The economic burden of asthma prior to death: a nationwide descriptive study

Background

In addition to the clinical burden, asthma is responsible for a high economic burden. However, little is known about the economic burden of asthma prior to death.

Objective

We performed an economic analysis to describe the costs during 12 and 24 months prior to asthma death between 2013 and 2017 in France.

Methods

An observational cohort study was established using the French national health insurance database. Direct medical and non-medical costs, as well as costs related to absence from the workplace, were included in the analysis.

Results

In total, 3,829 patients were included in the final analysis. Over 24 and 12 months prior to death, total medical costs per patient were €27,542 [26,545-28,641] and €16,815 [16,164-17,545], respectively. Total medical costs clearly increased over 24 months prior to death. Over 12 months prior to death, costs increased significantly according to age categories, with mean total costs of €8,592, €15,038, and €17,845, respectively, for the categories <18 years old, 18-75 years old, and 75+ years old (p < 0.0001). Over 12 months prior to death, costs were statistically higher in patients with a dispensation of six or more SABA canisters compared to those with a dispensation of five or less canisters (p < 0.0001). In multivariate analysis, comorbidities, hospital as location of death, and dispensation of 12 or more canisters of SABA per year are independent factors of the highest costs.

Conclusion

To conclude, the economic burden of asthma death is high and increases with time, age, and SABA dispensation.

[Performing pharmacoepidemiological studies using the French health insurance data warehouse (SNDS): How to translate guidelines into practice]

The French health insurance data warehouse named SNDS is one of the largest medico-administrative in the world allowing for powerful pharmacoepidemiological studies, based on real-life data collected prospectively. In addition to the absolute necessity of a strong pharmacological rationale, recommendations have been thought to improve the quality of pharmacoepidemiological studies. These guidelines emphasize the importance of an accurate definition of the study population, outcome and exposure, especially for studies performed on medico-administrative databases. Compliance with certain guidelines, particularly those concerning the identification of a specific population or an outcome and the definition of risk periods or exposure periods, may be difficult when performing studies on the SNDS because of its structure and the nature of the data recorded. The objective of this article is to provide advice for the conduct of pharmacoepidemiological studies according to the recommendationswhen using the SNDS, given its specificities. The performing of reliable studies from this rich but complex data warehouse requires the expertise of researchers with deep knowledge both in the SNDS and in pharmacological reasoning.

Performing pharmacoepidemiological studies using the French health insurance data warehouse (SNDS): How to translate guidelines into practice

The French health insurance data warehouse named SNDS is one of the largest medico-administrative in the world allowing for powerful pharmacoepidemiological studies, based on real-life data collected prospectively. In addition to the absolute necessity of a strong pharmacological rationale, recommendations have been thought to improve the quality of pharmacoepidemiological studies. These guidelines emphasize the importance of an accurate definition of the study population, outcome and exposure, especially for studies performed on medico-administrative databases. Compliance with certain guidelines, particularly those concerning the identification of a specific population or an outcome and the definition of risk periods or exposure periods, may be difficult when performing studies on the SNDS because of its structure and the nature of the data recorded. The objective of this article is to provide advice for the conduct of pharmacoepidemiological studies according to the recommendations when using the SNDS, given its specificities. The performing of reliable studies from this rich but complex data warehouse requires the expertise of researchers with deep knowledge both in the SNDS and in pharmacological reasoning.

Prevalence and bleeding risk associated with the concomitant use of direct oral anticoagulants and antiarrhythmic drugs in patients with atrial fibrillation, based on the French healthcare insurance database

PURPOSE

Pharmacokinetic interactions exist between apixaban or rivaroxaban, and CYP3A4 and P-glycoprotein inhibitors such as amiodarone, verapamil and diltiazem. We aimed to estimate the prevalence of exposure to this drug-drug association (DDA) and to assess the bleeding risk associated in patients with atrial fibrillation (AF).

METHODS

We conducted a cohort study using a representative 1/97^th sample of the French healthcare insurance database between 2014 and 2019. Patients with AF receiving apixaban or rivaroxaban were included and followed-up until hospitalization for bleeding, death, discontinuation of apixaban or rivaroxaban, exposure to strong CYP3A4 inhibitor, or until December 31^st 2019, whichever came first. Primary outcome was hospitalization for bleeding registered as primary diagnosis. The association between the exposure to the DDA and hospitalization for bleeding was evaluated as a time-dependent variable in Cox model.

RESULTS

Between 2014 and 2019, the AF population under apixaban or rivaroxaban represented 10,392 patients. During the study period, the annual average prevalence of DDA exposure in this population was 38.9%. Among the 10,392 patients, 223 (2.1%) were hospitalized for bleeding, of which 75 (33.6%) received the association and 148 (66.4%) received apixaban or rivaroxaban alone. There was no association between DDA exposure and risk of hospitalization for bleeding (aHR = 1.19, [95% CI: 0.90, 1.58]). Age (HR 1.03 [1.02, 1.05]) and male gender (HR 1.72 [1.28, 2.30]) were associated with an increased risk of hospitalization for bleeding.

CONCLUSION

Exposure to antiarrhythmic drugs was not associated with an increased risk of hospitalization for bleeding in patients with AF under rivaroxaban or apixaban.

Incidence of heart failure following exposure to a protein kinase inhibitor, a French population-based study

AIMS

Pharmacovigilance signals of heart failure (HF) following exposure to protein kinase inhibitors (PKIs) have been detected in recent years. Our aim was to identify the PKIs most frequently associated with the development of HF.

METHODS

Using the French National Healthcare Database, all patients newly exposed to a PKI between January 2011 and June 2014 were followed up for 18 months. Specific hospitalization diagnosis and long-term HF-related disease codes were used to identify HF patients. HF incidence rate ratios (IRRs) were measured and adjusted hazard ratios (aHRs) were estimated using a Cox model. Sensitivity analyses were performed to limit the potential indication and competitive risk bias.

RESULTS

Thirteen PKIs were studied. Among the 49 714 new PKI users registered during the study period, the mean IRR of HF was 3.38 per 100 person-years, with a median time to onset of 155 days. We found a significant increase in the incidence of HF for six medicinal products: pazopanib (aHR = 2.42, 95% confidence interval [CI] 1.67-3.52), dasatinib (aHR = 2.22, 95% CI 1.42-3.44), ruxolitinib (aHR = 2.11, 95% CI 1.69-2.64), crizotinib (aHR = 1.71, 95% CI 1.07-2.72), everolimus (aHR = 1.45, 95% CI 1.26-1.67) and vemurafenib (aHR = 1.37, 95% CI 1.01-1.86). Sensitivity analyses were consistent with our primary analysis.

CONCLUSIONS

The current study provides knowledge on HF following exposure to a PKI. Additional studies could confirm these results for dasatinib, everolimus, pazopanib and ruxolitinib, and particularly for the two medicinal products with results slightly above the significance threshold, namely, crizotinib and vemurafenib, in our sensitivity analyses.

Progressive multifocal leukoencephalopathy: epidemiology and spectrum of predisposing conditions

Population-based data on the epidemiology of progressive multifocal leukoencephalopathy, its predisposing conditions and mortality rate are lacking, although such data are crucial to raise awareness among clinicians and to lay foundations for future therapeutic trials in immunomodulating therapies. In our study, patients were identified by interrogating the French national healthcare reimbursement database from 1 January 2008 to 31 December 2017, using progressive multifocal leukoencephalopathy International Classification of Diseases code and a patient's selection algorithm. Overall incidence rate, 1-year all-cause mortality rate and survival patterns were calculated, and factors associated with death were identified using a multivariate Cox proportional hazards regression model. Our cohort is the largest to date, comprising 584 patients with incident progressive multifocal leukoencephalopathy. The overall incidence in France from 2010 to 2017 was stable during the study period at 0.11 per 100 000 person-years, 95% confidence interval [0.10-0.12]. Predisposing diseases were HIV infection (43.7%), followed by haematological malignancies (21.9%), chronic inflammatory diseases (20.2%), solid organ transplantation (4.3%), solid neoplasm (4.1%) and primary immune deficiency (1.5%). The 1-year mortality rate was 38.2%, with a 95% confidence interval (34.2-42.2). In multivariate analysis, factors independently associated with death were older age [adjusted hazard ratio 0.33 (0.20-0.53) for patients aged 20 to 40 compared with patients aged over 60], male gender [adjusted hazard ratio 0.73 (0.54-0.99) for females compared with males] and predisposing immunosuppressive disease, with the highest risk for solid neoplasms [adjusted hazard ratio 4.34 (2.25-8.37)], followed by haematological malignancies [adjusted hazard ratio 3.13 (1.85-5.30)] and HIV infection [adjusted hazard ratio 1.83 (1.12-3.00)], compared with chronic inflammatory diseases. Immune reconstitution inflammatory syndrome was notified in 7.0% of patients. In conclusion, incidence of progressive multifocal leukoencephalopathy is stable in France, and HIV infection remains the main predisposing disease. This large-size cohort uncovers a higher risk of mortality for male patients compared to females, and the worst prognosis for patients with solid neoplasm, while prognosis in patients with haematological malignancies appeared less dismal than in previous studies.

Healthcare resource consumption prior to asthma-related death: a nationwide descriptive study

BACKGROUND

Although asthma mortality declined sharply until the mid-2000s, a stagnation in mortality has been observed over the past decade in different countries.

OBJECTIVE

The objective of this study is to describe healthcare resource consumption for patients who died from asthma in France.

METHOD

This study was conducted using data from the French National Health Data System. Patients who died from asthma between 2013 and 2017 were identified by the ICD10 codes J45 and J46. Health care consumption data were collected. Patients were categorized into four categories according to age: ⩾75, (18-75), (12-18), (0-12). Daily doses of ICS were categorized according to GINA guidelines.

RESULTS

A total of 3829 patients were included. No ICS or an inadequate ICS dose was observed in 43.8%, 50.6%, 48.1%, and 54.0% of patients aged ⩾75, (18-74), (12-18), and (0-12) years, respectively. Dispensation of six or more SABA canisters was observed in 37.2%, 49.0%, and 70.3% of patients aged of ⩾75, (18-75), and (12-18) years, respectively. Omalizumab dispensation rate was very low [1.1% and 2.8% in patients aged ⩾75 and (18-75) years)]. The proportion of patients with a pulmonologist office visit was 13.8% and 14.6% in patients ⩾75 and (18-75) years, respectively. A lung function test was noted in only 18.6%, 28.3%, and 25.9% of patients ⩾75, (18-75) and (12-18) years, respectively.

CONCLUSION

Half of the patients who died from asthma received inadequate ICS doses and only a small proportion had access to biological therapies. Less than 15% were referred to a specialist.

Incessant pericarditis following the second dose of SARS-CoV-2 mRNA vaccine successfully treated with anakinra: a case report

Background

The SARS-CoV-2 pandemic has led to the development of the first mRNA vaccines used in humans. These vaccines are well tolerated, safe, and highly effective; however, post-marketing surveillance is revealing potential rare adverse effects. We report a case of incessant pericarditis following administration of the second dose of mRNA-1273 SARS-CoV-2 vaccine, unresponsive to conventional therapy, and successfully treated with anakinra.

Case summary

A 30-year-old man presented to the Emergency Department for incessant pericarditis unresponsive to evacuative pericardiocentesis and conventional first-line anti-inflammatory therapy. Given the typical ‘inflammatory phenotype’ clinically characterized by fever, C-reactive protein (CRP) elevation, and leucocytosis, we decided, in agreement with the rheumatologist team, to avoid glucocorticoid and to administer anakinra. A sudden clinical and echocardiographic improvement was observed, with complete resolution of the symptoms and of the pericardial effusion; similarly, CRP values progressively decreased. The patient was discharged at home; no recurrences of pericarditis were described at clinical and instrumental follow-up made 3 months later.

Discussion

Several cases of pericarditis have been described in patients who received the COVID-19 vaccination, especially with the mRNA vaccine that can induce a non-adaptive immunity response against the viral spike protein, triggering cardiac damage for a molecular mimicry mechanism; however, defined pathogenesis of pericarditis associated with mRNA vaccine is still missing. The clinical scenario described is characterized by the typical ‘inflammatory phenotype’, triggered by a disproportionate and uncontrolled activation of the inflammasome based on an interleukin-1 (IL-1) overproduction. We administered anakinra, an IL-1 blocking drug, with a sharp clinical, echocardiographic and laboratoristic improvement. The complete response observed in this case suggests that vaccine-related pericarditis could be triggered by an auto-inflammatory pathway based on IL-1 overproduction. Further research is, therefore, warranted to determine the mechanisms by which the mRNA vaccine may cause pericarditis in order to choose the most targeted therapy.

Levosimendan for acute right heart failure in COVID-19: another arrow in our quiver?

OBJECTIVE

SARS-CoV-2 infection is associated with a higher risk of acute right heart failure (RHF) due to primary right ventricle (RV) dilation and systemic inflammatory response, which in turn lead to microvascular and cardiomyocytes dysfunction, local hypoxia and multi-organ failure. In this clinical setting, levosimendan could be a viable therapy thanks to its right-heart tropism and its additional pleiotropic properties.

CASE REPORT

We present the case of a 72 years-old man with positive nasopharyngeal swab for SARS-CoV-2 infection, mild pulmonary involvement and clinical signs of new-onset RHF. We started a 12-hour levosimendan cycle to improve RV performance and reduce cardiac filling pressures.

RESULTS

We obtained a net clinical benefit in terms of acute RHF-related signs and symptoms, progressive renal and liver function improvement and concomitant reduction of high-sensitivity C-Reactive Protein and Interleukin-6 (IL-6) levels.

CONCLUSIONS

Acute RHF during SARS-CoV-2 infection could be related to a convergent widespread systemic inflammatory response. Thanks to its anti-inflammatory and anti-remodeling properties, levosimendan might represent a viable therapy in this clinical setting, contributing to the dampening of the inflammatory response.

Transcatheter versus surgical aortic valve replacement in patients with aortic stenosis: characterization of molecular pathways before and after treatment

Funding Acknowledgements

Type of funding sources: None.

Background/Introduction

Recently, the transcatheter aortic valve replacement (TAVR) has reformed the management of Aortic Stenosis (AS), providing a valid therapeutic alternative to surgical aortic valve replacement (SAVR). Although optimizing the timing of surgery is a crucial aspiration, the introduction of innovative pharmacological therapies able to modify disease evolution might help clinicians to treat patients in a non-invasive way. Several evidences pointed out the role of inflammation, oxidative stress, and pathological remodelling in AS natural history.

Purpose

The aim of this study is to assess biological pathways modifications after aortic valve replacement, comparing the transcatheter and the surgical approach.

Methods

We enrolled a total of 35 consecutive patients with severe symptomatic aortic stenosis undergoing aortic valve replacement with transcatheter (n = 19) or surgical (n = 16) approach. Biological samples were collected and stored before (T0) and 72 hours after the procedure (T1). We firstly performed gene expression arrays for a total of 132 genes, on two groups of pooled cDNA from peripheral blood mononuclear cells of TAVR (n = 10) and SAVR (n = 10) patients. Then, taking into account the most relevant result of the arrays, we selected 15 genes for validation.

Results

Our preliminary data showed several differences in the gene expression levels of the two groups under examination for a large number of molecules, mostly associated with the oxidative balance. More in detail, after procedure, TAVR patients showed higher levels of glutathione peroxidase 1 (GPX1, TAVR p = 0.029; SAVR p = 0.031) and glutathione reductase (GSR, p = 0.029), while SAVR patients showed higher expression of GPX1, catalase (CAT, p = 0.019) and NADPH oxidase 2 (NOX2, p = 0.008), thus confirming an intense post-operative oxidative stress particularly for patients undergoing surgery. Moreover, Caspase 3 (CASP3, p = 0.013), involved in apoptotic pathway and myocyte enhancer factor 2C (MEF2C, p = 0.036), implicated in overload induced hypertrophy genes showed a significantly reduction in their expression after TAVR.

Conclusions

In our study, we describe different gene expression signatures in patients with an AS diagnosis and their recalibration after AV replacement with two kinds of procedure, TAVR and SAVR. Our data describe for the first time an altered oxidative balance in patient undergoing aortic valve replacement, that is particularly evident for patients undergoing SAVR. A clearer understanding of biological processes taking place in the first hours post AV replacement lays the ground to a more efficient management of post-operative status and, in the incessant research for a tailored therapy, the results of our study add a little piece of information to assist clinicians in selecting the optimal procedure for each patient.

Risk of bleeding associated with nonsteroidal anti-inflammatory drug use in patients exposed to antithrombotic therapy: a case-crossover study

Concomitant nonsteroidal anti-inflammatory drug (NSAIDs) and antithrombotic drug use is associated with an increased risk of bleeding, mainly gastrointestinal. The goal of this study was to quantify the transient increase in the risk of hospitalization for bleeding associated with NSAID use in patients treated with antiplatelet agents or anticoagulants. We performed an unidirectional case-crossover study using the EGB (Échantillon généraliste de bénéficiaires), a permanent random sample of the French nationwide health database. Patients receiving antithrombotic therapy and hospitalized for bleeding between 2009 and 2017 were included. We compared their NSAID exposure during a 15-day hazard window immediately prior to hospital admission to three earlier 15-day control windows. The risk of hospitalization for bleeding associated with the recent use of NSAIDs was estimated using conditional logistic regression to estimate odds ratios. During the study period, 33 patients treated with anticoagulants and 253 treated with antiplatelet agents received NSAIDs and were included in the case-crossover analysis. We found an increased risk of hospitalization for gastrointestinal bleeding after exposure to NSAIDs with an adjusted OR of 3.59 (95%CI, 1.58;8.17) in patients receiving anticoagulant therapy and 1.44 (95%CI, 1.07;1.94) in patients receiving antiplatelet therapy. The risk of non-gastrointestinal bleeding was also increased after exposure to NSAIDs with an adjusted OR of 2.72 (95%CI, 1.23;6.04) in patients exposed to anticoagulant therapy. The risk of gastrointestinal and non-gastrointestinal bleeding increases after NSAID use in patients treated with anticoagulants, while the risk of gastrointestinal bleeding increases, but to a lesser extent in those treated with antiplatelets. This article is protected by copyright. All rights reserved.

Takotsubo syndrome: a way to reach a straightforward diagnosis

Background/Introduction

Acute stress-induced cardiomyopathy, also known as Takotsubo Syndrome (TTS), was originally classified as a benign disease. Nowadays, this assumption has changed, especially in its long-term outcome, due to TTS clinical presentation, that often mirrors the acute myocardial infarction (MI) phenotype. Current knowledge already delineate clinical features distinctive of TTS and MI patients, however, diagnosis requires multiple, expansive, and invasive medical examinations. Moreover, concerning the biological panorama, very slight is known and the lack of a tailored therapy is resented. Therefore, a biological profile for this clinical category could provide easier and less invasive diagnostic tools, leading edge towards novel therapeutic pathways.

Purpose

The aim of the study is to perform a biological profile of the TTS group compared to the ST Segment Elevation Myocardial Infarction (STEMI) in order to explore the molecular peculiarities attendant the pathophysiologic mechanisms.

Methods

We performed a gene expression array on two groups of pooled cDNA from peripheral blood mononuclear cells, from TTS (n=11) and STEMI (n=19) patients. We conducted gene expression validations for each enrolled patient through qPCR.

Results

Our preliminary data displayed several differences in gene expression levels of a grand number of cell adhesion signaling molecule between the two groups. As shown in figure 1, three gene were more expressed in TTS group: Nitric Oxide Synthase 3, also known as endothelial NOS (NOS3; p=0.002), Superoxide dismutase 1 (SOD1; p=0.03) and transferrin receptor (TFRC; p=0.005). Meanwhile, five gene displayed a higher expression in STEMI patients compared to TTS: phospholipase A2 Group 7 (PLA2G7; p=0.04), Galectin 8 (LGALS8; p=0.02), Intercellular Adhesion Molecule 1 (ICAM1; p=0.002), Hyaluronidase 2 (HYAL2; p=0.01) and Hyaluronan Receptor (CD44; p=0.0002).

Conclusions

The earliest results of this study led us to focus on fewer genes related to endothelial and oxidative stress pathways. TTS is habitually triggered by intense emotional or physical stress. Indeed, our results showed how TTS patients present higher expression of NOS3, SOD1 and TFRC, all components involved in the oxidative stress pathways. In STEMI patients, top expressed genes, such as HYAL2, CD44 and ICAM1, are all associated with extracellular matrix turnover, likely due to the presence of a stenotic plaque and the consequent endothelial derangement. The uncovering of diagnostic biomarkers in TTS might improve the early, non-invasive, stratification of this group of patients, thus facilitating novel and personalized therapeutics design.

Funding Acknowledgement

Type of funding sources: Public grant(s) – National budget only. Main funding source(s): The present study was supported by the Italian National Project Grant PRIN 2017.

Patterns of Tyrosine Kinase Inhibitor Utilization in Newly Treated Patients With Chronic Myeloid Leukemia: An Exhaustive Population-Based Study in France

We analyzed demographic characteristics, comorbidities and patterns of treatment with tyrosine kinase inhibitors (TKIs) in a cohort of 3,633 incident cases of chronic myeloid leukemia (CML) identified across France from 1 January 2011 to 31 December 2014. Patients were identified through a specific algorithm in the French Healthcare Data System and were followed up 12 months after inclusion in the cohort. The estimated incidence rate of CML for this period in France was 1.37 per 100,000 person-years (95% Confidence Interval 1.36-1.38) and was higher in men, with a peak at age 75-79 years. At baseline, the median age of the cohort was 60 years (Inter Quartile Range 47-71), the Male/Female ratio was 1.2, and 25% presented with another comorbidity. Imatinib was the first-line TKI for 77.6% of the patients, followed by nilotinib (18.3%) and dasatinib (4.1%). Twelve months after initiation, 86% of the patients remained on the same TKI, 13% switched to another TKI and 1% received subsequently three different TKIs. During the follow-up, 23% discontinued and 52% suspended the TKI. Patients received a mean of 16.7 (Standard Deviation (SD) 9.6) medications over the first year of follow-up, and a mean of 2.7 (SD 2.3) concomitant medications on the day of first TKI prescription: 24.4% of the patients received allopurinol, 6.4% proton pump inhibitors (PPI) and 6.5% antihypertensive agents. When treatment with TKI was initiated, incident CML patients presented with comorbidities and polypharmacy, which merits attention because of the persistent use of these concomitant drugs and the potential increased risk of drug-drug interactions.

An unusual case of death using a compacting machine

In the large series of forensic injury, death from accidental me-chanical asphyxiation in adults is rare and is usually secondary to suffocation, aspiration, strangulation caused by entrapment of clothing in machinery (deaths at work) or asphyxiation in the course of erotic maneuvers. Compression asphyxia is a form of violent mechanical asphyxia in which the asphyxiated insult is produced by means of a compression and constriction mechanism of the thoracic cage. The authors report an unusual case of asphyxiated death from chest com-pression resulting from the action of a compacting machine, which occurred in a person who had fallen asleep in a waste bin.

Vaccination during the First Diagnosis of Multiple Myeloma: A Cohort Study of the French National Health Insurance Database

Purpose: Infections are frequent and often result in serious complications in patients with multiple myeloma (MM). Prophylactic vaccination is recommended for influenza virus, Streptococcus pneumoniae (SP), and Hemophilus influenzaeb (Hib). The aims of this study were to measure the vaccination rates within 24 months after the diagnosis of multiple myeloma and to identify factors associated with vaccine use. Methods: MM patients were selected through the French national health insurance database from 1 January 2010 to 31 December 2015. Patients with a previous history of MM were excluded. Results: Vaccination rates against influenza, SP, and Hib among 22,831 newly diagnosed MM patients were, respectively, 28.5%, 10.3%, and 1.4%. Only 0.7% received all three vaccines. Factors associated with vaccination were young age, male gender, an absence of comorbidity, a history of higher medication and vaccine consumption, Herpes simplex virus (HSV), Varicella zoster virus (VZV), and the use of pneumocystis prophylaxis. Conclusion: The low rates of vaccination indicate the need to improve physician and MM patient adherence and education regarding vaccination.

Kv4 channel expression and kinetics in GABAergic and non-GABAergic rNST neurons

The rostral nucleus of the solitary tract (rNST) serves as the first central relay in the gustatory system. In addition to synaptic interactions, central processing is also influenced by the ion channel composition of individual neurons. For example, voltage-gated K⁺ channels such as outward K⁺ current (I_A) can modify the integrative properties of neurons. I_A currents are prevalent in rNST projection cells but are also found to a lesser extent in GABAergic interneurons. However, characterization of the kinetic properties of I_A, the molecular basis of these currents, as well as the consequences of I_A on spiking properties of identified rNST cells is lacking. Here, we show that I_A in rNST GABAergic (G+) and non-GABAergic (G-) neurons share a common molecular basis. In both cell types, there was a reduction in I_A following treatment with the specific Kv4 channel blocker AmmTx3. However, the kinetics of activation and inactivation of I_A in the two cell types were different with G- neurons having significantly more negative half-maximal activation and inactivation values. Likewise, under current clamp, G- cells had significantly longer delays to spike initiation in response to a depolarizing stimulus preceded by a hyperpolarizing prepulse. Computational modeling and dynamic clamp suggest that differences in the activation half-maximum may account for the differences in delay. We further observed evidence for a window current under both voltage clamp and current clamp protocols. We speculate that the location of Kv4.3 channels on dendrites, together with a window current for I_A at rest, serves to regulate excitatory afferent inputs.NEW & NOTEWORTHY Here, we demonstrate that the transient outward K⁺ current I_A occurs in both GABAergic and non-GABAergic neurons via Kv4.3 channels in the rostral (gustatory) solitary nucleus. Although found in both cell types, I_A is more prevalent in non-GABAergic cells; a larger conductance at more negative potentials leads to a greater impact on spike initiation compared with GABAergic neurons. An I_A window current further suggests that I_A can regulate excitatory afferent input to the nucleus.

Diabetes Remission and Relapse After Bariatric Surgery: a Nationwide Population-Based Study

PURPOSE

The long-term impact of bariatric surgery on the remission of type 2 diabetes (T2DM) remains to be clarified through large nationally representative cohorts. The objectives were to determine the incidence of T2DM remission and relapse after bariatric surgery, to determine the factors associated with remission and to establish a profile for patients at risk for relapse.

MATERIALS AND METHODS

We conducted a population-based cohort study using data from the French national health insurance database (Systeme national des données de santé [SNDS]). We had access to exhaustive regional data between 2013 and 2017 and to a national representative sample of the French population (EGB) from 2008 to 2018. Patients were included if they were adults and diabetics with incidental bariatric surgery.

RESULTS

This study shows that 50% of patients are in remission from diabetes after bariatric surgery within a median of 2 to 4 months. Diabetes relapse was observed in 13-20% within 10 years. The factors favouring remission already described were noted (non-insulin-dependent diabetes) and original factors were also identified, in particular the advantage of bypass surgery over sleeve gastrectomy, with more remissions and fewer relapses.

CONCLUSION

This study highlights a 50% prevalence of remission and a low prevalence of relapse. There are non-modifiable risk factors for remission and relapse (characteristics of diabetes, age, lipid-lowering therapy) and modifiable factors (type of surgery). Identifying these factors is essential for optimal management of patients. Additional data are essential to confirm the results of our analysis of the factors associated with relapse.

Bevacizumab as maintenance treatment in BRCA mutated patients with advanced ovarian cancer: A large, retrospective, multicenter case-control study

OBJECTIVE

The aim of this study was to investigate the correlation between BRCA mutational status and response to bevacizumab in a large advanced ovarian cancer (AOC) series.

METHODS

This is a multicenter, retrospective case-control study including upfront AOC treated between January 2015 and June 2019. The main inclusion criteria were: having received three weekly carboplatin-paclitaxel as first-line treatment, with or without Bevacizumab maintenance, knowledge of the BRCA mutational status.

RESULTS

Overall, 441 patients were included; 183 (41.5%) patients received bevacizumab (Cases), and 258 (58.5%) did not receive it (Controls). The BRCA mutated patients (BRCAmut) were 58 (39%) in the Cases group and 90 (34.9%) in the Controls group (p = .77). Patients who received bevacizumab had a significant 4-months increase in median progression free survival (mPFS: 21 vs. 17 months, p = .033). Concerning BRCAmut patients, no differences were shown between those who received bevacizumab or not in terms of mPFS (24 vs. 22 months, p = .3). Conversely, in BRCA wild-type (BRCAwt) population bevacizumab administration significantly prolonged mPFS (20 vs 15 months, p = .019). At multivariate analysis, independent factors of prolonged PFS were BRCA status (OR = 0.60), having received PDS (OR = 0.69), and complete cytoreduction (OR = 0.50), but not the bevacizumab administration (OR = 0.83, p = .22).

CONCLUSIONS

No evidence of oncological benefit in terms of PFS and OS related to bevacizumab maintenance therapy was found in BRCAmut patients. Differently, BRCAwt patients seem to benefit from antiangiogenic treatment in terms of mPFS.

Use of the French healthcare insurance database to estimate the prevalence of exposure to potential drug-drug interactions

PURPOSE

Drug-drug interactions (DDIs) require monitoring in an aging population with increasing polypharmacy exposure. We aimed to estimate the prevalence of exposure to potential DDIs using the French healthcare insurance system database, for six DDIs with various clinical relevance: angiotensin II receptor blockers or angiotensin-converting enzyme inhibitors and nonsteroidal anti-inflammatory drugs (ARBs-ACEIs + NSAIDs), antiplatelet agents and NSAIDs (AAP + NSAIDs), serotonergic drugs and tramadol (SD + T), statins and macrolides (S + M), oral anticoagulant and NSAIDs (OAC + NSAIDs), and colchicine and macrolides (C + M).

METHODS

We used exhaustive healthcare data from a 1/97th random sample of the population covered by the French health insurance system (EGB) between 2006 and 2016. Exposure to a DDI was defined as overlapping exposure to two interacting drugs. The prevalence of exposure was estimated by year.

RESULTS

Prevalence of exposure in 2016 was estimated at 3.7% for ARBs-ACEIs + NSAIDs, 1.5% for AAP + NSAIDs, 0.76% for SD + T, 0.36% for S + M, 0.24% for AOC + NSAIDs, and 0.02% for C + M. In 26% to 58% of episodes of exposure, the two interacting drugs were prescribed by the same physician and dispensed by the same pharmacy the same day. Between 2006 and 2016, the yearly prevalence was increasing for SD + T and for DDIs involving NSAIDs, and it was decreasing for those involving macrolides.

CONCLUSION

Exposures to potential DDIs in France are not uncommon with a high proportion resulting from a co-prescription by the same physician. Monitoring the prevalence of exposure to DDIs is needed to implement prevention measures. Administrative data enable this surveillance in large and representative cohorts.

β-Adrenoceptor Drugs and Parkinson's Disease: A Nationwide Nested Case-Control Study

BACKGROUND

Potential relationships between β-adrenergic drugs and α-synuclein synthesis in Parkinson's disease (PD) have been recently suggested.

OBJECTIVE

This study investigated the putative association between β-adrenoceptor drug exposure and PD occurrence.

METHODS

A nested case-control study was performed in the Echantillon Généraliste des Bénéficiaires (EGB) (a 1/97th random sample of affiliates to the French Insurance System). Incident PD patients diagnosed between 01/01/2008 and 31/12/2017 (index date) were matched 1:1 to controls by gender, birth year, and insurance scheme. Exposure to any β-agonist and to any β-antagonist was compared between cases and controls within 1-2 years before the index date, and exposure to salbutamol and to propranolol was individualized. The association between PD and β-adrenoceptor drugs was investigated through conditional logistic regression models adjusted for potential confounding factors. Because of a statistical interaction between β-agonists and diabetes, results were stratified according to the presence of diabetes.

RESULTS

Among the 2225 incident PD patients identified in the EGB (mean age 75.6 ± 10.2 years, sex ratio 1.04), no significant association was found between PD and β-antagonists (adjusted odds ratio [aOR] 1.05 [95% confidence interval 0.91-1.20]), except for propranolol (aOR 2.11 [1.38-3.23]). For β-agonists, a protective association in non-diabetic patients (aOR 0.75 [0.60-0.93]) and an opposite and significant association in diabetic patients (aOR 1.61 [1.02-2.55]) were observed. Similar results were found with salbutamol.

CONCLUSION

This study did not identify an increased risk of PD occurrence after β-antagonist exposure, except for propranolol (potential protopathic bias). The discordant results observed with β-agonists in patients with or without diabetes deserve further exploration of the influence of diabetic comorbidity on PD occurrence and evolution.

Real-world costs of illness of Hodgkin and the main B-Cell Non-Hodgkin lymphomas in France

Background: Lymphomas are costly diseases that suffer from a lack of detailed economic information, notably in a real-world setting. Decision-makers are increasing the search for Real-World Evidence (RWE) to assess the impact, in real-life, of healthcare management and to support their public decisions. Thus, we aimed to assess the real-world net costs of the active treatment phases of adult Hodgkin Lymphoma (HL), Follicular Lymphoma (FL) and Diffuse Large B Cell Lymphoma (DLBCL).Methods: We performed a retrospective cohort study using population-based data from a national representative sample of the French population covered by the health insurance system. Cost analysis was performed from the French health insurance perspective and took into account direct and sick leave compensation costs (€2,018). Healthcare costs were studied over the active treatment phase. We used multivariate modeling to adjust cost differences between lymphoma subtypes.Results: Analyses were performed on 224 lymphoma patients and 896 controls. The mean additional monthly costs due to HL, FL and DLBCL patients were respectively €5,188, €3,242 and €7,659 for the active treatment phase. The main additional cost driver was principally inpatient stay (hospitalization costs and costly cancer-related drugs), followed by outpatient medication and productivity loss. When adjusted, DLBCL remains significantly the most costly lymphoma subtype.Conclusion: This study provides an accurate assessment of the main lymphoma subtypes related cost with high magnitude of details in a real-world setting. We underline where potential cost saving could be realized via the use of biosimilar medication, and where lymphoma management could be improved with the early management of adverse events.KEY POINTSThis is one of the first studies which assess the additional cost of lymphoma in Europe, according the main sub-types of lymphoma and with real-world database.The additional monthly cost due to HL, FL and DLBCL patients were respectively €5,188, €3,242 and €7,659 for the active treatment phase and the main additional cost driver was principally inpatient stay (i.e. hospitalization costs and additional inpatient medicines, notably rituximab), followed by outpatient medication and productivity loss.This study provides an accurate and detailed lymphoma subtype cost description and comparison which supply data for efficiency evaluations and will allow French health policy to improve lymphoma management.

Salvage lymphadenectomy in recurrent ovarian cancer patients: Analysis of clinical outcome and BRCA1/2 gene mutational status

OBJECTIVE

This study is aimed to analyze the clinical outcome of recurrent ovarian cancer patients bearing isolated lymph-node recurrence (ILNR) who underwent salvage lymphadenectomy (SL). The prognostic role of clinicopathological variables and the mutational status of BRCA1/2 have also been investigated.

METHODS

This retrospective, single-institutional study included women with platinum-sensitive lymph node recurrence underwent to SL between June 2008 and June 2018. Univariate and multivariate analysis was performed to evaluate the impact of clinical parameters, and BRCA1/2 mutational status on post salvage lymphadenectomy progression-free survival (PSL-PFS).

RESULTS

As of June 2019, the median follow-up after SL was 30 months, and the relapse has been documented in 48 (56.5%) patients. In the whole series, the median PSL-PFS was 21 months, and the 3-year PSL-PFS was 36.7%. The median PSL-PFS, according to patients with ILNR (N = 71) versus patients with lymph-nodes and other sites of disease (N = 14), was 27 months versus 12 months, respectively. Univariate analysis of variables conditioning PSL-PFS showed that platinum-free interval (PFI) ≥12 months, normal Ca125 serum levels, and number of metastatic lymph-nodes ≤3 played a statistically significant favorable role. In multivariate analysis, PFI duration ≥12 months and the number of metastatic lymph nodes ≤3 were shown to keep their favorable, independent prognostic value on PSL-PFS.

CONCLUSIONS

In the context of SL, the patients with long PFI and low metastatic lymph node numbers at ILNR diagnosis have the best outcome. The BRCA mutational status seems not associated with clinical variables and PSL-PFS, differently from other sites of disease in ROC patients.

Carboplatin-paclitaxel compared to Carboplatin-Paclitaxel-Bevacizumab in advanced or recurrent endometrial cancer: MITO END-2 - A randomized phase II trial

OBJECTIVE

Increased Vascular Endothelial Growth Factor Receptor (VEGF) expression in endometrial cancer (EC) is associated with a poor prognosis. Preliminary clinical data reported Bevacizumab effectiveness in EC both as single agent and in combination with chemotherapy.

METHODS

In a phase II trial, patients with advanced (FIGO stage III-IV) or recurrent EC were randomized to receive Carboplatin-Paclitaxel standard dose for 6-8 cycles vs Carboplatin-Paclitaxel and Bevacizumab 15 mg/kg in combination with chemotherapy and maintenance until disease progression or unacceptable toxicity. The primary endpoint was progression free survival (PFS).

RESULTS

108 patients were randomized; PFS (10.5 vs 13.7 months, HR 0.84 p = 0.43), overall response rate (ORR 53.1% vs 74.4%) and overall survival (OS) (29.7 vs 40.0 months, HR 0.71 p = 0.24) resulted in a non-significant increase in Bevacizumab treated patients. The PFS increase became significant when an exploratory analysis with the Breslow test was used. Moreover, patients treated with Bevacizumab experienced a significant increase in 6-month disease control rate (70.4% vs 90.7%). Cardiovascular events were more frequent in the experimental arm ("de novo" grade ≥2 hypertension 21% vs 0% and grade ≥2 thromboembolic events 11% vs 2% in the Bevacizumab vs standard treatment arm, respectively).

CONCLUSIONS

Bevacizumab combined with chemotherapy in the treatment of advanced/recurrent EC failed to demonstrate a significant increase in PFS in the MITO END-2 trial. Nevertheless, these preliminary data suggests some effectiveness of the antiangiogenic agent which merits further exploration in a larger population with a better molecular characterization.

Is there overuse of proton pump inhibitors in B-cell non-Hodgkin lymphomas? A cohort study based on the French health insurance database in the Midi-Pyrénées region

Patients suffering from B-cell non-Hodgkin lymphomas (B-NHL) have an increased likelihood of being exposed to proton pump inhibitors (PPIs), related to several factors which have been reported in the literature. PPIs are among the drugs most likely to be prescribed inappropriately. Consequently, B-NHL patients could be particularly at risk of inappropriate PPI prescription, with potential adverse drug reactions. We aimed to evaluate the incidence of PPIs use and to identify factors associated with PPIs initiation during the active treatment phase of B-NHL. We conducted a new-user cohort study using regional data from the French national health insurance database in the Midi-Pyrénées region (southwestern France). Incident B-NHL patients were selected according to an algorithm of selection, validated with data from a cancer registry. Our study revealed that 48.9% (95% confidence interval [CI]: 45.2-52.6) of patients initiated PPIs during chemotherapy after B-NHL diagnosis. According to information available in the SNDS, recommended indications for PPI prescriptions were identified in 21.1% of cases. Median duration of treatment was 65.3 days (CI: 35-112). Determinants of PPIs initiation were peptic ulcer disease, gastroprotection (appropriate or not) for medications considered at risk (NSAIDs, glucocorticoids and anticoagulants), age, nonfollicular lymphoma, polypharmacy, gastroenterologists' consultations and being hospitalized in a university hospital. Around 50% of patients initiated PPI treatment during the chemotherapy phase with only one-fifth identified as appropriate prescriptions and with long durations of treatment in most cases. Given this background, appropriate PPI prescription should be promoted in B-NHL to avoid potential inappropriate chronic use and related adverse events.

Global lower limb muscle coactivation during walking at different speeds: Relationship between spatio-temporal, kinematic, kinetic, and energetic parameters

Muscle coactivation is the mechanism that regulates the simultaneous activity of antagonist muscles around the same joint. During walking, muscle joint coactivation varies within the gait cycle according to the functional role of the lower limb joints. In the present study, we used a time-varying multi-muscle coactivation function (TMCf) with the aim of investigating the coactivation of 12 lower limb muscles and its relationship with the gait cycle, gait speed (low, self-selected, and fast), ground reaction force, gait variability, and mechanical energy consumption, and recovery in a sample of 20 healthy subjects. Results show that the TMCf is speed dependent and highly repeatable within and between subjects, similar to the vertical force profile, and negatively correlated with energy recovery and positively correlated with both energy consumption and balance-related gait parameters. These findings suggest that the global lower limb coactivation behavior could be a useful measure of the motor control strategy, limb stiffness, postural stability, energy efficiency optimization, and several aspects in pathological conditions.

A novel approach for medical research on lymphomas: A study validation of claims-based algorithms to identify incident cases

The use of claims database to study lymphomas in real-life conditions is a crucial issue in the future. In this way, it is essential to develop validated algorithms for the identification of lymphomas in these databases. The aim of this study was to assess the validity of diagnosis codes in the French health insurance database to identify incident cases of lymphomas according to results of a regional cancer registry, as the gold standard.Between 2010 and 2013, incident lymphomas were identified in hospital data through 2 algorithms of selection. The results of the identification process and characteristics of incident lymphomas cases were compared with data from the Tarn Cancer Registry. Each algorithm's performance was assessed by estimating sensitivity, predictive positive value, specificity (SPE), and negative predictive value.During the period, the registry recorded 476 incident cases of lymphomas, of which 52 were Hodgkin lymphomas and 424 non-Hodgkin lymphomas. For corresponding area and period, algorithm 1 provides a number of incident cases close to the Registry, whereas algorithm 2 overestimated the number of incident cases by approximately 30%. Both algorithms were highly specific (SPE = 99.9%) but moderately sensitive. The comparative analysis illustrates that similar distribution and characteristics are observed in both sources.Given these findings, the use of claims database can be consider as a pertinent and powerful tool to conduct medico-economic or pharmacoepidemiological studies in lymphomas.

Non-cancer drug consumption during the early trajectory of lymphoma survivorship

PURPOSE

This study explored the use of non-cancer drugs in lymphoma survivors during the early trajectory (0 to 2 years) of cancer survivorship and determined the factors that influenced this consumption.

METHODS

Between January and March 2014, a cross-sectional survey was conducted to assess drug consumption in adult lymphoma survivors at the Toulouse University Hospital. This study was based on a questionnaire consisting of ten open questions related to medical prescription and/or self-medication occurring within the last 3 months.

RESULTS

A total of 83/103 lymphoma survivors returned the questionnaire. This study showed that 91.6% of patients were drug consumers (about twice more than the general French population). Twenty percent of patients were treated with≥5 drugs. Overall drug consumption mainly concerned analgesics, anti-inflammatory drugs and psychotropics. The presence of comorbidity, urban residence and female gender were associated with overall drug consumption. Moreover, half of survivors required at least one self-medication. Finally, only seven survivors (8.4%) reported no use of any medication.

CONCLUSION

This study shows that, at least during the early trajectory of cancer survivorship, lymphoma patients are heavily treated with non-cancer drug therapy. This drug consumption profile may have serious implications in terms of safety, overall benefit and health economics.

Effect of Restraining the Base of Support on the Other Biomechanical Features in Patients with Cerebellar Ataxia

This study aimed to analyze the biomechanical consequences of reducing the base of support in patients with ataxia. Specifically, we evaluated the spatio-temporal parameters, upper- and lower-body kinematics, muscle co-activation, and energy recovery and expenditure. The gaits of 13 patients were recorded using a motion analysis system in unperturbed and perturbed walking conditions. In the latter condition, patients had to walk using the same step width and speed of healthy controls. The perturbed walking condition featured reduced gait speed, step length, hip and knee range of motion, and energy recovery and increased double support duration, gait variability, trunk oscillation, and ankle joint muscle co-activation. Narrowing the base of support increased gait instability (e.g., gait variability and trunk oscillations) and induced patients to further use alternative compensatory mechanisms to maintain dynamic balance at the expense of a reduced ability to recover mechanical energy. A widened step width gait is a global strategy employed by patients to increase dynamic stability, reduce the need for further compensatory mechanisms, and thus recover mechanical energy. Our findings suggest that rehabilitative treatment should more specifically focus on step width training.

Identifying multiple myeloma patients using data from the French health insurance databases: Validation using a cancer registry

This study aimed to assess the performance of several algorithms based on hospital diagnoses and the long-term diseases scheme to identify multiple myeloma patients.Potential multiple myeloma patients in 2010 to 2013 were identified using the presence of hospital records with at least 1 main diagnosis code for multiple myeloma (ICD-10 "C90"). Alternative algorithms also considered related and associated diagnoses, combination with long-term conditions, or at least 2 diagnoses. Incident patients were those with no previous "C90" codes in the past 24 or 12 months. The sensitivity, specificity, and positive and negative predictive values (PPVs and NPVs) were computed, using a French cancer registry for the corresponding area and period as the criterion standard.Long-term conditions data extracted concerned 11,559 patients (21,846 for hospital data). The registry contained 125 cases of multiple myeloma. Sensitivity was 70% when using only main hospital diagnoses (specificity 100%, PPV 79%), 76% when also considering related diagnoses (specificity 100%, PPV 74%), and 90% with associated diagnoses included (100% specificity, 64% PPV).In relation with their good performance, selected algorithms can be used to study the benefit and risk of drugs in treated multiple myeloma patients.

Diagnostic accuracy of MDCT in the evaluation of patients with peritoneal carcinomatosis from ovarian cancer: is delayed enhanced phase really effective?

OBJECTIVE

To assess the diagnostic accuracy of delayed enhanced phase in addition to portal enhanced phase in MDCT imaging for depicting peritoneal carcinomatosis (PC) implants in patients with ovarian cancer.

PATIENTS AND METHODS

We retrospectively reviewed double-phase, portal enhanced phase (PEP) and delayed enhanced phase (DEP), MDCT-examinations of 40 patients with clinical suspicion of recurrent PC from histopathologically-proven ovarian cancer, previously treated with both cytoreductive surgery and adjuvant/neoadjuvant chemotherapy. Image assessment was performed by three independent blinded readers (2 experienced and 1 less-experienced radiologists) in 3 different reading sessions: PEP (set A), DEP (set B), and PVP + DEP (set C). All CT-images were qualitatively assessed on the basis of the location of the lesion (based on Sugarbaker scheme), presence (indicating a confidence level for the diagnosis of PC), size and pattern. Reference standard both for detection and exclusion of PC was the evaluation of double-phase MDCT exams performed by two experienced readers in consensus, knowing clinical and laboratoristic parameters as well as previous and subsequent imaging (follow-up minimum of 12 months). Sensitivity, specificity, PPV, NPV and diagnostic accuracy of each reader for each reading session were calculated and compared. A subgroup analysis based on lesion pattern was also performed.

RESULTS

On a total of 507 abdominal-pelvic sites evaluated, PC was found in 182 regions (35.9%). When considering experienced radiologists, no statistically significant differences (p>0.05) were found between the different sets of images. The analysis by less-experienced radiologist showed lower statistical results, which significantly improved when both PEP and DEP were evaluated. In the subgroup analysis, DEP showed significantly higher statistical results in the case of micronodular patterns.

CONCLUSIONS

Our results indicate that the CT-acquisition protocol in patients with ovarian cancer for tumor staging should be based on portal phase alone, with a significant radiation dose reduction, whereas the addition of delayed phase images is useful for less-experienced readers.

Psychotropic drug initiation during the first diagnosis and the active treatment phase of B cell non-Hodgkin's lymphoma: a cohort study of the French national health insurance database

PURPOSE

Patients with B cell non-Hodgkin's lymphomas (B-NHLs) are known to be at risk of developing psychological disorders. The aims of this study were to measure the incidence of psychotropic drug use during the diagnosis and the active treatment phase in comparison with controls from the general population, and to identify factors associated with this use.

METHODS

B-NHL patients were selected through the French national health insurance database in the Midi-Pyrénées region (southwestern France) from January 1, 2011, to April 31, 2013. Patients with a previous history of B-NHL and/or psychotropic drug treatment were excluded.

RESULTS

Among 745 newly diagnosed B-NHL patients, psychotropic treatment was initiated in 31.5 % (95 % CI [28.1-34.9]), compared to 7.6 % (95 % CI [7.57-7.64]) in the general population during the same period. This incidence was comparable in colorectal cancer patients (33.5 %) but higher than that in patients with myocardial infarction (23.5 %) or with a first knee replacement surgery (22.4 %). Anxiolytics and hypnotics were the most frequently used drugs. Median duration of treatment was 37 days for anxiolytics and 58 days for hypnotics, with 20.8 % of patients remaining under treatment at 8 months. Factors associated with psychotropic drug initiation were young age, health care consumption in the year before diagnosis, and initial care at a university hospital.

CONCLUSION

The high rate of psychotropic drug initiation reflects a high level of anxiety at the initial phase of B-NHL patients' trajectory. This pharmacoepidemiological study reveals inappropriate use in some patients, which should now be investigated in lymphoma survivorship.

Clinical predictors of fever in stroke patients: relevance of nasogastric tube

OBJECTIVES

Fever frequently occurs in stroke patients and worsens their prognosis. However, only few studies have assessed the determinants of fever in acute stroke, and no study has specifically addressed the possible prediction of the development of fever.

MATERIALS AND METHODS

This investigation included 536 patients with acute stroke and a body temperature <=37°C during the first 24 h of stay. Ninety-two of them (17.2%) subsequently developed fever (defined as a temperature >=37.5°C starting after 24 h). Among the clinical variables available during the first 24 h from admission, those predictive of the subsequent appearance of fever were searched for. One hundred further patients had a temperature >37°C during the first 24 h.

RESULTS

In univariate analysis, many variables were predictive of the subsequent development of fever, but in multivariate analysis, only the following four predictors remained significant (odds ratio [95% confidence interval], P value): nasogastric tube (4.0 [2.2-7.4], <0.0001), atrial fibrillation (2.3 [1.4-3.8], 0.001), total anterior circulation syndrome (2.0 [1.2-3.5], 0.01), and urinary catheter (1.9 [1.1-3.3], 0.01). Among the 52 (9.7%) patients with three or four predictors, 31 (59.6%) subsequently developed fever. In addition, the factors independently associated with a temperature >37°C during the first 24 h were as follows: National Institutes of Health Stroke Scale (P < 0.0001), hemorrhagic stroke (P = 0.0008), atrial fibrillation (P = 0.002), and total parenteral nutrition (P = 0.03).

CONCLUSIONS

In patients with acute stroke, four clinical variables were found to be independently associated with the risk of developing fever and, of them, nasogastric tube was the strongest and most significant one.