Erythrocyte sedimentation rate in a population sample of women with special reference to its clinical and prognostic significance

Cancer Risk and Prognosis after a Hospital Contact for an Elevated Erythrocyte Sedimentation Rate

BACKGROUND

An elevated erythrocyte sedimentation rate (ESR) may be a marker of occult cancer.

METHODS

We linked Danish medical databases to examine cancer incidence in patients with a first-time hospital contact for elevated ESR during 1980 to 2013. We calculated standardized incidence ratios (SIR) of cancer compared with the general population, and comorbidity-adjusted HRs (aHR) versus matched population comparisons without elevated ESR. We also compared survival among patients with cancer with elevated ESR with that among patients with cancer without elevated ESR.

RESULTS

During median follow-up of 4.9 years, we observed 3,926 cancers among 18,540 patients with a first-time hospital contact for elevated ESR. The risk for any cancer diagnosed during the first year following the contact for elevated ESR was 8.5% [95% confidence interval (CI), 8.1%-8.9%]. The overall 1-year cancer incidence was markedly elevated [SIR 5.3 (95% CI, 5.1-5.6); aHR 5.8 (95% CI, 5.4-6.3)] and was more than 3-fold elevated for most hematologic cancers and for cancers of the peritoneum and connective tissue in the abdominal wall, kidney, and adrenal glands. After the first year, patients were at increased risk of developing especially hematologic cancers. Patients diagnosed with cancer within 1 year after a contact for elevated ESR had poorer survival compared with matched cancer comparisons [adjusted mortality rate ratio 1.2 (95% CI, 1.1-1.3)].

CONCLUSIONS

Elevated ESR is a strong marker of undiagnosed cancer and is associated with poorer survival.

IMPACT

Our findings may help clinicians in assessing absolute risk, common sites, and prognosis of cancers discovered after hospital contact with elevated ERS.

'I'm fishing really'--inflammatory marker testing in primary care: a qualitative study

Background

Inflammatory markers can be helpful as part of the diagnostic workup for specific diseases or for monitoring disease activity. A third use is as a screening and/or triage tool to differentiate between the presence or absence of disease. Most research into inflammatory markers looks at diagnosis of specific diseases and comes from secondary care. Qualitative studies to explore when and why clinicians use these tests in primary care are lacking.

Aim

To identify clinicians’ approaches to inflammatory marker testing in primary care.

Design and setting

Qualitative study with 26 GPs and nurse practitioners.

Method

Interviews were conducted using a semi-structured topic guide. Clinicians reviewed recent cases of inflammatory marker testing in their pathology inbox. Interviews were audiorecorded and transcribed. Qualitative analysis was conducted by two of the authors.

Results

Clinicians are uncertain about the appropriate use of inflammatory markers and differ in their approach to testing patients with undifferentiated symptoms. Normal or significantly elevated inflammatory markers are seen as helpful, but mildly raised inflammatory markers in the context of non-specific symptoms are difficult to interpret. Clinicians describe a tension between not wanting to ‘miss anything’ and, on the other hand, being wary of picking up borderline abnormalities that can lead to cascades of further tests. Diagnostic uncertainty is a common reason for inflammatory marker testing, with the aim to reassure; however, paradoxically, inconclusive results can generate a cycle of uncertainty and anxiety.

Conclusion

Further research is needed to define when inflammatory marker testing is useful in primary care and how to interpret results.

Ordering and interpreting rheumatologic laboratory tests

Many mechanical and systemic conditions can cause joint pain and synovitis. When rheumatologic illness is suspected, the initial evaluation begins with an accurate history, physical examination, and selective use of confirmatory testing, which can help avoid common pitfalls inherent in serologic evaluation. Tests for erythrocyte sedimentation rate, C-reactive protein level, rheumatoid factor, antinuclear antibodies, anticardiolipin antibodies and lupus anticoagulant, HLA-B27, uric acid level, and Lyme disease, either alone or in combination, may support certain diagnoses. Using these tests nonselectively may yield false-positive results, causing unnecessary concern and expense. However, using these tests effectively may reduce the number of unneeded invasive procedures.

[Development and long-term prognosis of unexplained persistent inflammatory biologic syndromes]

PURPOSE

Unexplained inflammatory syndrome is a frequent and worrying condition in Internal Medicine. However, the long-term clinical outcome of these patients cannot be inferred from the literature. The aim of this study is to describe the long-term follow-up and the prognosis of a group of patients hospitalised for an inflammatory syndrome and discharged without causal diagnosis.

METHODS

This retrospective study was carried out on 46 patients, 15 men and 31 women, aged 21 to 90 years, hospitalised between 1992 and 1999. Data concerning the hospital stay were obtained from the patients' medical record. Follow-up was performed by consulting the treating physician.

RESULTS

The prognosis of these patients is fairly good. In one third of the cases, the inflammatory syndrome resolved spontaneously (n = 13). In the second third, a definite diagnosis was established after discharge (n = 14) and consisted mainly of chronic inflammatory diseases (n = 9), cured with a specific treatment. In the remaining third (n = 12), the inflammatory syndrome persisted, in clinically asymptomatic patients.

CONCLUSION

These results suggest that the persistence of an inflammatory syndrome is not a poor prognostic factor. Thus we propose for patients discharged with an undiagnosed persistent inflammatory syndrome despite thorough investigations, a simple clinical and biological follow-up instead of repeated etiological investigations.

The erythrocyte sedimentation rate in general practice: clinical assessment based on case histories

Thirteen case histories were mailed to 273 general practitioners to study the clinical assessment of the ESR. Participants were asked to state their reference limits for the ESR, as well as action values for the ESR in several clinical situations typical of primary care. The action value should represent the minimal ESR change from a given value necessary to initiate some kind of action towards the patient. The response rate was 76%. In most case histories, half the general practitioners reacted on an ESR change of 10 mm h-1 or less, which is usually due to analytical and biological variation, thus underlining the need for good analytical quality. In general the response was of the same magnitude irrespective of type of case history, i.e. whether the ESR was used in case finding, in diagnosis, or in follow-up. Estimation of the reference limit displayed considerable variation, and knowledge of a previous 'normal' ESR was of minor clinical importance. Furthermore, we found substantial variation regarding the change in ESR necessary to take action in different clinical situations. In principle, for many general practitioners the action value increased as the given ESR increased whereas others reacted on a constant change in ESR, or the change necessary to take action depended on the clinical situation. We conclude that both the different assessments as to the clinical significance of the ESR, and the unawareness of the significance of analytical and biological variation indicate that guidelines for rational use are needed.

Clinical use of the erythrocyte sedimentation rate in the evaluation of febrile intravenous drug users

STUDY OBJECTIVE

To investigate the use of the erythrocyte sedimentation rate in the evaluation of febrile IV drug users.

DESIGN

Prospective observational cohort study.

SETTING

Municipal hospital emergency department.

TYPE OF PARTICIPANTS

One hundred six IV drug users aged 18 years or older, with rectal temperatures of 37.8 C or more.

INTERVENTIONS

Clinical and laboratory variables were obtained by trained research assistants, using a standardized data collection instrument.

RESULTS

The erythrocyte sedimentation rate was the only variable consistently associated with illness severity in both the univariate and multivariable analyses (P < .0001). At an erythrocyte sedimentation rate of 100 mm/hr or more, the test had a specificity of 96% (95% confidence interval, 81% to 100%). In contrast, the erythrocyte sedimentation rate displayed a relatively poor sensitivity at low values (88% [95% confidence interval, 77% to 95%] at an erythrocyte sedimentation rate less than 20).

CONCLUSION

An erythrocyte sedimentation rate of 100 or more should be regarded as a marker for serious illness in IV drug users with fever, but a "normal" erythrocyte sedimentation rate of less than 20 does not reliably exclude the presence of serious disease in this patient population.

The erythrocyte sedimentation rate; its use and usefulness in primary health care

Although the erythrocyte sedimentation rate (ESR) is frequently used and well known to both doctors and patients, the rationale behind its clinical use has been little explored. In this study we evaluated 559 consultations in general practice when an ESR was performed. It was most often done in response to musculoskeletal aches and pains, followed by respiratory tract problems, a general feeling of illness, and abdominal complaints. In half the cases it was used for diagnostic purposes, and in a third for monitoring progression of disease or treatment. In these cases the general practitioners found the test useful. Fourteen per cent were taken as a screening procedure, and were afterwards evaluated as being of little or no clinical value. In 60% of the consultations the test exerted its influence mainly by supporting or reinforcing the doctor's clinical opinion. In 11% the results were unexpected, and forced the doctor to reconsider. In 22% the results were felt to be of little or no clinical consequence. The ESR is perceived as very useful by the doctors when a specific diagnosis is considered. The test in itself is rather unspecific. Its major impact lies in its ability to help reinforce or lessen diagnostic probabilities. It is imperative, though, for the doctor to have a pretest hypothesis against which the test result can be evaluated. An ESR taken without an aim, or when somatic disease is unlikely, is of little or no clinical value.

Clinical utility of erythrocyte sedimentation rate and plasma protein analysis in the elderly

The utilization and interpretation of the erythrocyte sedimentation rate in the elderly have been surrounded by controversy and confusion. To improve the understanding of the erythrocyte sedimentation rate and its determinants in the aged, a defined population of 111 ambulatory, retirement-home residents underwent thorough clinical and laboratory evaluation. Westergren erythrocyte sedimentation rate, Wintrobe erythrocyte sedimentation rate, and plasma viscosity measurements were all significantly correlated with one another as well as with plasma proteins, particularly fibrinogen and globulins. Age per se had no influence on the erythrocyte sedimentation rate in the study population. On the basis of standard upper limits of normal for younger populations, the Wintrobe sedimentation rate was most commonly abnormal and plasma viscosity least commonly abnormal. The "normal" upper limit of 20 mm/hour for Westergren sedimentation rate was also the optimal limit of normal by receiver operating characteristic analysis of the study population. Although the sensitivity of the Westergren sedimentation rate for the presence of an inflammatory condition or monoclonal gammopathy was only 0.55, the specificity was 0.96, and the positive predictive value of an elevated erythrocyte sedimentation rate being associated with a clinical disorder was 0.93. The enhanced clinical utility of the erythrocyte sedimentation rate in this population compared with other elderly populations may be due to a low prevalence of anemia and hypoalbuminemia. In such populations, the erythrocyte sedimentation rate may remain a useful clinical test, regardless of patient age.

Erythrocyte sedimentation rate and cardiovascular disease. Results from a population study of women in Göteborg, Sweden

In a prospective study of a population sample of women, the erythrocyte sedimentation rate (ESR) was studied in relation to the incidence of myocardial infarction, angina pectoris, stroke and intermittent claudication. ESR could not be proved to be predictive of these manifestations of cardiovascular disease. Similar results were obtained when the population was studied cross-sectionally. The ESR was higher in women with hyperlipidaemia (serum triglyceride greater than or equal to 2.0 mmol/l or serum cholesterol greater than or equal to 9 mmol/l), in women with arterial hypertension (treated or untreated, with systolic blood pressure greater than or equal to 160 mm Hg or diastolic blood pressure greater than 95 mm Hg or both) and in overweight women (women within the upper 10 centiles of weight index) compared to women of the same age in the population sample who did not fulfill the criteria according to the above definitions. ESR was similar in hyperuricaemic women (upper 5 centiles of serum uric acid) and in those who were not hyperuricaemic. No association was found between smoking habits and ESR. Weak correlations were found between ESR and serum triglycerides, serum cholesterol and serum uric acid, respectively. Although some correlations were found, ESR cannot replace other examinations in the search for risk factors for cardiovascular disease.

Erythrocyte sedimentation rate in women with different manifestations of joint disease

A comprehensive population study of women aged 44-46 was carried out in Göteborg, Sweden in 1974-75. The mean erythrocyte sedimentation rate (ESR) and the rate of high ESR values (defined as ESR greater than or equal to 30 mm) were higher in women with manifestations of joint diseases than in other women, the differences being statistically significant for women with swollen or deformed finger joints and symptoms from the wrists. Women with manifestations of active joint disease at the time of the examination had even higher ESR values, the differences being statistically significant also for women with symptoms from the finger joints. High ESR values were more common in women with a positive serological test for rheumatoid factor and joint manifestations indicating arthritis and osteoarthrosis. The "arthritis" and "osteoarthrosis" groups each included about one-third of the subjects with rheumatoid factor. It is concluded that although ESR values are moderately increased in subjects with different manifestations of joint disease, the vast majority of such subjects have ESR values less than 30 mm.