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1.
BMC Gastroenterol ; 21(1): 263, 2021 Jun 12.
Artigo em Inglês | MEDLINE | ID: mdl-34118892

RESUMO

BACKGROUND: Insulin is highly recommended for diabetes management in persons with liver cirrhosis. However, few studies have evaluated its long-term effects in these persons. We conducted this study to compare the risks of mortality, liver-related complications, and cardiovascular events in persons with type 2 diabetes mellitus (T2DM) and compensated liver cirrhosis. METHODS: From January 1, 2000, to December 31, 2012, we selected 2047 insulin users and 4094 propensity score-matched nonusers from Taiwan's National Health Insurance Research Database. Cox proportional hazard models were used to assess the risks of outcomes. RESULTS: The mean follow-up time was 5.84 years. The death rate during the follow-up period was 5.28 and 4.07 per 100 person-years for insulin users and nonusers, respectively. In insulin users, the hazard ratios and 95% confidence intervals (CIs) of all-cause mortality, hepatocellular carcinoma, decompensated cirrhosis, hepatic failure, major cardiovascular events, and hypoglycemia were 1.31 (1.18-1.45), 1.18 (1.05-1.34), 1.53 (1.35-1.72), 1.26 (1.42-1.86), 1.41 (1.23-1.62), and 3.33 (2.45-4.53), respectively. CONCLUSIONS: This retrospective cohort study indicated that among persons with T2DM and compensated liver cirrhosis, insulin users were associated with higher risks of death, liver-related complications, cardiovascular events, and hypoglycemia compared with insulin nonusers.


Assuntos
Diabetes Mellitus Tipo 2 , Neoplasias Hepáticas , Diabetes Mellitus Tipo 2/complicações , Diabetes Mellitus Tipo 2/tratamento farmacológico , Diabetes Mellitus Tipo 2/epidemiologia , Humanos , Hipoglicemiantes/efeitos adversos , Insulina/uso terapêutico , Cirrose Hepática/complicações , Cirrose Hepática/epidemiologia , Modelos de Riscos Proporcionais , Estudos Retrospectivos
2.
Medicine (Baltimore) ; 100(22): e26121, 2021 Jun 04.
Artigo em Inglês | MEDLINE | ID: mdl-34087861

RESUMO

ABSTRACT: This community-based study aimed to elucidate whether there is a gender difference in the effect of metabolic syndrome (MetS) and its individual components on an elevated risk for incident colorectal adenoma.A prospective cohort study was conducted by enrolling 59,767 subjects aged 40 years or older between 2001 and 2009 in Keelung, Taiwan, to test this hypothesis, excluding those with a prior history of colorectal cancer and those with colorectal cancer diagnosed at the first screening. Cox proportional hazards regression models were used to assess the effect of MetS in terms of a dichotomous classification, each individual component and the number of components for males and females.Colorectal adenoma was present in 2.7% (n = 652) of male participants and 1.1% (n = 403) of female participants. The prevalence rate of MetS was 26.7% and 23.3% for males and females, respectively. The effect of MetS on colorectal adenoma was statistically significant and similar for the 2 genders, with an adjusted hazard ratio (aHR) of 1.33 (95% CI: 1.13-1.58) in males and 1.33 (95% CI: 1.06-1.66) in females after adjustment for confounders. However, MetS led to higher risk of advanced colorectal adenoma in men than in women. Regarding the effect of each component of MetS on colorectal adenoma, abnormal waist circumference and hypertriglyceridemia led to an elevated risk of colorectal adenoma in both genders. A rising risk of colorectal adenoma among females was noted in those with a moderately higher level of glycemia (100-125 mg/dL, aHR = 1.44, 95% CI: 1.12-1.85). Hypertriglyceridemia and high blood pressure were associated with an increased risk of advance colorectal adenoma in males.Both male and female subjects with MetS had a higher risk of colorectal adenoma. The contributions from individual components of MetS varied by gender. These findings suggest that the possible risk reduction of colorectal adenoma through metabolic syndrome-based lifestyle modifications may differ between genders.


Assuntos
Adenoma/epidemiologia , Neoplasias Colorretais/epidemiologia , Síndrome Metabólica/epidemiologia , Adulto , Idoso , Pesos e Medidas Corporais , Feminino , Humanos , Hipertensão/epidemiologia , Hipertrigliceridemia/epidemiologia , Masculino , Pessoa de Meia-Idade , Modelos de Riscos Proporcionais , Estudos Prospectivos , Fatores de Risco , Distribuição por Sexo , Taiwan/epidemiologia
3.
Medicine (Baltimore) ; 100(22): e26218, 2021 Jun 04.
Artigo em Inglês | MEDLINE | ID: mdl-34087899

RESUMO

ABSTRACT: This study evaluated the severe hepatic outcome (SHO) in patients with schizophrenia and viral hepatitis who received antipsychotics.Using the nationwide Taiwan National Health Insurance Research Database, patients first diagnosed with schizophrenia between 2002 and 2013 were identified. Patients diagnosed with schizophrenia who had viral hepatitis, including hepatitis B virus (HBV) or hepatitis C virus (HCV), were designated as the viral hepatitis group. A control group without viral hepatitis was matched for age, sex, and index year in a 2:1 ratio. Patients with severe hepatic outcomes before enrollment were excluded. The 2 cohorts were observed until December 31, 2013. The primary endpoint was occurrence of a SHO, including liver cancer, liver failure, liver decompensation, or transplantation.Among the 16,365 patients newly diagnosed with schizophrenia between January 2002 and December 2013, we identified 614 patients with viral hepatitis and 1228 matched patients without viral hepatitis. Of these 1842 patients, 41 (2.22%) developed SHOs, including 26 (4.23%) in the viral hepatitis group and 15 (1.22%) in the control group, during the mean follow-up period of 3.71 ±â€Š2.49 years. Cox proportional hazard analysis indicated that the SHO risk increased by 3.58 (95% confidence interval [CI]: 1.859-6.754; P < .001) in patients with schizophrenia and viral hepatitis. Moreover, patients with schizophrenia having HCV had a higher SHO risk than those without viral hepatitis (hazard ratio: 5.07, 95% CI: 1.612-15.956; P < .0001). Patients having both schizophrenia and viral hepatitis, especially HCV, had a higher risk of SHOs.


Assuntos
Antipsicóticos/efeitos adversos , Hepatite B/psicologia , Hepatite C/psicologia , Palmitato de Paliperidona/uso terapêutico , Esquizofrenia/tratamento farmacológico , Adulto , Antipsicóticos/uso terapêutico , Estudos de Casos e Controles , Feminino , Seguimentos , Hepacivirus/isolamento & purificação , Hepatite B/complicações , Hepatite B/epidemiologia , Vírus da Hepatite B/isolamento & purificação , Hepatite C/complicações , Hepatite C/epidemiologia , Humanos , Falência Hepática/induzido quimicamente , Falência Hepática/metabolismo , Neoplasias Hepáticas/induzido quimicamente , Neoplasias Hepáticas/metabolismo , Transplante de Fígado/estatística & dados numéricos , Masculino , Pessoa de Meia-Idade , Palmitato de Paliperidona/efeitos adversos , Prevalência , Modelos de Riscos Proporcionais , Fatores de Risco , Esquizofrenia/complicações , Esquizofrenia/diagnóstico , Taiwan/epidemiologia
4.
BMC Geriatr ; 21(1): 355, 2021 06 10.
Artigo em Inglês | MEDLINE | ID: mdl-34112103

RESUMO

BACKGROUND: Since the outbreak of COVID-19, it has been documented that old age and underlying illnesses are associated with poor prognosis among COVID-19 patients. However, it is unknown whether sarcopenia, a common geriatric syndrome, is associated with poor prognosis among older COVID-19 patients. The aim of our prospective cohort study is to investigate the association between sarcopenia risk and severe disease among COVID-19 patients aged ≥60 years. METHOD: A prospective cohort study of 114 hospitalized older patients (≥60 years) with confirmed COVID-19 pneumonia between 7 February, 2020 and 6 April, 2020. Epidemiological, socio-demographic, clinical and laboratory data on admission and outcome data were extracted from electronic medical records. All patients were assessed for sarcopenia on admission using the SARC-F scale and the outcome was the development of the severe disease within 60 days. We used the Cox proportional hazards model to identify the association between sarcopenia and progression of disease defined as severe cases in a total of 2908 person-days. RESULT: Of 114 patients (mean age 69.52 ± 7.25 years, 50% woman), 38 (33%) had a high risk of sarcopenia while 76 (67%) did not. We found that 43 (38%) patients progressed to severe cases. COVID-19 patients with higher risk sarcopenia were more likely to develop severe disease than those without (68% versus 22%, p < 0.001). After adjustment for demographic and clinical factors, higher risk sarcopenia was associated with a higher hazard of severe condition [hazard ratio = 2.87 (95% CI, 1.33-6.16)]. CONCLUSION: We found that COVID-19 patients with higher sarcopenia risk were more likely to develop severe condition. A clinician-friendly assessment of sarcopenia could help in early warning of older patients at high-risk with severe COVID-19 pneumonia.


Assuntos
COVID-19 , Sarcopenia , Idoso , Feminino , Avaliação Geriátrica , Humanos , Modelos de Riscos Proporcionais , Estudos Prospectivos , SARS-CoV-2 , Sarcopenia/diagnóstico , Sarcopenia/epidemiologia , Inquéritos e Questionários
5.
J Prim Care Community Health ; 12: 21501327211018559, 2021.
Artigo em Inglês | MEDLINE | ID: mdl-34024181

RESUMO

PURPOSE: The purpose of the present study was to investigate body mass index, multi-morbidity, and COVID-19 Risk Score as predictors of severe COVID-19 outcomes. PATIENTS: Patients from this study are from a well-characterized patient cohort collected at Mayo Clinic between January 1, 2020 and May 23, 2020; with confirmed COVID-19 diagnosis defined as a positive result on reverse-transcriptase-polymerase-chain-reaction (RT-PCR) assays from nasopharyngeal swab specimens. MEASURES: Demographic and clinical data were extracted from the electronic medical record. The data included: date of birth, gender, ethnicity, race, marital status, medications (active COVID-19 agents), weight and height (from which the Body Mass Index (BMI) was calculated, history of smoking, and comorbid conditions to calculate the Charlson Comorbidity Index (CCI) and the U.S Department of Health and Human Services (DHHS) multi-morbidity score. An additional COVID-19 Risk Score was also included. Outcomes included hospital admission, ICU admission, and death. RESULTS: Cox proportional hazards models were used to determine the impact on mortality or hospital admission. Age, sex, and race (white/Latino, white/non-Latino, other, did not disclose) were adjusted for in the model. Patients with higher COVID-19 Risk Scores had a significantly higher likelihood of being at least admitted to the hospital (HR = 1.80; 95% CI = 1.30, 2.50; P < .001), or experiencing death or inpatient admission (includes ICU admissions) (HR = 1.20; 95% CI = 1.02, 1.42; P = .028). Age was the only statistically significant demographic predictor, but obesity was not a significant predictor of any of the outcomes. CONCLUSION: Age and COVID-19 Risk Scores were significant predictors of severe COVID-19 outcomes. Further work should examine the properties of the COVID-19 Risk Factors Scale.


Assuntos
COVID-19/mortalidade , Hospitalização/estatística & dados numéricos , Obesidade/epidemiologia , Índice de Massa Corporal , COVID-19/complicações , Teste para COVID-19 , Comorbidade , Feminino , Humanos , Masculino , Morbidade , Obesidade/complicações , Pandemias , Prognóstico , Modelos de Riscos Proporcionais , Estudos Retrospectivos , Fatores de Risco , SARS-CoV-2 , Índice de Gravidade de Doença
6.
Crit Rev Oncol Hematol ; 162: 103350, 2021 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-33989767

RESUMO

In trials of novel immuno-oncology drugs, the proportional hazards (PH) assumption often does not hold for the primary time-to-event (TTE) efficacy endpoint, likely due to the unique mechanism of action of these drugs. In practice, when it is anticipated that PH may not hold for the TTE endpoint with respect to treatment, the sample size is often still calculated under the PH assumption, and the hazard ratio (HR) from the Cox model is still reported as the primary measure of the treatment effect. Sensitivity analyses of the TTE data using methods that are suitable under non-proportional hazards (non-PH) are commonly pre-planned. In cases where a substantial deviation from the PH assumption is likely, we suggest designing the trial, calculating the sample size and analyzing the data, using a suitable method that accounts for non-PH, after gaining alignment with regulatory authorities. In this comprehensive review article, we describe methods to design a randomized oncology trial, calculate the sample size, analyze the trial data and obtain summary measures of the treatment effect in the presence of non-PH. For each method, we provide examples of its use from the recent oncology trials literature. We also summarize in the Appendix some methods to conduct sensitivity analyses for overall survival (OS) when patients in a randomized trial switch or cross-over to the other treatment arm after disease progression on the initial treatment arm, and obtain an adjusted or weighted HR for OS in the presence of cross-over. This is an example of the treatment itself changing at a specific point in time - this cross-over may lead to a non-PH pattern of diminishing treatment effect.


Assuntos
Neoplasias , Projetos de Pesquisa , Ensaios Clínicos como Assunto , Humanos , Neoplasias/tratamento farmacológico , Modelos de Riscos Proporcionais , Ensaios Clínicos Controlados Aleatórios como Assunto , Tamanho da Amostra
7.
Crit Rev Oncol Hematol ; 162: 103352, 2021 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-33991662

RESUMO

In numerous types of cancer, the primary tumor site can show a correlation with disease behavior and survival outcomes. In salivary gland tumors (SGTs) this association remains controversial. This study assessed the association between primary sites of SGTs and prognosis. Studies from five databases were assessed and a meta-analysis was performed using studies that presented 95 % confidence interval (95 % CI), hazard ratio (HR) and survival analysis. Gathered information from 46,361 patients showed that site had a prognostic impact on SGTs. Tumors involving minor salivary glands showed worse overall survival (HR = 1.60; 95 % CI = 1.17-2.19; p = 0.003), disease-specific survival (HR=1.63; 95 % CI = 1.12-2.37; p = 0.01), and cause-specific survival (HR=2.10; 95 % CI = 1.72-2.55; p = 0.00001). Tumors from major salivary glands showed better recurrence-free survival (HR=2.31; 95 % CI = 1.77-3.02; p = 0.00001), and locoregional control of disease (HR=2.66; 95 % CI = 1.20-5.91; p = 0.02). Our results showed that the primary site of SGTs has an impact on patient prognosis.


Assuntos
Neoplasias das Glândulas Salivares , Humanos , Prognóstico , Modelos de Riscos Proporcionais , Estudos Retrospectivos , Neoplasias das Glândulas Salivares/diagnóstico , Neoplasias das Glândulas Salivares/epidemiologia , Neoplasias das Glândulas Salivares/terapia , Análise de Sobrevida
8.
Comput Methods Programs Biomed ; 206: 106115, 2021 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-33992900

RESUMO

BACKGROUND AND OBJECTIVE: With the recent surge in availability of large biomedical databases mostly derived from electronic health records, the need for the development of scalable marginal survival models with faster implementation cannot be more timely. The presence of clustering renders computational complexity, especially when the number of clusters is high. Marginalizing conditional survival models can violate the proportional hazards assumption for some frailty distributions, disrupting the connection to a conditional model. While theoretical connections between proportional hazard and accelerated failure time models exist, a computational framework to produce both for either marginal or conditional perspectives is lacking. Our objective is to provide fast, scalable bridged-survival models contained in a unified framework from which the effects and standard errors for the conditional hazard ratio, the marginal hazard ratio, the conditional acceleration factor, and the marginal acceleration factor can be estimated, and related to one another in a transparent fashion. Methods We formulate a Weibull parametric frailty likelihood for clustered survival times that can directly estimate the four estimands. Under a nonlinear mixed model specification with positive stable frailties powered by Gaussian quadrature, we put forth a novel closed form of the integrated likelihood that lowered the computational threshold for fitting these models. The method is illustrated on a real dataset generated from electronic health records examining tooth-loss. RESULTS: Our novel closed form of the integrated likelihood significantly lowered the computational threshold for fitting these models by a factor of 12 (36 compared to 3 min) for the R package parfm, and a factor of 2400 for Gaussian Quadrature (4.6 days compared to 3 min) in SAS. Moreover, each of these estimands are connected by simple relationships of the parameters and the proportional hazards assumption is preserved for the marginal model. Our framework provides a flow of analysis enabling the fit of any/all of the 4 perspective-parameterization combinations. Conclusions We see the potential usefulness of our framework of bridged parametric survival models fitted with the Static-Stirling closed form likelihood. Bridged-survival models provide insights on subject-specific and population-level survival effects when their relation is transparent. SAS and R codes, along with implementation details on a pseudo data are provided.


Assuntos
Modelos Estatísticos , Análise por Conglomerados , Funções Verossimilhança , Distribuição Normal , Probabilidade , Modelos de Riscos Proporcionais , Análise de Sobrevida
9.
Environ Health Prev Med ; 26(1): 52, 2021 Apr 30.
Artigo em Inglês | MEDLINE | ID: mdl-33941074

RESUMO

INTRODUCTION: The survival of HIV/AIDS patients on antiretroviral therapy (ART) is determined by a number of factors, including economic, demographic, behavioral, and institutional factors. Understanding the survival time and its trend is crucial to developing policies that will result in changes. The aim of this study was to compare the survival estimates of different subgroups and look into the predictors of HIV/AIDS patient survival. METHODS: A retrospective cohort study of HIV/AIDS patients receiving ART at the University of Gondar teaching hospital was carried out. To compare the survival of various groups, a Kaplan-Meier survival analysis was performed. The Cox proportional hazards model was used to identify factors influencing HIV/AIDS patient survival rates. RESULTS: In the current study, 5.91% of the 354 HIV/AIDS patients under ART follow-up were uncensored or died. Age (HR = 1.051) and lack of formal education (HR = 5.032) were associated with lower survival rate, whereas family size of one to two (HR = 0.167), three to four (HR = 0.120), no alcoholic consumption (HR = 0.294), no smoking and chat use (HR = 0.101), baseline weight (HR = 0.920), current weight (HR = 0.928), baseline CD4 cell count (HR = 0.990), baseline hemoglobin (HR = 0.800), and no TB diseases were associated with longer survival rate. CONCLUSIONS: Fewer deaths were reported in a study area due to high patient adherence, compared to previous similar studies. Age, educational status, family size, alcohol consumption, tobacco and chat usage, baseline and current weight, baseline CD4 cell count, baseline hemoglobin, and tuberculosis (TB) diseases were all significant predictors of survival of HIV/AIDS patients.


Assuntos
Fármacos Anti-HIV/uso terapêutico , Infecções por HIV/mortalidade , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Estudos de Coortes , Etiópia/epidemiologia , Feminino , Infecções por HIV/tratamento farmacológico , Hospitais , Humanos , Masculino , Pessoa de Meia-Idade , Modelos de Riscos Proporcionais , Estudos Retrospectivos , Taxa de Sobrevida , Adulto Jovem
10.
Tumour Biol ; 43(1): 57-70, 2021.
Artigo em Inglês | MEDLINE | ID: mdl-33935125

RESUMO

OBJECTIVES: The tumor stage represents the single most important prognostic factor for colorectal cancer (CRC), although more accurate prognostics remain much needed. Previously, we identified CA125 as an independent significant prognostic factor, which we have further validated along with CEA, CA19-9, and CA242 in a large cohort of CRC patients. METHODS: Using enzyme-linked immunosorbent assays, we analyzed preoperative serum samples in 322 CRC patients operated on between 1998 and 2003. RESULTS: Using the Spearman's rho model, we calculated the correlation between our previous findings on MUC16 and CA125, for which the correlation coefficient was 0.808 (p < 0.001). The Cox regression analysis of the linear and logarithmic values of CEA, CA125, CA242, and CA19-9 identified only CA125 (hazard ratio [HR] 1.03; 95% confidence interval [95% CI] 1.02-1.04; p < 0.001) as significant when using the linear values. Survival among CRC patients with a high CA125 level was poor compared with CRC patients with a low CA125 level (HR 2.48; 95% CI 1.68-3.65; p < 0.001). In subgroup analyses, patients with high CA125 levels and aged ≤67 or >67, with stage I-II or III-IV, and both colon and rectal cancer exhibited poor prognoses. In the multivariate analysis, we used clinical pathological variables in the model, where age, gender, and stage served as the background characteristics. We dichotomized CA125 using the Youden maximal cutoff point, and the median values for CEA, CA19-9, and CA242. CA125 emerged as the only marker remaining significant and independent together with stage, location, and age (HR 1.91; 95% CI 1.24-2.95; p 0.003). CONCLUSIONS: CA125 represents a significant and independent prognostic factor in CRC patients, superior to CEA. Furthermore, CA242 served as a better prognostic marker than both CEA and CA19-9. We recommend including both CA125 and CA242 in prognostic clinical trials among CRC patients.


Assuntos
Antígenos Glicosídicos Associados a Tumores/sangue , Antígeno Ca-125/sangue , Antígeno Carcinoembrionário/sangue , Neoplasias Colorretais/sangue , Proteínas de Membrana/sangue , Adulto , Idoso , Idoso de 80 Anos ou mais , Biomarcadores Tumorais/sangue , Estudos de Coortes , Neoplasias Colorretais/patologia , Neoplasias Colorretais/cirurgia , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Período Pré-Operatório , Prognóstico , Modelos de Riscos Proporcionais , Análise de Sobrevida
11.
BMC Bioinformatics ; 22(1): 235, 2021 May 10.
Artigo em Inglês | MEDLINE | ID: mdl-33971812

RESUMO

BACKGROUND: Innovations in single cell technologies have lead to a flurry of datasets and computational tools to process and interpret them, including analyses of cell composition changes and transition in cell states. The diffcyt workflow for differential discovery in cytometry data consist of several steps, including preprocessing, cell population identification and differential testing for an association with a binary or continuous covariate. However, the commonly measured quantity of survival time in clinical studies often results in a censored covariate where classical differential testing is inapplicable. RESULTS: To overcome this limitation, multiple methods to directly include censored covariates in differential abundance analysis were examined with the use of simulation studies and a case study. Results show that multiple imputation based methods offer on-par performance with the Cox proportional hazards model in terms of sensitivity and error control, while offering flexibility to account for covariates. The tested methods are implemented in the R package censcyt as an extension of diffcyt and are available at https://bioconductor.org/packages/censcyt . CONCLUSION: Methods for the direct inclusion of a censored variable as a predictor in GLMMs are a valid alternative to classical survival analysis methods, such as the Cox proportional hazard model, while allowing for more flexibility in the differential analysis.


Assuntos
Modelos de Riscos Proporcionais , Simulação por Computador
12.
Anticancer Res ; 41(5): 2681-2688, 2021 May.
Artigo em Inglês | MEDLINE | ID: mdl-33952499

RESUMO

BACKGROUND/AIM: The aim of the study was to analyze the postoperative survival of colitis-associated colorectal cancer (CAC) with ulcerative colitis (UC), and the risk factors affecting it. PATIENTS AND METHODS: A questionnaire including postoperative survival was sent to 88 hospitals that reported CAC patients in the literature up until January, 2006 and to members of the Research Group of Intractable Inflammatory Bowel Disease. RESULTS: The 5-year postoperative overall survival (OS) of 170 CAC patients was 74.2% which was similar to sporadic colorectal cancer in Japan (72.1%). Pathologic TNM stage, histological type, type of surgical procedure (proctocolectomy, segmental resection), and preoperative cancer surveillance were statistically significant factors for OS. By Cox regression analysis, pathologic TNM stage and proctocolectomy were statistically significant prognostic factors for OS. CONCLUSION: In CAC with UC, the postoperative OS was similar to sporadic colorectal cancer. Pathologic TNM stage and proctocolectomy were confirmed as important prognostic factors.


Assuntos
Colite Ulcerativa/epidemiologia , Colite/epidemiologia , Neoplasias Colorretais/epidemiologia , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Criança , Colite/complicações , Colite/patologia , Colite/cirurgia , Colite Ulcerativa/complicações , Colite Ulcerativa/patologia , Colite Ulcerativa/cirurgia , Neoplasias Colorretais/complicações , Neoplasias Colorretais/patologia , Neoplasias Colorretais/cirurgia , Intervalo Livre de Doença , Feminino , Humanos , Japão/epidemiologia , Masculino , Pessoa de Meia-Idade , Período Pós-Operatório , Proctocolectomia Restauradora , Modelos de Riscos Proporcionais , Fatores de Risco , Inquéritos e Questionários , Adulto Jovem
13.
BMJ ; 373: n973, 2021 05 05.
Artigo em Inglês | MEDLINE | ID: mdl-33952509

RESUMO

OBJECTIVE: To analyse the association between survival from critical illness and suicide or self-harm after hospital discharge. DESIGN: Population based cohort study using linked and validated provincial databases. SETTING: Ontario, Canada between January 2009 and December 2017 (inclusive). PARTICIPANTS: Consecutive adult intensive care unit (ICU) survivors (≥18 years) were included. Linked administrative databases were used to compare ICU hospital survivors with hospital survivors who never required ICU admission (non-ICU hospital survivors). Patients were categorised based on their index hospital admission (ICU or non-ICU) during the study period. MAIN OUTCOME MEASURES: The primary outcome was the composite of death by suicide (as noted in provincial death records) and deliberate self-harm events after discharge. Each outcome was also assessed independently. Incidence of suicide was evaluated while accounting for competing risk of death from other causes. Analyses were conducted by using overlap propensity score weighted, cause specific Cox proportional hazard models. RESULTS: 423 060 consecutive ICU survivors (mean age 61.7 years, 39% women) were identified. During the study period, the crude incidence (per 100 000 person years) of suicide, self-harm, and the composite of suicide or self-harm among ICU survivors was 41.4, 327.9, and 361.0, respectively, compared with 16.8, 177.3, and 191.6 in non-ICU hospital survivors. Analysis using weighted models showed that ICU survivors (v non-ICU hospital survivors) had a higher risk of suicide (adjusted hazards ratio 1.22, 95% confidence interval 1.11 to 1.33) and self-harm (1.15, 1.12 to 1.19). Among ICU survivors, several factors were associated with suicide or self-harm: previous depression or anxiety (5.69, 5.38 to 6.02), previous post-traumatic stress disorder (1.87, 1.64 to 2.13), invasive mechanical ventilation (1.45, 1.38 to 1.54), and renal replacement therapy (1.35, 1.17 to 1.56). CONCLUSIONS: Survivors of critical illness have increased risk of suicide and self-harm, and these outcomes were associated with pre-existing psychiatric illness and receipt of invasive life support. Knowledge of these prognostic factors might allow for earlier intervention to potentially reduce this important public health problem.


Assuntos
Estado Terminal/psicologia , Comportamento Autodestrutivo/etiologia , Sobreviventes/psicologia , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Estudos de Casos e Controles , Cuidados Críticos , Estado Terminal/terapia , Feminino , Seguimentos , Humanos , Incidência , Masculino , Pessoa de Meia-Idade , Ontário/epidemiologia , Modelos de Riscos Proporcionais , Estudos Retrospectivos , Fatores de Risco , Comportamento Autodestrutivo/diagnóstico , Comportamento Autodestrutivo/epidemiologia , Comportamento Autodestrutivo/psicologia , Suicídio/psicologia , Suicídio/estatística & dados numéricos , Adulto Jovem
14.
Ann Palliat Med ; 10(4): 4661-4669, 2021 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-33966414

RESUMO

BACKGROUND: Critical limb artery ischemia is one of common complications after hemodialysis, with endovascular therapy (EVT) having become its first-line treatment. There is no relevant study investigating the relationship between EVT and the prognosis of hemodialysis patients with critical lower limb ischemia, the most common site of vascular dysfunction. METHODS: This was a retrospective, nonrandomized, single-center study. Hemodialysis patients with critical lower limb ischemia between May 2015 and October 2018 were included in this study. Their demographic and clinical data and the results of laboratory test were collected. The outcomes included all-cause mortality, amputation, and revascularization. Kaplan-Meier analysis and log-rank test were used to assess overall survival and amputation-free survival. Univariable and multivariable hazard Cox regression analyses were performed to determine risk factors of amputation and mortality. RESULTS: In all, 67 hemodialysis patients were finally included in this study. The median age of included patients was 69.8±8.7 years, and the median duration of hemodialysis was 44.1±9.2 months. There was no significant difference between patients receiving and not receiving EVT in collected demographic and clinical data except for the duration of hemodialysis (46.1±9.0 vs. 41.7±9.0 months; P=0.048). The level of high-density lipoprotein cholesterol (HDL-C) in patients receiving EVT was 1.4±0.6 mmol/L, which was significantly lower than the 1.9±0.6 mmol/L in patients not receiving EVT (P<0.001). The results from the Kaplan-Meier curves indicated that the incidences of all-cause mortality and amputation were much lower in patients receiving EVT than in those not receiving EVT (P=0.038 and P=0.020). Hazard Cox regression analysis also indicated that EVT played protective role in all-cause mortality and amputation in hemodialysis patients with lower limb ischemia. Age, nutritional risk, stroke, and C-reactive protein (CRP) were also determined as independent risk factors of all-cause mortality according to multivariable analysis. Additionally, duration of hemodialysis and smoking history were identified as independent risk factors of amputation. CONCLUSIONS: EVT could be an efficient treatment for critical lower limb ischemia in hemodialysis patients to reduce all-cause mortality and the incidence of amputation. Moreover, some risk factors, such as malnutritional and stroke, should be avoided to improve the prognosis of hemodialysis patients.


Assuntos
Procedimentos Endovasculares , Idoso , Artérias , Estado Terminal , Intervalo Livre de Doença , Humanos , Isquemia , Estimativa de Kaplan-Meier , Extremidade Inferior , Pessoa de Meia-Idade , Modelos de Riscos Proporcionais , Diálise Renal , Estudos Retrospectivos , Fatores de Risco , Resultado do Tratamento
15.
Lancet ; 397(10285): 1625-1636, 2021 05 01.
Artigo em Inglês | MEDLINE | ID: mdl-33933205

RESUMO

BACKGROUND: The effects of pharmacological blood pressure lowering at normal or high-normal blood pressure ranges in people with or without pre-existing cardiovascular disease remains uncertain. We analysed individual participant data from randomised trials to investigate the effects of blood pressure lowering treatment on the risk of major cardiovascular events by baseline levels of systolic blood pressure. METHODS: We did a meta-analysis of individual participant-level data from 48 randomised trials of pharmacological blood pressure lowering medications versus placebo or other classes of blood pressure-lowering medications, or between more versus less intensive treatment regimens, which had at least 1000 persons-years of follow-up in each group. Trials exclusively done with participants with heart failure or short-term interventions in participants with acute myocardial infarction or other acute settings were excluded. Data from 51 studies published between 1972 and 2013 were obtained by the Blood Pressure Lowering Treatment Trialists' Collaboration (Oxford University, Oxford, UK). We pooled the data to investigate the stratified effects of blood pressure-lowering treatment in participants with and without prevalent cardiovascular disease (ie, any reports of stroke, myocardial infarction, or ischaemic heart disease before randomisation), overall and across seven systolic blood pressure categories (ranging from <120 to ≥170 mm Hg). The primary outcome was a major cardiovascular event (defined as a composite of fatal and non-fatal stroke, fatal or non-fatal myocardial infarction or ischaemic heart disease, or heart failure causing death or requiring admission to hospital), analysed as per intention to treat. FINDINGS: Data for 344 716 participants from 48 randomised clinical trials were available for this analysis. Pre-randomisation mean systolic/diastolic blood pressures were 146/84 mm Hg in participants with previous cardiovascular disease (n=157 728) and 157/89 mm Hg in participants without previous cardiovascular disease (n=186 988). There was substantial spread in participants' blood pressure at baseline, with 31 239 (19·8%) of participants with previous cardiovascular disease and 14 928 (8·0%) of individuals without previous cardiovascular disease having a systolic blood pressure of less than 130 mm Hg. The relative effects of blood pressure-lowering treatment were proportional to the intensity of systolic blood pressure reduction. After a median 4·15 years' follow-up (Q1-Q3 2·97-4·96), 42 324 participants (12·3%) had at least one major cardiovascular event. In participants without previous cardiovascular disease at baseline, the incidence rate for developing a major cardiovascular event per 1000 person-years was 31·9 (95% CI 31·3-32·5) in the comparator group and 25·9 (25·4-26·4) in the intervention group. In participants with previous cardiovascular disease at baseline, the corresponding rates were 39·7 (95% CI 39·0-40·5) and 36·0 (95% CI 35·3-36·7), in the comparator and intervention groups, respectively. Hazard ratios (HR) associated with a reduction of systolic blood pressure by 5 mm Hg for a major cardiovascular event were 0·91, 95% CI 0·89-0·94 for partipants without previous cardiovascular disease and 0·89, 0·86-0·92, for those with previous cardiovascular disease. In stratified analyses, there was no reliable evidence of heterogeneity of treatment effects on major cardiovascular events by baseline cardiovascular disease status or systolic blood pressure categories. INTERPRETATION: In this large-scale analysis of randomised trials, a 5 mm Hg reduction of systolic blood pressure reduced the risk of major cardiovascular events by about 10%, irrespective of previous diagnoses of cardiovascular disease, and even at normal or high-normal blood pressure values. These findings suggest that a fixed degree of pharmacological blood pressure lowering is similarly effective for primary and secondary prevention of major cardiovascular disease, even at blood pressure levels currently not considered for treatment. Physicians communicating the indication for blood pressure lowering treatment to their patients should emphasise its importance on reducing cardiovascular risk rather than focusing on blood pressure reduction itself. FUNDING: British Heart Foundation, UK National Institute for Health Research, and Oxford Martin School.


Assuntos
Anti-Hipertensivos/uso terapêutico , Pressão Sanguínea , Doenças Cardiovasculares/prevenção & controle , Hipertensão/prevenção & controle , Doenças Cardiovasculares/tratamento farmacológico , Insuficiência Cardíaca/epidemiologia , Insuficiência Cardíaca/mortalidade , Hospitalização/estatística & dados numéricos , Humanos , Hipertensão/tratamento farmacológico , Análise de Intenção de Tratamento , Infarto do Miocárdio/epidemiologia , Infarto do Miocárdio/mortalidade , Isquemia Miocárdica/epidemiologia , Isquemia Miocárdica/mortalidade , Prevenção Primária , Modelos de Riscos Proporcionais , Prevenção Secundária , Acidente Vascular Cerebral/epidemiologia , Acidente Vascular Cerebral/mortalidade
16.
Lancet ; 397(10287): 1809-1818, 2021 05 15.
Artigo em Inglês | MEDLINE | ID: mdl-33964223

RESUMO

BACKGROUND: Stalled progress in controlling Plasmodium falciparum malaria highlights the need for an effective and deployable vaccine. RTS,S/AS01, the most effective malaria vaccine candidate to date, demonstrated 56% efficacy over 12 months in African children. We therefore assessed a new candidate vaccine for safety and efficacy. METHODS: In this double-blind, randomised, controlled, phase 2b trial, the low-dose circumsporozoite protein-based vaccine R21, with two different doses of adjuvant Matrix-M (MM), was given to children aged 5-17 months in Nanoro, Burkina Faso-a highly seasonal malaria transmission setting. Three vaccinations were administered at 4-week intervals before the malaria season, with a fourth dose 1 year later. All vaccines were administered intramuscularly into the thigh. Group 1 received 5 µg R21 plus 25 µg MM, group 2 received 5 µg R21 plus 50 µg MM, and group 3, the control group, received rabies vaccinations. Children were randomly assigned (1:1:1) to groups 1-3. An independent statistician generated a random allocation list, using block randomisation with variable block sizes, which was used to assign participants. Participants, their families, and the local study team were all masked to group allocation. Only the pharmacists preparing the vaccine were unmasked to group allocation. Vaccine safety, immunogenicity, and efficacy were evaluated over 1 year. The primary objective assessed protective efficacy of R21 plus MM (R21/MM) from 14 days after the third vaccination to 6 months. Primary analyses of vaccine efficacy were based on a modified intention-to-treat population, which included all participants who received three vaccinations, allowing for inclusion of participants who received the wrong vaccine at any timepoint. This trial is registered with ClinicalTrials.gov, NCT03896724. FINDINGS: From May 7 to June 13, 2019, 498 children aged 5-17 months were screened, and 48 were excluded. 450 children were enrolled and received at least one vaccination. 150 children were allocated to group 1, 150 children were allocated to group 2, and 150 children were allocated to group 3. The final vaccination of the primary series was administered on Aug 7, 2019. R21/MM had a favourable safety profile and was well tolerated. The majority of adverse events were mild, with the most common event being fever. None of the seven serious adverse events were attributed to the vaccine. At the 6-month primary efficacy analysis, 43 (29%) of 146 participants in group 1, 38 (26%) of 146 participants in group 2, and 105 (71%) of 147 participants in group 3 developed clinical malaria. Vaccine efficacy was 74% (95% CI 63-82) in group 1 and 77% (67-84) in group 2 at 6 months. At 1 year, vaccine efficacy remained high, at 77% (67-84) in group 1. Participants vaccinated with R21/MM showed high titres of malaria-specific anti-Asn-Ala-Asn-Pro (NANP) antibodies 28 days after the third vaccination, which were almost doubled with the higher adjuvant dose. Titres waned but were boosted to levels similar to peak titres after the primary series of vaccinations after a fourth dose administered 1 year later. INTERPRETATION: R21/MM appears safe and very immunogenic in African children, and shows promising high-level efficacy. FUNDING: The European & Developing Countries Clinical Trials Partnership, Wellcome Trust, and National Institute for Health Research Oxford Biomedical Research Centre.


Assuntos
Anticorpos Antiprotozoários/imunologia , Imunogenicidade da Vacina , Vacinas Antimaláricas/uso terapêutico , Malária/prevenção & controle , Proteínas de Protozoários/imunologia , Vacinas de Partículas Semelhantes a Vírus/uso terapêutico , Adjuvantes Imunológicos/administração & dosagem , Burkina Faso , Método Duplo-Cego , Feminino , Antígenos de Superfície da Hepatite B , Humanos , Lactente , Malária Falciparum/prevenção & controle , Masculino , Nanopartículas/administração & dosagem , Modelos de Riscos Proporcionais , Saponinas/administração & dosagem , Resultado do Tratamento
17.
Lancet ; 397(10287): 1830-1841, 2021 05 15.
Artigo em Inglês | MEDLINE | ID: mdl-33965067

RESUMO

BACKGROUND: Metabolic-bariatric surgery delivers substantial weight loss and can induce remission or improvement of obesity-related risks and complications. However, more robust estimates of its effect on long-term mortality and life expectancy-especially stratified by pre-existing diabetes status-are needed to guide policy and facilitate patient counselling. We compared long-term survival outcomes of severely obese patients who received metabolic-bariatric surgery versus usual care. METHODS: We did a prespecified one-stage meta-analysis using patient-level survival data reconstructed from prospective controlled trials and high-quality matched cohort studies. We searched PubMed, Scopus, and MEDLINE (via Ovid) for randomised trials, prospective controlled studies, and matched cohort studies comparing all-cause mortality after metabolic-bariatric surgery versus non-surgical management of obesity published between inception and Feb 3, 2021. We also searched grey literature by reviewing bibliographies of included studies as well as review articles. Shared-frailty (ie, random-effects) and stratified Cox models were fitted to compare all-cause mortality of adults with obesity who underwent metabolic-bariatric surgery compared with matched controls who received usual care, taking into account clustering of participants at the study level. We also computed numbers needed to treat, and extrapolated life expectancy using Gompertz proportional-hazards modelling. The study protocol is prospectively registered on PROSPERO, number CRD42020218472. FINDINGS: Among 1470 articles identified, 16 matched cohort studies and one prospective controlled trial were included in the analysis. 7712 deaths occurred during 1·2 million patient-years. In the overall population consisting 174 772 participants, metabolic-bariatric surgery was associated with a reduction in hazard rate of death of 49·2% (95% CI 46·3-51·9, p<0·0001) and median life expectancy was 6·1 years (95% CI 5·2-6·9) longer than usual care. In subgroup analyses, both individuals with (hazard ratio 0·409, 95% CI 0·370-0·453, p<0·0001) or without (0·704, 0·588-0·843, p<0·0001) baseline diabetes who underwent metabolic-bariatric surgery had lower rates of all-cause mortality, but the treatment effect was considerably greater for those with diabetes (between-subgroup I2 95·7%, p<0·0001). Median life expectancy was 9·3 years (95% CI 7·1-11·8) longer for patients with diabetes in the surgery group than the non-surgical group, whereas the life expectancy gain was 5·1 years (2·0-9·3) for patients without diabetes. The numbers needed to treat to prevent one additional death over a 10-year time frame were 8·4 (95% CI 7·8-9·1) for adults with diabetes and 29·8 (21·2-56·8) for those without diabetes. Treatment effects did not appear to differ between gastric bypass, banding, and sleeve gastrectomy (I2 3·4%, p=0·36). By leveraging the results of this meta-analysis and other published data, we estimated that every 1·0% increase in metabolic-bariatric surgery utilisation rates among the global pool of metabolic-bariatric candidates with and without diabetes could yield 5·1 million and 6·6 million potential life-years, respectively. INTERPRETATION: Among adults with obesity, metabolic-bariatric surgery is associated with substantially lower all-cause mortality rates and longer life expectancy than usual obesity management. Survival benefits are much more pronounced for people with pre-existing diabetes than those without. FUNDING: None.


Assuntos
Cirurgia Bariátrica , Diabetes Mellitus Tipo 2/complicações , Obesidade/cirurgia , Estudos de Casos e Controles , Causas de Morte , Estudos de Coortes , Ensaios Clínicos Controlados como Assunto , Humanos , Expectativa de Vida , Mortalidade , Obesidade/complicações , Modelos de Riscos Proporcionais , Estudos Prospectivos , Ensaios Clínicos Controlados Aleatórios como Assunto , Taxa de Sobrevida
18.
Sci Rep ; 11(1): 10066, 2021 05 12.
Artigo em Inglês | MEDLINE | ID: mdl-33980912

RESUMO

We investigated association between epidemiological and clinical characteristics of coronavirus disease 2019 (COVID-19) patients and clinical outcomes in Korea. This nationwide retrospective cohort study included 5621 discharged patients with COVID-19, extracted from the Korea Disease Control and Prevention Agency (KDCA) database. We compared clinical data between survivors (n = 5387) and non-survivors (n = 234). We used logistic regression analysis and Cox proportional hazards model to explore risk factors of death and fatal adverse outcomes. Increased odds ratio (OR) of mortality occurred with age (≥ 60 years) [OR 11.685, 95% confidence interval (CI) 4.655-34.150, p < 0.001], isolation period, dyspnoea, altered mentality, diabetes, malignancy, dementia, and intensive care unit (ICU) admission. The multivariable regression equation including all potential variables predicted mortality (AUC = 0.979, 95% CI 0.964-0.993). Cox proportional hazards model showed increasing hazard ratio (HR) of mortality with dementia (HR 6.376, 95% CI 3.736-10.802, p < 0.001), ICU admission (HR 4.233, 95% CI 2.661-6.734, p < 0.001), age ≥ 60 years (HR 3.530, 95% CI 1.664-7.485, p = 0.001), malignancy (HR 3.054, 95% CI 1.494-6.245, p = 0.002), and dyspnoea (HR 1.823, 95% CI 1.125-2.954, p = 0.015). Presence of dementia, ICU admission, age ≥ 60 years, malignancy, and dyspnoea could help clinicians identify COVID-19 patients with poor prognosis.


Assuntos
/epidemiologia , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Criança , Pré-Escolar , Feminino , Hospitalização , Humanos , Lactente , Unidades de Terapia Intensiva , Masculino , Pessoa de Meia-Idade , Prognóstico , Modelos de Riscos Proporcionais , República da Coreia/epidemiologia , Estudos Retrospectivos , Fatores de Risco , Adulto Jovem
19.
Zhonghua Yu Fang Yi Xue Za Zhi ; 55(5): 698-702, 2021 May 06.
Artigo em Chinês | MEDLINE | ID: mdl-34034414

RESUMO

The purpose of this study is to explore the smoking-related behaviors of people ≥60 years of age with respiratory diseases in Shangqiu area. A total of 550 patients with respiratory diseases ≥60 years old who were treated at the First People's Hospital of Shangqiu from April 2015 to April 2017 were selected as the survey subjects through random sampling. Among them, there were 351 males and 199 females; the age ranged from 60 to 86 (72.85±5.71) years old. Follow-up until April 2020, and the follow-up was 3 years or more and related information and death information were also collected. The multivariate Cox proportional hazard regression model was used to analyze the influence of smoking behavior in the survey subjects on the death risk of people with respiratory diseases ≥ 60 years old. A total of 550 cases were included in the survey, and 25 cases were lost to follow-up. The effective number was 525, and the survey effective rate was 95.45%. Among the 525 patients, 336 (64.00%) were males and 189 (36.00%) were females. The age ranged from 60 to 86 (72.69±5.64) years old. The education level was mainly high school and technical secondary school, accounting for 39.24% of the total population. The primary diseases included tracheitis/bronchitis, asthma, pneumonia, COPD and lung cancer. Among 525 patients with respiratory diseases ≥60 years old, non-smokers accounted for 11.05% (58/525), smokers accounted for 68.00% (357/525), and quitters accounted for 20.95% (110/525). The duration of smoking was more than 20 years, accounting for 33.33% (175/525). The smoking intensity was mainly moderate, accounting for 33.90% (178/525). The duration of smoking cessation was mainly<5 years, accounting for 8.76% (46/525). Follow-up until April 2020, the mortality rate of 525 patients with respiratory diseases ≥60 years old was 14.10% (74/525). Cox regression analysis showed that smoking duration, smoking intensity, cumulative smoking amount, and duration of smoking cessation were the influencing factors of death in patients with respiratory diseases ≥60 years old in Shangqiu area (P<0.05). It can be seen that smoking duration, smoking intensity, cumulative smoking amount, and smoking cessation duration may be independent risk factors for death in patients with respiratory diseases ≥ 60 years old in Shangqiu area, and may increase the relative risk of death.


Assuntos
Abandono do Hábito de Fumar , Fumar , Idoso , Idoso de 80 Anos ou mais , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Modelos de Riscos Proporcionais , Fatores de Risco , Inquéritos e Questionários
20.
Zhonghua Zhong Liu Za Zhi ; 43(5): 581-586, 2021 May 23.
Artigo em Chinês | MEDLINE | ID: mdl-34034479

RESUMO

Objective: To explore the effect of systolic blood pressure (SBP) trajectories on cancers. Methods: The relevant data of 54, 888 employees of Kailuan (Group) Limited Liability Company who participated in the 3 health examinations from 2006-2007, 2008-2009, 2010-2011 were collected and the new onset cancer cases were recorded. The systolic blood pressure trajectory grouping was carried out using the blood pressure measurement values of the 3 physical examinations. The life table method was used to calculate the incidence of cancer, and the multivariate Cox proportional hazard regression model was used to analyze the influence factors of cancer. Results: According to the systolic blood pressure trajectory, 54, 888 subjects were divided into 5 groups, including 14, 326 in the low-stable group, 25, 630 in the moderate-stable group, 5, 390 in the moderate-increasing group, 6, 438 in the elevated-lowering group, and 3, 104 in the elevated-stable group. A total of 1, 070 new onset cancer occurred during the follow-up period of (4.95±0.53) years. The incidence of cancer in the low-stable group, moderate-stable group, moderate-increasing group, elevated-lowering group and elevated-stable group were 1.3% (177/14, 326), 2.2% (491/25, 360), 3.1% (147/5, 390), 2.7% (156/6, 438) and 3.8% (99/3, 104), respectively, the difference was statistically significant (P<0.001). After adjusting for gender, age, smoking, drinking, physical exercise, body mass index (BMI), fasting blood glucose, total cholesterol, antihypertensive drugs, hypoglycemic drugs, and lipid-lowering drugs, multivariate Cox regression analysis showed that the systolic blood pressure trajectory was related to the incidence of cancer. Compared with the low-stable group, the Hazard ratio (HR) in the moderate-stable group, moderate-increasing group, elevated-lowering group and elevated-stable group were 1.413, 1.731, 1.557 and 1.907, respectively (all P<0.001). Conclusion: High systolic blood pressure trajectories is the risk factor for cancer.


Assuntos
Hipertensão , Neoplasias , Pressão Sanguínea , Humanos , Hipertensão/epidemiologia , Neoplasias/epidemiologia , Modelos de Riscos Proporcionais , Estudos Prospectivos , Fatores de Risco
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