Joel Monárrez-Espino

Revisión sistemática del efecto de las advertencias gráficas impresas en los paquetes de cigarrillos sobre el comportamiento de los fumadores

We used a structured approach to assess whether active smokers presented with pictorial warnings on cigarette packages (PWCP) had a higher probability of quitting, reducing, and attempting to quit smoking than did unexposed smokers. We identified 21 articles from among nearly 2500 published between 1993 and 2013, prioritizing coverage over relevance or quality because we expected to find only a few studies with behavioral outcomes. We found very large heterogeneity across studies, poor or very poor methodological quality, and generally null or conflicting findings for any explored outcome. The evidence for or against the use of PWCP is insufficient, suggesting that any effect of PWCP on behavior would be modest. Determining the single impact of PWCP on behavior requires studies with strong methodological designs and longer follow-up periods.

Type, Number or Both? A Population-Based Matched Case-Control Study on the Risk of Fall Injuries among Older People and Number of Medications beyond Fall-Inducing Drugs

Objectives Drug use is a modifiable risk factor for fall-related injuries in older people. Whereas the injurious effect of polypharmacy is established, that of low numbers of medications has not been fully ascertained. Neither do we know whether it is the number per se or the type of medications that actually matters. We assessed this question for fall injuries leading to hospitalization. Design National register-based, population-based, matched case-control study. Setting Community dwellers aged 65+ years living in Sweden between March 2006 and December 2009. Methods Cases (n = 64,399) were identified in the national inpatient register and four controls per case were randomly matched by gender, date of birth and residential area. The association between number of prescribed medications, assessed through linkage with the Swedish prescribed drug register, and the risk of injurious falls was estimated with odds ratios with 95% confidence intervals using conditional logistic regression, adjusted for demographic and health status. Results The number of medications was associated with an increased risk of fall injury in a dose-response fashion, even after adjustment for marital status, comorbidity and number of fall-risk-inducing drugs (FRIDs). Using ten or more medications was associated with an almost two-fold higher risk (adjusted OR: 1.76, 95% CI: 1.66 to 1.88). When stratified by use (or not) of at least one FRID, the association weakened slightly among both non-users (adjusted OR: 1.50, 95% CI: 1.34 to 1.67) and users (adjusted OR: 1.67, 95% CI: 1.58 to 1.77). Conclusion In older people, not only large but also small numbers of medications may affect the risk for them to sustain injurious falls. Although the mechanisms lying behind this are complex, the finding challenges the prevention strategies targeting either specific types of medications (FRIDs) or high numbers of them.

Number of medications and road traffic crashes in senior Swedish drivers: a population-based matched case-control study

Objective This study investigated the relationship between the number of different medications dispensed (NDMD) to senior drivers and the risk of injurious road traffic crashes (RTCs). Design A matched case-control study with data from various population-based national registers was conducted. Cases were drivers aged 50–80 years involved in a crash in Sweden between 2005 and 2009. Only the first non-alcohol-related RTC was studied. Controls were residents with a valid license who did not crash. Four controls were matched by sex, age (year and month of birth), and place of residence. Exposure to NDMD prior to the crash date was assessed using four time periods: 1–8, 1–15, 1–30 and 1–90 days. Conditional logistic regression was used and analyses adjusted for civil status, occupation and dispensation of medications affecting the cardiovascular or nervous systems (C/N). Results ORs (95% CI) increased progressively with the NDMD. For 1–8 days the OR ranged from 1.15 (1.10 to 1.20) for 1–2 medications to 1.27 (1.13 to 1.42) for five or more medications. The magnitude of the effect declined gradually with longer exposure periods, but remained when five or more medications were used. Adjusting for C/N medications resulted in slightly higher effects; for 1–8 days it ranged from 1.16 (1.10 to 1.23) for 1–2 medications to 1.35 (1.17 to 1.56) for five or more, with similar trends by exposure period. The highest effects were seen for single crashes and for drivers aged 66–80 years. Conclusions The NDMD was linked to the likelihood of a senior driver being involved in an injurious RTC. The strength of the association steadily increased with increased NDMD, especially when medications were taken closer to the index date, or when more than five medications were dispensed.

The role of marital status in the association between benzodiazepines, psychotropics and injurious road traffic crashes: a register-based nationwide study of senior drivers in Sweden.

Background Among senior drivers, benzodiazepines (BZDs) have a documented effect on the risk of road traffic crashes (RTCs). It remains unclear however if BZDs play the same role when considering marital status. Therefore, we aimed to investigate the role of marital status in the association between BZD use and injurious RTCs among senior drivers. Methods Matched case-control study based on five national Swedish registers (n = 154 225). Cases comprised the first non-alcohol-related injurious RTC sustained by drivers aged 50–80 years from July 2005 to December 2009 and controls included registered residents with a valid license who did not crash during that period. Four controls were matched to each case by sex, age and place of residence. Conditional logistic regression analysis for injurious RTC was performed with adjustment for occupation and number of medications. The main exposure was dispensation of BZDs, alone or in combination with other psychotropic medications, 1–30 days prior to the crash date stratified by marital status. Results BZD use, alone or in combination with other psychotropic medications, increased the risk of being involved in an RTC (BZD only: adjusted OR: 1.26, 95% CI: 1.17–1.36; BZDs and other psychotropics: adjusted OR: 1.25, 95% CI: 1.12–1.41). Compared to married drivers, those divorced (1.48, 1.43–1.53) and widowed (1.54; 1.45–1.63) had higher adjusted ORs. Marital status modified the association between BZDs and RTCs, particularly among younger male drivers. Conclusions Both BZDs and marital status independently affect the risk for senior drivers to be involved in an RTC. However, marital status plays a role in the association between BZD use and RTCs and this may have implications for targeting risk populations for RTCs among senior drivers.

Performance of Tuberculin Skin Test Compared to QFT-IT to Detect Latent TB Among High-risk Contacts in Mexico

BACKGROUND AND AIMS We undertook this study to compare the performance of tuberculin skin test (TST) and QuantiFERON-TB-Gold In-tube assay (QFT-IT) to identify latent TB infection (LTBI) among close contacts of pulmonary TB cases. METHODS A cross-sectional study was conducted in north central Mexico. Thirty nine TB index cases diagnosed between 2008 and 2010 and 123 corresponding close contacts were interviewed regarding their exposure time to the index case prior to TB diagnosis and relevant sociodemographic factors. TST (induration ≥5 and ≥10 mm) and QFT-IT (≥0.35 IU/mL) were tested to determine LTBI status. Kappa coefficients were used to assess the agreement between TST and QFT-IT. Multivariate logistic regression modeling using TST and QFT-IT as dependent variables, and cumulative exposure time and sociodemographic variables associated with LTBI were used as independent variables. RESULTS LTBI prevalence in adult contacts was 53.6 and 34.1% when TST cut-offs were set at ≥5 mm and ≥10, respectively, and 41.4% according to QFT-IT. Agreement between TST and QFT-IT was 73.1 and 74.8%, and kappa coefficients 0.47 and 0.46, for TST ≥5 and ≥10 mm, respectively, although these were higher when data were stratified by cumulative exposure, reaching 84.9% and 0.70 for TST ≥5 mm if exposure was ≥500 h/month. None of the predictive variables analyzed for LTBI using multivariate regression was significantly associated. CONCLUSIONS TST ≥5 mm appears to be a useful test to identify LTBI among closely exposed contacts in this geographic setting.

Expression kinetics of metalloproteinases and their tissue inhibitors in experimental murine pulmonary tuberculosis.

ABSTRACT Aim: Explore the temporal expression of metalloproteinases (MMPs) and tissue inhibitors of metalloproteinases (TIMPs) during experimental tuberculosis induced by virulent Mycobacterium tuberculosis strain H37Rv. Methods: BALB/c mice were infected via endotracheal instillation with H37Rv. Groups of mice were euthanized at different time points during infection. RNA was isolated from the lungs, and the expression of MMP-3, 8, 9, 10, 12, 13 and TIMP-1-4 was determined by quantitative PCR. Immunohistochemical detection of MMP-3, MMP-9, and MMP-10 was done to determine the cell source. Results: The infection with H37Rv-induced inflammation resulted in maximal up-regulation of MMP-3, 8, 9, 10, 12 and 13 at day 21 postinfection. Additionally, MMP-13 showed another expression peak during late disease at day 60. Airway epithelium and macrophages were the most common MMP-3 and MMP-9 immunopositive cells, while for MMP-10, macrophages and endothelial cells were the most common, particularly at days 14 and 21 in well-formed granulomas. During late disease, vacuolated macrophages in pneumonic areas and bronchial epithelium showed mild MMP immunostaining. Conclusions: MMP-3, 8, 9, 10, 12, and 13 are maximally expressed at the peak of granuloma formation in the mouse tuberculosis model, with no compensation in levels or timing of TIMP expression. This data opens the possibility of participation of these molecules in the granuloma process.

Impact of vaccination on influenza mortality in children <5 years old in Mexico

BACKGROUND Influenza is a leading cause of respiratory tract infections among children. In Mexico, influenza vaccination was included in the National Immunization Program since 2004. However, the population health effects of the vaccine on children have not been fully described. Thus, we estimated the impact of influenza immunization in terms of mortality associated with this virus among children younger than 5years of age in Mexico. METHODS Mortality rates and years of life lost associated with influenza were estimated using national mortality register data for the period 1998-2012. Age-stratified and cause-specific mortality rates were estimated for all-cause, respiratory and cardiovascular events. Influenza-associated mortality was compared between the period prior to introduction of the influenza vaccine as part of the National Immunization Program (1998-2004) and the period thereafter (2004-2012). RESULTS During the 1998-2012 winter seasons, the average number of all-cause, respiratory and cardiovascular deaths attributable to influenza were 1186, 794 and 21, respectively. Influenza-associated mortality was higher prior to the vaccination period than after influenza was included in the immunization program for all-cause (mean 1660 vs. 780) and respiratory (mean 1063 vs. 563) mortality, but no reduction was seen for cardiovascular mortality. The proportion of all-cause and respiratory deaths attributable to influenza was significantly lower in the post-vaccine period compared with the pre-vaccine period (P<0.001), but no reduction was seen in the proportion of cardiovascular deaths. There was an average annual reduction of 66,558years of life lost in the post-vaccine compared with the pre-vaccine period. CONCLUSION The introduction of influenza vaccination within the Mexican Immunization Program was associated with a reduction in mortality rates attributable to this virus among children younger than 5years of age.

Serial QuantiFERON-TB Gold In-Tube assay and tuberculin skin test to diagnose latent tuberculosis in household Mexican contacts: conversion and reversion rates and associated factors using conventional and borderline zone definitions

A cohort of 123 adult contacts was followed for 18‐24 months (86 completed the follow-up) to compare conversion and reversion rates based on two serial measures of QuantiFERON (QFT) and tuberculin skin test (TST) (PPD from TUBERSOL, Aventis Pasteur, Canada) for diagnosing latent tuberculosis (TB) in household contacts of TB patients using conventional (C) and borderline zone (BZ) definitions. Questionnaires were used to obtain information regarding TB exposure, TB risk factors and socio-demographic data. QFT (IU/mL) conversion was defined as <0.35 to ≥0.35 (C) or <0.35 to >0.70 (BZ) and reversion was defined as ≥0.35 to <0.35 (C) or ≥0.35 to <0.20 (BZ); TST (mm) conversion was defined as <5 to ≥5 (C) or <5 to >10 (BZ) and reversion was defined as ≥5 to <5 (C). The QFT conversion and reversion rates were 10.5% and 7% with C and 8.1% and 4.7% with the BZ definitions, respectively. The TST rates were higher compared with QFT, especially with the C definitions (conversion 23.3%, reversion 9.3%). The QFT conversion and reversion rates were higher for TST ≥5; for TST, both rates were lower for QFT <0.35. No risk factors were associated with the probability of converting or reverting. The inconsistency and apparent randomness of serial testing is confusing and adds to the limitations of these tests and definitions to follow-up close TB contacts.

Treatment With Bupropion and Varenicline for Smoking Cessation and the Risk of Acute Cardiovascular Events and Injuries: a Swedish Case-Crossover Study

Introduction Bupropion and varenicline are non-nicotine medications used for smoking cessation that mitigate craving and withdrawal symptoms. We aim to investigate whether these drugs increase the risk of selected acute adverse outcomes when used in medical practice. Methods Population-based case-crossover design using data from Swedish health and administrative registers. Adult individuals diagnosed with acute myocardial infarction, stroke, suicide, suicide attempt, fall injury, or that suffered a road traffic crash from 01.10.2006 for bupropion, or from 01.03.2008 for varenicline, until 31.12.2013 were included. Different lengths of exposure periods were analyzed within the 12-week hazard period prior to the adverse outcome (1-14, 15-28, and 29-84 days). The control period was matched using the interval preceding the hazard period (85-168 days), and breaking it up into equivalent periods (85-98, 99-112, and 113-168 days). Conditional logistic regression with each case considered as one stratum was used to estimate adjusted odds ratios (OR) and confidence intervals (CI). Results Neither medication was associated with consistent higher risks for any of the adverse outcomes. For bupropion and varenicline, respectively, in the 1-14 days hazard period, OR (95% CI) were: myocardial infarction 1.14 (0.55 to 2.34) and 1.06 (0.70 to 1.62); stroke 1.16 (0.39 to 3.47) and 1.26 (0.72 to 2.17), and traffic crashes 0.85 (0.39 to 1.85) and 1.48 (0.90 to 2.41). In the other periods, ORs were similar or even lower. For falls and suicidal events ORs were generally below one for both drugs. Conclusion The available evidence suggests that if prescription guidelines are properly followed regarding potential contraindications both of these medications could be considered relatively safe. Implications The reliable exposure and diagnosis assessment used in this nationwide register-based study, along with the number of cases gathered makes this sample one of the largest of its type to assess potential side effects associated with the use of these drugs. Neither medication was associated with consistent higher risks for any of the adverse outcomes studied.

Breakfast Skipping, Anxiety, Exercise, and Soda Consumption are Associated with Diet Quality in Mexican College Students

ABSTEACT Despite the reported poor dietary habits and risk of weight gain in college students, they remain understudied in Mexico. Mexican college students are in a rapidly changing economic environment; a shift from a traditional, homemade cuisine to a diet more heavily influenced by an industrialized culture seems to be occurring, potentially affecting the quality of their dietary intake. A health and nutrition survey was conducted among 450 Mexican college students to study the relationship between sociodemographic factors and diet quality. Dietary data were used to build macro- and micronutrient scores, dichotomized as low and normal quality. Adjusted odds (OR [95% CI]) were computed to determine the probability of low dietary quality. Breakfast skipping (5.3 [1.2, 22.7]) and risk of anxiety (2.3 [1.3, 4.4]) were associated with a greater risk of low macronutrient quality, and caloric intake < 1,800 kcal (5.8 [3.5, 9.7]), breakfast skipping (3.7 [1.4, 10.3]), vigorous exercise ≤ 1 h/wk (2.6 [1.3, 5.2]), and soda consumption > 250 mL/d (2.0 [1.2, 3.3]) with low micronutrient quality.