The Impact of Socioeconomic Factors,Coverage and Access to Health on Heart Ischemic Disease Mortality in a Brazilian Southern State: A Geospatial Analysis

Background:No other disease has killed more than ischemic heart disease (IHD) for the past few years globally. Despite the advances in cardiology, the response time for starting treatment still leads patients to death because of the lack of healthcare coverage and access to referral centers.Objectives:To analyze the spatial disparities related to IHD mortality in the Parana state, Brazil.Methods:An ecological study using secondary data from Brazilian Health Informatics Department between 2013–2017 was performed to verify the IHD mortality. An spatial analysis was performed using the Global Moran and Local Indicators of Spatial Association (LISA) to verify the spatial dependency of IHD mortality. Lastly, multivariate spatial regression models were also developed using Ordinary Least Squares and Geographically Weighted Regression (GWR) to identify socioeconomic indicators (aging, income, and illiteracy rates), exam coverage (catheterization, angioplasty, and revascularization rates), and access to health (access index to cardiologists and chemical reperfusion centers) significantly correlated with IHD mortality. The chosen model was based on p < 0.05, highest adjusted R² and lowest Akaike Information Criterion.Results:A total of 22,920 individuals died from IHD between 2013–2017. The spatial analysis confirmed a positive spatial autocorrelation global between IDH mortality rates (Moran’s I: 0.633, p < 0.01). The LISA analysis identified six high-high pattern clusters composed by 66 municipalities (16.5%). GWR presented the best model (Adjusted R²: 0.72) showing that accessibility to cardiologists and chemical reperfusion centers, and revascularization and angioplasty rates differentially affect the IHD mortality rates geographically. Aging and illiteracy rate presented positive correlation with IHD mortality rate, while income ratio presented negative correlation (p < 0.05).Conclusion:Regions of vulnerability were unveiled by the spatial analysis where sociodemographic, exam coverage and accessibility to health variables impacted differently the IHD mortality rates in Paraná state, Brazil.Highlights

• The increase in ischemic heart disease mortality rates is related to geographical disparities.
• The IHD mortality is differentially associated to socioeconomic factors, exam coverage, and access to health.
• Higher accessibility to chemical reperfusion centers did not necessarily improve patient outcomes in some regions of the state.
• Clusters of high mortality rate are placed in regions with low amount of cardiologists, income and schooling.

     

Hereditary alpha-tryptasemia in 101 patients with mast cell activation–related symptomatology including anaphylaxis

BackgroundHereditary alpha-tryptasemia (HαT) is an autosomal dominant genetic trait characterized by multiple copies of the alpha-tryptase gene at the TPSAB1 locus. Previously described symptomatology involves multiple organ systems and anaphylaxis. The spectrum of mast cell activation symptoms is unknown, as is its association with specific genotypes.ObjectiveTo describe clinical, laboratory, and genetic characteristics of patients referred for the evaluation of mast cell activation–related symptoms and genotype-confirmed HαT.MethodsWe retrospectively describe clinical characteristics, baseline tryptase, and tryptase genotype in 101 patients. Patients were referred for mast cell activation–related symptoms and underwent genotyping to confirm diagnosis of HαT.ResultsOf 101 patients, 80% were female with average tryptase of 17.2 ng/mL. Tryptase was less than 11.4 ng/mL in 8.9% and greater than 20 ng/mL in 22.3% (range 6.2-51.3 ng/mL). KIT D816V mutation was negative in all subjects tested. 2α:3β was the most common genotype but did not correlate with tryptase levels. Unprovoked anaphylaxis was noted in 57% of the subjects with heterogeneous genotypes. Most common symptoms include gastrointestinal, cutaneous, psychiatric, pulmonary, cardiovascular, and neurologic. A total of 85% of patients were taking H₁- or H₂-antihistamines with partial symptom relief. Omalizumab was effective at suppressing anaphylaxis or urticaria in 94% of the patients.ConclusionHαT encompasses a broad range of baseline tryptase and should be considered in patients with symptoms of mast cell activation and tryptase levels greater than 6.2 ng/mL. Patients may present with complex symptomatology including cutaneous, gastrointestinal, neurologic, and psychiatric symptoms and anaphylaxis, some of which respond to omalizumab.     

Anemia and Hematopoietic Factor Deficiencies in Patients after Endoscopic Gastrostomy: A Nine-Year and 472-Patient Study

Introduction and aims: Patients undergoing percutaneous endoscopic gastrostomy (PEG) may present protein-energy malnutrition, anemia and deficiencies of hematopoietic factors, e.g., iron, folate and vitamin B12. There are no comprehensive studies on anemia or other hematological changes in PEG-patients. Our aim was to evaluate the hematological status of dysphagic patients that had undergone PEG and its association with clinical outcome. Methods: This research comprises a retrospective study of patients followed by our Artificial Feeding Team, submitted to PEG from 2010 to 2018. Patients were divided into two etiological groups: neurological dysphagia (ND) and head/neck or esophageal disorders (HNE). Laboratory data included serum albumin, hemoglobin, mean corpuscular volume, ferritin, transferrin, iron, vitamin B12 and folate. Survival after PEG was recorded in months, until death or December 2018. Results: We evaluated 472 patients; 250 (53%) presented anemia at the moment of gastrostomy, mostly normocytic (n = 219), with laboratory data suggestive of anemia of chronic disease (ACD). Six patients (1.3%) presented vitamin B12 deficiency and 57 (12.1%) presented folate deficit. No statistically significant difference in hemoglobin was found between the etiological groups (p = 0.230). Folate and vitamin B12 levels were lower in the HNE group (p < 0.01). A positive correlation between hemoglobin and survival was present (p < 0.01, r = 0.289), and hemoglobin levels were lower in the deceased population (p < 0.01). Conclusion: Anemia is frequent in PEG-patients, mostly with the features of ACD or multifactorial. It is associated with significant decrease in survival and may be viewed as a marker of severe metabolic distress, signaling poor outcome.     

Discrepancy between clinical and pathological neck staging in oral cavity carcinomas

Introduction

The presence of cervical lymph node metastases in patients with oral cavity squamous cell carcinoma reduces survival by up to 50%.

Teriparatide Followed by Denosumab in Premenopausal Idiopathic Osteoporosis: Bone Microstructure and Strength by HR-pQCT

Premenopausal women with idiopathic osteoporosis (PreMenIOP) have marked deficits in skeletal microstructure. We have reported that sequential treatment with teriparatide and denosumab improves central skeletal bone mineral density (BMD) by dual-energy X-ray absorptiometry and central QCT in PreMenIOP. We conducted preplanned analyses of high-resolution peripheral quantitative computed tomography (HR-pQCT) scans from teriparatide and denosumab extension studies to measure effects on volumetric BMD (vBMD), microarchitecture, and estimated strength at the distal radius and tibia. Of 41 women enrolled in the parent teriparatide study (20 mcg daily), 34 enrolled in the HR-pQCT study. HR-pQCT participants initially received teriparatide (N = 24) or placebo (N = 10) for 6 months; all then received teriparatide for 24 months. After teriparatide, 26 enrolled in the phase 2B denosumab extension (60 mg q6M) for 24 months. Primary outcomes were percentage change in vBMD, microstructure, and stiffness after teriparatide and after denosumab. Changes after sequential teriparatide and denosumab were secondary outcomes. After teriparatide, significant improvements were seen in tibial trabecular number (3.3%, p = 0.01), cortical area and thickness (both 2.7%, p < 0.001), and radial trabecular microarchitecture (number: 6.8%, thickness: 2.2%, separation: −5.1%, all p < 0.02). Despite increases in cortical porosity and decreases in cortical density, whole-bone stiffness and failure load increased at both sites. After denosumab, increases in total (3.5%, p < 0.001 and 3.3%, p = 0.02) and cortical vBMD (1.7% and 3.2%; both p < 0.01), and failure load (1.1% and 3.6%; both p < 0.05) were seen at tibia and radius, respectively. Trabecular density (3.5%, p < 0.001) and number (2.4%, p = 0.03) increased at the tibia, while thickness (3.0%, p = 0.02) increased at the radius. After 48 months of sequential treatment, significant increases in total vBMD (tibia: p < 0.001; radius: p = 0.01), trabecular microstructure (p < 0.05), cortical thickness (tibia: p < 0.001; radius: p = 0.02), and whole bone strength (p < 0.02) were seen at both sites. Significant increases in total vBMD and bone strength parameters after sequential treatment with teriparatide followed by denosumab support the use of this regimen in PreMenIOP. © 2022 American Society for Bone and Mineral Research (ASBMR).     

Effects of physical exercise after treatment of early breast cancer: systematic review and meta-analysis

Purpose

Randomized clinical trials are inconclusive regarding the role of physical exercise in anthropometric measurements, quality of life, and survival in breast cancer patients. Our aim was to conduct a systematic review and meta-analysis to assess the effects of physical exercise on these outcomes in women who went through curative treatment of early-stage breast cancer.

Methods

Pubmed, Embase, Cochrane Library were searched for randomized clinical trial comparing physical exercise (counseling or structured programs with supervised/individualized exercise sessions) with usual care in women that went through for breast cancer treatment. Primary outcomes were overall survival and disease-free survival, while secondary outcomes were weight loss, body mass index, waist–hip ratio, percentage of body fat, and quality of life.

Results

We found 60 randomized clinical trials, only one of them showed mortality data; the HR for mortality was 0.45 (95% CI 0.21–0.97) for the intervention group when compared to the control group. Physical exercise was associated with weight reduction (??1.36 kg, 95% CI ??2.51 to ??0.21, p?=?0.02), lower body mass index (??0.89 kg/m², 95% CI ??1.50 to ??0.28, p?<?0.01), and lower percentage of body fat (??1.60 percentage points, 95% CI ??2.31 to ??0.88, p?<?0.01). There was an increase in the quality of life (standardized mean difference of 0.45, 95% CI 0.20–0.69, p?<?0.01).

Conclusions

The articles found had heterogeneous types of intervention, but they showed significant effects on anthropometric measures and quality of life. Among them, only one study had mortality as outcome and it showed physical exercise as a protective intervention. Despite these findings, publication bias and poor methodological quality were presented. Physical exercise should be advised for breast cancer survivors since it has no adverse effects and can improve anthropometrics measures and quality of life. PROSPERO registry: CRD42014008743.

     

Migration from Mexico to the United States: A high‐speed cancer transition

Differences and similarities in cancer patterns between the country of Mexico and the United States' Mexican population, 11% of the entire US population, have not been studied. Mortality data from 2008 to 2012 in Mexico and California were analyzed and compared for causes of cancer death among adult and pediatric populations, using standard techniques and negative binomial regression. A total of 380,227 cancer deaths from Mexico and California were included. Mexican Americans had 49% and 13% higher mortality than their counterparts in Mexico among males and females, respectively. For Mexican Immigrants in the US, overall cancer mortality was similar to Mexico, their country of birth, but all‐cancers‐combined rates mask wide variation by specific cancer site. The most extreme results were recorded when comparing Mexican Americans to Mexicans in Mexico: with mortality rate ratios ranging from 2.72 (95% CI: 2.44–3.03) for colorectal cancer in males to 0.28 (95% CI: 0.24–0.33) for cervical cancer in females. These findings further reinforce the preeminent role that the environment, in its multiple aspects, has on cancer. Overall, mortality from obesity and tobacco‐related cancers was higher among Mexican origin populations in the US compared to Mexico, suggesting a higher risk for these cancers, while mortality from prostate, stomach, and especially cervical and pediatric cancers was markedly higher in Mexico. Among children, brain cancer and neuroblastoma patterns suggest an environmental role in the etiology of these malignancies as well. Partnered research between the US and Mexico for cancer studies is warranted.