OBJECTIVE — To systematically review the incidence of posttransplantation diabetes (PTD), risk factors for its development, prognostic implications, and optimal management. RESEARCH DESIGN AND METHODS — We searched databases (MEDLINE, EMBASE, the Cochrane Library, and others) from inception to September 2000, reviewed bibliographies in reports retrieved, contacted transplantation experts, and reviewed specialty journals. Two reviewers independently determined report inclusion (original studies, in all languages, of PTD in adults with no history of diabetes before transplantation), assessed study methods, and extracted data using a standardized form. Meta-regression was used to explain between-study differences in incidence. RESULTS — Nineteen studies with 3,611 patients were included. The 12-month cumulative incidence of PTD is lower (10% in most studies) than it was 3 decades ago. The type of immunosuppression explained 74% of the variability in incidence (P 0.0004). Risk factors were patient age, nonwhite ethnicity, glucocorticoid treatment for rejection, and immunosuppression with high-dose cyclosporine and tacrolimus. PTD was associated with decreased graft and patient survival in earlier studies; later studies showed improved outcomes. Randomized trials of treatment regimens have not been conducted. CONCLUSIONS — Physicians should consider modification of immunosuppressive regimens to decrease the risk of PTD in high-risk transplant recipients. Randomized trials are needed to evaluate the use of oral glucose-lowering agents in transplant recipients, paying particular attention to interactions with immunosuppressive drugs. Diabetes Care 25:583–592, 2002

A systematic review of the literature

Background Questions remain about the strength and shape of the dose-response relationship between fruit and vegetable intake and risk of cardiovascular disease, cancer and mortality, and the effects of specific types of fruit and vegetables. We conducted a systematic review and meta-analysis to clarify these associations. Methods PubMed and Embase were searched up to 29 September 2016. Prospective studies of fruit and vegetable intake and cardiovascular disease, total cancer and all-cause mortality were included. Summary relative risks (RRs) were calculated using a random effects model, and the mortality burden globally was estimated; 95 studies (142 publications) were included. Results For fruits and vegetables combined, the summary RR per 200 g/day was 0.92 [95% confidence interval (CI): 0.90-0.94, I 2 = 0%, n = 15] for coronary heart disease, 0.84 (95% CI: 0.76-0.92, I 2 = 73%, n = 10) for stroke, 0.92 (95% CI: 0.90-0.95, I 2 = 31%, n = 13) for cardiovascular disease, 0.97 (95% CI: 0.95-0.99, I 2 = 49%, n = 12) for total cancer and 0.90 (95% CI: 0.87-0.93, I 2 = 83%, n = 15) for all-cause mortality. Similar associations were observed for fruits and vegetables separately. Reductions in risk were observed up to 800 g/day for all outcomes except cancer (600 g/day). Inverse associations were observed between the intake of apples and pears, citrus fruits, green leafy vegetables, cruciferous vegetables, and salads and cardiovascular disease and all-cause mortality, and between the intake of green-yellow vegetables and cruciferous vegetables and total cancer risk. An estimated 5.6 and 7.8 million premature deaths worldwide in 2013 may be attributable to a fruit and vegetable intake below 500 and 800 g/day, respectively, if the observed associations are causal. Conclusions Fruit and vegetable intakes were associated with reduced risk of cardiovascular disease, cancer and all-cause mortality. These results support public health recommendations to increase fruit and vegetable intake for the prevention of cardiovascular disease, cancer, and premature mortality.

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Fruit and vegetable intake and the risk of cardiovascular disease, total cancer and all-cause mortality-a systematic review and dose-response meta-analysis of prospective studies.

http://repositorio.inger.gob.mx/jspui/bitstream/20.500.12100/17171/1/PIIS0140673614613477.pdf

The burden of disease in older people and implications for health policy and practice

Older adults in the emergency department: A systematic review of patterns of use, adverse outcomes, and effectiveness of interventions

Colorectal cancer (CRC) ranks third among the most commonly diagnosed cancers worldwide, with wide geographical variation in incidence and mortality across the world. Despite proof that screening can decrease CRC incidence and mortality, CRC screening is only offered to a small proportion of the target population worldwide. Throughout the world there are widespread differences in CRC screening implementation status and strategy. Differences can be attributed to geographical variation in CRC incidence, economic resources, healthcare structure and infrastructure to support screening such as the ability to identify the target population at risk and cancer registry availability. This review highlights issues to consider when implementing a CRC screening programme and gives a worldwide overview of CRC burden and the current status of screening programmes, with focus on international differences.

https://gut.bmj.com/content/gutjnl/64/10/1637.full.pdf

Colorectal cancer screening: a global overview of existing programmes

Background During the siesta, blood pressure declines like it does during night sleep. Because cardiovascular and cerebrovascular events cluster during the morning hours, when hemodynamic changes from nocturnal baseline are maximal, we hypothesized that an additional sleep period during the day (the siesta) may increase cardiovascular and cerebrovascular events, and thus mortality. Methods A prospective population-based cohort study of 455 70-year-old residents of Jerusalem, Israel, using self-reported siesta at baseline and 612years of total mortality data. Results The prevalence of the practice of the siesta was 60.7%. It was more prevalent among men than women (68% vs 51%,P Conclusions The siesta seems to be an independent predictor of mortality. It is still unknown whether this association is causal.

https://jamanetwork.com/journals/jamainternalmedicine/articlepdf/485087/ioi80497.pdf

The Siesta in the Elderly: Risk Factor for Mortality?

Objective To determine the costs and health effects of interventions to combat breast, cervical, and colorectal cancers in order to guide resource allocation decisions in developing countries.

Setting Two World Health Organization sub-regions of the world: countries in sub-Saharan Africa with very high adult and high child mortality (AfrE); and countries in South East Asia with high adult and high child mortality (SearD). 

Design Cost effectiveness analysis of prevention and treatment strategies for breast, cervical, and colorectal cancer, using mathematical modelling based on a lifetime population model.

Data sources Demographic and epidemiological data were taken from the WHO mortality and global burden of disease databases. Estimates of intervention coverage, effectiveness, and resource needs were based on clinical trials, treatment guidelines, and expert opinion. Unit costs were taken from the WHO-CHOICE price database.

Main outcome measures Cost per disability adjusted life year (DALY) averted, expressed in international dollars ($Int) for the year 2005.

Results In both regions certain interventions in cervical cancer control (screening through cervical smear tests or visual inspection with acetic acid in combination with treatment) and colorectal cancer control (increasing the coverage of treatment interventions) cost <$Int2000 per DALY averted and can be considered highly cost effective. In the sub-Saharan African region screening for colorectal cancer (by colonoscopy at age 50 in combination with treatment) costs $Int2000–6000 per DALY averted and can be considered cost effective. In both regions certain interventions in breast cancer control (treatment of all cancer stages in combination with mammography screening) cost $Int2000–6000 per DALY averted and can also be considered cost effective. Other interventions, such as campaigns to eat more fruit and vegetable or subsidies in colorectal cancer control, are not cost effective according to the criteria defined.

Conclusion Highly cost effective interventions to combat cervical and colorectal cancer are available in the African and Asian sub-regions. In cervical cancer control, these include screening through smear tests or visual inspection in combination with treatment. In colorectal cancer, increasing treatment coverage is highly cost effective (screening through colonoscopy is cost effective in the African sub-region). In breast cancer control, mammography screening in combination with treatment of all stages is cost effective.

https://www.bmj.com/content/bmj/344/bmj.e614.full.pdf

Cost effectiveness of strategies to combat breast, cervical, and colorectal cancer in sub-Saharan Africa and South East Asia: mathematical modelling study

The methods that have been used to estimate the clinical and economic impact of vaccination programmes are not always uniform, which makes it difficult to compare results between economic analyses. Furthermore, the relative efficiency of vaccination programmes can be sensitive to some of the more controversial aspects covered by general guidelines for the economic evaluation of healthcare programmes, such as discounting of health gains and the treatment of future unrelated costs. In view of this, we interpret some aspects of these guidelines with respect to vaccination and offer recommendations for future analyses. These recommendations include more transparency and validation, more careful choice of models (tailored to the infection and the target groups), more extensive sensitivity analyses, and for all economic evaluations (also nonvaccine related) to be in better accordance with general guidelines. We use these recommendations to interpret the evidence provided by economic evaluation applied to viral hepatitis vaccination. We conclude that universal hepatitis B vaccination (of neonates, infants or adolescents) seems to be the most optimal strategy worldwide, except in the few areas of very low endemicity, where the evidence to enable a choice between selective and universal vaccination remains inconclusive. While targeted hepatitis A vaccination seems economically unattractive, universal hepatitis A vaccination strategies have not yet been sufficiently investigated to draw general conclusions.

Economic evaluation of vaccination programmes: a consensus statement focusing on viral hepatitis.

OBJECTIVE: To evaluate the cost effectiveness of a short-term home health care program for older people, Home Hospitalization (HH), compared with the alternative of regular ambulatory care with general or geriatric hospitalization as necessary.



SETTING: Our HH was initiated in November 1991 to serve Jerusalem residents. Program staff included physicians, nurses, and paramedical professionals. Other medical/hospital services were provided nonselectively by the general medical personnel of the various hospitals in Jerusalem.



STUDY DESIGN: Patients over the age of 65 were either referred to the HH program (study group; n = 36,500) or to routine medical care (control group; n = 9000) depending on their Sick Fund assignment. Hospital utilization rates per enrollee were studied prospectively and compared both between the two groups and with hospitalization rates in the year before the initiation of the program.



RESULTS: During the first 26 months of operation, the HH program cared for 741 older persons for a total of 37,290 days' care at an average daily cost of $30.06 (1992) and $23.64 (1993). Annual general hospitalization rates per person declined in the study group from 2.80 days in the 1991 baseline period to 2.65 days in 1992 and to 2.54 days in 1993. Hospitalization rates in the control group increased from 2.62 in 1991 to 2.70 days/member and 2.71 days/member in 1992 and 1993, respectively. Annual geriatric hospitalization rates declined considerably in the study group from the 1991 baseline of 1.49 to 1.34 (1992) to 1.33 (1993). The control group experienced a small decrease from 1.64 (1991) to 1.58 (1992) and then a rise to 1.68 days per member in 1993.



For the 26-month duration of the program, estimated savings of 20,773 general hospital days ($5.54 million) and 8486 geriatric hospital days ($0.98 million) exceeded its costs ($0.97 million), providing a cost/benefit ratio of 5.7/1. In addition, patient satisfaction was high.



CONCLUSION: The HH program provided a cost effective substitute for care in a geriatric or general hospital for Jerusalem's elderly.

MODELS OF GERIATRICS PRACTICE: Decreased Hospital Utilization By Older Adults Attributable to a Home Hospitalization Program

Study Objective: To examine the effects of daytime rest without sleep and duration of the siesta on mortality. Design: Longitudinal observation. Setting and Participants: Population sample of 442 community-dwelling 70-year-old subjects examined both at home and in a geriatric hospital. Interventions: N/A Measurements and Results: Overall mortality for those who neither rested nor slept was 9.3%, for those who rested without sleep 10.9%, and for those who slept 19%, p<0.02. Males had higher mortality (19%) than females (10%), p<0.006. Rest without sleep had no effect on mortality: in males, 13%, 21%, 18% for no rest, rest of less than one hour, or more than one hour with respective 8%, 6% and 4% in females. However, daytime sleep in males of more than one hour had 28.2% mortality, whereas sleep of one hour or less had 13.6% mortality, p=0.02. In females mortality rate was not different by sleep duration: 16% and 13.6% for those who slept for one hour or less, or more than one hour, respectively. In a multivariate analysis in females, a siesta of one hour or less was associated with risk odds ratio (ROR) of 4.67 and 95% confidence interval (CI) 1.22 - 17.80 and of one to two hours, ROR was 5.57 and 95% Cl 1.05 -29.49. For males, siesta of less than one hour was not associated with excess risk, ROR 0.9 and 95% Cl 0.39 - 2.38; a siesta of one to two hours with ROR of 2.61 and 95% Cl 1.01 - 6.80; and two hours or more ROR 13.6 and 95% CI 0.98 - 2.10. Conclusions: Rest without sleep is not associated with excess risk of mortality. However, siesta of one to two hours is associated with increased mortality in males whereas, in women, a siesta of less than one hours confers the excess risk.

/pdf/the-siesta-and-mortality-in-the-elderly-effect-of-rest-2lv2eoujk0.pdf

Gary M. Ginsberg

Papers

The Siesta in the Elderly: Risk Factor for Mortality?

Cost effectiveness of strategies to combat breast, cervical, and colorectal cancer in sub-Saharan Africa and South East Asia: mathematical modelling study

Economic evaluation of vaccination programmes: a consensus statement focusing on viral hepatitis.

MODELS OF GERIATRICS PRACTICE: Decreased Hospital Utilization By Older Adults Attributable to a Home Hospitalization Program

The siesta and mortality in the elderly: effect of rest without sleep and daytime sleep duration.