RESUMO
INTRODUCTION AND AIM: Direct-acting antiviral (DAA) agents are highly effective for treatment of chronic hepatitis C virus (HCV) yet access to treatment remains a serious challenge. The aim of this study was to identify barriers to treatment initiation with DAA-containing regimens in an urban clinic setting. MATERIALS AND METHODS: A retrospective cohort of all chronic HCV patients seen in an urban academic practice in Jacksonville, FL, USA from 1/2014 to 1/2017 was analyzed. Baseline characteristics were recorded and a review of medical records was performed to identify barriers to treatment initiation and overall success rates. RESULTS: Two-hundred and forty patients with chronic HCV were analyzed. Fifty-six percent of patients were African-American and 63% were insured through Medicaid/county programs or uninsured. Sixty-nine percent had barriers to initiating antiviral therapy categorized as psychosocial (n=112), provider (n=26), medical (n=20), and insurance-related factors (n=7). The most commonly encountered psychosocial barriers included failure to keep appointments (79/240, 33%), active substance abuse (18/240, 8%), and failure to obtain laboratory testing (11/240, 5%). Overall, only 27% of patients evaluated were initiated on DAA-containing regimens with 18% reaching SVR12 within the 36-month study period. CONCLUSION: In conclusion, only 27% of patients who presented to an urban academic practice with chronic HCV received DAA-containing regimens over a 36-month period. Psychosocial issues were the major barriers to antiviral therapy. These findings illustrate the need for an integrated approach that addresses psychosocial factors as well as comorbidities and adherence to care in order to increase rates of HCV treatment in at risk patients.
Assuntos
Antivirais/uso terapêutico , Acessibilidade aos Serviços de Saúde , Hepatite C Crônica/tratamento farmacológico , Cooperação do Paciente , Serviços Urbanos de Saúde , Agendamento de Consultas , Quimioterapia Combinada , Feminino , Florida/epidemiologia , Conhecimentos, Atitudes e Prática em Saúde , Acessibilidade aos Serviços de Saúde/economia , Hepatite C Crônica/economia , Hepatite C Crônica/etnologia , Hepatite C Crônica/psicologia , Humanos , Seguro Saúde , Masculino , Pessoa de Meia-Idade , Cooperação do Paciente/etnologia , Cooperação do Paciente/psicologia , Estudos Retrospectivos , Transtornos Relacionados ao Uso de Substâncias/etnologia , Transtornos Relacionados ao Uso de Substâncias/psicologia , Resposta Viral Sustentada , Fatores de Tempo , Resultado do TratamentoAssuntos
Brachyspira/isolamento & purificação , Colo/patologia , Diarreia/diagnóstico , Infecções por Bactérias Gram-Negativas/diagnóstico , Infecções por HIV/complicações , Mucosa Intestinal/patologia , Microvilosidades/patologia , Biópsia , Colonoscopia , Histocitoquímica , Humanos , Masculino , Microscopia , Pessoa de Meia-IdadeRESUMO
BACKGROUND: Smoking causes genetic damage in buccal cells and increases the risk of oral cancer. Because folate is instrumental in DNA synthesis and repair, it is a determinant of genetic stability and therefore might attenuate the genotoxic effects of smoking. OBJECTIVE: Our aim was to compare the presence of folate metabolites and select indicators of genetic damage in the mouths of chronic smokers and nonsmokers. DESIGN: Dietary, biochemical, and molecular correlates of folate status were measured in healthy smoker (n = 35) and nonsmoker (n = 21) groups of comparable age, sex, and body mass indexes. RESULTS: After correction for dietary intake, the smokers displayed lower plasma, erythrocyte, and buccal mucosal cell (BMC) folate (20%, 32%, and 50% lower, respectively; P < 0.05) and lower plasma vitamin B-12 and pyridoxal 5-phosphate (P < 0.05) than did nonsmokers. Folate in the BMCs of smokers comprised significantly greater proportions of pteroylmonoglutamate, formyltetrahydrofolate, and 5,10-methenyltetrahyrofolate than did folate in the BMCs of nonsmokers. Although the degree of genomic methylation and uracil incorporation in the buccal cells of the 2 groups were not significantly different, the BMC micronucleus index, a cytologic indicator of genetic damage, in the smokers was 2-fold that of the nonsmokers (9.57 compared with 4.44 micronuclei/1000 cells; P < 0.0001). Neither systemic nor oral folate status was an independent predictor of micronuclei. CONCLUSIONS: Chronic smoking is associated with a lower systemic status of several B vitamins, reduced oral folate, and changes in folate form distribution in the mouth. However, the cytologic damage that is evident in the mouths of smokers does not correlate with oral folate status.
Assuntos
DNA/metabolismo , Ácido Fólico/metabolismo , Mucosa Bucal/patologia , Estado Nutricional , Fumar/efeitos adversos , Adulto , Idoso , Idoso de 80 Anos ou mais , Estudos de Casos e Controles , Aberrações Cromossômicas , Eritrócitos/química , Feminino , Ácido Fólico/sangue , Ácido Fólico/química , Humanos , Masculino , Testes para Micronúcleos , Pessoa de Meia-Idade , Mucosa Bucal/citologia , Fosfato de Piridoxal/sangue , Fumar/sangue , Fumar/metabolismo , Complexo Vitamínico B/sangueRESUMO
CONTEXT: Lymphoid aggregates are seen in a minority of bone marrow biopsy specimens, and when present, their neoplastic nature is often apparent by morphologic evaluation. However, the distinction between benign and malignant aggregates can be a diagnostic challenge when there are multiple aggregates with no documented history of lymphoma. OBJECTIVE: To aid in the distinction between benign and malignant B-cell lymphoid aggregates. DESIGN: Previously, we described specific distribution patterns for B and T lymphocytes within bone marrow aggregates. To statistically analyze the significance of these patterns as well as previously reported criteria, we examined 128 bone marrow specimens with benign aggregates and 78 specimens with documented malignant B-cell aggregates and calculated specific odds ratios (ORs) and 95% confidence intervals (CIs) to aid in differentiating between benign and malignant B-cell aggregates. RESULTS: Aggregates with infiltrative edges (OR, 80.54; 95% CI, 31.76-204.21), a B-cell pattern (OR, 30.08; 95% CI, 13.28-68.10), paratrabecular location (OR, 10.17; 95% CI, 3.96-26.12), size greater than 600 µm (OR, 6.83: 95% CI, 3.61-12.93), or cytologic atypia correlated with malignancy. CONCLUSIONS: When taken collectively, the presence of more than 2 of these characteristic features was strongly predictive of malignancy.
Assuntos
Linfócitos B/patologia , Biomarcadores Tumorais/metabolismo , Células da Medula Óssea/patologia , Medula Óssea/patologia , Tecido Linfoide/patologia , Linfoma de Células B/patologia , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Linfócitos B/metabolismo , Biópsia , Células da Medula Óssea/metabolismo , Criança , Diagnóstico Diferencial , Feminino , Humanos , Imunofenotipagem , Masculino , Pessoa de Meia-Idade , Valor Preditivo dos Testes , Linfócitos T/metabolismo , Linfócitos T/patologia , Adulto JovemRESUMO
Benign lymphoid aggregates are seen in only a minority of bone marrow specimens, but their distinction from non-Hodgkin lymphoma, particularly B-cell lymphomas, can represent a diagnostic challenge. Although criteria have been proposed to help distinguish between benign and malignant aggregates, a detailed description of the distribution patterns of B and T lymphocytes within benign lymphoid aggregates has not been investigated. One hundred thirty-seven cases of bone marrow specimens containing benign aggregates were studied with a panel of immunostains. A subset of these cases was also examined for immunoglobulin gene rearrangements by polymerase chain reaction. The aggregates were categorized based on size, location (paratrabecular or random), presence of infiltrating edges, and distribution of lymphoid cell populations. In addition, we examined 40 cases of bone marrow biopsies with documented malignant lymphoid aggregates for comparison purposes. We report that the distribution of B and T lymphocytes within lymphoid aggregates may serve as a useful criterion to aid in the separation between benign and malignant aggregates. When aggregates exhibit a predominance of T cells, consist of a central core of T cells surrounded by a rim of B cells, or have a mixed distribution of B and T cells, they are more likely to be benign. On the other hand, an increased likelihood of malignancy occurs when aggregates exhibit a predominance of B cells or consist of a central core of B cells surrounded by a rim of T cells (excluding germinal center formation), and assessing other features worrisome of malignancy (large aggregate size, presence of infiltrative edges, cellular atypia, and paratrabecular location, among others) is warranted.
Assuntos
Linfócitos B/patologia , Células da Medula Óssea/patologia , Tecido Linfoide/patologia , Linfócitos T/patologia , Adulto , Idoso , Idoso de 80 Anos ou mais , Linfócitos B/metabolismo , Biomarcadores Tumorais/metabolismo , Diagnóstico Diferencial , Feminino , Rearranjo Gênico do Linfócito T/genética , Humanos , Imunoglobulinas/genética , Linfoma de Células B/diagnóstico , Linfoma de Células B/genética , Linfoma de Células B/metabolismo , Linfoma de Células T/diagnóstico , Linfoma de Células T/genética , Linfoma de Células T/metabolismo , Masculino , Pessoa de Meia-Idade , Reação em Cadeia da Polimerase , Linfócitos T/metabolismoAssuntos
Doença da Artéria Coronariana/diagnóstico , Vasos Coronários/diagnóstico por imagem , Vasos Coronários/patologia , Placa Aterosclerótica/diagnóstico , Tomografia de Coerência Óptica/métodos , Ultrassonografia de Intervenção/métodos , Animais , Modelos Animais de Doenças , Masculino , Coelhos , Reprodutibilidade dos Testes , SuínosRESUMO
Folic acid (FA) supplements and food fortification are used to prevent neural tube defects and to lower plasma homocysteine. Through exposure to food fortification and vitamin supplement use, large populations in the United States and elsewhere have an unprecedented high FA intake. We evaluated dietary and supplemental intakes of folate and FA in relation to an index of immune function, natural killer cell (NK) cytotoxicity, among 105 healthy, postmenopausal women. Among women with a diet low in folate (<233 microg/d), those who used FA-containing supplements had significantly greater NK cytotoxicity (P = 0.01). However, those who consumed a folate-rich diet and in addition used FA supplements > 400 microg/d had reduced NK cytotoxicity compared with those consuming a low-folate diet and no supplements (P = 0.02). Prompted by this observation, we assessed the presence of unmetabolized FA in plasma as a biochemical marker of excess FA. Unmetabolized folic acid was detected in 78% of plasma samples from fasting participants. We found an inverse relation between the presence of unmetabolized FA in plasma and NK cytotoxicity. NK cytotoxicity was approximately 23% lower among women with detectable folic acid (P = 0.04). This inverse relation was stronger among women >or= 60 y old and more pronounced with increasing unmetabolized FA concentrations (P-trend = 0.002). Because of the increased intake of FA in many countries, our findings highlight the need for further studies on the effect of long-term high FA intake on immune function and health.