Intervention Efficacy of Slightly Processed Allergen/Meat in Oral Immunotherapy for Seafood Allergy: A Systematic Review, Meta-Analysis, and Meta-Regression Analysis in Mouse Models and Clinical Patients

Background: Seafood allergy is a significant global health concern that greatly impacts a patient's quality of life. The intervention efficacy of oral immunotherapy (OIT), an emerging intervention strategy, for seafood allergy remains controversial. This study aimed to perform a systematic review and meta-analysis to evaluate the efficacy of slightly processed allergen/meat from fish and crustacea in OIT, both in mouse models and clinical patients. Methods: A comprehensive literature search was performed in four mainstream databases and the EBSCOhost database to identify all relevant case-control and cohort studies. The aim was to elucidate the intervention efficacy, encompassing various processing methods and assessing the efficacy of multiple major allergens in OIT. Results: The meta-analysis included five case-control studies on crustacean allergens in mouse models and 11 cohort studies on meat from fish and crustacea in clinical patients for final quantitative assessments. In mouse models, crustacean allergen substantially decreased the anaphylactic score after OIT treatment (mean difference (MD) = -1.30, p < 0.01). Subgroup analyses with low-level heterogeneities provided more reliable results for crab species (MD = -0.63, p < 0.01, I2 = 0), arginine kinase allergen (MD = -0.83, p < 0.01, I2 = 0), and Maillard reaction processing method (MD = -0.65, p < 0.01, I2 = 29%), respectively. In clinical patients, the main meta-analysis showed that the slightly processed meat significantly increased the incidence rate of oral tolerance (OT, incidence rate ratio (IRR) = 2.90, p < 0.01). Subgroup analyses for fish meat (IRR = 2.79, p < 0.01) and a simple cooking treatment (IRR = 2.36, p = 0.01) also demonstrated a substantial increase in the incidence rate of OT. Sensitivity and meta-regression analyses successfully identified specific studies contributing to heterogeneity in mouse models and clinical patients, although these studies did not impact the overall significant pooled effects. Conclusions: This meta-analysis provides preliminary evidence for the high intervention efficacy of slightly processed allergen/meat from fish and crustacea in OIT, both in mouse models and clinical patients. The Maillard reaction and cooking processing methods may emerge as potentially effective approaches to treating allergen/meat in OIT for clinical patients, offering a promising and specific treatment strategy for seafood allergy. However, these findings should be interpreted cautiously, and further supporting evidence is necessary.

Incidence of melanoma and non-melanoma skin cancer in patients with celiac disease: a systematic review and meta-analysis

There is conflicting observational evidence regarding the association between skin cancer and celiac disease (CD). The purpose of this review was to investigate the incidence rate ratio (IRR) of skin cancer incidence between patients with and without CD. MEDLINE and EMBASE databases were searched on October 27th, 2021 and eight articles were identified for review. Quality assessment was conducted using the Newcastle Ottawa Scale. Seven articles were included in meta-analysis for a pooled estimate of IRR across all skin cancers, malignant melanoma (MM), and non-melanoma skin cancers (NMSC). In total, 74,860 CD patients were followed for 710,214 person-years in the meta-analysis. Overall combined incidence was 99.8 cases per 100,000 person-years. Meta-analysis of all skin cancer incidence showed no significant difference in CD patients compared to controls (IRR: 1.06; 95% CI: 0.95, 1.17; p=0.29; I2: 0%). Five studies reported on MM incidence; there was no significant difference in incidence compared to controls (IRR: 0.87, 95% CI: 0.72, 1.06; p=0.22; I2: 9%). Five studies reported on NMSC incidence, revealing a significantly increased risk of NMSC in CD patients (IRR: 1.14; 95% CI: 1.01, 1.28; p=0.04; I2: 0%). Our findings suggest a significantly increased incidence of NMSC in CD patients compared to control data and no significant association between CD and MM incidence. The findings are limited by the quantity and quality of the evidence. Nonetheless, clinicians should emphasize the importance of sun protection, such as sunscreen usage and self-examination for patients with CD.

Long-Term Opioid Use and Dementia Risk in Patients With Chronic Pain

OBJECTIVE

This study aimed to investigate the association between long-term opioid use and the risk of dementia in patients with chronic pain.

DESIGN

A head-to-head propensity score-matched (PSM) comparative cohort study was conducted to examine the effect of long-term opioid use on dementia risk. A time-varying Cox regression analysis was performed to calculate adjusted hazard ratios (aHRs) with 95% CIs to identify independent predictors of dementia risk.

SETTING AND PARTICIPANTS

The study included 41,636 patients after PSM, with 20,968 in the opioid use group (≥180 defined daily doses per year) and 20,968 in the non-opioid use group.

METHODS

Multivariate Cox regression analysis was conducted to compare the dementia risk between the opioid use and non-opioid use groups. The incidence of dementia was calculated as the number of cases per 10,000 person-years for each group. Adjusted incidence ratios were determined to assess the dementia risk associated with opioid use.

RESULTS

The multivariate Cox regression analysis showed that the aHR for dementia risk in the opioid use group, compared with the non-opioid use group, was 1.86 (95% CI 1.25-2.09; P < .001). The incidence of dementia was higher among opioid users (44.09 per 10,000 person-years) compared with nonusers (38.85 per 10,000 person-years). The adjusted incidence ratio for dementia risk in the opioid use group, compared with the nonuse group, was 1.13 (95% CI: 1.07-1.21, P < .001).

CONCLUSIONS AND IMPLICATIONS

Long-term opioid use may be associated with an increased risk of dementia in patients with chronic pain. These findings highlight the need for cautious prescribing and monitoring of opioid use in this population, considering the potential long-term cognitive implications.

Herpes Zoster Risk in Patients with Rheumatoid Arthritis and Its Association with Medications Used

Rheumatoid arthritis (RA) was associated with the risk of incident herpes zoster (HZ), which might be influenced by medication use by RA patients. We aimed to investigate the association of RA with the risk of incident HZ and how the HZ risk effected by RA medications in CIC RA patients. We conducted an observational study including population-based representative insurance claims data of 19,673 patients with RA and 39,346 matched patients without RA during 1997-2010 from the Taiwan National Health Insurance Research Database; we identified 1651 patients with catastrophic illness-certified (CIC) RA and 11,557 matched patients with non-CIC RA. Exploratory analyses assessed the association between RA/CIC RA and risk of incident HZ and its complications. The association of prescribed medications with HZ risk in CIC RA patients was also estimated. The incidence rates of HZ were higher in CIC RA patients and non-CIC RA than in the matched people without RA (21.95 and 14.03 vs. 7.36 events per 1000 person-years, respectively). The adjusted incidence rate ratio (95% confidence interval (CI)) for HZ was 1.74 (1.65-1.84) in RA patients vs. matched non-RA and 1.65 (1.44-1.89) in CIC RA patients vs. non-CIC RA. For HZ complications, RA had a 2.85-fold higher risk than non-RA, and CIC RA had a 1.78-fold higher risk than non-CIC RA. Moreover, in CIC RA patients, prednisolone use was associated with incident HZ risk compared with prednisolone nonuse (adjusted odds ratio 1.48, 1.08-2.03); prolonged prednisolone use (approximately 5 years) increased the risk (adjusted odds ratio 2.16, 1.46-3.19). Our results suggested that RA was positively associated with HZ risk, particularly in RA patients with prednisolone use.

SARS-CoV-2 Infection Rates Following Use of Regular Compared With Defective Respirators When Caring for COVID-19 Patients: A Retrospective Follow-up Study

BACKGROUND

There is strong observational evidence that respirators are highly effective in protecting the users from being infected with Middle East respiratory syndrome and severe acute respiratory syndrome coronavirus (SARS-CoV), but the evidence for SARS-CoV-2 during daily work is limited. This study utilized a subset of healthcare workers' temporary use of a new brand respirator with frequent defects when caring for coronavirus disease 2019 (COVID-19) patients to assess the protective effect of regular respirators against SARS-CoV-2 infection.

METHODS

We retrospectively followed 463 participants wearing a regular respirator and 168 wearing the new brand respirator day-by-day when caring for COVID-19 patients until testing polymerase chain reaction positive for SARS-CoV-2 between 27th December 2020 and 14th January 2021.

RESULTS

We observed seven and eight incident SARS-CoV-2-infected cases. This corresponded with daily infection rates of 0.2 and 0.5%, an incidence rate ratio of 0.4 [95% confidence interval (CI) 0.1; 1.0], and an incidence rate difference of 0.3% (95% CI -0.1; 0.8) when comparing a regular with the new brand respirator.

DISCUSSION

We regard the new brand respirator a sham intervention, and this study thus provides further evidence for the protective effect of respirators when exposed to SARS-CoV-2 virus.

Corrigendum: Gender differences in tuberculosis incidence rates-A pooled analysis of data from seven high-income countries by age group and time period

[This corrects the article DOI: 10.3389/fpubh.2022.997025.].

Effects of H1-Antihistamines on hepatocellular carcinoma risk in patients with type 2 diabetes mellitus

PURPOSE

H1-antihistamines (AHs) may exert protective effects against cancer. We investigated the association of AH use with hepatocellular carcinoma (HCC) risk in type 2 diabetes mellitus (T2DM) patients without hepatitis B virus (HBV) or hepatitis C virus (HCV) infection.

METHODS

The data of patients with T2DM enrolled from Taiwan's National Health Insurance Research Database were examined for the period of January 1, 2008, to December 31, 2018. We used the Kaplan-Meier method and Cox proportional hazards regression to evaluate the AH use-HCC risk association.

RESULTS

After 1:1 propensity score matching was performed, the two cohorts were each divided into AH users (n = 47,990) and nonusers (n = 47,990). The risk of HCC was significantly lower in AH users than in AH nonusers (adjusted hazard ratio [aHR]: 0.55 95% confidence interval [95% CI], 0.46 to 0.67; IRR: 0.70; 95% CI, 0.60 to 0.84), respectively. The dose-response relationship between AH use and HCC risk was also observed (aHRs: 0.58, 0.56, 0.50, and 0.41 for 28-35, 36-49, 50-77, and >77 cumulative defined daily doses of AH, respectively).

CONCLUSION

AH use can reduce HCC risk in T2DM patients without HBV or HCV infection in a dose-dependent manner.

Prevalence and 5-year trend of incidence for medical illnesses after the diagnosis of bipolar disorder: A nationwide cohort study

OBJECTIVE

Medical comorbidities are prevalent in patients with bipolar disorder. Evaluating longitudinal trends of the incidence of medical illnesses enables implementation of early prevention strategies to reduce the high mortality rate in this at-risk population. However, the incidence risks of medical illnesses in the early stages of bipolar disorder remain unclear. This study investigated the incidence and 5-year trend of medical illnesses following bipolar disorder diagnosis.

METHODS

We identified 11,884 patients aged 13-40 years who were newly diagnosed as having bipolar disorder during 1996-2012 and 47,536 age- and sex-matched controls (1:4 ratio) who represented the general population from Taiwan's National Health Insurance Research Database. We estimated the prevalence and incidence of individual medical illnesses yearly across the first 5 years after the index date. The adjusted incidence rate ratio was calculated to compare the occurrence of specific medical illnesses each year between the bipolar disorder group and control group using the Poisson regression model.

RESULTS

Apart from the prevalence, the adjusted incidence rate ratios of most medical illnesses were >1.00 across the first 5-year period after bipolar disorder diagnosis. Cerebrovascular diseases, ischaemic heart disease, congestive heart failure, other forms of heart disease, renal disease and human immunodeficiency virus infection exhibited the highest adjusted incidence rate ratios during the first year. Except for that of renal disease, the 5-year trends of the adjusted incidence rate ratios decreased for cerebrovascular diseases, cardiovascular diseases (e.g. ischaemic heart disease, other forms of heart disease, and vein and lymphatic disease), gastrointestinal diseases (e.g. chronic hepatic disease and ulcer disease) and communicable diseases (e.g. human immunodeficiency virus infection, upper respiratory tract infection and pneumonia).

CONCLUSION

Incidence risks of medical illnesses are increased in the first year after bipolar disorder diagnosis. Clinicians must carefully evaluate medical illnesses during this period because the mortality rates from medical illnesses are particularly high in people with bipolar disorder.

Gender differences in tuberculosis incidence rates-A pooled analysis of data from seven high-income countries by age group and time period

Introduction

Gender differences in the incidence rates for tuberculosis are occasionally reported. However, the magnitude and consistency of the differences by age group, among different populations, and over extended periods of time are not clear.

Materials and methods

We obtained national data from seven countries from open-access internet sites or personal communications with official representatives. We computed the male-to-female incidence rate ratios (IRRs) by country and year for every age group and pooled these ratios using meta-analytic methods. Meta-regression analysis was performed to estimate the contribution of age, country, and calendar years to the variation in the IRRs.

Results

In the age groups of < 1, 1-4, 5-9, and 10-14, the pooled male-to-female IRRs (with 95% CI) were as follows: 1.21 (1.05, 1.40), 0.99 (0.95, 1.04), 1.01 (0.96, 1.06), and 0.83 (0.77, 0.89), respectively. In the age groups 15-44, 45-64, and 65+ years, incidence rates were significantly higher in men, with IRRs of 1.25 (1.16, 1.35), 1.79 (1.56, 2.06), and 1.81 (1.66, 1.96), respectively. Meta-regression analysis revealed that age significantly contributed to the variation in the IRRs.

Conclusions

There were gender differences in the incidence rates for tuberculosis, with higher rates in boys aged less than one, no significant differences in boys of ages 1-9, and higher rates in boys/men older than 15. The only excess in female gender was in the age group 10-14 years. The age-related gender differences in tuberculosis incidence rates observed over several countries indicate the importance of including sex as a biological variable when assessing the risk factors for tuberculosis.

Ratio estimators of intervention effects on event rates in cluster randomized trials

We consider five asymptotically unbiased estimators of intervention effects on event rates in non‐matched and matched‐pair cluster randomized trials, including ratio of mean counts r1, ratio of mean cluster‐level event rates r2, ratio of event rates r3, double ratio of counts r4, and double ratio of event rates r5. In the absence of an indirect effect, they all estimate the direct effect of the intervention. Otherwise, r1, r2, and r3 estimate the total effect, which comprises the direct and indirect effects, whereas r4 and r5 estimate the direct effect only. We derive the conditions under which each estimator is more precise or powerful than its alternatives. To control bias in studies with a small number of clusters, we propose a set of approximately unbiased estimators. We evaluate their properties by simulation and apply the methods to a trial of seasonal malaria chemoprevention. The approximately unbiased estimators are practically unbiased and their confidence intervals usually have coverage probability close to the nominal level; the asymptotically unbiased estimators perform well when the number of clusters is approximately 32 or more per trial arm. Despite its simplicity, r1 performs comparably with r2 and r3 in trials with a large but realistic number of clusters. When the variability of baseline event rate is large and there is no indirect effect, r4 and r5 tend to offer higher power than r1, r2, and r3. We discuss the implications of these findings to the planning and analysis of cluster randomized trials.

Infectious Respiratory Diseases Decreased during the COVID-19 Pandemic in South Korea

Infectious respiratory diseases are highly contagious and very common, and thus can be considered as one of the leading causes of morbidity and mortality worldwide. We followed up the incidence rates (IRs) of eight infectious respiratory diseases, including chickenpox, measles, pertussis, mumps, invasive pneumococcal disease, scarlet fever, rubella, and meningococcal disease, after COVID-19 mitigation measures were implemented in South Korea, and then compared those with the IRs in the corresponding periods in the previous 3 years. Overall, the IRs of these diseases before and after age- or sex-standardization significantly decreased in the intervention period compared with the pre-intervention periods (p < 0.05 for all eight diseases). However, the difference in the IRs of all eight diseases between the IRs before and after age-standardization was significant (p < 0.05 for all periods), while it was not significant with regard to sex-standardization. The incidence rate ratios for eight diseases in the pre-intervention period compared with the intervention period ranged from 3.1 to 4.1. These results showed the positive effects of the mitigation measures on preventing the development of respiratory infectious diseases, regardless of age or sex, but we need to consider the age-structure of the population to calculate the effect size. In the future, some of these measures could be applied nationwide to prevent the occurrence or to reduce the transmission during outbreaks of these infections. This study provides evidence for strengthening the infectious disease management policies in South Korea.

Do Case-Control Studies Always Estimate Odds Ratios?

Case-control studies are an important part of the epidemiologic literature, yet confusion remains about how to interpret estimates from different case-control study designs. We demonstrate that not all case-control study designs estimate odds ratios. On the contrary, case-control studies in the literature often report odds ratios as their main parameter even when using designs that do not estimate odds ratios. Only studies using specific case-control designs should report odds ratios, whereas the case-cohort and incidence-density sampled case-control studies must report risk ratio and incidence rate ratios, respectively. This also applies to case-control studies conducted in open cohorts, which often estimate incidence rate ratios. We also demonstrate the misinterpretation of case-control study estimates in a small sample of highly cited case-control studies in general epidemiologic and medical journals. We therefore suggest that greater care be taken when considering which parameter is to be reported from a case-control study.

Determinants of Fertility in Bangladesh: Evidence From the 2014 Demographic and Health Survey

This study uses the cumulative fertility approach to examine a wide variety of factors affecting fertility among all ever-married women of childbearing ages in Bangladesh. Data are taken from the 2014 Bangladesh Demographic and Health Survey. The mean number of children ever born for all women is 2.45 and for women aged 40 to 49 years is 3.89. The one-way analysis of variance is performed to observe differences in the mean number of children ever born across the levels of covariates. The generalized linear model with Poisson link function is carried out to examine the effect of covariates on fertility. The incidence rate ratio is greater than one, that is, fertility is higher among women who are Muslims, illiterates, or primary school graduates; have no access to mass media; give the first birth at the age of 15 years or earlier; ever use any contraceptive; and desired three or more babies as the ideal number of children. Type of place of residence, administrative divisions, husband’s education, respondent’s working status, husband’s occupation, age at first marriage, and the spousal age difference are also significant to some extent, especially for assessing the fertility of all women.

Race-, Age-, and Anatomic Site-Specific Gender Differences in Cutaneous Melanoma Suggest Differential Mechanisms of Early- and Late-Onset Melanoma

In order to explore melanoma risk factors through gender-, age-, race-, and site-specific incidence rates, malignant melanoma cases from the Caucasian whites and non-whites were retrieved from the US SEER database. Age-standardized, age-, and site-specific tumor rates were calculated. All races and both genders showed positive annual average percentage changes (AAPCs) over the years, but AAPCs varied at different body sites, with men's trunk exhibiting the fastest increase. Non-whites were diagnosed at a significantly younger age than whites and showed a trend towards fewer gender differences in the age of diagnosis. However, non-whites and whites showed a similar pattern of age-specific gender differences in the incidence rate ratios. A consistent spiked difference (female vs. male, incidence rate ratio (IRR) >2) was observed at or near the age of 20⁻24 in all race groups and at all body sites. The highest female vs. male IRR was found in the hip and lower extremities, and the lowest IRR was found in the head and neck region in all races. These race-, gender-, and site-dependent differences suggest that age-associated cumulative sun exposure weighs significantly more in late-onset melanomas, while genetics and/or pathophysiological factors make important contributions to early-onset melanomas.

The Italian National Rare Diseases Registry: a model of comparison and integration with Hospital Discharge Data

BACKGROUND

Italy has been the first country at European level to implement a population-based public health registry dedicated to rare diseases. This study describes the current situation of the Italian National Rare Diseases Registry (NRDR) and compares its data with those from the National Hospital Discharge Database (HDD).

METHODS

Three rare diseases were analysed: Huntington disease (HD), Hereditary Haemorragic Telangiectasia (HHT) and Prader-Willi Syndrome (PWS), selected for their different characteristics. The two sources (NRDR and HDD) were linked: incidence rate ratio (IRR), sensitivity and predictive positive value (PPV) were calculated.

RESULTS

Incidence rates from NRDR and from HDD were compared by age groups, and IRR calculated: 1.08 for HD, 1.41 for HHT, 1.21 for PSW. For HD, sensitivity was 0.52 and PPV 0.48; for HHT sensitivity was 0.71 and PPV 0.52; for PWS the sensitivity was 0.71 and PPV 0.58. We found a strong regional variability in the results.

CONCLUSIONS

The integrated use of the two sources helps tracking those cases that are not captured by the Registry; further, it is a precious tool to accurately describe clinical histories of rare disease affected individuals, in terms of concomitant pathologies and medical procedures performed during hospitalization.

Projected number of children with isolated spina bifida or down syndrome in England and Wales by 2020

Children with major congenital anomalies often require lifelong access to health and social care services. Estimating future numbers of affected individuals can aid health and social care planning. This study aimed to estimate the number of children aged 0-15 years living with spina bifida or Down syndrome in England and Wales by 2020. Cases of spina bifida and Down syndrome born during 1998-2013 were identified from the Northern Congenital Abnormality Survey and the National Down Syndrome Cytogenetic Register, respectively. The number of infants born with spina bifida during 1998-2019 were estimated by applying the average prevalence rate in the North of England to actual and projected births in England and Wales. Poisson regression was performed to estimate the number of infants born with Down syndrome in England and Wales during 1998-2013 and 2004-2019. The numbers of children aged 0-15 living with spina bifida or Down syndrome in 2014 and in 2020 were then estimated by multiplying year- and age-specific survival estimates by the number of affected births. An estimated 956 children with isolated spina bifida, 623 children with spina bifida and hydrocephalus and 11,592 children with Down syndrome aged 0-15 years will be living in England and Wales by 2020, increases of 7.2%, 12.0% and 12.7% since 2014, respectively. Due to improvements in survival, an increase in population size and changes in maternal age distribution at delivery, we anticipate further increases in the number of children living with spina bifida or Down syndrome by 2020.

Incidence and prevalence of hepatitis B in patients with diabetes mellitus in the UK: A population-based cohort study using the UK Clinical Practice Research Datalink

We assessed the incidence and prevalence of hepatitis B (Hep B) in patients with or without diabetes mellitus (DM) using the UK Clinical Practice Research Datalink (CPRD). This was a retrospective, observational study of diabetic and nondiabetic cohorts aged 0-80 years using CPRD (NCT02324218). Incidence rates (IR) for each cohort were calculated. Crude and adjusted (Poisson regression) IR ratios (IRR) were estimated with 95% confidence intervals (CI) to compare the cohorts. Hep B prevalence stratified by age, and hospitalization related to Hep B was also calculated. Of 7 712 043 subjects identified, 4 839 770 were included (DM: 160 760; non-DM: 4 679 010). Mean ages were 54.4 and 32.0 years, and 57.20% and 50.14% were male in the diabetic and nondiabetic cohorts, respectively. Hep B was identified in 29 diabetic and 845 nondiabetic subjects; IR was 4.03 per 100 000 person-years and 2.88 per 100 000 person-years, respectively. The adjusted IRR was 1.00 (95% CI: 0.70-1.50) between diabetic and nondiabetic cohorts. Hep B prevalence was higher in the diabetic cohort (0.01%-0.26%) than in the nondiabetic cohort (0.00%-0.03%) across the different age groups. Hep B-associated hospitalization IR was higher in the diabetic cohort (4.98-10.91) than the nondiabetic cohort (0.26-2.44). The Hep B IR, hospitalization and prevalence were higher in males in both cohorts. In conclusion, the risk of incident Hep B diagnosis in the diabetic cohort was not different from that in the nondiabetic cohort. However, prevalence of Hep B and Hep B-associated hospitalization rate was higher in the diabetic than in the nondiabetic cohort.

Bicycle helmet effectiveness is not overstated

OBJECTIVE

The objective of this study was to discuss the challenges in estimating bicycle helmet effectiveness from case-control studies of injured cyclists and to estimate helmet effectiveness from cases and available exposure data.

METHODS

Data were extracted from studies of cyclists in Seattle; Victoria and New South Wales, Australia; and The Netherlands. Estimates of helmet use were used as exposure to compute relative risks for Seattle and Victorian data. Cycling distance data are routinely collected in The Netherlands; however, these data cannot be disaggregated by helmet use, which makes it unsuitable for estimating helmet effectiveness. Alternative controls were identified from larger cohorts for the Seattle and New South Wales cases.

RESULTS

Estimates of helmet effectiveness were similar from odds ratios (ORs) using hospital controls or from relative risks (RRs) using helmet use estimates (Seattle: OR = 0.339, RR = 0.444; Victoria: OR = 0.500, RR = 0.353). Additionally, the odds ratios using hospital controls were similar when controls were taken from a larger cohort for head injury of any severity (Seattle: OR = 0.250, alt OR = 0.257; NSW: OR = 0.446, alt OR = 0.411) and for serious head injury (Seattle: OR = 0.135, alt OR = 0.139; NSW: OR = 0.335, alt OR = 0.308). Although relevant exposure data were unavailable for The Netherlands, the odds ratio for helmet effectiveness of those using racing, mountain, or hybrid bikes was similar to other estimates (OR = 0.371).

CONCLUSIONS

Despite potential weaknesses with case-control study designs, the best available evidence suggests that helmet use is an effective measure of reducing cycling head injury.

Secular trend in the incidence of hip fracture in Catalonia, Spain, 2003-2014

Objectives

to describe the secular trend and seasonal variation in the incidence of hip fracture (HF) over 12 years (2003-2014) in Catalonia, the community with the highest incidence of HF in Spain.

Methods

data about age, gender, type of fracture and month of hospitalisation among patients aged 65 years and older discharged with a diagnosis of HF were collected. Crude and age-standardised annual incidence rate were reckoned. To analyse HF trend, the age/sex-adjusted average annual change in incidence (incidence rate ratio, IRR) was calculated.

Results

we identified 100,110 HF in the period, with an increase of 16.9% (women 13.4%; men 28.4%). Trochanteric fractures were the most frequent (55.8%). The crude incidence rate (per 100,000 population) decreased from 677.2 (95% confidence interval (95% CI) 662.0-692.7) to 657.6 (95% CI 644.0-671.5). The standardised incidence rate decreased from 754.0 (95% CI 738.6-769.3) to 641.5 (95% CI 627.7-655.3), with a sharp decrease in women (-16.8%) while it was stable in men. The incidence by type of fracture was stable. The trend throughout the period showed a slight decrease with IRR 0.99 (95% CI 0.98-0.99; P = 0.025). The incidence was stable in the oldest group (+85 years), while there was a downward trend in the younger groups. A significant seasonal pattern was observed, with more cases in winter and less in summer (spring as reference).

Conclusions

the secular trend reveals a decreasing incidence of HF although the absolute number has increased in the last 12 years in Catalonia. Trochanteric fractures were the most prevalent and a seasonal pattern was observed, with more cases in winter.

Smoking and renal function in people living with human immunodeficiency virus: a Danish nationwide cohort study

INTRODUCTION

Smoking is a main risk factor for morbidity and mortality in people living with human immunodeficiency virus (PLHIV), but its potential association with renal impairment remains to be established.

METHODS

We did a nationwide population-based cohort study in Danish PLHIV to evaluate the association between smoking status and 1) overall renal function and risk of chronic kidney disease (CKD), 2) risk of any renal replacement therapy (aRRT), and 3) mortality following aRRT. We calculated estimated creatinine clearance using the Cockcroft-Gault equation (CG-CrCl), and evaluated renal function graphically. We calculated cumulative incidence of CKD (defined as two consecutive CG-CrCls of ≤60 mL/min, ≥3 months apart) and aRRT and used Cox regression models to calculate incidence rate ratios (IRRs) for risk of CKD, aRRT, and mortality rate ratios (MRRs) following aRRT.

RESULTS

From the Danish HIV Cohort Study, we identified 1,475 never smokers, 768 previous smokers, and 2,272 current smokers. During study period, we observed no association of smoking status with overall renal function. Previous and current smoking was not associated with increased risk of CKD (adjusted IRR: 1.1, 95% confidence interval [CI]: 0.7-1.7; adjusted IRR: 1.3, 95% CI: 0.9-1.8) or aRRT (adjusted IRR: 0.8, 95% CI: 0.4-1.7; adjusted IRR: 0.9, 95% CI: 0.5-1.7). Mortality following aRRT was high in PLHIV and increased in smokers vs never smokers (adjusted MRR: 3.8, 95% CI: 1.3-11.2).

CONCLUSION

In Danish PLHIV, we observed no strong association between smoking status and renal function, risk of CKD, or risk of aRRT, but mortality was increased in smokers following aRRT.

Inflammatory bowel disease is associated with an increased risk of melanoma: a systematic review and meta-analysis

BACKGROUND & AIMS

Inflammatory bowel disease (IBD) has been associated with an increased risk of nonmelanoma skin cancer, particularly among patients treated with thiopurines. It is unclear whether IBD affects risk for melanoma. We performed a systematic review and meta-analysis of cohort studies to determine the risk of melanoma in patients with IBD.

METHODS

We conducted a systematic search of bibliographic databases through March 2013. Cohort studies reporting incident melanoma after IBD diagnosis and an estimate of incidence rate ratio or standardized incidence rate were included in the analysis. Pooled relative risk (RR) estimates with 95% confidence intervals (CIs) were calculated using the random-effects model.

RESULTS

Our analysis included 12 studies, comprising a total of 172,837 patients with IBD; 179 cases of melanoma were reported from 1940 to 2009. The pooled crude incidence rate of melanoma in patients with IBD was 27.5 cases/100,000 person-years (95% CI, 19.9-37.0). Overall, IBD was associated with a 37% increase in risk of melanoma (12 studies: RR, 1.37; 95% CI, 1.10-1.70). The risk was increased among patients with Crohn's disease (7 studies: RR, 1.80; 95% CI, 1.17-2.75) and ulcerative colitis (7 studies: RR, 1.23; 95% CI, 1.01-1.50). The risk of melanoma was higher in studies performed before introduction of biologic therapies (before 1998) (8 studies: RR, 1.52; 95% CI, 1.02-2.25) but not in studies performed after 1998 (2 studies: RR, 1.08; 95% CI, 0.59-1.96).

CONCLUSIONS

Based on a meta-analysis, IBD has been associated with an increased risk of melanoma, independent of the use of biologic therapy. Patients diagnosed with IBD should be counseled on their risk for melanoma.

Major increase in admission- and incidence rates of acute colonic diverticulitis

PURPOSE

Hospitalization for acute colonic diverticulitis has become more and more frequent. We studied the changes in the rate of admission and incidence of the disease during the last 25 years.

METHODS

We performed a retrospective analysis of all cases treated for acute diverticulitis during 1988-2012 at one hospital serving a defined population in Mid-Norway. The study made a distinction between admission rates and incidence rates. The admission rates defined the total number of cases admitted, while the incidence rates defined the number of new patients hospitalized for acute diverticulitis (first admission). Poisson regression was used to analyse factors associated with diverticulitis incidence rates.

RESULTS

A total of 851 admissions in 650 different patients were identified, with an overall admission rate of 38.5 (CI 35.9 to 41.1) per 100,000 person-years. The admission rate increased from 17.9 (CI 14.1 to 22.3)/100,000 during 1988-1992 to 51.1 (CI 44.8 to 58.0)/100,000 during 2008-2012. Poisson regression analysis showed a significant increase in admission rates with a factor of 2.8 (C.I. 2.2 to 3.5) during 25 years. The overall incidence rate (IRR) of new patients was 29.4 (CI 27.1 to 31.7)/100,000 person-years. IRR increased significantly with a factor of 2.6 (CI 1.96 to 3.34) during 25 years, while IRR for perforations increased even more, by a factor of 3.3 (CI 1.24 to 8.58).

CONCLUSION

The hospital admission rates as well as incidence rates for acute colonic diverticulitis increased significantly during the 25-year time span.

Comparing the cancer in Ninawa during three periods (1980-1990, 1991-2000, 2001-2010) using Poisson regression

BACKGROUND

Iraq fought three wars in three consecutive decades, Iran-Iraq war (1980-1988), Persian Gulf War in 1991, and the Iraq's war in 2003. In the nineties of the last century and up to the present time, there have been anecdotal reports of increase in cancer in Ninawa as in all provinces of Iraq, possibly as a result of exposure to depleted uranium used by American troops in the last two wars. This paper deals with cancer incidence in Ninawa, the most importance province in Iraq, where many of her sons were soldiers in the Iraqi army, and they have participated in the wars.

MATERIALS AND METHODS

The data was derived from the Directorate of Health in Ninawa. The data was divided into three sub periods: 1980-1990, 1991-2000, and 2001-2010. The analyses are performed using Poisson regressions. The response variable is the cancer incidence number. Cancer cases, age, sex, and years were considered as the explanatory variables. The logarithm of the population of Ninawa is used as an offset. The aim of this paper is to model the cancer incidence data and estimate the cancer incidence rate ratio (IRR) to illustrate the changes that have occurred of incidence cancer in Ninawa in these three periods.

RESULTS

There is evidence of a reduction in the cancer IRR in Ninawa in the third period as well as in the second period. Our analyses found that breast cancer remained the first common cancer; while the lung, trachea, and bronchus the second in spite of decreasing as dramatically. Modest increases in incidence of prostate, penis, and other male genitals for the duration of the study period and stability in incidence of colon in the second and third periods. Modest increases in incidence of placenta and metastatic tumors, while the highest increase was in leukemia in the third period relates to the second period but not to the first period. The cancer IRR in men was decreased from more than 33% than those of females in the first period, more than 39% in the second period, and regressed to 9.56% in the third period.

CONCLUSION

Our paper confirms the media reports that there are increases in the number of cancer cases, but when it analyzed statistically with population growth in the Ninawa province, there are decreases in incidence rates in most cancer types.

Identification of quality of care deficiencies in elderly surgical patients by measuring adherence to process-based quality indicators

BACKGROUND

The ability to measure surgical quality of care is important and can lead to improvements in patient safety. As such, processes should be carried out in an identical fashion for all patients, regardless of how vulnerable or complex they are. Our objectives were to assess quality of surgical care delivered to elderly patients and to determine the association between patient characteristics and quality of care.

STUDY DESIGN

This is a retrospective pilot cohort study, conducted in a single university-affiliated hospital. Using the institution's National Surgical Quality Improvement Program (NSQIP) database (2009 to 2010), 143 consecutive patients 65 years or older, undergoing elective major abdominal surgery, were selected. Adherence to 15 process-based quality indicators (QIs) was measured, and a pass rate was calculated for each individual QI. The association between patient characteristics (age, sex, Charlson Comorbidity Index, functional status, wound class) and patient quality score was assessed using multiple linear regression.

RESULTS

Quality indicators with the lowest pass rates included postoperative delirium screening (0%), level of care documentation (0.7%), cognition and functional assessment at discharge (4.9%), oral intake documentation (12.6%), and pressure ulcer risk assessment (35.0%). The mean patient quality score was 46.8% ± 10.7% (range 16.7% to 75.0%). No association was found between patient characteristics and patient quality score.

CONCLUSIONS

Quality of care delivered to elderly patients undergoing major surgery at our institution was generally poor and independent of patient characteristics. Although quality appears to be uniform across different patients, these results provide targets for quality improvement initiatives.

Does hepatitis C viremia or genotype predict the risk of mortality in individuals co-infected with HIV?

BACKGROUND & AIMS

The influence of HCV-RNA levels and genotype on HCV disease progression is not well studied. The prognostic value of these markers was investigated in HIV/HCV co-infected individuals from the EuroSIDA cohort.

METHODS

EuroSIDA is a prospective cohort of 18,295 HIV-1 infected patients in 105 centres across Europe, Israel, and Argentina. All subjects with known HCV antibody (HCVAb) status (n=13,025) were enrolled in the present study.

RESULTS

4044 (31.0%) patients had detectable HCVAb. After adjustment, HCVAb+ patients had an increased incidence of liver-related death (LRD) compared to HCVAb- individuals (IRR 8.90; 95% CI 5.60-14.14, p<0.0001). Information on HCV-RNA was available for 2709 (67.0%) HCVAb+ patients and 2010 (74.2%) were HCV-RNA+. Of 1907 patients with measured HCV genotype, 1008 (52.9%), 62 (3.3%), 567 (29.7%), and 270 (14.2%) were infected with genotype 1, 2, 3 and 4, respectively. Patients with detectable HCV-RNA had similar incidence of non-LRD, but higher incidence of LRD compared to HCVAb+ aviremic patients (adjusted IRR 1.18; 95% CI 0.93-1.50, p=0.17) and (adjusted IRR 2.11; 95% CI 1.30-3.42, p=0.0025), respectively. In patients with HCV viremia, HCV-RNA levels and HCV genotype did not influence the risk of non-LRD or LRD.

CONCLUSIONS

HCV seropositive HIV patients had a 9-fold increased risk of LRD compared to patients who were HCV seronegative. Risk of death from any cause or LRD was not influenced by level of HCV viremia or HCV genotype.

Do rehospitalization rates differ among injury severity levels in the NIDRR Traumatic Brain Injury Model Systems program?

OBJECTIVE

To compare the rate and nature of rehospitalization in a cohort of patients enrolled in the National Institute on Disability and Rehabilitation Research Traumatic Brain Injury Model Systems (TBIMS) who have disorders of consciousness (DOC) at the time of rehabilitation admission with those in persons with moderate or severe traumatic brain injury (TBI) but without DOC at rehabilitation admission.

DESIGN

Prospective observational study.

SETTING

Inpatient rehabilitation within TBIMS with annual follow-up.

PARTICIPANTS

Of 9028 persons enrolled from 1988 to 2009 (N=9028), 366 from 20 centers met criteria for DOC at rehabilitation admission and follow-up data, and another 5132 individuals met criteria for moderate (n=769) or severe TBI (n=4363).

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Participants and/or their family members completed follow-up data collection including questions about frequency and nature of rehospitalizations at 1 year postinjury. For the subset of participants with DOC, additional follow-up was conducted at 2 and 5 years postinjury.

RESULTS

The DOC group demonstrated an overall 2-fold increase in rehospitalization in the first year postinjury relative to those with moderate or severe TBI without DOC. Persons with DOC at rehabilitation admission have a higher rate of rehospitalization across several categories than persons with moderate or severe TBI.

CONCLUSIONS

Although the specific details of rehospitalization are unknown, greater injury severity resulting in DOC status on rehabilitation admission has long-term implications. Data highlight the need for a longitudinal approach to patient management.

Use of stabilized inverse propensity scores as weights to directly estimate relative risk and its confidence intervals

OBJECTIVES

Inverse probability of treatment weighting (IPTW) has been used in observational studies to reduce selection bias. For estimates of the main effects to be obtained, a pseudo data set is created by weighting each subject by IPTW and analyzed with conventional regression models. Currently, variance estimation requires additional work depending on type of outcomes. Our goal is to demonstrate a statistical approach to directly obtain appropriate estimates of variance of the main effects in regression models.

METHODS

We carried out theoretical and simulation studies to show that the variance of the main effects estimated directly from regressions using IPTW is underestimated and that the type I error rate is higher because of the inflated sample size in the pseudo data. The robust variance estimator using IPTW often slightly overestimates the variance of the main effects. We propose to use the stabilized weights to directly estimate both the main effect and its variance from conventional regression models.

RESULTS

We applied the approach to a study examining the effectiveness of serum potassium monitoring in reducing hyperkalemia-associated adverse events among 27,355 diabetic patients newly prescribed with a renin-angiotensin-aldosterone system inhibitor. The incidence rate ratio (with monitoring vs. without monitoring) and confidence intervals were 0.46 (0.34, 0.61) using the stabilized weights compared with 0.46 (0.38, 0.55) using typical IPTW.

CONCLUSIONS

Our theoretical, simulation results and real data example demonstrate that the use of the stabilized weights in the pseudo data preserves the sample size of the original data, produces appropriate estimation of the variance of main effect, and maintains an appropriate type I error rate.