RESUMEN
BACKGROUND: With the emergence of the concept of value-based care, efficient resource allocation has become an increasingly prominent factor in surgical decision-making. Validated machine learning (ML) models for cost prediction in outpatient spine surgery are limited. As such, we developed and internally validated a supervised ML algorithm to reliably identify cost drivers associated with ambulatory single-level lumbar decompression surgery. METHODS: A retrospective review of the New York State Ambulatory Surgical Database was performed to identify patients who underwent single-level lumbar decompression from 2014 to 2015. Patients with a length of stay of >0 were excluded. Using pre- and intraoperative parameters (features) derived from the New York State Ambulatory Surgical Database, an optimal supervised ML model was ultimately developed and internally validated after 5 candidate models were rigorously tested, trained, and compared for predictive performance related to total charges. The best performing model was then evaluated by testing its performance on identifying relationships between features of interest and cost prediction. Finally, the best performing algorithm was entered into an open-access web application. RESULTS: A total of 8402 patients were included. The gradient-boosted ensemble model demonstrated the best performance assessed via internal validation. Major cost drivers included anesthesia type, operating room time, race, patient income and insurance status, community type, worker's compensation status, and comorbidity index. CONCLUSIONS: The gradient-boosted ensemble model predicted total charges and associated cost drivers associated with ambulatory single-level lumbar decompression using a large, statewide database with excellent performance. External validation of this algorithm in future studies may guide practical application of this clinical tool.
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Aprendizaje Automático , Columna Vertebral , Humanos , Columna Vertebral/cirugía , Estudios Retrospectivos , Predicción , DescompresiónRESUMEN
BACKGROUND: Retinal vessel calibre and vascular dilation/constriction in response to flicker light provocation may provide a measure distinguishing patients suffering from diabetes mellitus and/or cardiovascular disease. METHODS: One hundred and sixteen age and sex matched patients with diabetes mellitus (DM), cardiovascular disease (CVD) and both DM and CVD (DM + CVD) underwent systemic and intraocular pressure measurements. Retinal vessel calibres were assessed using a validated computer-based program to compute central retinal artery and vein equivalents (CRVE) from monochromatic retinal images. Vessel dilation and constriction responses to flicker light provocation were assessed by continuous retinal vessel diameter recordings. Plasma endothelial markers von Willebrand factor (vWf) and soluble E selectin (sEsel) were measured by ELISA. RESULTS: Retinal vessel calibres were comparable across groups but CRVE correlated significantly with disease duration in DM patients (r = 0.57, p < 0.001). Patients suffering DM only exhibited reduced arterial vasomotion at rest and reduced arterial constriction following flicker light induced vessel dilation compared to patients with CVD and those suffering both CVD + DM (p = 0.030). Patients suffering from CVD + DM exhibited significant differences between each flicker cycle in regards to arterial maximum constriction (p = 0.006) and time needed to reach arterial maximum dilation (p = 0.004), whereas the other two groups did not show such inconsistencies between individual flicker cycles. vWf was raised in CVD + DM compared to the other two groups (p ≤ 0.02), whilst sEsel was raised in CVD + DM compared to DM alone (p = 0.044). CONCLUSIONS: Dynamic retinal vascular calibres as obtained by continuous diameter measurements using flicker light provocation can reveal subtle differences between groups suffering from CVD with and without DM. This difference in reaction pattern and lack of arterial constriction in DM may provide a suitable marker to monitor progression.
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Enfermedades Cardiovasculares/fisiopatología , Diabetes Mellitus Tipo 1/fisiopatología , Diabetes Mellitus Tipo 2/fisiopatología , Retinopatía Diabética/fisiopatología , Arteria Retiniana/fisiopatología , Vena Retiniana/fisiopatología , Vasoconstricción , Vasodilatación , Anciano , Biomarcadores/sangre , Enfermedades Cardiovasculares/sangre , Enfermedades Cardiovasculares/diagnóstico , Diabetes Mellitus Tipo 1/sangre , Diabetes Mellitus Tipo 1/diagnóstico , Diabetes Mellitus Tipo 2/sangre , Diabetes Mellitus Tipo 2/diagnóstico , Retinopatía Diabética/sangre , Retinopatía Diabética/diagnóstico , Progresión de la Enfermedad , Selectina E/sangre , Ensayo de Inmunoadsorción Enzimática , Femenino , Humanos , Presión Intraocular , Luz , Masculino , Persona de Mediana Edad , Estimulación Luminosa , Valor Predictivo de las Pruebas , Pronóstico , Factores de Riesgo , Factor de von Willebrand/análisisRESUMEN
The recently completed EMPA-REG study showed that empagliflozin significantly decreased the major adverse cardiac events (MACE) endpoint, which comprised cardiovascular death, non-fatal myocardial infarction (MI) and stroke, in patients with high-risk type 2 diabetes (T2DM), primarily through a reduction in cardiovascular death, without a significant decrease in either MI or stroke. In the PROactive study, pioglitazone decreased the MACE endpoint by a similar degree to that observed in the EMPA-REG study, through a marked reduction in both recurrent MI and stroke and a modest reduction in cardiovascular death. These observations suggest that pioglitazone might be an ideal agent to combine with empagliflozin to further reduce cardiovascular events in patients with high-risk diabetes as empagliflozin also promotes salt/water loss and would be expected to offset any fluid retention associated with pioglitazone therapy. In the present paper, we provide an overview of the potential benefits of combined pioglitazone/empagliflozin therapy to prevent cardiovascular events in patients with T2DM.
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Enfermedades Cardiovasculares/prevención & control , Diabetes Mellitus Tipo 2/tratamiento farmacológico , Medicina Basada en la Evidencia , Hipoglucemiantes/uso terapéutico , Moduladores del Transporte de Membrana/uso terapéutico , Inhibidores del Cotransportador de Sodio-Glucosa 2 , Tiazolidinedionas/uso terapéutico , Animales , Compuestos de Bencidrilo/efectos adversos , Compuestos de Bencidrilo/uso terapéutico , Enfermedades Cardiovasculares/complicaciones , Diabetes Mellitus Tipo 2/complicaciones , Diabetes Mellitus Tipo 2/metabolismo , Angiopatías Diabéticas/prevención & control , Cardiomiopatías Diabéticas/prevención & control , Quimioterapia Combinada , Glucósidos/efectos adversos , Glucósidos/uso terapéutico , Humanos , Hipoglucemiantes/efectos adversos , Moduladores del Transporte de Membrana/efectos adversos , Pioglitazona , Transportador 2 de Sodio-Glucosa/metabolismo , Tiazolidinedionas/efectos adversosRESUMEN
AIM: Treatment of type 2 diabetes with glucagon-like peptide-1 (GLP-1) receptor agonists may be limited by gastrointestinal side effects (GISE) in some patients. Risk factors for developing GISE are not known. We analysed patient characteristics that were associated with GISE among patients treated with the GLP-1 receptor agonist liraglutide. METHODS: Data was obtained from an audit database of liraglutide use based in clinical practice in the UK. Patients were grouped into those who did not report GISE, those who reported GISE but continued liraglutide and those who discontinued liraglutide due to GISE within 26 weeks of treatment. Baseline variables of age, diabetes duration, HbA1c, weight, BMI, blood pressure, lipids, gender, ethnicity, alanine transaminotransferase, estimated glomerular filtration rate (eGFR) and diabetes treatment types were tested for possible associations with GISE outcome. Significant variables in univariate analyses were entered into ordinal logistic regression analyses. RESULTS: A total of 4442 patients were suitable for analysis. A total of 3905 (87.9%) did not report GISE, 297 (6.7%) and 240 (5.4%) had GISE and continued and discontinued treatment, respectively. Age, weight, eGFR, metformin status and insulin status were associated with GISE outcome in univariate analyses (P all <0.05). In the final regression model, age (adjusted OR 1.15 [95%CI 1.05,1.26], P=0.002) and non-metformin use (adjusted OR 0.76 [95%CI 0.60,0.96], P=0.020) were associated with worse GISE outcome. CONCLUSION: Older age and non-metformin use were associated with more significant GISE leading to discontinuation of liraglutide treatment. The reasons for these findings are unclear and warrant further investigation.
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Diabetes Mellitus Tipo 2/tratamiento farmacológico , Enfermedades Gastrointestinales/inducido químicamente , Enfermedades Gastrointestinales/epidemiología , Hipoglucemiantes/efectos adversos , Liraglutida/efectos adversos , Metformina/uso terapéutico , Adulto , Factores de Edad , Anciano , Peso Corporal/efectos de los fármacos , Quimioterapia Combinada , Femenino , Humanos , Hipoglucemiantes/uso terapéutico , Liraglutida/uso terapéutico , Masculino , Metformina/efectos adversos , Persona de Mediana Edad , Estudios Retrospectivos , Factores de Riesgo , Resultado del Tratamiento , Reino Unido/epidemiologíaAsunto(s)
Carcinógenos/toxicidad , Angiopatías Diabéticas/prevención & control , Hipoglucemiantes/efectos adversos , Tiazolidinedionas/efectos adversos , Animales , Humanos , Estudios Observacionales como Asunto , Pioglitazona , Ensayos Clínicos Controlados Aleatorios como Asunto , Ratas , Factores de Riesgo , Retirada de Medicamento por Seguridad , OrinaRESUMEN
On 8 April 2014, a US jury ordered Takeda and Eli Lilly to pay $9 bn in punitive damages after finding that they had concealed the cancer risks associated with pioglitazone. By contrast, on 28 August 2014, the long-awaited outcome of the 10-year Kaiser Permanente Northern California study was announced. That study was specifically designed to investigate whether patients exposed to pioglitazone were at an increased risk of bladder cancer and found no association; thus, at last, the controversial issue has been resolved. A review, in retrospect, of the story of the proposed link between pioglitazone and bladder cancer reveals flaws at every stage. In 2012, a BMJ editorial, in keeping with some other contemporary reports, stated 'it can confidently be assumed that pioglitazone increases the risk of bladder cancer'. Examination of the information which led to such a statement shows that: 1) the pre-clinical findings of bladder cancer in male rats is not indicative of human risk; 2) there is no association between bladder cancer and pioglitazone in randomized controlled trials, once cases that could not plausibly be related to treatment are removed; and 3) the observational studies that have suggested a link have over-extrapolated from the data: pioglitazone-treated patients had more risk factors for bladder cancer than those not treated with pioglitazone. Meanwhile careful study of randomized controlled trials shows evidence of cardiovascular benefit from pioglitazone in Type 2 diabetes, a condition which results, more than anything, in premature cardiovascular death and morbidity.
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Sistema Cardiovascular/efectos de los fármacos , Diabetes Mellitus Tipo 2/tratamiento farmacológico , Tiazolidinedionas/efectos adversos , Tiazolidinedionas/farmacología , Neoplasias de la Vejiga Urinaria/epidemiología , Animales , Modelos Animales de Enfermedad , Determinación de Punto Final , Femenino , Humanos , Hipoglucemiantes/efectos adversos , Hipoglucemiantes/farmacología , Hipoglucemiantes/uso terapéutico , Estimación de Kaplan-Meier , Estudios Longitudinales , Masculino , Pioglitazona , Ratas , Estudios Retrospectivos , Factores de Riesgo , Tiazolidinedionas/uso terapéuticoRESUMEN
AIMS: The response to glucagon-like peptide 1 receptor agonist treatment may be influenced by endogenous ß-cell function. We investigated whether urinary C-peptide creatinine ratio assessed before or during liraglutide treatment was associated with treatment response. METHODS: A single, outpatient urine sample for urinary C-peptide creatinine ratio was collected 2 h after the largest meal of the day among two separate groups: (1) subjects initiating liraglutide (0.6 â 1.2 mg daily) or (2) subjects already treated with liraglutide for 20-32 weeks. The associations between pretreatment and on-treatment urinary C-peptide creatinine ratio and HbA1c change at 32 weeks were assessed using univariate and multivariate analyses (the ratio was logarithm transformed for multivariate analyses). Changes in HbA1c according to pretreatment urinary C-peptide creatinine ratio quartiles are shown. RESULTS: One hundred and sixteen subjects (70 pretreatment, 46 on treatment) with Type 2 diabetes from 10 diabetes centres were studied. In univariate analyses, neither pretreatment nor on-treatment urinary C-peptide creatinine ratio correlated with HbA1c change (Spearman rank correlation coefficient, r = -0.17, P = 0.17 and r = -0.20, P = 0.19, respectively). In multi-linear regression analyses, entering baseline HbA1c and log urinary C-peptide creatinine ratio, pretreatment and on-treatment log urinary C-peptide creatinine ratio became significantly associated with HbA1c change (P = 0.048 and P = 0.040, respectively). Mean (sd) HbA1c changes from baseline in quartiles 1 to 4 of pretreatment urinary C-peptide creatinine ratio were -3 ± 17 mmol/mol (-0.3 ± 1.6%) (P = 0.52), -12 ± 15 mmol/mol (-1.1 ± 1.4%) (P = 0.003), -11 ± 13 mmol/mol (-1.0 ± 1.2%) (P = 0.002) and -12±17 mmol/mol (-1.1±1.6%) (P=0.016), respectively. CONCLUSIONS: Postprandial urinary C-peptide creatinine ratios before and during liraglutide treatment were weakly associated with the glycaemic response to treatment. Low pretreatment urinary C-peptide creatinine ratio may be more useful than higher values by predicting poorer glycaemic response.
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Péptido C/orina , Creatinina/orina , Diabetes Mellitus Tipo 2/tratamiento farmacológico , Péptido 1 Similar al Glucagón/análogos & derivados , Incretinas/uso terapéutico , Periodo Posprandial , Anciano , Diabetes Mellitus Tipo 2/orina , Femenino , Péptido 1 Similar al Glucagón/uso terapéutico , Hemoglobina Glucada/análisis , Humanos , Liraglutida , Masculino , Persona de Mediana Edad , Resultado del TratamientoRESUMEN
Recent suggestions that glucagon-like peptide-1 (GLP-1)-based therapies could cause pancreatitis, and even pancreatic cancer, are based on: ANIMAL STUDIES: The worrying histological changes are not reproduced in all studies and are unexpectedly variable with different GLP-1-based therapies. AN OBSERVATIONAL STUDY: Singh's findings that pancreatitis is doubled with GLP-1-based therapies could relate to their use in obese patients who are prone to pancreatitis risk factors--gallstones and hypertriglyceridaemia. The other observational studies do not find an association between GLP-1-based therapies and pancreatitis. US FOOD AND DRUG ADMINISTRATION ADVERSE EVENT REPORTING SYSTEM: The increased reports of pancreatitis and pancreatic cancer are likely to be attributable to 'notoriety bias'. A STUDY OF ORGAN DONOR PANCREASES: Butler's findings for those on GLP-1-based therapies vs. those not, could have other explanations. Meanwhile: META ANALYSIS: Randomized control trials with GLP-1-based therapies do not find increased pancreatitis risk. Meta-analysis of 53 randomized controlled trials including 20 212 dipeptidyl peptidase-4 inhibitor-treated patients found a significantly reduced risk of major adverse cardiovascular events [odds ratio 0.689 (0.528-0.899), P = 0.006] for dipeptidyl peptidase-4 inhibitors compared with control subjects. CARDIOVASCULAR RISK: The evidence suggests that there is more than a possibility that some of the GLP-1 receptor agonists, and possibly also some dipeptidyl peptidase-4 inhibitors, may be associated with reduced cardiovascular events. Eight ongoing long-term cardiovascular randomized controlled trials will report from September 2013 onwards. These trials should resolve the issue of pancreatitis risk and substantiate the extent of benefit. CONCLUSION: Whilst we should remain vigilant, currently the balance of evidence is strongly in support of GLP-1-based therapy, with benefits far outweighing potential risks.
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Enfermedades Cardiovasculares/prevención & control , Diabetes Mellitus Tipo 2/tratamiento farmacológico , Incretinas/uso terapéutico , Neoplasias Pancreáticas/inducido químicamente , Pancreatitis/inducido químicamente , Receptores de Glucagón/agonistas , Sistemas de Registro de Reacción Adversa a Medicamentos , Enfermedades Cardiovasculares/etiología , Diabetes Mellitus Tipo 2/complicaciones , Diabetes Mellitus Tipo 2/patología , Angiopatías Diabéticas/prevención & control , Inhibidores de la Dipeptidil-Peptidasa IV/efectos adversos , Inhibidores de la Dipeptidil-Peptidasa IV/uso terapéutico , Exenatida , Femenino , Péptido 1 Similar al Glucagón/efectos adversos , Péptido 1 Similar al Glucagón/análogos & derivados , Péptido 1 Similar al Glucagón/uso terapéutico , Receptor del Péptido 1 Similar al Glucagón , Humanos , Incretinas/efectos adversos , Liraglutida , Masculino , Neoplasias Pancreáticas/patología , Pancreatitis/patología , Selección de Paciente , Péptidos/efectos adversos , Péptidos/uso terapéutico , Ensayos Clínicos Controlados Aleatorios como Asunto , Medición de Riesgo , Factores de Riesgo , Ponzoñas/efectos adversos , Ponzoñas/uso terapéuticoAsunto(s)
Conducción de Automóvil , Diabetes Mellitus Tipo 1/tratamiento farmacológico , Diabetes Mellitus Tipo 2/tratamiento farmacológico , Péptido 1 Similar al Glucagón/análogos & derivados , Péptido 1 Similar al Glucagón/agonistas , Hipoglucemiantes/uso terapéutico , Concesión de Licencias , Péptidos/uso terapéutico , Ponzoñas/uso terapéutico , Glucemia/efectos de los fármacos , Aprobación de Recursos/legislación & jurisprudencia , Diabetes Mellitus Tipo 1/sangre , Diabetes Mellitus Tipo 2/sangre , Relación Dosis-Respuesta a Droga , Exenatida , Femenino , Péptido 1 Similar al Glucagón/uso terapéutico , Humanos , Hipoglucemia/complicaciones , Liraglutida , Masculino , Persona de Mediana Edad , Reino UnidoRESUMEN
It is uncertain what should be done with insulin dose if starting exenatide. In the ABCD nationwide exenatide audit, many patients with type 2 diabetes had worsened glycaemia when insulin was stopped. If starting exenatide, insulin should not be stopped but weaned off only if there is significant glycaemic response.
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Diabetes Mellitus Tipo 2/tratamiento farmacológico , Insulina/administración & dosificación , Péptidos/uso terapéutico , Ponzoñas/uso terapéutico , Adulto , Anciano , Glucemia/efectos de los fármacos , Relación Dosis-Respuesta a Droga , Quimioterapia Combinada , Exenatida , Femenino , Humanos , Hipoglucemiantes/uso terapéutico , Masculino , Persona de Mediana Edad , Estudios Retrospectivos , Reino UnidoRESUMEN
Low male participation in voluntary counselling and testing (VCT) services at antenatal clinics (ANCs) represents a lost HIV-prevention opportunity. A three-arm randomized controlled trial (RCT) was conducted that offered VCT at a neighbourhood health centre, bar or church to the male partners of pregnant women attending a maternity unit in Kinshasa, Democratic Republic of Congo (DRC). The primary outcome was the proportion of male participation at VCT; secondary outcomes were uptake of couple counselling and determinants of male and couple participation. From a total of 2706 women included in the study, 591 male partners (22%) attended one of the three venues. Male participation was significantly higher in bars (26%, P < 0.001), and higher but not statistically significant in church-based VCT (21%, P = 0.163) compared with health centre VCT (18%). Male participation in VCT associated with ANCs was higher in non-health service settings, particularly in bars. A combination of different strategies rather than single targeted interventions will be needed to increase VCT uptake in male partners of women seeking VCT at ANCs.
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Consejo/métodos , Atención Prenatal/métodos , Parejas Sexuales , Programas Voluntarios/estadística & datos numéricos , Adolescente , Adulto , Instituciones de Atención Ambulatoria , Distribución de Chi-Cuadrado , Consejo/estadística & datos numéricos , República Democrática del Congo , Femenino , Infecciones por VIH/prevención & control , Humanos , Modelos Logísticos , Masculino , Embarazo , Atención Prenatal/estadística & datos numéricos , Religión , Factores SocioeconómicosRESUMEN
AIM: To assess the extent, safety, efficacy and tolerability of reported off-licence exenatide use through a nationwide audit. METHODS: The Association of British Clinical Diabetologists hosted a password-protected, online collection of anonymized data of exenatide use in real clinical practice. Three hundred and fifteen contributors from 126 centres across UK provided data on 6717 patients. HbA1c and weight changes, exenatide discontinuation, adverse events and treatment satisfaction were compared between non-insulin and insulin-treated patients. RESULTS: Four thousand eight hundred and fifty-seven patients had baseline and follow-up treatment status with mean (±s.d.) baseline HbA1c 9.45 ± 1.69% and BMI 40.0 ± 8.2 kg/m(2) . Of the 4857 patients, 1921 (39.6%) used exenatide with insulin. Comparing patients who continued insulin with exenatide with non-insulin-treated patients, mean (±s.e.) latest HbA1c and weight reduction (median 26 weeks) were 0.51 ± 0.06 versus 0.94 ± 0.04% (p < 0.001) and 5.8 ± 0.2 versus 5.5 ± 0.1 kg (p = 0.278). Insulin-treated patients had higher rates of exenatide discontinuation (31.0 vs. 13.9%, p < 0.001), hypoglycaemia (8.9 vs. 6.1%, p < 0.001), gastrointestinal side effects (28.4 vs. 25.0%, p = 0.008) and treatment dissatisfaction (20.8 vs. 5.7%, p < 0.001). However, 34.2% of the patients continuing insulin still achieved HbA1c reduction ≥1%. There was significant insulin discontinuation, dose reduction and greater sulphonylurea discontinuation among insulin-treated patients. CONCLUSIONS: Addition of exenatide to obese, insulin-treated patients can improve glycaemia and weight. Adverse events were statistically but probably not clinically significantly higher, but combination treatment was less well tolerated. Overall, exenatide was less effective in lowering HbA1c among insulin-treated patients, although significant number of insulin-treated patients still achieved significant HbA1c, weight and insulin reductions. Further research into identifying obese, insulin-treated patients who will tolerate and benefit from exenatide treatment is urgently needed.
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Diabetes Mellitus Tipo 2/tratamiento farmacológico , Hipoglucemiantes/uso terapéutico , Insulina/administración & dosificación , Obesidad/tratamiento farmacológico , Péptidos/administración & dosificación , Ponzoñas/administración & dosificación , Pérdida de Peso/efectos de los fármacos , Índice de Masa Corporal , Diabetes Mellitus Tipo 2/epidemiología , Relación Dosis-Respuesta a Droga , Interacciones Farmacológicas , Quimioterapia Combinada , Exenatida , Femenino , Hemoglobina Glucada/efectos de los fármacos , Humanos , Hipoglucemiantes/efectos adversos , Insulina/efectos adversos , Masculino , Auditoría Médica , Persona de Mediana Edad , Obesidad/epidemiología , Péptidos/efectos adversos , Resultado del Tratamiento , Reino Unido , Ponzoñas/efectos adversosRESUMEN
OBJECTIVES: To create a fetal size nomogram for use in sub-Saharan Africa and compare the derived centiles with reference intervals from developed countries. METHODS: Fetal biometric measurements were obtained at entry to antenatal care (11-22 weeks' gestation) and thereafter at 4-week intervals from pregnant women enrolled in a longitudinal ultrasound study in Kinshasa, Democratic Republic of Congo. The study population comprised 144 singleton gestations with ultrasound-derived gestational age within 14 days of the menstrual estimate. A total of 755 monthly ultrasound scans were included with a mean +/- SD of 5 +/- 1 (range, 2-8) scans per woman. Estimated fetal weight (EFW) was calculated at each ultrasound examination using the Hadlock algorithm. A general mixed-effects linear regression model that incorporated random effects for both the intercept and slope was fitted to log-transformed EFW to account for both mean growth and within-fetus variability in growth. Reference centiles (5(th), 10(th), 50(th), 90(th) and 95(th) centiles) were derived from this model. RESULTS: Nomograms derived from developed populations consistently overestimated the 50(th) centile EFW value for Congolese fetuses by roughly 5-12%. Differences observed in the 10(th) and 90(th) centiles were inconsistent between nomograms, but generally followed a pattern of overestimation that decreased with advancing gestational age. CONCLUSIONS: In low-resource settings, endemic malaria and maternal nutritional factors, including low prepregnancy weight and pregnancy weight gain, probably lead to lower fetal weight and utilization of nomograms derived from developed populations is not appropriate. This customized nomogram could provide more applicable reference intervals for diagnosis of intrauterine growth restriction in sub-Saharan African populations.
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Retardo del Crecimiento Fetal/diagnóstico por imagen , Nomogramas , Atención Prenatal/métodos , Ultrasonografía Prenatal/métodos , Adolescente , Adulto , África del Sur del Sahara , Tamaño Corporal , Femenino , Retardo del Crecimiento Fetal/epidemiología , Edad Gestacional , Humanos , Estudios Longitudinales , Embarazo , Valores de Referencia , Adulto JovenRESUMEN
Maternal malaria and under-nutrition are established risk factors for small-for-gestational-age (SGA) births; however, whether malaria is associated with intrauterine growth restriction (IUGR) is unknown. We investigated IUGR risk among 177 HIV-negative pregnant women enrolled in a longitudinal ultrasound study conducted in Democratic Republic of Congo from May 2005 to May 2006. Malaria infection, maternal anthropometrics, and ultrasound estimated fetal weight were measured monthly. All positive malaria cases were treated and intermittent presumptive therapy (IPTp) provided. Log-binomial regression models for IUGR were fitted using generalized estimating equations to account for statistical clustering of repeat IUGR measurements. Twenty-nine percent of fetuses experienced an episode of IUGR with the majority occurring in the third trimester. The risk of IUGR associated with malaria was greatest after three or more cumulative infections (RR 3.3, 95% CI 1.3-8.2) and was two- to eight-fold higher among women with evidence of under-nutrition. Receiving antimalarial treatment in the previous month (for IPTp or treatment) was significantly protective against IUGR (RR 0.5, 95% CI 0.3-0.7). The interaction observed between malaria and under-nutrition suggests that antenatal programmes in malaria endemic areas should incorporate nutritional screening and supplementation in addition to IPTp.
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Retardo del Crecimiento Fetal/diagnóstico por imagen , Malaria/complicaciones , Desnutrición/complicaciones , Complicaciones del Embarazo , Adolescente , Adulto , República Democrática del Congo , Femenino , Humanos , Estudios Longitudinales , Malaria/tratamiento farmacológico , Embarazo , Factores de Riesgo , Ultrasonografía , Adulto JovenRESUMEN
Use of well persons as the comparison group for laboratory-confirmed cases of sporadic salmonellosis may introduce ascertainment bias into case-control studies. Data from the 1996-1997 FoodNet case-control study of laboratory-confirmed Salmonella serogroups B and D infection were used to estimate the effect of specific behaviours and foods on infection with Salmonella serotype Enteritidis (SE). Persons with laboratory-confirmed Salmonella of other serotypes acted as the comparison group. The analysis included 173 SE cases and 268 non-SE controls. SE was associated with international travel, consumption of chicken prepared outside the home, and consumption of undercooked eggs prepared outside the home in the 5 days prior to diarrhoea onset. SE phage type 4 was associated with international travel and consumption of undercooked eggs prepared outside the home. The use of ill controls can be a useful tool in identifying risk factors for sporadic cases of Salmonella.
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Microbiología de Alimentos , Intoxicación Alimentaria por Salmonella/epidemiología , Intoxicación Alimentaria por Salmonella/microbiología , Salmonella enteritidis/aislamiento & purificación , Adolescente , Adulto , Anciano , Estudios de Casos y Controles , Niño , Preescolar , Femenino , Contaminación de Alimentos , Humanos , Lactante , Modelos Logísticos , Masculino , Persona de Mediana Edad , Vigilancia de la Población , Factores de Riesgo , Salmonella/aislamiento & purificación , Encuestas y Cuestionarios , Estados Unidos/epidemiologíaRESUMEN
This study examined the prevalence of HIV and other sexually transmitted infections (STIs) in pregnant women in Kinshasa, the Democratic Republic of the Congo (DRC). Between April and July 2004, antenatal attendees at two of the largest maternity clinics in Kinshasa were tested to identify HIV status, syphilis, Chlamydia trachomatis (CT) and Neisseria gonorrhoeae (NG). HIV seroprevalence was 1.9% in 2082 women. With PCR techniques, CT and NG infections were also uncommon in the first 529 women (1.7% and 0.4%, respectively). No active syphilis infection case was identified by Treponema pallidum haemagglutination assay (TPHA) and rapid plasma reagin test (RPR). A woman's risk of HIV infection was significantly associated with her reporting a male partner having had other female sexual partners (OR 2.7, 95% CI 1.2-6.2). The continuing low seroprevalence of HIV in pregnant women from Kinshasa was confirmed. Understanding factors associated with this phenomenon could help prevent a future HIV epidemic in low HIV transmission areas in Africa.
Asunto(s)
Infecciones por VIH/epidemiología , Complicaciones Infecciosas del Embarazo/epidemiología , Enfermedades de Transmisión Sexual/epidemiología , Adulto , Infecciones por Chlamydia/diagnóstico , Infecciones por Chlamydia/epidemiología , República Democrática del Congo/epidemiología , Ensayo de Inmunoadsorción Enzimática , Femenino , Gonorrea/diagnóstico , Gonorrea/epidemiología , Infecciones por VIH/diagnóstico , Humanos , Modelos Logísticos , Reacción en Cadena de la Polimerasa , Embarazo , Complicaciones Infecciosas del Embarazo/diagnóstico , Prevalencia , Factores de Riesgo , Enfermedades de Transmisión Sexual/diagnóstico , Sífilis/diagnóstico , Sífilis/epidemiologíaRESUMEN
BACKGROUND: After decades of improved tuberculosis (TB) control in Russia, notification rates started to rise in 1992. Russia also faces a fast growing human immunodeficiency virus (HIV) epidemic. OBJECTIVE: To document the extent and characteristics of HIV co-infection in TB patients in St Petersburg, Russia. DESIGN: A prospective cross-sectional study of HIV coinfected culture-positive TB cases. Between 15 June 2002 and 31 March 2003, TB cases at the St Petersburg City TB hospitals and dispensaries were screened for HIV infection. At the HIV Prevention and Treatment Center, HIV-infected individuals were offered TB screening. RESULTS: Forty-nine HIV-infected culture-positive TB cases were identified, mainly at TB hospitals and dispensaries. Most were new pulmonary TB cases. The majority were young (69% < or = 30 years of age), male (84%), unemployed (94%) individuals with a history of injection drug use (IDU) (92%), and, in 35% of cases a history of incarceration. Active case finding was high among contacts of cases (9%), but was not successful in HIV-infected IDUs. CONCLUSION: Although the HIV seroprevalence rate is rising among TB patients, HIV does not yet appear to be driving the St Petersburg TB epidemic. Aggressive collaborative TB-HIV control efforts may still avert adverse effects of HIV on the TB epidemic.