDLINE | ID: mdl-31318603

RESUMO

Objectives. To evaluate the effectiveness of video messaging on adolescent organ donor designation rates.Methods. We randomized adolescent driver education classes in Massachusetts, between July 2015 and February 2018, to receive 1 of 3 organ donation video messaging interventions (informational, testimonial, or blended). Adolescents completed questionnaires before and after the intervention and at 1-week follow-up; we compared their registration status at time of obtaining driver's license with that of a regionally matched historical comparison group.Results. Donor designation rates were higher for those exposed to video messaging than for the historical comparison group (60% vs 50%; P < .001). Testimonial (64%) and blended messaging (65%) yielded higher donor designation rates than informational messaging (51%; P = .013). There was a statistically significant messaging × time interaction effect for donation knowledge (P = .03), with blended and informational messaging showing more gains in knowledge from before to after the intervention (P < .001; d = 0.69 and P < .001; d = 0.45, respectively), compared with testimonial messaging (d = 0.09; P = .22).Conclusions. Testimonial messaging is most effective in producing a verifiable and demonstrable impact on donor designation rates among adolescents, and driver education classes are an efficient venue for disseminating organ donation messaging to youths.Trial Registration. ClinicalTrials.gov; identifier: NCT03013816.


Assuntos
Doadores de Tecidos/estatística & dados numéricos , Adolescente , Comportamento do Adolescente , Condução de Veículo/educação , Feminino , Humanos , Masculino , Massachusetts/epidemiologia , Distribuição Aleatória
10.
JAMA Netw Open ; 2(6): e196405, 2019 06 05.
Artigo em Inglês | MEDLINE | ID: mdl-31251378

RESUMO

Importance: The opioid epidemic increasingly affects pregnant women and developing fetuses, resulting in high rates of neonatal abstinence syndrome. However, longitudinal studies that prospectively observe newborns with neonatal abstinence syndrome or with maternal opioid use and examine their long-term physical and neurodevelopmental outcomes are lacking. Objective: To examine prenatal risk factors associated with maternal opioid use during pregnancy and the short-term and long-term health consequences on their children. Design, Setting, and Participants: This cohort study analyzed data from the Boston Birth Cohort, an urban, low-income, multiethnic cohort that enrolled mother-newborn pairs at birth at Boston Medical Center (Boston, Massachusetts) starting in 1998, and a subset of children were prospectively observed at Boston Medical Center pediatric primary care and subspecialty clinics from birth to age 21 years. Data analysis began in June 2018 and was completed in May 2019. Exposures: In utero opioid exposure was defined as maternal self-reported opioid use and/or clinical diagnosis of neonatal abstinence syndrome. Main Outcomes and Measures: Pregnancy outcomes, postnatal child physical health, and major neurodevelopmental disabilities, documented in maternal and child medical records. Results: This study included 8509 Boston Birth Cohort mother-newborn pairs for prenatal and perinatal analyses. Of those, 3153 children continued to receive pediatric care at Boston Medical Center and were included in assessing postnatal outcomes. Overall, 454 of the 8509 children (5.3%) in the Boston Birth Cohort had in utero opioid exposure. At birth, opioid exposure was associated with higher risks of fetal growth restriction (odds ratio [OR], 1.87; 95% CI, 1.41-2.47) and preterm birth (OR, 1.49; 95% CI, 1.19-1.86). Opioid exposure was associated with increased risks of lack of expected physiological development (OR, 1.80; 95% CI, 1.17-2.79) and conduct disorder/emotional disturbance (OR, 2.13; 95% CI, 1.20-3.77) among preschool-aged children. In school-aged children, opioid exposure was associated with a higher risk of attention-deficit/hyperactivity disorder (OR, 2.55; 95% CI, 1.42-4.57). Conclusions and Relevance: In this sample of urban, high-risk, low-income mother-child pairs, in utero opioid exposure was significantly associated with adverse short-term and long-term outcomes across developmental stages, including higher rates of physical and neurodevelopmental disorders in affected children. Efforts to prevent the opioid epidemic and mitigate its health consequences would benefit from more intergenerational research.


Assuntos
Analgésicos Opioides/efeitos adversos , Retardo do Crescimento Fetal/epidemiologia , Exposição Materna/efeitos adversos , Mães , Transtornos Relacionados ao Uso de Opioides/epidemiologia , Efeitos Tardios da Exposição Pré-Natal/epidemiologia , Adulto , Estudos de Coortes , Grupos Étnicos , Feminino , Retardo do Crescimento Fetal/induzido quimicamente , Humanos , Recém-Nascido , Massachusetts/epidemiologia , Exposição Materna/estatística & dados numéricos , Mães/psicologia , Mães/estatística & dados numéricos , Transtornos Relacionados ao Uso de Opioides/psicologia , Pobreza , Gravidez , Resultado da Gravidez , Efeitos Tardios da Exposição Pré-Natal/induzido quimicamente , Fatores de Risco , População Urbana , Adulto Jovem
11.
Occup Environ Med ; 76(7): 448-454, 2019 07.
Artigo em Inglês | MEDLINE | ID: mdl-31186370

RESUMO

OBJECTIVE: Violence from care recipients and family members, including both verbal and physical abuse, is a serious occupational hazard for healthcare and social assistance workers. Most workplace violence studies in this sector focus on hospitals and other institutional settings. This study examined verbal abuse in a large home care (HC) aide population and evaluated risk factors. METHODS: We used questionnaire survey data collected as part of a larger mixed methods study of a range of working conditions among HC aides. This paper focuses on survey responses of HC aides (n=954) who reported on verbal abuse from non-family clients and their family members. Risk factors were identified in univariate and multivariable analyses. RESULTS: Twenty-two per cent (n=206) of aides reported at least one incident of verbal abuse in the 12 months before the survey. Three factors were found to be important in multivariable models: clients with dementia (relative risk (RR) 1.38, 95% CI 1.07 to 1.78), homes with too little space for the aide to work (RR 1.52, 95% CI 1.17 to 1.97) and predictable work hours (RR 0.74, 95% CI 0.58 to 0.94); two additional factors were associated with verbal abuse, although not as strongly: having clients with limited mobility (RR 1.35, 95% CI 0.94 to 1.93) and an unclear plan for care delivery (RR 1.27, 95% CI 0.95 to 1.69). Aides reporting verbal abuse were 11 times as likely to also report physical abuse (RR 11.53; 95% CI 6.84 to 19.45). CONCLUSIONS: Verbal abuse is common among HC aides. These findings suggest specific changes in work organisation and training that may help reduce verbal abuse.


Assuntos
Visitadores Domiciliares/estatística & dados numéricos , Exposição Ocupacional/estatística & dados numéricos , Comportamento Verbal , Violência no Trabalho/estatística & dados numéricos , Adulto , Demência , Feminino , Humanos , Masculino , Massachusetts/epidemiologia , Pessoa de Meia-Idade , Limitação da Mobilidade , Abuso Físico/estatística & dados numéricos , Fatores de Risco , Inquéritos e Questionários , Local de Trabalho/estatística & dados numéricos
12.
Emerg Infect Dis ; 25(8): 1592-1593, 2019 08.
Artigo em Inglês | MEDLINE | ID: mdl-31146799

RESUMO

Subtropical lone star tick larvae typically emerge in late summer. We found clusters of host-seeking lone star tick larvae during early June 2018 in New York and Massachusetts, USA. Invasion and persistence of this tick in more northern locations may have been promoted by adaptation to an accelerated life cycle.


Assuntos
Vetores Aracnídeos , Ixodidae , Infestações por Carrapato/epidemiologia , Animais , Feminino , Ixodidae/classificação , Larva , Masculino , Massachusetts/epidemiologia , New York/epidemiologia , Vigilância em Saúde Pública , Estações do Ano
13.
Anesthesiology ; 131(3): 477-491, 2019 09.
Artigo em Inglês | MEDLINE | ID: mdl-31166241

RESUMO

BACKGROUND: Postoperative delirium and postoperative cognitive dysfunction share risk factors and may co-occur, but their relationship is not well established. The primary goals of this study were to describe the prevalence of postoperative cognitive dysfunction and to investigate its association with in-hospital delirium. The authors hypothesized that delirium would be a significant risk factor for postoperative cognitive dysfunction during follow-up. METHODS: This study used data from an observational study of cognitive outcomes after major noncardiac surgery, the Successful Aging after Elective Surgery study. Postoperative delirium was evaluated each hospital day with confusion assessment method-based interviews supplemented by chart reviews. Postoperative cognitive dysfunction was determined using methods adapted from the International Study of Postoperative Cognitive Dysfunction. Associations between delirium and postoperative cognitive dysfunction were examined at 1, 2, and 6 months. RESULTS: One hundred thirty-four of 560 participants (24%) developed delirium during hospitalization. Slightly fewer than half (47%, 256 of 548) met the International Study of Postoperative Cognitive Dysfunction-defined threshold for postoperative cognitive dysfunction at 1 month, but this proportion decreased at 2 months (23%, 123 of 536) and 6 months (16%, 85 of 528). At each follow-up, the level of agreement between delirium and postoperative cognitive dysfunction was poor (kappa less than .08) and correlations were small (r less than .16). The relative risk of postoperative cognitive dysfunction was significantly elevated for patients with a history of postoperative delirium at 1 month (relative risk = 1.34; 95% CI, 1.07-1.67), but not 2 months (relative risk = 1.08; 95% CI, 0.72-1.64), or 6 months (relative risk = 1.21; 95% CI, 0.71-2.09). CONCLUSIONS: Delirium significantly increased the risk of postoperative cognitive dysfunction in the first postoperative month; this relationship did not hold in longer-term follow-up. At each evaluation, postoperative cognitive dysfunction was more common among patients without delirium. Postoperative delirium and postoperative cognitive dysfunction may be distinct manifestations of perioperative neurocognitive deficits.


Assuntos
Disfunção Cognitiva/epidemiologia , Delírio/epidemiologia , Complicações Pós-Operatórias/epidemiologia , Idoso , Estudos de Coortes , Comorbidade , Feminino , Seguimentos , Humanos , Masculino , Massachusetts/epidemiologia , Prevalência , Estudos Retrospectivos , Fatores de Risco
14.
JAMA Pediatr ; 173(7): 657-662, 2019 07 01.
Artigo em Inglês | MEDLINE | ID: mdl-31081861

RESUMO

Importance: Firearm injury is the second leading cause of death in the United States for children and young adults. The risk of unintentional and self-inflicted firearm injury is lower when all household firearms are stored locked. Objective: To estimate the reduction in youth firearm suicide and unintentional firearm mortality that would result if more adults in households with youth stored household guns locked. Design, Setting, and Participants: A modeling study using Monte Carlo simulation of youth firearm suicide and unintentional firearm mortality in 2015. A simulated US national sample of firearm-owning households where youth reside was derived using nationally representative rates of firearm ownership and storage and population data from the US Census to test a hypothetical intervention, safe storage of firearms in the home, on youth accidental death and suicide. Data analyses were performed from August 3, 2017, to January 9, 2018. Exposures: Observed and counterfactual household-level safe firearm storage (ie, storing all firearms locked), the latter estimated by varying the probability that a hypothetical intervention increased safe firearm storage beyond that observed in 2015. Main Outcomes and Measures: Observed and counterfactual counts of firearm suicide and unintentional firearm mortality among youth aged 0 to 19 years, the latter estimated by incorporating an empirically based estimate of the mortality benefit expected from additional safe storage (beyond that observed in 2015). Results: A hypothetical intervention among firearm owners residing with children with a 20% probability of motivating these owners to lock all household firearms was significantly associated with a projected reduction in youth firearm mortality (median incidence rate ratio = 0.90; interquartile range, 0.87-0.93). In the overall model, 6% to 32% of deaths were estimated to be preventable depending on the probability of motivating safer storage. Conclusions and Relevance: Results of this modeling study suggest that a relatively modest uptake of a straightforward safe storage recommendation-lock all household firearms-could result in meaningful reductions in firearm suicide and unintentional firearm fatalities among youth. Approaches that will motivate additional parents to store firearms safely are needed.


Assuntos
Acidentes Domésticos/prevenção & controle , Características da Família , Armas de Fogo , Suicídio/prevenção & controle , Ferimentos por Arma de Fogo/epidemiologia , Acidentes Domésticos/tendências , Adolescente , Criança , Pré-Escolar , Feminino , Humanos , Incidência , Lactente , Recém-Nascido , Masculino , Massachusetts/epidemiologia , Método de Monte Carlo , Estudos Retrospectivos , Suicídio/tendências , Taxa de Sobrevida/tendências , Ferimentos por Arma de Fogo/prevenção & controle , Adulto Jovem
15.
Pregnancy Hypertens ; 16: 148-153, 2019 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-31056151

RESUMO

OBJECTIVE: To examine the association of low fetal fraction of cell-free DNA (cfDNA) with placental compromise and adverse perinatal outcomes. MATERIALS AND METHODS: This was a retrospective cohort utilizing a sample of convenience including 639 women undergoing cfDNA screening at our institution from January 2013 to January 2017. Low fetal fraction was defined as less than the 25th percentile. Indicators of placental compromise were examined individually and as a composite outcome, including hypertensive disease of pregnancy, intrauterine growth restriction, abruption, and oligohydramnios. Neonatal outcomes, including preterm delivery, low Apgar scores, and small for gestational age, also were examined. We calculated risk ratios (RR) and 95% confidence intervals (CI). RESULTS: Low fetal fraction was associated with placental compromise (RR 1.6 [CI 1.1-2.2]), hypertensive disease of pregnancy (RR 1.6 [CI 1.003-2.6]), and preeclampsia with severe features (RR 3.3 [CI 1.2-8.9]). Low fetal faction was not associated with preterm delivery, low Apgar scores, or small for gestational age. CONCLUSIONS: Low fetal fraction of cfDNA among asymptomatic women may serve as a predictor of subsequent placental dysfunction and hypertensive disease.


Assuntos
Ácidos Nucleicos Livres/sangue , Hipertensão Induzida pela Gravidez/epidemiologia , Placenta/fisiopatologia , Adulto , Biomarcadores/sangue , Estudos de Coortes , Feminino , Feto/patologia , Humanos , Hipertensão Induzida pela Gravidez/sangue , Hipertensão Induzida pela Gravidez/diagnóstico , Recém-Nascido , Massachusetts/epidemiologia , Valor Preditivo dos Testes , Gravidez , Resultado da Gravidez , Diagnóstico Pré-Natal , Estudos Retrospectivos
16.
Drug Alcohol Depend ; 200: 59-63, 2019 07 01.
Artigo em Inglês | MEDLINE | ID: mdl-31100636

RESUMO

BACKGROUND AND AIMS: While prescribed and illicit opioid use are primary drivers of the national surges in overdose deaths, opioid overdose deaths in which stimulants are also present are increasing in the U.S. We determined the social determinants and sociodemographic factors associated with opioid-only versus polysubstance opioid overdose deaths in Massachusetts. Particular attention was focused on the role of stimulants in opioid overdose deaths. METHODS: We analyzed all opioid-related overdose deaths from 2014 to 2015 in an individually-linked population database in Massachusetts. We used linked postmortem toxicology data to identify drugs present at the time of death. We constructed a multinomial logistic regression model to identify factors associated with three mutually exclusive overdose death groups based on toxicological results: opioid-related deaths with (1) opioids only present, (2) opioids and other substances not including stimulants, and (3) opioids and stimulants with or without other substances. RESULTS: Between 2014 and 2015, there were 2,244 opioid-related overdose deaths in Massachusetts that had accompanying toxicology results. Toxicology reports indicated that 17% had opioids only, 36% had opioids plus stimulants, and 46% had opioids plus another non-stimulant substance. Persons older than 24 years, non-rural residents, those with comorbid mental illness, non-Hispanic black residents, and persons with recent homelessness were more likely than their counterparts to die with opioids and stimulants than opioids alone. CONCLUSIONS: Polysubstance opioid overdose is increasingly common in the US. Addressing modifiable social determinants of health, including barriers to mental health services and homelessness, is important to reduce polysubstance use and overdose deaths.


Assuntos
Analgésicos Opioides/efeitos adversos , Estimulantes do Sistema Nervoso Central/efeitos adversos , Overdose de Drogas/mortalidade , Transtornos Relacionados ao Uso de Opioides/mortalidade , Determinantes Sociais da Saúde/tendências , Fatores Socioeconômicos , Adolescente , Adulto , Analgésicos Opioides/administração & dosagem , Estimulantes do Sistema Nervoso Central/administração & dosagem , Criança , Overdose de Drogas/diagnóstico , Feminino , Humanos , Masculino , Massachusetts/epidemiologia , Pessoa de Meia-Idade , Transtornos Relacionados ao Uso de Opioides/diagnóstico , Adulto Jovem
17.
Scand J Trauma Resusc Emerg Med ; 27(1): 51, 2019 Apr 30.
Artigo em Inglês | MEDLINE | ID: mdl-31039813

RESUMO

BACKGROUND: Sepsis is a common critical condition caused by the body's overwhelming response to certain infective agents. Many biomarkers, including the serum lactate level, have been used for sepsis diagnosis and guiding treatment. Recently, the Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3) recommended the Sequential Organ Failure Assessment (SOFA) and the quick SOFA (qSOFA) rather than lactate for screening sepsis and assess prognosis. Here, we aim to explore and compare the prognostic accuracy of the lactate level, the SOFA score and the qSOFA score for mortality in septic patients using the public Medical Information Mart for Intensive Care III database (MIMIC III). METHODS: The baseline characteristics, laboratory test results and outcomes for sepsis patients were retrieved from MIMIC III. Survival was analysed by the Kaplan-Meier method. Univariate and multivariate analysis was performed to identify predictors of prognosis. Receiver operating characteristic curve (ROC) analysis was conducted to compare lactate with SOFA and qSOFA scores. RESULTS: A total of 3713 cases were initially identified. The analysis cohort included 1865 patients. The 24-h average lactate levels and the worst scores during the first 24 h of ICU admission were collected. Patients in the higher lactate group had higher mortality than those in the lower lactate group. Lactate was an independent predictor of sepsis prognosis. The AUROC of lactate (AUROC, 0.664 [95% CI, 0.639-0.689]) was significantly higher than that of qSOFA (AUROC, 0.547 [95% CI, 0.521-0.574]), and it was similar to the AUROC of SOFA (AUROC, 0.686 [95% CI, 0.661-0.710]). But the timing of lactate relative to SOFA and qSOFA scores was inconsistent. CONCLUSION: Lactate is an independent prognostic predictor of mortality for patients with sepsis. It has superior discriminative power to qSOFA, and shows discriminative ability similar to that of SOFA.


Assuntos
Cuidados Críticos/métodos , Ácido Láctico/sangue , Sepse/sangue , Idoso , Idoso de 80 Anos ou mais , Biomarcadores/sangue , Bases de Dados Factuais , Feminino , Mortalidade Hospitalar/tendências , Humanos , Unidades de Terapia Intensiva , Masculino , Massachusetts/epidemiologia , Pessoa de Meia-Idade , Escores de Disfunção Orgânica , Prognóstico , Curva ROC , Estudos Retrospectivos , Sepse/diagnóstico , Sepse/mortalidade , Taxa de Sobrevida/tendências
19.
JAMA Netw Open ; 2(3): e190554, 2019 03 01.
Artigo em Inglês | MEDLINE | ID: mdl-30874776

RESUMO

Importance: Physician burnout is common, and prevalence may differ throughout a clinician's career. Burnout has negative consequences for physician wellness, patient care, and the health care system. Identifying factors associated with burnout is critical in designing and implementing initiatives to reduce burnout. Objective: To measure trends and identify factors associated with physician burnout. Design, Setting, and Participants: Survey study conducted from May 16 to June 15, 2014, and again from May 16 to June 15, 2017, measuring rates of physician burnout in a large academic medical practice. Factors associated with burnout out were evaluated. In 2014, 1774 of 1850 eligible physicians (95.9%) completed the survey. In 2017, 1882 of 2031 (92.7%) completed the survey. Exposures: Medical specialty, demographic characteristics, years in practice, and reported rates of burnout. Main Outcomes and Measures: Burnout rates measured at 2 points and risk factors associated with burnout. Results: Respondents included 1027 men (57.9%) and 747 women (42.1%) in 2014 and 962 men (51.1%) and 759 women (40.3%) in 2017. The mean (SD) number of years since training completion was 15.3 (11.3) in the 2014 survey data and 15.1 (11.3) in the 2017 data. Burnout increased from 40.6% to 45.6% between the 2 points. The increased rate was associated with an increase in exhaustion (from 52.9% in 2014 to 57.7% in 2017; difference, 4.8%; 95% CI, 1.6%-8.0%; P = .004) and cynicism (from 44.8% in 2014 to 51.1% in 2017; difference, 6.3%; 95% CI, 3.1%-9.6%; P < .001). Compared with midcareer physicians (11-20 years since training), early-career physicians (≤10 years since training) were more susceptible to burnout (odds ratio, 1.36; 95% CI, 1.05-1.77), while physicians in their late career (>30 years since training) were less vulnerable (odds ratio, 0.59; 95% CI, 0.40-0.88). Conclusions and Relevance: Efforts to alleviate physician burnout and administrative burden require a combination of a shared commitment from physicians and organizations and central and locally implemented programs. Continued research is necessary to establish the most effective initiatives to decrease physician burnout at the individual and organizational level.


Assuntos
Esgotamento Profissional/epidemiologia , Médicos/estatística & dados numéricos , Estudos Transversais , Feminino , Humanos , Satisfação no Emprego , Masculino , Massachusetts/epidemiologia , Médicos/organização & administração , Fatores de Risco
20.
Medicine (Baltimore) ; 98(13): e15059, 2019 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-30921236

RESUMO

During the last decades, the increased number of percutaneous interventions procedures causes a significant change in the profile of patients referred to coronary artery bypass grafting (CABG). We aimed to study changes in patients' characteristics and procedural outcomes of patients referred to CABG in a community hospital during the first 15 years of the millennium.A historical cohort study of all patients who underwent CABG in Cape Cod Hospital was performed. The period was divided into 2 sub-periods, 2000 to 2008 and 2009 to 2014. Patients' characteristics and procedure outcomes were compared. Data on age, sex, comorbidities, Society of Thoracic Surgery risk scores and surgical adverse outcomes (stroke, coma, and 30-days mortality) were collected.During the study period, 1108 patients underwent CABG; 612 were operated before 2009 and 496 after. Age and sex were similar in the 2 periods. The patients in the later period presented lower risk for mortality and stroke (P <.001). Diabetes (DM) was more common in the later period (P <.001) while peripheral vascular disease (PVD) (P <.001) and left main disease (LM) (P = .017) were more common in the earlier period. Mortality rates were similar between the 2 periods. Post-operative stroke (1.8%) and coma (0.8%) were presented only in the later period. In conclusion, a significant change in CABG patients' characteristics was observed.In conclusion, patients in the later period had lower risk score and were more likely to present with DM and less with PVD and LM. Despite the lower risk, the mortality rate was similar.


Assuntos
Ponte de Artéria Coronária/estatística & dados numéricos , Doença da Artéria Coronariana/cirurgia , Mortalidade Hospitalar/tendências , Complicações Pós-Operatórias/epidemiologia , Idoso , Estudos de Coortes , Ponte de Artéria Coronária/efeitos adversos , Doença da Artéria Coronariana/mortalidade , Diabetes Mellitus/epidemiologia , Feminino , Hospitais Comunitários/estatística & dados numéricos , Humanos , Masculino , Massachusetts/epidemiologia , Pessoa de Meia-Idade , Complicações Pós-Operatórias/etiologia , Fatores de Risco , Resultado do Tratamento
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