Overweight and Obesity Are Associated With Acute Kidney Injury and Acute Respiratory Distress Syndrome, but Not With Increased Mortality in Hospitalized COVID-19 Patients: A Retrospective Cohort Study

OBJECTIVE

To evaluate the association between overweight and obesity on the clinical course and outcomes in patients hospitalized with COVID-19.

DESIGN

Retrospective, observational cohort study.

METHODS

We performed a multicenter, retrospective, observational cohort study of hospitalized COVID-19 patients to evaluate the associations between overweight and obesity on the clinical course and outcomes.

RESULTS

Out of 1634 hospitalized COVID-19 patients, 473 (28.9%) had normal weight, 669 (40.9%) were overweight, and 492 (30.1%) were obese. Patients who were overweight or had obesity were younger, and there were more women in the obese group. Normal-weight patients more often had pre-existing conditions such as malignancy, or were organ recipients. During admission, patients who were overweight or had obesity had an increased probability of acute respiratory distress syndrome [OR 1.70 (1.26-2.30) and 1.40 (1.01-1.96)], respectively and acute kidney failure [OR 2.29 (1.28-3.76) and 1.92 (1.06-3.48)], respectively. Length of hospital stay was similar between groups. The overall in-hospital mortality rate was 27.7%, and multivariate logistic regression analyses showed that overweight and obesity were not associated with increased mortality compared to normal-weight patients.

CONCLUSION

In this study, overweight and obesity were associated with acute respiratory distress syndrome and acute kidney injury, but not with in-hospital mortality nor length of hospital stay.

[Agranulocytosis/granulocytopenia after long-term use of thiamazole]

Agranulocytosis/granulocytopenia is a rare side effect of thyreostatics. Earlier publications state that for thiamazole this side effect occurs during the first few months of treatment. In two patients this thiamazole-induced agranulocytosis/granulocytopenia only occurred after years of treatment. A 53-year-old man presented with fever after a visit to Suriname. He had used thiamazole for 12 years for Graves' hyperthyroidism. The second patient, a 31-year-old woman, presented at the emergency department with fever and sore throat after 13 years of intermittent treatment with thiamazole. Both patients had an agranulocytosis/granulocytopenia and leukopenia. This was thought to be a side effect of thiamazole and blood values normalised after cessation of therapy. Both patients were treated empirically with broad-spectrum antibiotics during the agranylocytic period. They then received radioactive sodium iodide. To our knowledge this case report is the first to describe agranulocytosis/granulocytopenia following long-term treatment with thiamazole.

[Gastric bypass surgery effective for morbid obesity]

OBJECTIVE

Evaluation of the results of Roux-en-Y gastric bypass in morbid obesity.

DESIGN

Descriptive.

METHODS

All patients undergoing gastric bypass surgery in St. Antonius Hospital in Nieuwegein, the Netherlands, between 2002 and 2008 were analysed. Indications were a body mass index (BMI) >or= 40 kg/m2 or a BMI >or= 35 kg/m2 with severe co-morbidity. Principal outcomes were excess weight loss after at least 1 year of follow-up, surgery-related morbidity and mortality.

RESULTS

290 patients with a median age of 42.5 years (range: 21-66) underwent gastric bypass surgery (open: n = 233, laparoscopic: n = 57). The median preoperative overweight above standard weight was 78.7 kg (range: 30.1-190.3) and the median BMI was 49.5 kg/m2 (range: 33.2-84.9). This concerned a secondary intervention after a previous unsuccessful bariatric procedure in 99/290 patients (34.1%). There were 189 patients with a follow-up of more than 1 year. The procedure was successful (>or= 50% excess weight loss) in 135/189 patients (71.4%). The median excess weight loss was 58.6% (range: 7.7-102.4). The BMI decreased by a median of 16.2 kg/m(2) (range: 0.9-42.9). Patients undergoing primary surgery lost a higher percentage of excess weight than patients undergoing secondary surgery (median percentage excess weight loss 61.4% versus 53.5% , and a median decrease in BMI of 17.8 versus 11.9 kg/m2). The most frequently occurring early complications (within 30 days of surgery) were anastomotic leak (n = 15) and wound infection (n = 11). Late complications included anastomotic stricture (n = 18) and cicatricial hernia (n = 15). Mortality was 0.7% (n = 2).

CONCLUSION

Gastric bypass surgery was an effective treatment strategy for morbid obesity and had acceptable surgery-related morbidity and mortality.

Antihypertensive medication and the risk of acute pancreatitis: the European case-control study on drug-induced acute pancreatitis (EDIP)

OBJECTIVE

Angiotensin-converting enzyme (ACE) inhibitors and diuretics have been associated with acute pancreatitis. We quantified the risk of acute pancreatitis associated with the use of antihypertensive medication in the European study on drug-induced acute pancreatitis (EDIP).

MATERIAL AND METHODS

The EDIP study is a multicenter population-based European case-control investigation of the association between drug use and acute pancreatitis. Patients between 40 and 85 years of age hospitalized for acute pancreatitis were included in the study between 1 October 1994 and 31 December 1998. For each case, age- and gender-matched community controls were recruited. Detailed information on drug use and potential confounders (e.g. comorbidity, alcohol use) was obtained through a structured interview.

RESULTS

In all, 724 patients with acute pancreatitis and 1791 community controls were identified and interviewed. Use of ACE inhibitors in the week prior to the index date was associated with an increased risk of acute pancreatitis (adjusted odds ratio 1.5; 95% CI: 1.1-2.2). The risk of acute pancreatitis associated with ACE inhibitors increased with higher daily doses and was highest in the first 6 months of therapy. Calcium channel blockers increased the risk of acute pancreatitis (adjusted odds ratio 1.5; 95% CI: 1.1-2.1) without an apparent dose- or response relationship. Loop and thiazide diuretic use was not associated with an increased risk of acute pancreatitis. Potassium-sparing diuretics elevated the risk of acute pancreatitis, albeit non-significantly.

CONCLUSION

Use of ACE inhibitors is associated with a modest increase in the risk of acute pancreatitis during the first months of treatment.

Unlicensed and off-label prescription of respiratory drugs to children

Many respiratory drugs are not available in formulations suitable for infants and toddlers. Efficacy and safety research is mostly restricted to older children. However, respiratory drugs are frequently used in children for common diseases like asthma, upper and lower respiratory tract infections, rhinitis and sinusitis. The unlicensed and off-label use of respiratory drugs in children were studied. A population-based cohort study was conducted by using the computerised medical records in the Integrated Primary Care Information project. The study population comprised a random sample from all children aged 0-16 yrs who were registered with a general practitioner in 1998. All prescriptions for respiratory drugs during the study period were classified according to their licensing and off-label status. The study population comprised 13,426 patients (51.7% male, median age 8.7 yrs), of whom 2,502 (19%) received 5,253 prescriptions for respiratory drugs in 1998. A total of 3,306 (62.9%) prescriptions concerned licensed drugs. Of the remaining 1,947 prescriptions (37.1%), 882 (16.8%) were unlicensed for use in children, and 1,065 (20.3%) were prescribed off-label. The 1-yr cumulative risk of receiving an unlicensed or off-label prescription was 45% among children with at least one prescription for a respiratory drug. This population-based study showed that a large proportion of respiratory drugs prescribed by the general practitioner are unlicensed for use in children, or licensed but prescribed in an off-label manner. Results have to be interpreted with caution because they may unjustly suggest inaccurate prescribing, whereas it may be difficult to treat children with respiratory symptoms and diseases, because for many respiratory drugs paediatric data on safety and efficacy are insufficient. These findings underline the importance of research on suitable formulations, dosages and efficacy of respiratory drugs in children.

Determinants for drug prescribing to children below the minimum licensed age

OBJECTIVES

In the light of the undesired effects that unlicensed and off-label drug use might have, it is necessary to study the determinants affecting the prescribing of such drugs. Prescription of drugs to children younger than the minimum licensed age may carry the highest risk of adverse reactions. To obtain insight into the factors that affect prescription of drugs to children below the minimum licensed age, we conducted a population-based case-control study.

METHODS

The case-control study was nested in a cohort of 13,426 children aged 0-16 years, who were registered in the Integrated Primary Care Information (IPCI) project, a longitudinal observational general practitioners' database in the Netherlands. "Cases" were children who received a drug prescription for which they were below the minimum licensed age. To each case we matched up to four controls based on GP practice and patient age. As potential risk factors we evaluated the use of health care resources, and acute and chronic morbidity.

RESULTS

We identified 447 cases who were matched to 1355 controls. The cases consulted their GPs significantly more often during the preceding half year, had more drug prescriptions, and had more specialist referrals than the controls. Respiratory diseases were the most important determinants for the prescription of drugs to children below the minimum licensed age. In adolescents, migraine and other headaches were the most important reasons.

CONCLUSIONS

This study showed that children suffering from respiratory disease or migraine have the highest risk of receiving a drug prescription for which the patient is below the minimum licensed age. Regulatory authorities and the pharmaceutical industry should be stimulated to improve the evaluation of drug efficacy and safety in children.

Unlicensed and off-label drug use in a paediatric ward of a general hospital in the Netherlands

OBJECTIVES

Many drugs used in paediatric care are not licensed for that use or are prescribed outside the terms of the product license (off-label). Studies in the UK and Europe showed a large number of unlicensed and off-label drug prescription in specialised paediatric health care centres. We determined the extent and nature of use of unlicensed drugs and off-label prescriptions in children in a general hospital in the Netherlands.

METHODS

We conducted a longitudinal prospective cohort study in a dynamic population consisting of patients admitted to the paediatric ward and the neonatology unit of a general hospital during a 19-week period. Drug-licensing status of all prescriptions given to these patients was determined.

RESULTS

A total of 1017 prescriptions was administered to 293 paediatric patients for 114 different drugs. The median number of prescriptions per patient was three (interquartile range 2-5). The most commonly administered drugs were acetaminophen (14%), cefotaxime (8%), amoxicillin (7%), caffeine (4%) and prednisolone (4%). Four hundred and forty-three (44%) prescriptions were off-label, and 285 (28%) were for unlicensed drugs. Ninety-two percent of patients received one or more unlicensed or off-label prescriptions, and this proportion was significantly higher in children below 6 months of age than in older children.

CONCLUSIONS

This study shows that the extent of unlicensed and off-label drug prescription in a paediatric ward and neonatology unit of a general hospital is large and not smaller than in an academic paediatric setting. Lack of paediatric drug labelling is therefore not solely a problem with drugs used in university hospitals, but also in general hospitals. Efforts must be taken to change the current situation.

Incidence of priapism in the general population

OBJECTIVES

To assess the incidence of priapism in the general population.

METHODS

We conducted a population-based retrospective cohort study within a general practitioners research database. Our study population comprised all male patients with permanent registration status with a general practitioner. All patients with an International Classification for Primary Care code for penile problems (Y01, Y04, Y08) were identified. In addition, a free text search on priapism and painful erection was conducted. The computerized medical records from all potential patients were reviewed, and we requested additional information from the general practitioner if priapism was suspected.

RESULTS

The total study cohort comprised 145,071 men, with a total follow-up of 341,133 person-years. Five patients developed a first occurrence of priapism during the follow-up period, corresponding to an overall incidence rate of 1.5 per 100,000 person-years (95% confidence interval 0.2 to 2.8). The incidence rate in men 40 years old and older was 2.9 per 100,000 person-years (95% confidence interval 0.1 to 5.7). No cause of priapism was apparent in 2 patients, 2 cases occurred after intracavernous injection of vasodilators, and 1 patient experienced priapism because of sickle cell disease.

CONCLUSIONS

The incidence of priapism is low but seems higher than was previously assumed.

Incidence and mortality of acute pancreatitis between 1985 and 1995

BACKGROUND

The incidence of acute pancreatitis seems to have increased in Western countries. It has been suggested that this increase can be explained by improved diagnostic procedures. We performed a nationwide study to assess the annual sex- and age-specific incidence and mortality rates of acute pancreatitis in the Netherlands between 1985 and 1995, a period in which diagnostic procedures did not change considerably.

METHODS

We conducted a population-based retrospective follow-up study in which we used automated hospital discharge data accumulated by Prismant Health Care Information. All patients admitted with acute pancreatitis (ICD-9CM, 577.0) in the Netherlands were identified. We accounted for referrals to other hospitals to avoid double counting and for miscoding of chronic pancreatitis as acute pancreatitis. The annual population size was retrieved from the Netherlands Central Statistics Office.

RESULTS

The observed incidence of acute pancreatitis increased from 12.4/100,000 person-years (95% confidence interval (CI), 11.8-12.9) in 1985 to 15.9/100,000 person-years (95% CI, 15.3-16.5) in 1995. The annual mortality rate of acute pancreatitis remained fairly stable at 1.5/100,000 person-years. The incidence and mortality rate of acute pancreatitis increased considerably with age. The case-fatality proportion of first admissions for acute pancreatitis decreased from 14.3% to 10.7%. The case-fatality for relapses remained stable at 3.2%.

CONCLUSIONS

In this retrospective study the observed incidence of acute pancreatitis increased by 28% between 1985 and 1995. Due to a decrease in the case-fatality proportion, the mortality remained stable during this period.

Acute pancreatitis attributed to the use of interferon alfa-2b

Two patients experienced episodes of acute pancreatitis shortly after starting treatment with interferon alfa-2b (IFN-alpha) for a chronic hepatitis C infection. The first patient was a 40-year-old man who developed acute pancreatitis after 15 weeks of treatment with 3 MU IFN-alpha subcutaneously (SC) 3 times weekly and 1200 mg ribavirin. After disappearance of symptoms and normalization of laboratory values, oral intake of solid foods and IFN-alpha therapy were restarted. Within hours, a relapse of acute pancreatitis occurred. A rechallenge with IFN-alpha 4 days later was followed by a prompt increase in serum lipase level, and IFN-alpha therapy was discontinued. The second patient was a 38-year-old man who developed acute pancreatitis 2 hours after SC administration of 5 MU IFN-alpha. Ultrasound endoscopy showed sludge in the gallbladder. The patient was rechallenged 5 weeks later with 3 MU IFN-alpha SC. Although serum amylase and lipase levels increased after readministration of IFN-alpha, treatment was continued. The patient was readmitted 2 weeks later with severe abdominal pain, and IFN-alpha administration was discontinued. Considering the temporal relationship between the start of IFN-alpha treatment and development of acute pancreatitis, the absence of other clear etiologic factors for acute pancreatitis, disappearance of symptoms after discontinuation of IFN-alpha, and positive reactions to rechallenge, IFN-alpha is the most probable cause for development of acute pancreatitis in these patients.

The risk of acute pancreatitis associated with acid-suppressing drugs

AIMS

To assess the risk of acute pancreatitis associated with use of acid-suppressing drugs.

METHODS

We conducted a retrospective cohort study with a nested case-control design within the General Practice Research Database (GPRD) in the United Kingdom. The cohort included 180 178 persons aged 20-74 years, who had received at least one prescription of cimetidine, famotidine, nizatidine, ranitidine, lansoprazole, or omeprazole from January 1992 to September 1997 and who did not have major risk factors for pancreatic diseases. Patients with a computerized medical history compatible with idiopathic acute pancreatitis were validated through review of medical records. For the nested case-control analysis 1000 controls were randomly selected from the study population.

RESULTS

We identified 88 potential cases of idiopathic acute pancreatitis. Medical records were available for 86. After review of these records 36 cases of acute pancreatitis were confirmed. Seven cases occurred during nonuse, corresponding to a background incidence rate (IR) of 4.4/100 000 person-years (PY). Six cases occurred during current use of ranitidine (IR 10.5/100 000 PY), five patients were current users of cimetidine (IR 13.9/100 000 PY), and three were current users of omeprazole (IR 7.8/100 000 PY). There were no cases among current users of famotidine, lansoprazole, or nizatidine. Relative risk (RR) compared with nonuse and corrected for age, gender, calendar year and use of medication known to be associated with acute pancreatitis was 1.3 (95% CI: 0.4,4.1) for ranitidine, 2.1 (95% CI: 0.6,7.2) for cimetidine, and 1.1 (95% CI: 0.3,4.6) for omeprazole.

CONCLUSIONS

The results of this study do not support an association between acute pancreatitis and the use of acid-suppressing drugs, although a substantial increase in risk cannot be excluded with confidence.

Colitis may be part of the antiepileptic drug hypersensitivity syndrome

PURPOSE

To show that colitis may be part of the antiepileptic hypersensitivity syndrome.

METHODS

Description of two case histories.

RESULTS

The first patient was a 47-year-old man who developed fever, lymphadenopathy, influenza-like symptoms, facial edema, skin rash and diarrhea after 3 weeks of carbamazepine (CBZ) treatment. Laparotomy because of severe abdominal pain 2 weeks later showed severe colitis with perforations. The second patient was a 41-year-old woman who developed fever, diarrhea, and skin rash 4 weeks after start of CBZ treatment. A colon biopsy confirmed colitis. Stool examinations did not show pathogenic microorganisms, and there was no evidence of Crohn's disease or ulcerative colitis. Both patients had elevated liver enzymes, peripheral eosinophilia, and eosinophils in the infiltrate of the colon.

CONCLUSIONS

In view of the close temporal relation between start of CBZ intake and development of colitis, the presence of fever, lymphadenopathy, and rash, and improvement after discontinuation of CBZ, we conclude that the two patients developed an AED hypersensitivity syndrome. Our case histories demonstrate that severe colitis may be part of this syndrome.

Drug-associated acute pancreatitis: twenty-one years of spontaneous reporting in The Netherlands

OBJECTIVE

Drugs are considered a rare cause of acute pancreatitis. We conducted a descriptive study to assess which drugs have been associated with acute pancreatitis in spontaneous adverse drug reaction reports in The Netherlands.

METHODS

Our study is based on reports of drug-associated acute pancreatitis reported to the Netherlands Center for Monitoring of Adverse Reactions to Drugs and The Netherlands Pharmacovigilance Foundation LAREB between 1 January 1977 and 1 January 1998. We used an algorithm to validate the diagnosis and to assess the causal relationship between acute pancreatitis and use of the suspected drug.

RESULTS

A total of 55 cases were available for review. We excluded 11 (20.0%) reports, as we could not confirm the diagnosis of acute pancreatitis. Another 10 (18%) cases were excluded, as the causal relationship with the suspected drug was unlikely. In the remaining 34 reports, acute pancreatitis was labeled as definite in 11 (32%) and as probable in 23 (68%). The age of the patients ranged from 17 to 84 yr with a median of 41; 24 (71%) patients were female. Of the 34 cases, 27 (79%) recovered, five (15%) died, and in two (6%) the outcome is unknown. Azathioprine, cimetidine, interferon-alpha, methyldopa, metronidazole, olsalazine, and oxyphenbutazon all had a definite causal relationship with acute pancreatitis. Doxycycline, enalapril, famotidine, ibuprofen, maprotiline, mesalazine, and sulindac had a probable causal relationship with acute pancreatitis.

CONCLUSIONS

A variety of drugs was associated with acute pancreatitis in Dutch adverse drug reaction reports. Quantitative information about drug-induced pancreatitis is scanty. Epidemiological studies to assess the risk of drug-induced acute pancreas, therefore, are needed.

Attitudinal survey of voluntary reporting of adverse drug reactions

AIMS

Voluntary adverse drug reaction (ADR) reporting schemes have operated since the early sixties in many Western countries. It is generally recognized, however, that only a small proportion of ADRs is actually reported. The current survey was conducted to assess attitudes towards reporting of ADRs, and to study which types of ADRs are reported.

METHODS

A questionnaire seeking reasons for nonreporting was sent to a random sample of 10% of medical practitioners in The Netherlands in October 1997. After 6 weeks, a reminder was sent to those who had not responded.

RESULTS

One thousand four hundred and forty-two (73%) questionnaires were returned, of which 94% were complete. The percentage of GPs (51%) which had ever reported an ADR to the national reporting centre was significantly higher than the percentage of specialists (35%), who reported more often to the pharmaceutical industry (34% vs 48%). 86% of GPs, 72% of surgical specialists and 81% of medical specialists had ever diagnosed an ADR, which they had not reported. Uncertainty as to whether the reaction was caused by a drug (72%), the ADR being trivial (75%) or too well known (93%) were the most important reasons for not reporting. 18% were not aware of the need to report ADRs, 22% did not know how to report ADRs, 38% did not have enough time, 36% thought that reporting was too bureaucratic and only 26% of Dutch physicians knew which ADRs to report. A serious ADR, an unlabelled ADR, an ADR to a new drug, history of reporting of one or more ADRs, and specialty were all independently associated with reporting of 16 hypothetical ADRs. Surgical and medical specialists tended to report less often than GPs.

CONCLUSIONS

There is a considerable degree of underreporting, which might partly be explained by lack of knowledge and misconceptions about spontaneous reporting of adverse drug reactions.

Drug-associated acute pancreatitis: twenty-one years of spontaneous reporting in The Netherlands

OBJECTIVE

Drugs are considered a rare cause of acute pancreatitis. We conducted a descriptive study to assess which drugs have been associated with acute pancreatitis in spontaneous adverse drug reaction reports in The Netherlands.

METHODS

Our study is based on reports of drug-associated acute pancreatitis reported to the Netherlands Center for Monitoring of Adverse Reactions to Drugs and The Netherlands Pharmacovigilance Foundation LAREB between 1 January 1977 and 1 January 1998. We used an algorithm to validate the diagnosis and to assess the causal relationship between acute pancreatitis and use of the suspected drug.

RESULTS

A total of 55 cases were available for review. We excluded 11 (20.0%) reports, as we could not confirm the diagnosis of acute pancreatitis. Another 10 (18%) cases were excluded, as the causal relationship with the suspected drug was unlikely. In the remaining 34 reports, acute pancreatitis was labeled as definite in 11 (32%) and as probable in 23 (68%). The age of the patients ranged from 17 to 84 yr with a median of 41; 24 (71%) patients were female. Of the 34 cases, 27 (79%) recovered, five (15%) died, and in two (6%) the outcome is unknown. Azathioprine, cimetidine, interferon-alpha, methyldopa, metronidazole, olsalazine, and oxyphenbutazon all had a definite causal relationship with acute pancreatitis. Doxycycline, enalapril, famotidine, ibuprofen, maprotiline, mesalazine, and sulindac had a probable causal relationship with acute pancreatitis.

CONCLUSIONS

A variety of drugs was associated with acute pancreatitis in Dutch adverse drug reaction reports. Quantitative information about drug-induced pancreatitis is scanty. Epidemiological studies to assess the risk of drug-induced acute pancreas, therefore, are needed.

[Cholestatic hepatitis ascribed to the use of thiabendazole]

Two women, aged 27 and 42 years, both born in Surinam and both suffering from heterozygous thalassemia, developed cholestatic hepatitis three and two weeks respectively after the start of a two-day course of thiabendazol for Strongyloides stercoralis infection. Other causes of cholestasis were unlikely in view of the results of blood tests, echography and the endoscopic retrograde cholangiopancreaticography. The symptoms persisted for several months, and the liver function disorders for 7 years and one year, respectively. The incidence of thiabendazole-induced cholestatic hepatitis is unknown, but probably low.

[Provision of taxoids in 1996: inequality of care]

OBJECTIVE

To inventory the utilization of taxoids in 1996.

METHODS

A survey was conducted in february 1997 among the medical heads of 130 Dutch hospitals. The questions about the use of taxoids (paclitaxel and docetaxel) in 1996 concerned indications, numbers of patients treated, the funding and possible financial restrictions on the treatment. Three weeks after the mailing of the questionnaire, a reminder was sent to hospitals that had not responded. The data from 120 hospitals where oncological care was administered were analysed.

RESULTS

Of the 120 hospitals, 111 (92.5%) returned the questionnaire, from 114 locations. Twelve locations reported not having used taxoids, four of them partly for financial reasons. Taxoids had been used at 102 locations: at the expense of the hospital budget at 101 locations, and exclusively at the expense of sickness insurers at one location. At 27 locations, paclitaxel and docetaxel had also been issued in the context of trials, and at 7 locations also via special agreements with the insurers and (or) at the expense of the patient himself. Fifty-three of the 102 taxoid using hospitals had a financial upper limit or a maximum number of patients to be treated. Eighteen of the 102 locations where paclitaxel or docetaxel was issued reported that for financial reasons not all patients eligible for taxoids had been given these drugs. The indications varied from one hospital to another: 67 locations used them for first-phase treatment of patients with ovarian carcinoma, 96 locations for second-phase treatment of patients with ovarian carcinoma and at 91 locations, patients with mammary carcinoma were given taxoids when anthracyclines were no longer indicated.

CONCLUSION

Hospitals in 1996 varied greatly with regard to issuing of taxoids. This diversity in part had financial causes. Restrictions on the issuing of taxoids for financial reasons lead to unequal access to care.