Federico Angriman

Bicycle Use and Cyclist Safety Following Boston’s Bicycle Infrastructure Expansion, 2009–2012

OBJECTIVES To evaluate changes in bicycle use and cyclist safety in Boston, Massachusetts, following the rapid expansion of its bicycle infrastructure between 2007 and 2014. METHODS We measured bicycle lane mileage, a surrogate for bicycle infrastructure expansion, and quantified total estimated number of commuters. In addition, we calculated the number of reported bicycle accidents from 2009 to 2012. Bicycle accident and injury trends over time were assessed via generalized linear models. Multivariable logistic regression was used to examine factors associated with bicycle injuries. RESULTS Boston increased its total bicycle lane mileage from 0.034 miles in 2007 to 92.2 miles in 2014 (P < .001). The percentage of bicycle commuters increased from 0.9% in 2005 to 2.4% in 2014 (P = .002) and the total percentage of bicycle accidents involving injuries diminished significantly, from 82.7% in 2009 to 74.6% in 2012. The multivariable logistic regression analysis showed that for every 1-year increase in time from 2009 to 2012, there was a 14% reduction in the odds of being injured in an accident. CONCLUSIONS The expansion of Bostons bicycle infrastructure was associated with increases in both bicycle use and cyclist safety.

Weight loss after bariatric surgery in obese adolescents: a systematic review and meta-analysis

Of adolescents in the United States, 20% have obesity and current treatment options prioritize intensive lifestyle interventions that are largely ineffective. Bariatric surgery is increasingly being offered to obese adolescent patients; however, large-scale effectiveness data is lacking. We used MEDLINE, Embase, and Cochrane databases, and a manual search of references to conduct a systematic review and meta-analysis on overall weight loss after gastric band, gastric sleeve, and gastric bypass in obese adolescent patients (age ≤19) and young adults (age ≤21) in separate analyses. We provided estimates of absolute change in body mass index (BMI, kg/m2) and percent excess weight loss across 4 postoperative time points (6, 12, 24, and 36 mo) for each surgical subgroup. Study quality was assessed using a 10 category scoring system. Data were extracted from 24 studies with 4 having multiple surgical subgroups (1 with 3, and 3 with 2 subgroups), totaling 29 surgical subgroup populations (gastric band: 16, gastric sleeve: 5, gastric bypass: 8), and 1928 patients (gastric band: 1010, gastric sleeve: 139, gastric bypass: 779). Mean preoperative BMI (kg/m2) was 45.5 (95% confidence interval [CI]: 44.7, 46.3) in gastric band, 48.8 (95%CI: 44.9, 52.8) in gastric sleeve, and 53.3 (95%CI: 50.2, 56.4) in gastric bypass patients. The short-term weight loss, measured as mean (95%CI) absolute change in BMI (kg/m2) at 6 months, was -5.4 (-3.0, -7.8) after gastric band, -11.5 (-8.8, -14.2) after gastric sleeve, and -18.8 (-10.9, -26.6) after gastric bypass. Weight loss at 36 months, measured as mean (95%CI) absolute change in BMI (kg/m2) was -10.3 (-7.0, -13.7) after gastric band, -13.0 (-11.0, -15.0) after gastric sleeve, and -15.0 (-13.5, -16.5) after gastric bypass. Bariatric surgery in obese adolescent patients is effective in achieving short-term and sustained weight loss at 36 months; however, long-term data remains necessary to better understand its long-term efficacy.

Wells Score and Poor Outcomes Among Adult Patients With Subsegmental Pulmonary Embolism A Cohort Study

Introduction: Since the introduction of computed tomography pulmonary angiography, isolated subsegmental pulmonary embolism has become a commonly recognized clinical problem, but its clinical relevance remains unclear. The objective of the present study was to evaluate the extent to which the simplified Wells score discriminates between patients with varying levels of risk of complications after presenting with subsegmental pulmonary embolism. Materials and Methods: Retrospective cohort study. Patients included had subsegmental pulmonary embolism (1 or multiple emboli limited to subsegmental arteries). Primary explanatory variable was the simplified Wells score, categorized as high (>4) or low (≤4). The primary outcome was time to death or new venous thromboembolism. Kaplan-Meier techniques and Cox regression analysis were used to compare the survival experience of patients with high versus low Wells score with and without adjustment for active malignancy, age, Charlson score, previous venous thromboembolism, and previous major surgery in the last 30 days. Main Results: Seventy-nine patients with subsegmental pulmonary embolism were included. Patients with a high Wells score had a 4-fold increased risk of the composite outcome (hazard ratio = 4.2, 95% confidence interval [CI] = 2.0-8.9, P < .001). Other covariates significantly associated with increased risk in univariate analyses included active malignancy, a low serum albumin, and an increased Charlson score. In multivariate Cox regression analyses adjusting for these other factors, a high Wells score remained significant (hazard ratio 5.5, 95% CI 2.4-12.6, P < .001). Conclusion: High Wells score is associated with death or new venous thromboembolism during follow-up among patients with subsegmental pulmonary embolism. Clinical trial registration: ClinicalTrials.gov number, NCT01372514.

Malformaciones arteriovenosas pulmonares y complicaciones embólicas en pacientes con telangiectasia hemorrágica hereditaria

Patients with hereditary hemorrhagic telangiectasia (HHT) and pulmonary arteriovenous malformation (PAVM) face higher risk of embolic complications. It is not clear whether poor outcomes are related to PAVM severity or pulmonary symptoms. Furthermore, there is currently no available data on HHT patients in Argentina. We conducted a cross sectional study in a teaching hospital in Buenos Aires, Argentina. We describe baseline characteristics of HHT and compare the prevalence of embolic complications in patients with significant PAVM compared to patients without significant PAVM. One hundred and eight consecutive patients were included. Significant PAVM was defined as: contrast echocardiography grade 2 or greater; bilateral PAVM or feeding artery bigger than 3mm; or previous PAVM treatment. Primary composite outcome was defined as: cerebrovascular accident, cerebral abscess or peripheral embolism. 20% of participants had embolic complications, the most frequent one was stroke. Embolic complications were associated with significant PAVM and respiratory symptoms.

Predictive score for estimating cancer after venous thromboembolism: a cohort study

BackgroundVenous thromboembolism (VTE) has been associated with a higher risk of developing malignancy and mortality, and patients with VTE may therefore benefit from increased surveillance. We aimed to construct a clinical predictive score that could classify patients with VTE according to their risk for developing these outcomes.MethodsObservational cohort study using an existing clinical registry in a tertiary academic teaching hospital in Buenos Aires, Argentina. 1264 adult patients greater than 17 years of age presented new VTE between June 2006 and December 2011 and were included in the registry. We excluded patients with previous or incident cancer, those who died during the first month, and those with less than one year of follow up (< 5%). 540 patients were included. Primary outcome was new cancer diagnosis during one year of follow-up, secondary composite outcome was any new cancer diagnosis or death. The score was developed using a multivariable logistic regression model to predict cancer or death.ResultsDuring follow-up, one-quarter (26.4%) of patients developed cancer (9.2%) or died (23.7%). Patients with the primary outcome had more comorbidities, were more likely to have previous thromboembolism and less likely to have recent surgery. The final score developed for predicting cancer alone included previous episode of VTE, recent surgery and comorbidity (Charlson comorbidity score), [AUC of 0.75 (95% CI 0.66-0.84) and 0.79 (95% CI 0.63-0.95) in the derivation and validation cohorts, respectively]. The version of this score developed to predict cancer or death included age, albumin level, comorbidity, previous episode of VTE, and recent surgery [AUC = 0.72 (95% CI 0.66-0.78) and 0.71 (95% CI 0.63-0.79) in the derivation and validation cohorts, respectively].ConclusionsA simple clinical predictive score accurately estimates patients’ risk of developing cancer or death following newly diagnosed VTE. This tool could be used to help reassure low risk patients, or to identify high-risk patients that might benefit from closer surveillance and additional investigations.Trial registrationClinicalTrials.gov: NCT01372514.

Design and Testing of 2 Novel Scores That Predict Global Sagittal Alignment Utilizing Cervical or Lumbar Plain Radiographs

BACKGROUND Global sagittal deformity is an established cause of disability. However, measurements of sagittal alignment are often ignored when patients present with symptoms localizing to the cervical or lumbar spine. OBJECTIVE To develop scoring scales to predict the risk of sagittal malalignment in patients with only cervical or lumbar spine radiographs. METHODS A retrospective review of a prospectively maintained multicenter adult spinal deformity database was performed. Primary outcome (sagittal malalignment) was defined as a C7 plumbline ≥ 50 mm. Two multivariate logistic regressions were performed using patient characteristics and measurements derived from cervical or lumbar radiographs as covariates. Point scores were assigned to age, body mass index (BMI), and lumbar lordosis or T1 slope by rounding their &bgr; coefficients to the nearest integer. RESULTS Nine hundred seventy‐nine patients were included, with 652 randomly assigned to the derivation cohort (used to build the score) and 327 comprising the validation set. Final cervical score for the primary outcome included BMI ≥ 25 (1 point), age ≥ 55 yr (2 points), and T1 slope ≥ 27o (2 points). Final lumbar score for the primary outcome included BMI ≥ 25 (1 point), age ≥ 55 yr (1 point), and lumbar lordosis ≥ 45o (-1 points). High scores for both the cervical and lumbar spine presented with high specificity and positive likelihood ratios of sagittal malalignment. CONCLUSION We developed scoring scales to predict global sagittal malalignment utilizing clinical covariates and cervical or lumbar radiographs. Patients with high scores may prompt imaging with long‐cassette plain films to evaluate for global sagittal imbalance.

Long-Term Antipsychotic Use and Major Cardiovascular Events: A Retrospective Cohort Study

OBJECTIVE Chronic treatment with antipsychotics may result in both metabolic side effects and cardiovascular disease. Our aim was to evaluate the effect of antipsychotic medications categorized by their metabolic side effect profiles as low, intermediate, or high risk on major cardiovascular events. METHODS A retrospective cohort study was conducted in adult outpatients aged 30 years or older initiating antipsychotic treatment from 2002 to 2007. Antipsychotic medications were divided into 3 groups (low-, intermediate-, and high-risk) according to the severity of their side-effect profiles in developing metabolic abnormalities associated with cardiovascular disease. The primary outcome measure was the time to the composite of acute myocardial infarction, acute coronary syndrome, ischemic stroke, peripheral artery disease, or a new revascularization procedure. Inverse probability weighting of a marginal structural Cox model was used to adjust for confounding. RESULTS A total of 1,008 patients were included (mean age = 72.4 years, median follow-up = 36.5 months), and 19.6% of patients experienced the primary outcome. The adjusted hazard ratios of a major cardiovascular event for patients in the high- or intermediate-risk medication groups compared to the low-risk group were 2.82 (95% CI, 1.57-5.05) and 2.57 (95% CI, 1.43-4.63), respectively. CONCLUSIONS Older adult patients under antipsychotic regimens with high or intermediate risk of metabolic side effects may face a higher incidence of major cardiovascular events than those under a low-risk regimen during long-term follow-up.

Prediction of severe toxicity in adult patients under treatment with 5-fluorouracil: a prospective cohort study

5-Fluorouracil (5-FU) has long been used for the treatment of gastrointestinal tumors harboring interindividual variability in both the pharmacokinetic and the pharmacogenetic profiles, which in turn may lead to life-threatening toxicities. We carried out a prospective cohort study of adult patients initiating treatment with 5-FU between 2013 and 2015. Primary exposures of interest were the methylenetetrahydrofolate reductase single nucleotide polymorphism in exons 4 and 7 and 5′-untranslated region-thymidylate synthase VNTR genotypes, in addition to baseline clinical and demographic variables. The primary outcome was the time to the occurrence of severe toxicity. We used a Cox regression model to evaluate patients’ survival and toxicity experience and its association with baseline characteristics and a priori determined genetic polymorphisms. A total of 197 patients were included, 40.1% developed severe toxicity during follow-up. Variables that were significantly associated with developing severe toxicity were the European Organization for Research and Treatment of Cancer functional score [hazard ratio (HR): 0.98; 95% confidence interval (CI): 0.97–0.99]; type of tumor [anus (HR: 2.50; 95% CI: 1.07–5.82), head and neck/esophagus/stomach (HR: 2.95; 95% CI: 1.64–5.33)] and 5-FU continuous infusion regimens over 4–5 days (HR: 9.35; 95% CI: 2.68–32.59). We found a significant association between baseline functional status, type of tumor and continuous infusion regimens and the occurrence of severe toxicity during the follow-up of patients receiving 5-FU. No association was found with the genotypic variants evaluated. Future validation and modeling of an everyday easy-to-use score to predict toxicity among these subgroup of patients remains warranted.

Clinical outcomes of first-line antiretroviral therapy in Latin America: analysis from the LATINA retrospective cohort study

Nearly 2 million people are infected with human immunodeficiency virus (HIV) in Latin America. However, information regarding population-scale outcomes from a regional perspective is scarce. We aimed to describe the baseline characteristics and therapeutic outcomes of newly-treated individuals with HIV infection in Latin America. A Retrospective cohort study was undertaken. The primary explanatory variable was combination antiretroviral therapy based on either a protease inhibitor (PI) or a non-nucleoside reverse transcriptase inhibitor (NNRTI). The main outcome was defined as the composite of all-cause mortality and the occurrence of an AIDS-defining clinical event or a serious non-AIDS-defining event during the first year of therapy. The secondary outcomes included the time to a change in treatment strategy. All analyses were performed according to the intention to treat principle. A total of 937 treatment-naive patients from four participating countries were included (228 patients with PI therapy and 709 with NNRTI–based treatment). At the time of treatment initiation, the patients had a mean age of 37 (SD: 10) years and a median CD4 + T-cell count of 133 cells/mm3 (interquartile range: 47.5–216.0). Patients receiving PI-based regimens had a significantly lower CD4 + count, a higher AIDS prevalence at baseline and a shorter time from HIV diagnosis until the initiation of treatment. There was no difference in the hazard ratio for the primary outcome between groups. The only covariates associated with the latter were CD4 + cell count at baseline, study site and age. The estimated hazard ratio for the time to a change in treatment (NNRTI vs PI) was 0.61 (95% CI 0.47–0.80, p < 0.01). This study concluded that patients living with HIV in Latin America present with similar clinical outcomes regardless of the choice of initial therapy. Patients treated with PIs are more likely to require a treatment change during the first year of follow up.

Factores predictores de mortalidad intrahospitalaria en pacientes adultos con infecciones por Klebsiella pneumoniae resistente a carbapenémicos y colistín: un estudio de cohorte retrospectivo

BACKGROUND The emergence of colistin resistant carbapenemase-producing Klebsiella represents a therapeutic challenge and a worldwide problem. AIM To estimate the in-hospital mortality and identify the associated risk factors among patients with colistin-resistant carbapenemase-producing Klebsiella pneumoniae (KPC) that present with a clinical infection. METHODS We carried a retrospective cohort study, including adult patients infected with colistin-resistant KPC hospitalized at a tertiary teaching hospital in Buenos Aires, Argentina during the year 2016. The main outcome was in-hospital mortality. We used generalized lineal models to evaluate potential predictors of mortality. RESULTS 18 patients that developed a colistin-resistant KPC clinical infection were identified and included in the final analysis. In-hospital mortality in this cohort was 38.9%. The presence of bacteremia, acute renal injury at the time of diagnosis and septic shock were associated with the main outcome. CONCLUSIONS Infections due to colistin-resistant KPC among in-hospital patients was frequent and was associated with high mortality rate. In our cohort, both shock and acute kidney injury were associated with a higher likelihood of poor outcomes. Further studies are warranted to evaluate the role of these and others risk factors so as to aid in the early detection of high risk patients.