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Giunta DH, Karlsson P, Younus M, Berglind IA, Kieler H, Reutfors J. Validation of diagnoses of liver disorders in users of systemic azole antifungal medication in Sweden. BMC Gastroenterol 2024; 24:21. [PMID: 38182992 PMCID: PMC10770890 DOI: 10.1186/s12876-023-03110-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/02/2023] [Accepted: 12/28/2023] [Indexed: 01/07/2024] Open
Abstract
BACKGROUND Liver disorders are important adverse effects associated with antifungal drug treatment. However, the accuracy of Clinical International Classification of Diseases (ICD)-10 codes in identifying liver disorders for register based research is not well-established. This study aimed to determine the positive predictive value (PPV) of the ICD-10 codes for identifying patients with toxic liver disease, hepatic failure, and jaundice among patients with systemic antifungal treatment. METHODS Data from the Swedish Prescribed Drug Register and the National Patient Register were utilized to identify adult patients who received systemic azole antifungal drugs and had a recorded diagnosis of toxic liver disease (K71.0, K71.1, K71.2, K71.6, K71.8, K71.9), hepatic failure (K72.0, K72.9), or jaundice (R17) between 2005 and 2016. The medical records of all included patients were reviewed. Prespecified criteria were used to re-evaluate and confirm each diagnosis, serving as the gold standard to calculate PPVs with 95% confidence intervals (95% CI) for each diagnostic group. RESULTS Among the 115 included patients, 26 were diagnosed with toxic liver disease, 58 with hepatic failure, and 31 with jaundice. Toxic liver disease was confirmed in 14 out of 26 patients, yielding a PPV of 53.8% (95% CI 33.4-73.4%). Hepatic failure was confirmed in 26 out of 38 patients, resulting in a PPV of 62.1% (95% CI 48.4-74.5%). The highest PPV was found in jaundice, with 30 confirmed diagnoses out of 31, yielding a PPV of 96.8% (95% CI 83.3-99.9%). CONCLUSION Among patients who received azole antifungal treatment and were subsequently diagnosed with a liver disorder, the PPV for the diagnosis of jaundice was high, while the PPVs for toxic liver disease and hepatic failure were lower.
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Affiliation(s)
- Diego Hernan Giunta
- Centre for Pharmacoepidemiology, Karolinska Institutet, Karolinska University Hospital T2:02, 171 76, Stockholm, Sweden.
| | - Pär Karlsson
- Centre for Pharmacoepidemiology, Karolinska Institutet, Karolinska University Hospital T2:02, 171 76, Stockholm, Sweden
| | - Muhammad Younus
- Safety Surveillance Research, Worldwide Medical and Safety, Pfizer Inc, Collegeville, PA, USA
| | - Ina Anveden Berglind
- Centre for Pharmacoepidemiology, Karolinska Institutet, Karolinska University Hospital T2:02, 171 76, Stockholm, Sweden
- Center for Occupational and Environmental Medicine, Stockholm Region, Stockholm, Sweden
| | - Helle Kieler
- Centre for Pharmacoepidemiology, Karolinska Institutet, Karolinska University Hospital T2:02, 171 76, Stockholm, Sweden
| | - Johan Reutfors
- Centre for Pharmacoepidemiology, Karolinska Institutet, Karolinska University Hospital T2:02, 171 76, Stockholm, Sweden
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Yagi T, Mannheimer B, Reutfors J, Ursing J, Giunta DH, Kieler H, Linder M. Bleeding events among patients concomitantly treated with direct oral anticoagulants and macrolide or fluoroquinolone antibiotics. Br J Clin Pharmacol 2023; 89:887-897. [PMID: 36098510 PMCID: PMC10092847 DOI: 10.1111/bcp.15531] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2022] [Revised: 08/11/2022] [Accepted: 08/19/2022] [Indexed: 01/18/2023] Open
Abstract
Fluoroquinolones and macrolides may, due to a potential drug-drug interaction, increase the concentration of any concomitantly administered direct oral anticoagulant (DOAC) and thereby increase the risk of severe bleeding. However, clinical evidence for such an effect is scarce. The present study aimed to evaluate the association between the use of fluoroquinolones or macrolides and bleeding events in patients with concomitant DOAC use. This was a nationwide cohort study including 19 288 users of DOACs in 2008-2018 using information from Swedish national health registers. We compared the incidence of bleeding events associated with use of fluoroquinolones or macrolides using doxycycline as a negative control. Cox regression was used to calculate crude and adjusted hazard ratios (aHRs) in time windows of various length of follow-up after the start of antibiotic use. The incidence rates for fluoroquinolones and macrolides ranged from 12 to 24 and from 12 to 53 bleeding events per 100 000 patients in the investigated time windows. The aHRs (95% confidence interval) for use of fluoroquinolones and macrolides were 1.29 (0.69-2.44) and 2.60 (0.74-9.08) at the concomitant window, 1.31 (0.84-2.03) and 1.79 (0.75-4.29) at 30 days, and 1.34 (0.99-1.82) and 1.28 (0.62-2.65) at 150 days, respectively. With regard to fluoroquinolones, the present study suggests that the risk of bleeding when combined with DOACs, if any, is small. Codispensation of macrolides in patients on DOACs was not associated with an increased risk of bleeding. However, due to the small number of macrolide users, the results must be interpreted with caution.
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Affiliation(s)
- Tatsuya Yagi
- Department of Medicine Solna, Centre for Pharmacoepidemiology, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden
| | - Buster Mannheimer
- Department of Clinical Science and Education at Södersjukhuset, Karolinska Institutet, Stockholm, Sweden
| | - Johan Reutfors
- Department of Medicine Solna, Centre for Pharmacoepidemiology, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden
| | - Johan Ursing
- Department of Clinical Sciences, Danderyd Hospital, Karolinska Institutet, Stockholm, Sweden
| | - Diego Hernan Giunta
- Department of Medicine Solna, Centre for Pharmacoepidemiology, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden
| | - Helle Kieler
- Department of Medicine Solna, Centre for Pharmacoepidemiology, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden
| | - Marie Linder
- Department of Medicine Solna, Centre for Pharmacoepidemiology, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden
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Giunta DH, Carvalho de Souza M, Kneipp Dias MB, Szklo M, de Almeida LM. Time trends and age-period-cohort analysis of cervical cancer mortality rate in Brazil. J Cancer Policy 2020; 25:100230. [PMID: 36895140 DOI: 10.1016/j.jcpo.2020.100230] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2020] [Revised: 03/28/2020] [Accepted: 04/13/2020] [Indexed: 10/24/2022]
Abstract
BACKGROUND Cervical cancer (CC) is a common preventable and curable disease that may lead to death. Our aim was to describe the patterns of time trends in CC mortality rates among women in Brazil from 1980 to 2017, and identify the influence of age, period and birth cohort (APC) stratified by region (North NR, Northeast NER, Southeast SER, South SR, Center-Western region CWR). METHODS We performed a time-series analysis using secondary data bases. Crude (MR) and WHO age-standardized CC mortality rates (aMR) were estimated per 100,000 women. We evaluated time trends using permutation joinpoint regression models (JP) and APC models to estimate the effect of APC on MR. RESULTS The JP analysis showed a temporal decrease in all regions, except the NR, which had an annual percentage increase of 0.44 (95%CI 0.2 - 0.7). MR in the NR was 2 to 4 times higher than in the other regions. We observed steady increases in MR with age in the NR and NER. A plateau after age 40 was observed in SER, SR, and CWR. The NR and NER MR ratio stabilized around the year 2000. Birth cohort effect showed decreasing MR ratio from 1900 to 1970 for all regions, except the NR, which showed increasing MR rate from older to more recent cohorts. CONCLUSION We showed relevant differences in cervical MR by region, which may reflect inequality in access to primary and secondary prevention as well as treatment, particularly in the NR.
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Affiliation(s)
- Diego Hernan Giunta
- Internal Medicine Research Unit / Research Department, Hospital Italiano de Buenos Aires, Tte. Gral. Juan Domingo Perón 4190, Ciudad Autónoma de Buenos Aires, CP C1199ABB, Argentina.
| | - Mirian Carvalho de Souza
- Population Research Division, National Cancer Institute, Ministry of Health Brazil, R. Marquês de Pombal, 125 - Centro, Rio de Janeiro, RJ 20230-240, Brazil.
| | - Maria Beatriz Kneipp Dias
- Population Research Division, National Cancer Institute, Ministry of Health Brazil, R. Marquês de Pombal, 125 - Centro, Rio de Janeiro, RJ 20230-240, Brazil.
| | - Moyses Szklo
- Population Research Division, National Cancer Institute, Ministry of Health Brazil, R. Marquês de Pombal, 125 - Centro, Rio de Janeiro, RJ 20230-240, Brazil; Division of Epidemiology, The Johns Hopkins University, Johns Hopkins Bloomberg School of Public Health, 615 N. Wolfe Street, Baltimore, MD 21205, USA.
| | - Liz Maria de Almeida
- Population Research Division, National Cancer Institute, Ministry of Health Brazil, R. Marquês de Pombal, 125 - Centro, Rio de Janeiro, RJ 20230-240, Brazil.
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Benchimol JA, Elizondo CM, Giunta DH, Schapira MC, Pollan JA, Barla JD, Carabelli GS, Boietti BR. Survival and functionality in the elderly over 85 years of age with hip fracture. Rev Esp Cir Ortop Traumatol (Engl Ed) 2020; 64:265-271. [PMID: 32247622 DOI: 10.1016/j.recot.2020.02.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2019] [Revised: 01/09/2020] [Accepted: 02/02/2020] [Indexed: 10/24/2022] Open
Abstract
BACKGROUND There is a tendency for the aging population to fracture their hips. Our aim was to compare survival and functionality at one year, among elderly and very elderly patients with hip fracture. MATERIAL AND METHODS A prospective cohort of patients included in the Institutional Registry of Elderly Patients with Hip Fracture between 2014 and 2017. We classified patients as elderly patients (EP) <65 and <85 years and very elderly patients (VEP) ≥85 years. RESULTS We included 952 patients, 43% were EP and 57% were VEP. The proportion of women was 84% and 86% (P=.33) and with 2 or more points in the Charlson comorbidities index (28 and 31%, P= .36), respectively. The VEP were more dependent according to the Barthel score (34% and 62%, P<.01) and frailer according to the Edmonton score (30% and 61%, P<.01). One-year survival was 91% (95% CI 86-93) in the EP and 76% (95% CI 70-89) in the VEP. In-hospital complications were more frequent in the VEP 12% (7% in the EP, P<.01). Age is an independent risk factor for one-year survival (HR 2.11; 95% CI 1.36-3.29, P<.001). CONCLUSIONS Age is a risk factor for the VEP group survival despite fragility and comorbidities. Because of their vulnerability, an appropriate care plan should be considered for VEP.
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Affiliation(s)
- J A Benchimol
- Servicio de Clínica Médica, Hospital Italiano de Buenos Aires, Ciudad Autónoma de Buenos Aires, Argentina; Sección de Geriatría, Hospital Italiano de Buenos Aires, Ciudad Autónoma de Buenos Aires, Argentina.
| | - C M Elizondo
- Servicio de Clínica Médica, Hospital Italiano de Buenos Aires, Ciudad Autónoma de Buenos Aires, Argentina; Área de Investigación en Medicina Interna, Hospital Italiano de Buenos Aires, Ciudad Autónoma de Buenos Aires, Argentina
| | - D H Giunta
- Servicio de Clínica Médica, Hospital Italiano de Buenos Aires, Ciudad Autónoma de Buenos Aires, Argentina; Área de Investigación en Medicina Interna, Hospital Italiano de Buenos Aires, Ciudad Autónoma de Buenos Aires, Argentina
| | - M C Schapira
- Servicio de Clínica Médica, Hospital Italiano de Buenos Aires, Ciudad Autónoma de Buenos Aires, Argentina; Sección de Geriatría, Hospital Italiano de Buenos Aires, Ciudad Autónoma de Buenos Aires, Argentina
| | - J A Pollan
- Servicio de Clínica Médica, Hospital Italiano de Buenos Aires, Ciudad Autónoma de Buenos Aires, Argentina
| | - J D Barla
- Servicio de Ortopedia, Hospital Italiano de Buenos Aires, Ciudad Autónoma de Buenos Aires, Argentina
| | - G S Carabelli
- Servicio de Ortopedia, Hospital Italiano de Buenos Aires, Ciudad Autónoma de Buenos Aires, Argentina
| | - B R Boietti
- Servicio de Clínica Médica, Hospital Italiano de Buenos Aires, Ciudad Autónoma de Buenos Aires, Argentina; Área de Investigación en Medicina Interna, Hospital Italiano de Buenos Aires, Ciudad Autónoma de Buenos Aires, Argentina; Sección de Geriatría, Hospital Italiano de Buenos Aires, Ciudad Autónoma de Buenos Aires, Argentina
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Roson M, Benchimol J, Rodota L, Cabrera P, Carabelli GS, Barla JD, Giunta DH, Elizondo MC, Boietti BR. [Effect of nutritional status on mortality and functional recovery in older adults with hip fracture]. Acta Ortop Mex 2020; 34:96-102. [PMID: 33244909] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/11/2023]
Abstract
INTRODUCTION Malnutrition is a common problem in the elderly population but has not been fully studied in elderly people with hip fractures. The goal is to estimate annual mortality based on nutrition in the elderly with hip fracture and compare motor functionality. MATERIAL AND METHODS Retrospective cohort of patients over 65 years of age with hip fracture included in the Institutional Register of The Elderly with Hip Fracture of a University Hospital, between July 2014 and July 2018. Nutritional status with Mini Nutritional Assessment Short-Form (MNA-SF) was assessed at hospital admission. Motor functional capacity was evaluated with Parker Scale (PS) basal, at three and 12 months. RESULTS 1,253 patients were included. 49.92% (CI95% 47.12-52.72) were malnourished. The annual mortality of the well-nourished (WN) was 9.45% (CI95% 7.23-12.30) against 21.52% (CI95% 18.12-25.45; p 0.001) of the malnourished (MN). The risk of death was associated with malnutrition HR 2.45 (CI95% 1.75-3.43; p 0.001). After adjusting it by age, sex, fragility, AVD, Charlson comorbility index and dementia, the risk remained HR 1.71 (CI95% 17-2.49; p = 0.005). With respect to functionality, the basal Parker Scale median (EP) for the WN group was 9 (RIC6-9) and for MN was 5 (RIC3-9) p 0.001, 6 months (RIC3-6) and 4 (RIC2-6) p 0.001 and 12 months 6 (RIC4-7) and 3 (RIC2-6) p 0.001. CONCLUSIONS There is an association between the malnutrition of the elderly with hip fracture and its mortality with a year of evaluation; we also find a difference in motor functionality.
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Affiliation(s)
- M Roson
- Servicio de Alimentación. Hospital Italiano de Buenos Aires. Buenos Aires, Argentina
| | - J Benchimol
- Servicio de Clínica Médica. Hospital Italiano de Buenos Aires. Buenos Aires, Argentina
| | - L Rodota
- Servicio de Alimentación. Hospital Italiano de Buenos Aires. Buenos Aires, Argentina
| | - P Cabrera
- Servicio de Alimentación. Hospital Italiano de Buenos Aires. Buenos Aires, Argentina
| | - G S Carabelli
- Servicio de Ortopedia y Traumatología. Hospital Italiano de Buenos Aires. Buenos Aires, Argentina
| | - J D Barla
- Servicio de Ortopedia y Traumatología. Hospital Italiano de Buenos Aires. Buenos Aires, Argentina
| | - D H Giunta
- Servicio de Clínica Médica. Hospital Italiano de Buenos Aires. Buenos Aires, Argentina
| | - M C Elizondo
- Servicio de Clínica Médica. Hospital Italiano de Buenos Aires. Buenos Aires, Argentina
| | - B R Boietti
- Servicio de Clínica Médica. Hospital Italiano de Buenos Aires. Buenos Aires, Argentina
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Giunta DH, Alonso Serena M. Nonattendance rates of scheduled outpatient appointments in a university general hospital. Int J Health Plann Manage 2019; 34:1377-1385. [PMID: 31062463 DOI: 10.1002/hpm.2797] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2019] [Accepted: 04/09/2019] [Indexed: 11/08/2022] Open
Abstract
OBJECTIVE We aimed to estimate nonattendance to scheduled medical ambulatory appointments rates globally and by subgroups. DESIGN AND PARTICIPANTS We designed a retrospective cohort of all adult outpatients over 18 years old who requested at least one scheduled ambulatory medical appointment from 1 January 2015 to 31 December 2016. SETTING Hospital Italiano de Buenos Aires is a university general hospital in the Autonomous City of Buenos Aires, Argentina. It includes an integrated health care network that is formed by two high complexity hospitals and 22 primary care centers. RESULTS The age median was 60.4 years, and 31.33% of the appointments were scheduled by men; 2 526 549 appointments fulfilled selection criteria, belonging to 348 420 patients. The global nonattendance rate was 27.84% (95% CI, 27.79-27.9). The nonattendance rate to general practitioner appointments was 25.53% (95% CI, 25.42-25.63); to clinical specialties, 27.78% (95% CI, 27.68-27.87); and to surgical specialties, 29.31% (95% CI, 29.23-29.4). CONCLUSIONS Because of the consistent variability of nonattendance in different settings, it is strongly recommended that local estimates are used in the design of effective interventions to improve adherence with outpatient healthcare scheduled appointments.
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Affiliation(s)
- Diego Hernan Giunta
- Internal Medicine Research Unit, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
| | - Marina Alonso Serena
- Internal Medicine Research Unit, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
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Genoud NW, Alonso Serena M, Díaz MH, Esteban JA, Peroni JH, Giunta DH, Grande Ratti MF, Martínez B. [Assessment of an educational intervention regarding blood cultures as process indicators in an emergency department in Argentina]. J Healthc Qual Res 2018; 33:278-283. [PMID: 30401423 DOI: 10.1016/j.jhqr.2018.05.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2018] [Revised: 05/08/2018] [Accepted: 05/10/2018] [Indexed: 06/08/2023]
Abstract
OBJECTIVE The aim of this study was to describe 2 process indicators related to taking blood cultures (BC) in an Adult Emergency Department of a tertiary university hospital in Buenos Aires,and to describe the changes after a series of educational activities for health professionals was implemented during May 2016 as regards the appropriate indication of BC and the proper collection technique. MATERIALS AND METHODS A retrospective cohort study was designed to assess its effectiveness, which consecutively included all patients admitted during 2015-2016. The BC request rate was used as a process indicator, and the percentage of contaminated BCs and the true positives rate were used as quality indicators. Both were measured monthly and prospectively during the period of study. RESULTS The annual adjusted rate of BC requests was 4.9% (95% CI 4.8-5) in 2015 and 2.9% (95% CI 2.8-2.9) in 2016. The rate of false positive (contaminated) BCs was 4.5% in 2015 and 4.3% after the educational intervention. The true positive BCs were 8.3% in 2015 and 12% post-intervention. CONCLUSIONS These findings prove how important and effective the educational interventions are.
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Affiliation(s)
- N W Genoud
- Sección de Infectología, Clínica Médica, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina; Central de Emergencias de Adultos, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
| | - M Alonso Serena
- Área de Investigación en Medicina Interna, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina.
| | - M H Díaz
- Central de Emergencias de Adultos, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina; Clínica Médica, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
| | - J A Esteban
- Central de Emergencias de Adultos, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina; Clínica Médica, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
| | - J H Peroni
- Central de Emergencias de Adultos, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina; Sección de Neumonología, Clínica Médica, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
| | - D H Giunta
- Área de Investigación en Medicina Interna, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina; Clínica Médica, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina; Departamento de Investigación, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
| | - M F Grande Ratti
- Área de Investigación en Medicina Interna, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina; Servicio de Medicina Familiar y Comunitaria, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina; Área Epidemiológica, Dirección de Promoción de la Salud y Control de Enfermedades no Transmisibles, Ministerio de Salud de la Nación, Buenos Aires, Argentina
| | - B Martínez
- Central de Emergencias de Adultos, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina; Clínica Médica, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
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Giunti G, Giunta DH, Guisado-Fernandez E, Bender JL, Fernandez-Luque L. A biopsy of Breast Cancer mobile applications: state of the practice review. Int J Med Inform 2017; 110:1-9. [PMID: 29331247 DOI: 10.1016/j.ijmedinf.2017.10.022] [Citation(s) in RCA: 62] [Impact Index Per Article: 8.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2016] [Revised: 09/11/2017] [Accepted: 10/31/2017] [Indexed: 10/18/2022]
Abstract
BACKGROUND Breast cancer is the most common cancer in women. The use of mobile software applications for health and wellbeing promotion has grown exponentially in recent years. We systematically reviewed the breast cancer apps available in today's leading smartphone application stores and characterized them based on their features, evidence base and target audiences. METHODS A cross-sectional study was performed to characterize breast cancer apps from the two major smartphone app stores (iOS and Android). Apps that matched the keywords "breast cancer" were identified and data was extracted using a structured form. Reviewers independently evaluated the eligibility and independently classified the apps. RESULTS A total of 1473 apps were a match. After removing duplicates and applying the selection criteria only 599 apps remained. Inter-rater reliability was determined using Fleiss-Cohen's Kappa. The majority of apps were free 471 (78.63%). The most common type of application was Disease and Treatment information apps (29.22%), Disease Management (19.03%) and Awareness Raising apps (15.03%). Close to 1 out of 10 apps dealt with alternative or homeopathic medicine. The majority of the apps were intended for patients (75.79%). Only one quarter of all apps (24.54%) had a disclaimer about usage and less than one fifth (19.70%) mentioned references or source material. Gamification specialists determined that 19.36% contained gamification elements. CONCLUSIONS This study analyzed a large number of breast cancer-focused apps available to consumers. There has been a steady increase of breast cancer apps over the years. The breast cancer app ecosystem largely consists of start-ups and entrepreneurs. Evidence base seems to be lacking in these apps and it would seem essential that expert medical personnel be involved in the creation of medical apps.
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Affiliation(s)
- G Giunti
- Salumedia Tecnologias, Seville, Spain; University of Oulu, Oulu, Finland.
| | - D H Giunta
- Internal Medicine Research Unit, Department of Internal Medicine, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
| | - E Guisado-Fernandez
- University College Dublin, Dublin, Ireland; Insight Centre for Data Analytics, University College Dublin, Dublin, Ireland
| | - J L Bender
- ELLICSR Health, Wellness and Cancer Survivorship Centre, Princess Margaret Cancer Centre, University Health Network, Toronto, ON, Canada; Centre for Global eHealth Innovation, Toronto General Hospital, University Health Network, Toronto, ON, Canada; Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada
| | - L Fernandez-Luque
- Qatar Computing Research Institute, Hamad Bin Khalifa University, Qatar Foundation, Doha, Qatar
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Serra MM, Besada CH, Cabana Cal A, Saenz A, Stefani CV, Bauso D, Golimstok AB, Bandi JC, Giunta DH, Elizondo CM. Central nervous system manganese induced lesions and clinical consequences in patients with hereditary hemorrhagic telangiectasia. Orphanet J Rare Dis 2017; 12:92. [PMID: 28521822 PMCID: PMC5437640 DOI: 10.1186/s13023-017-0632-2] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2016] [Accepted: 04/13/2017] [Indexed: 12/18/2022] Open
Abstract
BACKGROUND Around 47-74% of patients with hereditary hemorrhagic telangiectasia (HHT) have hepatic vascular malformations (HVMs); magnetic resonance images (MRI) of the central nervous system (CNS) might show in T1 sequences a hyper-intensity signal in different areas, mainly in the basal ganglia (BG) as consequence of manganese (Mn) deposits as observed in cirrhotic patients. These patients might suffer from different neuropsychiatric disorders (hepatic encephalopathy). In HHT patients, even in the presence of hepatic shunts, hepatocellular function is usually preserved. Additionally, Mn shares iron absorption mechanisms, transferrin and CNS transferrin receptors. In iron deficiency conditions, the Mn may harbor transferrin and access BG. The objectives were to describe frequency of BG Mn deposit-induced lesions (BGMnIL) in HHT patients, its relationship with iron deficiency anemia (IDA) and HVMs. Finally, explore the association between neuropsychological and motor consequences. We performed a cross-sectional study. We determined HHT patients with or without BG-MnIL by the MRI screening of the CNS. We included all patients with lesions and a random sample of those without lesions. All patients underwent standardized and validated neuropsychological assessment to evaluate BG actions. Results were analyzed with multiple logistic regression, adjusting for potential confounders. RESULTS Among 307 participants from a cohort included in the Institutional HHT Registry, 179 patients had MRI performed and Curaçao Criteria ≥3. The prevalence of BG-MnIL was 34.6% (95%CI 27.69-42.09). While neuropsychological symptoms were present in all patients, BG-MnIL patients performed poorly in three of the neuropsychological tests (serial dotting, line tracing time, number connection test A). HVMs frequency in BG-MnIL was 95.1%, versus 71.4% in those without lesions (p < 0.001). IDA frequency was 90.3% versus 54% (p < 0.001). When IDA is present, estimated risk for BG-MnIL is remarkably high (OR 7.73, 95%CI 2.23-26.73). After adjustment for possible confounders (gender, age, presence of HVMs), IDA was still associated with increased risk of BG-MnIL (adjusted OR 6.32, 95% CI 2.32-17.20; p < 0.001). CONCLUSIONS Physicians should assess BG-MnIL in HHT patients in CNS-MRI. IDA and HVMs present increased risk of lesions. Patients with BG-MnIL have neuropsychological impairment, and they might benefit from sparing IDA, or undergoing future therapeutic options. TRIAL REGISTRATION NCT01761981 . Registered January 3rd 2013.
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Affiliation(s)
- M M Serra
- Internal Medicine Department. Hospital Italiano de Buenos Aires. Argentina (HIBA), Presidente Perón 4190, Cuidad Autónoma de Buenos Aires, C1199ABB, Argentina. .,HHT Unit. Hospital Italiano de Buenos Aires, Ciudad Autonoma de Buenos Aires, Argentina. .,ARG (Argentine Rendu Study Group), Ciudad Autonoma de Buenos Aires, Argentina.
| | - C H Besada
- Radiology Department, HIBA, Ciudad Autonoma de Buenos Aires, Argentina
| | - A Cabana Cal
- Neurology Department, HIBA, Ciudad Autonoma de Buenos Aires, Argentina
| | - A Saenz
- ARG (Argentine Rendu Study Group), Ciudad Autonoma de Buenos Aires, Argentina
| | - C V Stefani
- Neurology Department, HIBA, Ciudad Autonoma de Buenos Aires, Argentina
| | - D Bauso
- Neurology Department, HIBA, Ciudad Autonoma de Buenos Aires, Argentina
| | - A B Golimstok
- Neurology Department, HIBA, Ciudad Autonoma de Buenos Aires, Argentina
| | - J C Bandi
- Internal Medicine Department. Hospital Italiano de Buenos Aires. Argentina (HIBA), Presidente Perón 4190, Cuidad Autónoma de Buenos Aires, C1199ABB, Argentina.,HHT Unit. Hospital Italiano de Buenos Aires, Ciudad Autonoma de Buenos Aires, Argentina.,Hepatology area, HIBA, Ciudad Autonoma de Buenos Aires, Argentina
| | - D H Giunta
- Internal Medicine Department. Hospital Italiano de Buenos Aires. Argentina (HIBA), Presidente Perón 4190, Cuidad Autónoma de Buenos Aires, C1199ABB, Argentina.,Internal Medicine Research Unit, HIBA, Ciudad Autonoma de Buenos Aires, Argentina
| | - C M Elizondo
- Internal Medicine Department. Hospital Italiano de Buenos Aires. Argentina (HIBA), Presidente Perón 4190, Cuidad Autónoma de Buenos Aires, C1199ABB, Argentina.,ARG (Argentine Rendu Study Group), Ciudad Autonoma de Buenos Aires, Argentina.,Internal Medicine Research Unit, HIBA, Ciudad Autonoma de Buenos Aires, Argentina
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10
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Warley F, Bonella MB, Giunta DH, Elizondo CM, Ferreyro BL. [Associated factors with the presence of secondary neoplastic cells in the cerebrospinal fluid of patients with suspected carcinomatous meningitis]. Rev Fac Cien Med Univ Nac Cordoba 2017; 74:26-32. [PMID: 28379128] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/07/2023] Open
Abstract
BACKGROUND Improvement in oncologic therapy has increased survival in oncologic patients. There has been a concomitant increase in the incidence of secondary meningeal involvement. Early diagnosis is mandatory. OBJECTIVE To identify factors associated with the presence of secondary neoplastic cells in cerebrospinal fluid of patients with suspected carcinomatous meningitis (CM) Methods: Cross-sectional study involving adult patients with solid cancer diagnosis and suspected CM between 2004 and 2014 at Hospital Italiano de Buenos Aires. All included patients had at least one lumbar puncture with cerebrospinal fluid (CSF) analysis. CM cases were defined by the presence of neoplastic cells in CFS. We evaluated the association of each factor (cancer characteristics, clinical engagement of central nervous system, CSF analysis) with CM using a logistic regression model. RESULTS We included 77 patients: mean age was 62 years (SD 13.1), 58.4% (45) were female. The most common oncologic disease was lung cancer 29.9% (23), followed by breast 23.4% (18) cancer. CM was detected in 23.4% (18) patients. In univariate analysis, glychorrachia, the CSF leukocyte count, the meningeal involvement on MRI, headache and delirium were significantly associated with MC. In the multivariate model that included the variables significantly associated in the crude analysis, the only variable that remained significantly associated with MC was the glychorrachia (OR 0.93 95%CI 0.9 - 0.97, p <0.001). DISCUSSION These results suggest that as the glychorrachia increases, the probability of having MC decreases. These findings are consistent with previous studies.
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Affiliation(s)
- Fernando Warley
- Departamento de Medicina Interna, Hospital Italiano de Buenos Aires. Área de Investigación en Medicina Interna, departamento de Medicina Interna, Hospital Italiano de Buenos Aires
| | - María Belén Bonella
- Departamento de Medicina Interna, Hospital Italiano de Buenos Aires. Área de Investigación en Medicina Interna, departamento de Medicina Interna, Hospital Italiano de Buenos Aires
| | - Diego Hernan Giunta
- Área de Investigación en Medicina Interna, departamento de Medicina Interna, Hospital Italiano de Buenos Aires
| | - Cristina M Elizondo
- Área de Investigación en Medicina Interna, departamento de Medicina Interna, Hospital Italiano de Buenos Aires
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Aguirre MA, Boietti BR, Nucifora E, Sorroche PB, González Bernaldo de Quirós F, Giunta DH, Posadas-Martínez ML. Incidence rate of amyloidosis in patients from a medical care program in Buenos Aires, Argentina: a prospective cohort. Amyloid 2016; 23:184-187. [PMID: 27470486 DOI: 10.1080/13506129.2016.1207626] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
BACKGROUND There are limited data concerning the incidence density (ID) of ATTRwt, AL and AA amyloidosis in the Argentinean population. Our aim was to estimate the ID of ATTRwt, AL and AA amyloidosis at the Hospital Italiano Medical Care Program in Buenos Aires, Argentina. METHODS Population was all members of a hospital-based health maintenance organization who were affiliated since January 2006 to December 2014. Each person was followed contributing time at risk since January 2006 or enrollment date to the final date. Incident cases of amyloidosis were captured from the institutional registry of amyloidosis. Incidence rate was calculated with 95% confidence intervals. RESULTS During the nine-year study period, there were 15 patients with ATTRwt, 12 with AL and 2 with AA amyloidosis for 1 105 152 person-years of follow-up. The crude ID of ATTRwt amyloidosis was 13.5 (95%CI 8.1-22.4), that of AL amyloidosis 11 (95%CI: 6-19) and that of AA amyloidosis 1.8 (95%CI: 0.5-7.2) per 1 000 000 person-years. The highest ID was found in men (31.7 for ATTRwt, 15.9 for AL and 2.27 for AA amyloidosis per 1 000 000 person-years). The ID adjusted to the population of the city of Buenos Aires was 6.46 (95%CI: 3.17-9.74) for ATTRwt, 6.13 (95%CI: 2.57-9.7) for AL and 1.21 (95%CI: 0.56 to 2.99) for AA amyloidosis. CONCLUSIONS This is the first paper to report the incidence density of ATTRwt, AL and AA amyloidosis in Latin America. Our results are consistent with other studies from other regions. Although systemic amyloidosis is a rare disease, it is a major health problem because of its morbi-mortality.
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Affiliation(s)
- María Adela Aguirre
- a Internal Medicine Department, Hospital Italiano de Buenos Aires , Argentina
| | | | - Elsa Nucifora
- a Internal Medicine Department, Hospital Italiano de Buenos Aires , Argentina
| | | | | | - Diego Hernan Giunta
- a Internal Medicine Department, Hospital Italiano de Buenos Aires , Argentina
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12
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Ayus JC, Fuentes NA, Negri AL, Moritz ML, Giunta DH, Kalantar-Zadeh K, Nigwekar SU, Thadhani RI, Go AS, De Quiros FGB. Mild prolonged chronic hyponatremia and risk of hip fracture in the elderly. Nephrol Dial Transplant 2016; 31:1662-9. [PMID: 27190372 DOI: 10.1093/ndt/gfw029] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2016] [Accepted: 01/29/2016] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Hip fractures are among the most serious bone fractures in the elderly, producing significant morbidity and mortality. Several observational studies have found that mild hyponatremia can adversely affect bone, with fractures occurring as a potential complication. We examined if there is an independent association between prolonged chronic hyponatremia (>90 days duration) and risk of hip fracture in the elderly. METHODS We performed a retrospective cohort study in adults >60 years of age from a prepaid health maintenance organization who had two or more measurements of plasma sodium between 2005 and 2012. The incidence of hip fractures was assessed in a very restrictive population: subjects with prolonged chronic hyponatremia, defined as plasma sodium values <135 mmol/L, lasting >90 days. Multivariable Cox regression was performed to determine the hazard ratio (HR) for hip fracture risk associated with prolonged chronic hyponatremia after adjustment for the propensity to have hyponatremia, fracture risk factors and relevant baseline characteristics. RESULTS Among 31 527 eligible patients, only 228 (0.9%) had prolonged chronic hyponatremia. Mean plasma sodium was 132 ± 5 mmol/L in hyponatremic patients and 139 ± 3 mmol/L in normonatremic patients (P < 0.001). The absolute risk for hip fracture was 7/282 in patients with prolonged chronic hyponatremia and 411/313 299 in normonatremic patients. Hyponatremic patients had a substantially elevated rate of hip fracture [adjusted HR 4.52 (95% CI 2.14-9.6)], which was even higher in those with moderate hyponatremia (<130 mmol/L) [adjusted HR 7.61 (95% CI 2.8-20.5)]. CONCLUSION Mild prolonged chronic hyponatremia is independently associated with hip fracture risk in the elderly population, although the absolute risk is low. However, proof that correcting hyponatremia will result in a reduction of hip fractures is lacking.
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Affiliation(s)
- Juan Carlos Ayus
- Renal Consultants of Houston, Houston, TX, USA Nephrology Section, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
| | - Nora Angelica Fuentes
- Internal Medicine Research Unit, Internal Medicine Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
| | - Armando Luis Negri
- Instituto de Investigaciones Metabólicas, Universidad del Salvador, Buenos Aires, Argentina
| | - Michael L Moritz
- Division of Nephrology, Department of Pediatrics, Children's Hospital of Pittsburgh of UPMC, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Diego Hernan Giunta
- Internal Medicine Research Unit, Internal Medicine Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
| | - Kamyar Kalantar-Zadeh
- Division of Nephrology and Hypertension, University of California, Irvine, CA, USA Division of Research, Kaiser Permanente Northern California, Oakland, CA, USA
| | - Sagar U Nigwekar
- Nephrology Division, Massachusetts General Hospital, Boston, MA, USA
| | - Ravi I Thadhani
- Nephrology Division, Massachusetts General Hospital, Boston, MA, USA
| | - Alan S Go
- Division of Research, Kaiser Permanente Northern California, Oakland, CA, USA Departments of Epidemiology, Biostatistics and Medicine, University of California, San Francisco, San Francisco, CA, USA Department of Health Research and Policy, Stanford University School of Medicine, Stanford, CA, USA
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13
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Posadas-Martinez ML, Rojas LP, Vazquez FJ, De Quiros FB, Waisman GD, Giunta DH. Statistical Process Control: A Quality Tool for a Venous Thromboembolic Disease Registry. J Registry Manag 2016; 43:82-86. [PMID: 27556842] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/06/2023]
Abstract
OBJECTIVE We aim to describe Statistical Control Process as a quality tool for the Institutional Registry of Venous Thromboembolic Disease (IRTD), a registry developed in a community-care tertiary hospital in Buenos Aires, Argentina. METHODS The IRTD is a prospective cohort. The process of data acquisition began with the creation of a computerized alert generated whenever physicians requested imaging or laboratory study to diagnose venous thromboembolism, which defined eligible patients. The process then followed a structured methodology for patient's inclusion, evaluation, and posterior data entry. To control this process, process performance indicators were designed to be measured monthly. These included the number of eligible patients, the number of included patients, median time to patient's evaluation, and percentage of patients lost to evaluation. Control charts were graphed for each indicator. RESULTS The registry was evaluated in 93 months, where 25,757 patients were reported and 6,798 patients met inclusion criteria. The median time to evaluation was 20 hours (SD, 12) and 7.7% of the total was lost to evaluation. Each indicator presented trends over time, caused by structural changes and improvement cycles, and therefore the central limit suffered inflexions. CONCLUSION Statistical process control through process performance indicators allowed us to control the performance of the registry over time to detect systematic problems. We postulate that this approach could be reproduced for other clinical registries.
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Vazquez FJ, Posadas-Martínez ML, de Quirós FGB, Giunta DH. Prognosis of patients with suspected pulmonary embolism in Buenos Aires: a prospective cohort study. BMC Pulm Med 2014; 14:200. [PMID: 25510385 PMCID: PMC4274703 DOI: 10.1186/1471-2466-14-200] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2014] [Accepted: 12/11/2014] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND The prognosis of patients with suspected pulmonary embolism (PE) in whom PE has been ruled out (RPE) is unclear. We aimed to evaluate survival and diagnosis of new cancer in suspected PE patients at follow up. METHODS A prospective cohort study nested in a prospective Institutional Registry of Venous Thromboembolic Disease was performed between 2006 and 2011. This study was designed to evaluate all consecutive, incident cases of suspected PE in adults. The study was performed at the Hospital Italiano de Buenos Aires, a tertiary level hospital, in hospitalized patients and outpatients. Suspected PE cases were collected using a computerized system that alerts whenever a physician requests pulmonary angiography, angiotomography, or ventilation-perfusion scintigraphy. PE was defined by pre-specified criteria and RPE was defined when diagnostic tests were negative for PE. RESULTS We included 1736 cases of suspected PE. The prevalence of PE was 29% (n = 504). There was no difference in the overall survival at 30 days and follow-up between PE and RPE patients. The presence of provoked or unprovoked venous thromboembolic disease in these patients did not affect survival. The main causes of death were PE in the confirmed PE group (60%), and neoplasm (42%) and sepsis (37%) in the RPE group. Survival at 90 days was 63% for PE (95% CI 58-67%) and 67% for RPE patients (95% CT 64-69%). At follow-up, there was no difference in diagnosis of new cancer between PE and RPE patients (2% vs 2%, p = 0.82), even when taking into account the unprovoked group. CONCLUSIONS Even when the main cause of death in PE patients is PE itself, the overall mortality is similar between PE and RPE patients. The reason for this finding could be because of the more frequent and severe comorbidities in RPE than in PE patients. TRIAL REGISTRATION HomeClinicalTrial.gov: NCT01372514.
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Affiliation(s)
- Fernando Javier Vazquez
- Department of Internal Medicine, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina.
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Vázquez FJ, Posadas-Martínez ML, Sevilla SG, Giunta DH, Gándara E. The role compression ultrasound in hospitalized patients with suspected pulmonary embolism. Thromb Res 2014; 134:1162-3. [PMID: 25220940 DOI: 10.1016/j.thromres.2014.08.019] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2014] [Revised: 08/18/2014] [Accepted: 08/19/2014] [Indexed: 11/24/2022]
Affiliation(s)
- F J Vázquez
- Internal Medicine Research Unit, Internal Medicine Department, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina; Internal Medicine Department, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina.
| | - M L Posadas-Martínez
- Internal Medicine Research Unit, Internal Medicine Department, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina; Internal Medicine Department, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina.
| | - S G Sevilla
- Department of Medicine, Austral University, Pilar Buenos Argentina.
| | - D H Giunta
- Internal Medicine Research Unit, Internal Medicine Department, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina; Internal Medicine Department, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina.
| | - E Gándara
- Divison of Hematology-Department of Medicine. University of Ottawa-Ottawa Hospital. Ottawa, Canada; Ottawa Hospital Research Institute, Ottawa, Canada
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Cristiano E, Rojas JI, Romano M, Frider N, Machnicki G, Giunta DH, Calegaro D, Corona T, Flores J, Gracia F, Macias-Islas M, Correale J. The epidemiology of multiple sclerosis in Latin America and the Caribbean: a systematic review. Mult Scler 2012; 19:844-54. [DOI: 10.1177/1352458512462918] [Citation(s) in RCA: 53] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
Abstract
The incidence and prevalence of multiple sclerosis (MS) varies geographically as shown through extensive epidemiological studies performed mainly in developed countries. Nonetheless, scant data is available in Latin America and the Caribbean (LAC). The objective of this review is to assess epidemiological data of MS in LAC. We conducted a systematic review of published articles and gray literature from January 1995 to May 2011. Twenty-two studies met the inclusion criteria after full-text review. Incidence data were found in only three studies and ranged from 0.3 to 1.9 annual cases per 100,000 person-years. Prevalence was reported in 10 studies and ranged from 0.83 to 21.5 cases per 100,000 inhabitants. The most prevalent subtype of MS was the relapsing–remitting form (48% to 91% of the series). No data about mortality were found. This study showed low frequency for MS in LAC compared with North American and European countries. The role of environmental and genetic factors should be well studied, providing new insights about its etiology.
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Affiliation(s)
- E Cristiano
- Department of Neurology, MS Clinic, Hospital Italiano de Buenos Aires, Argentina
| | - JI Rojas
- Department of Neurology, MS Clinic, Hospital Italiano de Buenos Aires, Argentina
| | - M Romano
- Department of Neurocience, Centro de Educación Médica e Investigaciones Clínicas Norberto Quirno, CEMIC, Argentina
| | - N Frider
- Regional Medical Director in Neuroscience, Novartis Latinoamerica & Canada
| | - G Machnicki
- Global Health Economics and Outcomes Research, Novartis Latinoamerica & Canada
| | - DH Giunta
- Department of Internal Medicine, Section of Epidemiology, Hospital Italiano de Buenos Aires, Argentina
| | - D Calegaro
- Hospital das Clinicas-Universidade de São Paulo, Brazil
| | - T Corona
- Laboratory of Neurodegenerative Diseases, National Institute of Neurology and Neurosurgery, Mexico
| | - J Flores
- Laboratory of Neurodegenerative Diseases, National Institute of Neurology and Neurosurgery, Mexico
| | - F Gracia
- Multiple Sclerosis Clinic, Santo Tomás Hospital, Panamá
| | - M Macias-Islas
- Neurosciences Department, CUCS, Guadalajara University, Mexico
| | - J Correale
- Department of Neurology, Raúl Carrea Institute for Neurological Research, FLENI, Argentina
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