Risk of heart failure following short-term non-steroidal anti-inflammatory drug use in patients with type 2 diabetes mellitus

Background

Fluid retention is a known but underappreciated side-effect of non-steroidal anti-inflammatory drug (NSAID) use. As type 2 diabetes mellitus (T2DM) has been linked to both subclinical cardiomyopathy and a decline in kidney function, short-term NSAID use could lead to subsequently development of heart failure (HF) due to aberrations in fluid balances.

Purpose

We investigated associations between short-term NSAID use and the risk of HF in a nationwide cohort of patients with T2DM.

Methods

Using nationwide Danish registers, we identified patients diagnosed with T2DM during 1998–2018. Follow-up began 120 days after first-time T2DM diagnosis among patients without prior heart failure or a rheumatological diagnosis indicating long-term NSAID use.

To describe use of NSAID among patients with T2DM, we reported proportions of patients claiming at least 1, 2, 3 or 4 prescriptions of NSAID within one year of start of follow-up. We investigated associations between use of NSAIDs (celecoxib, diclofenac, ibuprofen and naproxen) and new-onset HF hospitalizations using a case-crossover design with 28-day exposure windows and reported odds ratios (OR) with 95% confidence intervals (CI). The case-crossover design uses each individual as his or her own control making it suitable to study the effect of short-term exposure on immediate events while mitigating unmeasured confounding. Sensitivity analyses using exposure windows of 14 and 42 days were performed as well.

Results

A total of 334,950 patients with T2DM was included (47.7% female, median age of 61 [interquartile range 50–70]). Celecoxib and naproxen were rarely used; on the contrary, prescriptions of diclofenac and ibuprofen were claimed at least once within one year from the beginning of follow-up by 4.9% and 15.5% of patients, respectively–0.9% and 2.7% claimed at least four prescriptions (Figure 1).

The risk of new-onset HF hospitalization was increased following use of diclofenac or ibuprofen with corresponding ORs of 1.3 (95% CI 1.0 to 1.7) and 1.3 (95% CI 1.1 to 1.5) using 28-day exposure windows. An increased risk following use of celecoxib or naproxen was not found (Figure 2).

Conclusion

NSAIDs diclofenac and ibuprofen were both widely used and associated with an increased risk of new-onset HF hospitalization in patients with T2DM. This suggests a previously unknown and serious, clinically relevant concern of NSAID use in patients with T2DM.

Funding Acknowledgement

Type of funding sources: Private grant(s) and/or Sponsorship. Main funding source(s): Ib Mogens Kristiansens Almene FondHelsefonden

Cardiovascular risk following cannabinoid treatment for patients with chronic pain

Background

Treatment with medical cannabis for chronic pain is in popular demand, and a rising number of countries allow physicians to prescribe medical cannabis for pain management. However, data on drug-safety is scarce. Studies have showed a risk of cardiovascular side effects following use of recreational cannabis warranting further investigations into the safety of prescribing medical cannabis.

Purpose

We investigated risk of new-onset arrhythmias (tachy- or bradyarrhythmia and conduction disorders), acute coronary syndrome (ACS) and heart failure (HF) following use of prescribed medical cannabis compared with no use in a nationwide cohort of patients with chronic pain.

Methods

Using nationwide Danish registers, a cohort of patients with chronic pain and without prior history of arrhythmias, ACS, HF or prescribed medical cannabis (cannabinoid, cannabidiol or dronabinol) use were followed from 2018–2021. Any patient from the cohort initiating first-time treatment with medical cannabis was identified and matched 1:10 to corresponding controls within the cohort using incidence density sampling. Matching parameters were age group, sex, and chronic pain diagnosis. Follow-up was initiated at the date of the first claimed prescription of medical cannabis or the corresponding date among controls. We reported 180-day standardized absolute risks (AR) with 95% confidence intervals (CI) and risk ratios (RR) from fitted multivariable logistic regression models comparing patients exposed to medical cannabis with patients not exposed. Separate analyses for each chronic pain group were conducted as well.

Results

Among 1.6 million patients with chronic pain, 4,562 patients claimed at least one prescription of medical cannabis (exposed) and were each matched to 10 controls (non-exposed). Exposed and non-exposed patients were identical in relation to matching parameters; however, exposed patients were slightly more comorbid, and a larger proportion was concomitantly treated with other pain medication (Table). The risk of new-onset arrhythmia was elevated among exposed patients with 180-day AR of 0.71% (95% CI 0.47%–0.94%) compared with 0.43% (95% CI 0.37%–0.49%) yielding a RR of 1.64 (95% CI 1.04–2.23). The risk of new-onset ACS and HF was not increased comparing exposed to non-exposed with corresponding 180-day ARs of 0.13% (95% CI 0.03%-0.23%) vs 0.11% (95% CI 0.08%–0.14% and 0.13% (95% CI 0.03%–0.24%) vs 0.14% (95% CI 0.11%–0.17% (corresponding RRs of 1.2 [95% CI 0.3–2.1] and 0.9 [95% CI 0.2–1.7]) (Figure). Subgroup analyses of each chronic pain group yielded similar results.

Conclusion

In a nationwide cohort of patients with chronic pain, use of medical cannabis was associated with a 64% risk increase of arrhythmias compared with no use. This poses a potential health concern and is vital knowledge for any physician prescribing medical cannabis. Use of medical cannabis was not associated with an elevated risk of ACS or HF.

Funding Acknowledgement

Type of funding sources: Private grant(s) and/or Sponsorship. Main funding source(s): Ib Mogens Kristiansens Almene FondHelsefonden

Antiplatelet therapy and risk of adverse cardiovascular events in peripheral artery disease

Background

Antiplatelet therapy has been shown to reduce adverse cardiovascular (CV) events in patients with PAD, but despite the well-established medication benefit, large-scale epidemiological data evaluating antiplatelet agent of choice with low bleeding risk and high antithrombotic effect is sparse.

Purpose

We explored Danish healthcare registers to examine guideline-recommended antiplatelet therapy and associated risk of adverse CV outcomes in patients with PAD.

Methods

All patients with a first-time diagnosis of PAD between January 1, 1997 and December 31, 2016 were identified. Patients alive six months after diagnosis were divided into four treatment groups: aspirin, clopidogrel, dual therapy (DAPT), and no antiplatelet therapy. Logistic regression models were used to estimate 1-year risk of myocardial infarction (MI), stroke, CV death, all-cause mortality, and gastrointestinal (GI) bleeding.

Results

We identified a total of 85,771 PAD patients [median age 70.6 (IQR 63–77 years), 52% male]. The results suggest that compared to no antiplatelet therapy, use of clopidogrel alone significantly decreased 1-year risk of incident MI, stroke, CV death and all-cause mortality with odds ratios 0.56 (CI 0.46–0.68), 0.69 (CI 0.59–0.81), 0.72 (CI 0.56–0.94), and 0.79 (CI 0.65–0.97) respectively. Likewise, aspirin monotherapy was associated with only a marginal reduction in 1-year risk of stroke by 11% and all-cause mortality by 7%. Odds ratios for GI bleeding were estimated to be 1.18 (CI 1.04–1.34), 1.34 (CI 0.94–1.91), and 1.54 (CI 1.05–2.26) for aspirin, clopidogrel, and DAPT groups, respectively.

Conclusion

In this nationwide study, clopidogrel is associated with significantly reduced risk of MI, stroke, CV death and all-cause mortality with low risk of bleeding and appears to support clopidogrel as antiplatelet agent of choice for CV risk reduction in patients with PAD.

Funding Acknowledgement

Type of funding sources: None.

Usage and risk with phosphodiesterase type 5 inhibitors in male patients with chronic ischemic heart disease on oral organic nitrates

Background

Combining oral organic nitrates (OON) with phosphodiesterase type 5 (PDE5) inhibitors is contraindicated. Growing and liberal use of PDE5 inhibitors for erectile dysfunction among patients with ischemic heart disease (IHD) could pose serious health consequences especially among patients with IHD on OON.

Purpose

We hypothesize that concomitant prescription of OON and PDE5 inhibitors is prevalent and has increased in recent years, and further that possible co-exposure could be associated with an increased risk of ischemic stroke, myocardial infarction (MI) or acute coronary angiography (CAG).

Methods

During 2000–2018, we included all male patients with history of IHD between 18 and 85 years of age from nationwide Danish health registers. Patients with a history of pulmonary hypertension were excluded and not followed up afterwards if they developed the condition during follow-up. From this cohort, we identified an OON treated subgroup defined by two consecutively redeemed prescriptions of OON within 180 days from each other. Further, to become a case or control, patients had to redeem a prescription of OON within 180 days prior to the event or corresponding date among controls.

Temporal trends during 2001–2018 of PDE5 inhibitor use were calculated among all male patients with IHD and the subgroup on OON. Among OON treated patients, we examined associations between PDE5 inhibitor use and risk of ischemic stroke, MI or CAG using a case-crossover design where each individual serves as his/her own control thereby controlling for time-invariant confounding. The case-crossover design compares an individual's exposure in an index period just before the event occurred to a reference period prior to the index period. We investigated periods of varying length (7, 14, 21 and 28 days). To account for possible temporal trends in the use of PDE5 inhibitors, we also conducted a case-time-control analysis using a control group matched on age and calendar year.

Results

We identified 249,541 male patients with IHD (median age 65 years [IQR 56–73]), and a subgroup of 42,073 (17%) on OON treatment (median age 70 years [IQR 62–77]). From 2001 to 2018, the use of PDE5 inhibitors saw a 6-fold increase among all male IHD patients and a 10-fold rise in the subgroup on OON (Figure 1). The risk of ischemic stroke, MI or CAG following exposure to PDE5 inhibitors was not increased in the OON subgroup in neither the case-crossover nor the case-time-control analyses (Figure 2).

Conclusions

The use of PDE5 inhibitors has increased 6-fold since 2001 among male patients with IHD, and 10-fold among patients on OON–notwithstanding an established absolute contraindication. However, we did not find any evidence of an increased risk of ischemic stroke, MI or acute CAG following exposure to PDE5 inhibitors in the OON subgroup. This suggests that patients on OON are adequately informed and comply with the recommended pause in OON medication prior to PDE5 inhibitor use.

Funding Acknowledgement

Type of funding sources: Private grant(s) and/or Sponsorship. Main funding source(s): Ib Mogens Kristiansens Almene FondandHelsefonden

Gastrointestinal bleeding risk following concomitant treatment with oral glucocorticoids in patients with atrial fibrillation on direct-acting oral anticoagulants

Background

Oral glucocorticoids and direct-acting oral anticoagulants (DOAC) have both been associated with a risk of gastrointestinal (GI) bleeding. However, drug safety, especially regarding the risk of bleeding, in relation to concomitant treatment with oral glucocorticoids and DOACs is insufficiently explored.

Purpose

We aimed to investigate the short-term risk of GI bleeding in patients with atrial fibrillation (AF) following concomitant treatment with DOACs and oral glucocorticoids.

Methods

Register-based, retrospective and nationwide Danish study including patients with AF and on DOAC treatment during 2012–2018. Patients were defined as exposed to oral glucocorticoids from the date of a redeemed prescription and 60 days forward. We associated concomitant treatment with GI bleeding and reported hazard ratios (HR) via a nested case-control design and standardized 60-day absolute risk adjusted for comorbidities using a cohort design. In both analyses, exposed were compared to non-exposed controls matched on age, sex, calendar year, follow-up time and DOAC agent.

Results

We included 98,376 patients (age [interquartile range]: 75 [68– 82], 44% females) with AF on DOAC treatment. The use of oral glucocorticoids among included patients was widespread with 16% redeeming at least one prescription within three years, 4% redeeming at least five (Figure 1A). Lung disease was the most frequent indication (Figure 1B). Concomitant treatment with DOACs and oral glucocorticoids was associated with an increased incidence of GI bleeding (total n=4,946) compared with only DOAC treatment, including a dose-response trend (<20mg daily dose, HR [95% confidence interval (CI)]: 1.64 [1.38–1.95]; ≥20mg daily dose, HR [95% CI]: 2.29 [1.90–2.77]). Likewise, the standardized 60-day absolute risk of GI bleeding from first oral glucocorticoid exposure was increased compared with non-exposed (Figure 2).

Conclusion

Caution should be exercised when prescribing even short-term oral glucocorticoid treatment for DOAC treated patients, most notably in high doses and for patients with elevated bleeding risk.

Funding Acknowledgement

Type of funding sources: Foundation. Main funding source(s): Ib Mogens Kristiansens Almene FondandHelsefonden

One-year mortality risk after new onset comorbidity and worsening heart failure in patients with chronic heart failure

Background

Heart failure (HF) is a progressive disease characterized by risk of congestion and often accompanied by a significant burden of comorbidities. At the time of HF diagnosis, these are associated with a poor outcome, but it is relatively unknown whether hospitalization due to new-onset comorbidities carries the same subsequent mortality risk as hospitalization for worsening HF.

Purpose

To assess one-year mortality risk after hospitalization due to new-onset chronic comorbidity compared to a hospitalization with worsening HF in a nationwide cohort of patients with HF.

Methods

In Danish administrative registers, we identified all patients, aged 40–95 years with a first-time HF diagnosis from 2000 through 2016. Patients were included if they survived the initial 120 days and collected prescribed renin-angiotensin system inhibitor and beta-blocker. In analyses stratified on age and baseline burden of comorbidity (based on Charlson Comorbidity Index (CCI) excluding myocardial infarction and HF, we estimated absolute one-year mortality risk continuously during follow-up, using landmarking and flexible semi-parametric methods. If a patient had a comorbidity hospitalization equivalent to an increase in his/ her CCI or a HF hospitalization, one-year mortality risk was estimated immediately hereafter. In analyses assuming constant risks during follow-up, we calculated absolute risks and risk ratios for new comorbidity- or HF hospitalizations compared to patients without events.

Results

We included 81,788 patients, median age 72 (Q1-Q3:63–80), 36% women. At baseline, 57% had CCI=0, 22% CCI=1, 9% CCI=2 and 12% CCI≥3. High age and baseline CCI were associated with increased mortality risk throughout follow-up. Both new comorbidity- and HF hospitalizations at any time during follow-up were associated with increased mortality risk (p<0.001) (Figure), and the risk was approximately constant over time. Among patients with baseline CCI=0, new-onset comorbidity (incident increase in CCI) was associated with a higher mortality risk than a HF hospitalization in all age groups, risk ratios with “no event” as reference: Age 40–64: 5.4 (95%-CI: 4.5–6.4) vs 2.5 (95%-CI: 2.1–2.9); age 65–74: 4.2 (95%-CI: 3.7–4.7) vs 2.2 (95%-CI: 1.9–2.5); age 75–84: 3.4 (95%-CI: 3.2–3.7) vs 2.3 (95%-CI: 2.1–2.5) and age 85–95: 2.6 (95%-CI: 2.4–2.8) vs 2.2 (95%-CI: 2.0–2.4) (figure). Across all strata, new-onset comorbidity was associated with at least similar risk as a HF hospitalization at any time during follow-up.

Conclusions

For patients with HF, hospitalization for new-onset chronic comorbidity was associated with at least the same mortality risk as worsening HF, independently of age. This finding highlights the prognostic impact of comorbidity for patients with HF and warrants further investigations in the mechanisms underlying the mortality.

Funding Acknowledgement

Type of funding source: Foundation. Main funding source(s): Danish Heart Foundation

Effect of beta blocker therapy following myocardial infarction in optimally treated patients in the reperfusion era – a Danish, nationwide, and registry-based cohort study

Background and purpose

European and American cardiovascular treatment guidelines advocate for two and three years of beta-blocker (BB) treatment, respectively, following myocardial infarction (MI). Contemporary continued efficacy of longer-term use of BB in stable coronary artery disease has been debated in the era of reperfusion. We aim to investigate the cardio-protective effect associated with BB treatment in patients following MI.

Methods

Using nationwide databases, we included optimally treated patients with first-time MI undergoing coronary angiography (CAG) or percutaneous coronary intervention (PCI) during admission and treated with both acetyl-salicylic acid and statins post-discharge between 2003 and 2017. Patients with prior history of MI, BB use or any other possible indication or contraindication for BB treatment (heart failure, cardiac arrhythmias or procedures, asthma, chronic obstructive pulmonary disease) were excluded. Continued BB exposure was defined as two redeemed prescriptions within the first 180 days following discharge, one of them within 90 days. Follow-up began 180 days following discharge in patients alive and with no further cardiovascular events or procedures prior. Patients were followed for a maximum of three years. Primary outcomes were cardiovascular death and recurrent MI in patients stratified by BB treatment using adjusted Cox regression models.

Results

A total of 27,068 patients optimally treated for MI were included (57% acute PCI, 26% sub-acute PCI, 17% CAG without intervention). At study start 180 days following MI, 79% of the patients were on BB treatment (median age 61 years, 75% male) and 21% were not (median age 62 years, 69% male). Cumulative incidence of cardiovascular death and recurrent MI did not differ significantly comparing patients on BB treatment with patients not on BB treatment (Figure). In multivariable analyses, BB treatment was associated with a similar risk of cardiovascular death and recurrent MI compared to the patients not receiving BB treatment (hazard ratios with [95% confidence intervals] correspondingly; 0.89 [0.68–1.17] and 1.02 [0.89–1.18]) (Figure 1). When stratifying the cohort according to calendar year and type of procedure during admission, we found similar results as the main analysis. No interaction for sex was found.

Conclusions

In this nationwide cohort study of optimally treated patients following MI at 180 days in the reperfusion era, we found a very good prognosis with only 1.2% suffering cardiovascular death and 4.7% suffering a recurrent MI within three years. In total 79% of patients were receiving BB treatment, but we found no difference suggesting BB to be associated with an improved cardiovascular prognosis. These findings challenge current clinical practice and guideline recommendation, suggesting that the role of long-term BB use may be obsolete among optimally treated MI patients. Further investigations, preferably a randomized trial, are warranted.

Figure 1

Funding Acknowledgement

Type of funding source: Foundation. Main funding source(s): Ib Mogens Kristiansens Almene Fond, Snedkermester Sophus Jacobsen og Hustru Astrid Jacobsens Fond

P1953Risk of upper gastrointestinal bleeding following myocardial infarction: a novel prediction model for assessing appropriateness of proton pump inhibition therapy

Background

Upper gastrointestinal bleeding following myocardial infarction continues to be a severe complication associated with increased mortality; however, bleeding events might be avoided by appropriate therapy with proton pump inhibitors.

Purpose

To develop and validate a prediction model aimed at identifying patients at increased risk of upper gastrointestinal bleeding following myocardial infarction.

Methods

Based on multiple nationwide Danish registers, all patients initiating dual antiplatelet or anticoagulant therapy in combination with antiplatelet following myocardial infarction between 2003 and 2016 were identified. Primary outcome of interest was one-year risk of upper gastrointestinal bleeding. A derivation cohort including all patients between 2003 and 2013 was selected, whereas patients identified between 2014 and 2016 was employed for internal validation. Multiple logistic regression was used to predict person specific risks based on age, history of gastrointestinal bleeding or peptic ulcer, anaemia or gastrointestinal cancer, use of nonsteroidal anti-inflammatory drugs, oral anticoagulants, selective serotonin reuptake inhibitors or loop diuretics. We compared our model with the European Society of Cardiology (ESC) guideline recommendation on gastrointestinal bleeding risk assessment.

Results

A total of 61 543 patients with myocardial infarction were identified for the study. In the total cohort, the median age was 68 years (IQR: 58–77), 85.0% (52 334) underwent coronary angiography, 2.6% (1 608) had a history of gastrointestinal bleeding and 7.1% (4 354) used oral anticoagulants. The average one-year risk of upper gastrointestinal bleeding was 1.04% (95% CI: 0.95–1.14%), and mean predicted risk of the model was 1.04% (IQR: 0.64–1.26%). The discriminative ability of the model evaluated by area under the curve was 74.2% (95% CI: 66.9–78.6%) in the validation cohort. The proposed risk model demonstrated improved sensitivity and specificity at the specific threshold of the ESC risk schemes (Figure 1). Results remain principally unchanged regardless of inclusion or exclusion of patients initiating proton pump inhibitors at baseline. Furthermore, using cross-validation for the model evaluation produced similar discrimination results.

Figure 1

Conclusion

Based on nationwide registers a novel prediction model aimed at identifying patients at increased risk of upper gastrointestinal bleeding was developed and validated; the model observed moderate discrimination in the validation cohort providing possible benefit for clinicians in terms of communicating absolute risk to the patients and determining the appropriateness of initiating preventive therapy.

Acknowledgement/Funding

The Danish Heart Foundation

Sequential trials in the context of competing risks: Concepts and case study, with R and SAS code

Sequential designs and competing risks methodology are both well established. Their combined use has recently received some attention from a theoretical perspective, but their joint application in practice has been discussed less. The aim of this paper is to provide the applied statistician with a basic understanding of both sequential design theory and competing risks methodology and how to combine them in practice. Relevant references to more detailed theoretical discussions are provided, and all discussions are illustrated using a real case study. Extensive R and SAS code is provided in the online Supplementary Material.

Sealing Occlusal Dentin Caries in Permanent Molars: 7-Year Results of a Randomized Controlled Trial

The purpose of this study was to investigate the possibility of postponing restorative intervention of manifest occlusal caries in young, permanent dentition by non-invasive sealing. This RCT-designed study included 521 occlusal lesions in 521 patients aged 6 to 17 y. Based on clinical and radiographic assessments, all lesions required restorative treatment. After randomization (ratio 2:1), 368 resin sealings and 153 composite-resin restorations were performed by 68 dentists in 9 municipalities. The primary aims were to 1) analyze survival of sealings until replacement by restoration, 2) compare longevity of sealings and restorations until retreatments, and 3) compare effectiveness of sealings and restorations to halt caries progression in sealed lesions and beneath restorations. Furthermore, we aimed to identify factors influencing longevity and the effectiveness of sealings and restorations. Treatments were annually controlled, clinically and radiographically. After 7 y, the drop out rate was 8%, and 54% of the treatments were completed due to age. Of the sealings, 48% were retreated, including 31% replaced by restorations; 12% were still functioning. Of the restorations, 7% were repaired/renewed and 20% were still functioning. No endodontics was performed. Kaplan-Meier and Cox regression survival analyses were performed on 341 sealings and 152 restorations in first and second molar teeth. The 7-y survival was 37% (CI, 29% to 45%) for sealings and 91% (CI, 85% to 96%) for restorations (P < 0.001). The median survival time for sealings not replaced by restorations was 7.3 y (CI, 6.4 y to NA). Survival of sealings was increased in patients with low caries risk and/or excellent oral hygiene, second molars compared with first molars, and lesions not extending the middle one-third of the dentin. Survival of sealings was not influenced by municipality, sex, eruption stage or clinical surface cavitation. The results underline that it is possible to postpone or avoid restorative intervention of occlusal dentin caries lesions in young permanent teeth by non-invasive sealing. Knowledge Transfer Statement: The first restoration can ultimately be fatal for a young permanent tooth. A restoration may not be the final treatment but the start of an ongoing treatment with still more loss of tooth substance. The present study shows the possibility of treating occlusal dentin caries lesions with non-invasive resin sealings instead of conventional resin composite restorations in children and adolescents. Improved oral health can be expected.

Interleukin-1 receptor antagonist for refractory anti-MDA5 clinically amyopathic dermatomyopathy

Autoantibodies targeting the melanoma-differentiation-associated gene-5 (MDA5)-encoded ribonucleic acid helicase are associated with clinically amyopathic dermatomyopathy (CADM). Marked systemic inflammation, skin ulcers and severe interstitial lung disease seem frequent. DM treatment consists of immunosuppressants and/or intravenous immunoglobulins, but evidence-based knowledge is lacking. Anakinra (an interleukin-1 receptor antagonist (IL-1RA)) use in this setting has never been reported. Herein, we report on a case of anakinra dramatic and rapid efficacy against general and extramuscular (e.g. calcinosis, arthritis, skin ulcers) in a patient with severe and refractory CADM. Unfortunately, short-term follow-up prevented efficacy evaluation against interstitial lung disease. IL-1RA could be a promising treatment for refractory CADM.

[Idiopathic retroperitoneal fibrosis: a multicentric retrospective study of 30 French cases and follow-up of the renal function]

PURPOSE

Idiopathic retroperitoneal fibrosis (IRF) is an inflammatory disorder, affecting the aorta and the surrounding vessels and tissues. The prognosis is mainly driven by the risks of chronic kidney disease and relapse. Our aim was to assess the prevalence of chronic kidney disease at follow-up.

METHODS

We retrospectively reviewed the medical records of patients diagnosed for IRF in Seine-Saint-Denis (France) between 1987 and 2011. We collected informations about presentation, radiologic findings and follow-up. Diagnosis of IRF was confirmed when all the following criteria were met: infiltration of the infrarenal aorta or iliac vessels, absence of aneurysmal dilation, lack of clinical suspicion of malignancy.

RESULTS

Thirty patients were identified, with a male/female ratio of 4.9. Mean age was 55±13 years old. The mean creatinine clearance was 66 mL/min/1.73 m(2) and the mean CRP was 45±36 mg/L. In 24 (80%) patients, the location of IRF was periaortic and periiliac. Eleven patients (37%) underwent a diagnostic biopsy, and 14 (47%) required an ureteral procedure. A mean follow-up of 63 months was available for 29 patients: 69% relapsed, 7 developed chronic renal disease (24%), and one died of urinary sepsis. Older age (P=0.023), diabetes (P=0.007), and initial renal insufficiency (P=0.05) were associated with a risk of chronic renal insufficiency.

CONCLUSION

The high frequency of relapses and chronic renal disease emphasizes the need of close follow-up in patients diagnosed with IRF.

Estrogen receptor genotypes, menopausal status, and the lipid effects of tamoxifen

Tamoxifen induces important changes in serum lipid profiles in some women; however, little information is available to predict which women will experience improved lipid profiles during tamoxifen therapy. As part of a multicenter prospective observational trial in 176 breast cancer patients, we tested the hypothesis that tamoxifen-induced lipid changes were associated with genetic variants in candidate target genes (CYP2D6, ESR1, and ESR2). Tamoxifen lowered low-density lipoprotein cholesterol (P<0.0001) by 23.5 mg/dl (13.5-33.5 mg/dl) and increased triglycerides (P=0.006). In postmenopausal women, the ESR1-XbaI and ESR2-02 genotypes were associated with tamoxifen-induced changes in total cholesterol (P=0.03; GG vs GA/AA) and triglycerides (P=0.01; gene-dose effect), respectively. In premenopausal women, the ESR1-XbaI genotypes were associated with tamoxifen-induced changes in triglycerides (P=0.002; gene-dose effect) and high-density lipoprotein (P=0.004; gene-dose effect). Our results suggest that estrogen receptor genotyping may be useful in predicting which women would benefit more from tamoxifen.

[Still disease in adult: a Senegalese case report]

INTRODUCTION

The adult Still's disease is a systematic disease rarely reported in the black Africans. We are reporting a case characterized among other difficulties by its diagnostic difficulties.

OBSERVATION

It is about a 29 years old black Senegalese woman patient, without particular antecedents, which presented a systematic chronic syndrome composed of a pharyngitis, a polyarthritis and general symptoms (fever, chills, sweats, change of the general state), a cutaneous eruption, a polyadenopathy, a hepatosplenomegaly. The biological analyses showed among others, an inflammatory syndrome (VS at 115 mm in the 1st hour, CRP at 100 mg/L, WBC at 10,400/mm3 with neutrophilia), a hyperferritinemia in 643 ng/l with collapse of the glycosylated ferritin at 13% (N between 60 in 80%). After elimination of any autoimmune or neoplastic suppurative infectious pathology in the decline of a check up as exhaustive as possible, the diagnosis of a Still disease in adult had been retained. Their was improvement under the combination of prednisone and methotrexate.

CONCLUSION

Although it is exceptional in black African, this pathology shall be however part of the differential diagnoses of any unexplained systematic sign. The dosage of the ferritinemia and its glycosylated fraction as well as the resort to the criteria of Yamaguchi and Fautrel's classification of Still Disease in Adult shall allow to establish more prematurely the diagnosis of this potentially severe affection.

Pulmonary embolism and deep jugular venous thrombosis resulting from compression by a lipoma

Lipomas usually extend in subcutaneous tissues and rarely may be compressive. We report a case of neck lipoma resulting in jugular vein thrombosis and pulmonary embolism in a patient treated by clozapine. Clozpine may be considered an associated risk factor for thrombosis. This case suggests that performing a regional evaluation may be particularly important when thrombophlebitis occurs.

[Whipple disease, initially diagnosed as sarcoidosis]

INTRODUCTION

Whipple disease is a multisystem infectious disease caused by Tropheryma whipplei. We report a case in which an initial diagnosis of sarcoidosis was changed to Whipple disease endocarditis.

CASE

Based on clinical, radiographic, endoscopic and histologic findings, this 61-year-old man was diagnosed with sarcoidosis. Initial response to corticotherapy was good, but the patient required 35 mg of prednisone daily. The subsequent onset of clinical and laboratory signs of inflammation cast doubt on the diagnosis. After cardiac ultrasound revealed a mass 1 cm in diameter on the mitral valve, apparently vegetation, we diagnosed culture-negative infective endocarditis and ruled out most possible causes. PCR of a duodenal biopsy sample showed Tropheryma whipplei, thus confirming the diagnosis of Whipple disease, despite normal histological findings. After 3 weeks of intravenous gentamicin and amoxicillin treatment, oral cotrimoxazole was substituted. Follow-up transesophageal ultrasound showed no mitral vegetation. The patient, still under cotrimoxazole, has been off prednisone for 13 months and is completely asymptomatic.

CONCLUSION

This case is an illustration of the difficulty in distinguishing Whipple disease from sarcoidosis in practice and of the importance of that distinction.

Uvéite et thyroïdite associée à HTLV-1

INTRODUCTION

The oncovirus HTLV-1 is aetiologically associated with uveitis and autoimmune thyroiditis in endemic areas. The association of uveitis with autoimmune thyroiditis in HTLV-1 carriers is less common moreover in non-endemic area.

EXEGESE

We report two original cases of simultaneous uveitis and autoimmune thyroiditis in HTLV-1 carriers, without other disease due to HTLV-1. The visual outcome was favorable in both cases.

CONCLUSION

A significant correlation exists between hyperthyroidism, uveitis and HTLV-1, but still needs to be confirmed. The autoimmune or immune mediated mecanism of HTLV-1 may be involved in the uveitis and the thyroidits.

Prévalence et facteurs de risque de l'hépatite A au sein d'une population de patients infectés par le virus de l'immunodéficience humaine

BACKGROUND

There are common risk factors between hepatitis A virus (HAV) and human immuno deficiency virus (HIV) infections.

OBJECTIVES

We tried to evaluate if HIV-infected patients could be at risk for HAV. More over, HAV could worsen prognosis of HIV infection and HAV vaccination was then to be considered. Thus we assessed the prevalence and risk factors of HAV infection in an HIV-infected population.

PATIENTS AND METHODS

Seroprevalence and risk factors for HAV were studied among 154 HIV-positive patients followed in a Parisian hospital (mean age: 42 years, male patients: 70.8%, female patients: 29.2%). They were screened for HAV antibodies and answered a questionnaire on risk factors for HAV and means of HIV contamination.

RESULTS

The global prevalence was 72.7% [IC95%: 65.7-79.7]. We excluded patients who were born in highly endemic areas where seroprevalence reached 60% [IC95%: 51.2-70]. The HAV seroprevalence was almost 100% in migrants from highly endemic countries and for those born before 1946. The multivariate analysis showed that risk factors were the geographic origin [OR=20.88; IC95%: 2.40-181], age [OR = 2.33; IC95%: 1.24-4.39], and hemophilia [OR = 13.78; IC95%: 1.34-141].

CONCLUSION

Our results suggest that a screening test for HAV antibodies should be performed before vaccination, especially in HIV-infected patients born after 1946 or in non-endemic countries.

Association of peripheral multifocal choroiditis with sarcoidosis: a study of thirty-seven patients

OBJECTIVE

To assess the clinical spectrum of peripheral multifocal choroiditis (PMC) and its association with sarcoidosis.

METHODS

Thirty-seven patients examined between November 1997 and November 2001 who met all diagnostic criteria for PMC were included in this retrospective study. Patients were assessed for the following signs of sarcoidosis: typical changes on chest radiography or computed tomography; predominantly CD4 lymphocytosis in bronchoalveolar lavage fluid; elevated serum angiotensin-converting enzyme levels; elevated gallium uptake; and noncaseating granuloma on biopsy.

RESULTS

Most of the patients were female (30 of 37; 81%) and white (30 of 37; 81%). Mean +/- SD age at onset was 57.5 +/- 18.7 years. Seven (19%) of the 37 patients had biopsy-proven sarcoidosis and 18 patients (49%) with presumed sarcoidosis met at least 2 of the above-mentioned criteria for sarcoidosis but had normal biopsy results. Twelve patients (32%) had an indeterminate diagnosis. Patients with presumed sarcoidosis did not differ from those with proven sarcoidosis as regards the above-mentioned criteria, except for noncaseating granuloma, implying that more than two-thirds of patients (predominantly whites) had underlying sarcoidosis. Most patients with positive gallium scintigraphy had increased mediastinal uptake, as described in sarcoidosis. Patients with underlying sarcoidosis had more severe visual impairment due to cystoid macular edema (CME). Weekly methotrexate (0.3 mg/kg) seemed to control CME.

CONCLUSION

White patients with PMC should be considered to have sarcoidosis. The identification of sarcoidosis in patients with severe ocular disease can help with therapeutic choices.

Response to antiviral treatment in hepatitis C virus-associated marginal zone lymphomas

A link between chronic hepatitis C virus (HCV) infection and low-grade B-cell lymphomas has been suggested by epidemiological studies. Marginal zone lymphomas (MZLs) including splenic lymphomas with villous lymphocytes are among the most frequently reported subgroups in the setting of chronic HCV infection. In this study, we examined the effect of antiviral treatment in eight patients with HCV-associated MZL. We found that five out of eight patients have responded to interferon alpha and ribavirin. In some cases, hematologic responses were correlated to virologic responses. In addition, we report a case of large granular lymphocyte leukemia occurring in association with MZL and HCV, and responding to interferon and ribavirin. We suggest that there is an etiologic link between HCV and antigen-driven lymphoproliferative disorders.

Tuberculosis due to Mycobacterium bovis after alemtuzumab administration

We describe a patient with relapsing B chronic lymphocytic leukemia who developed systemic bacille Calmette-Guérin infection (BCGitis) after administration of alemtuzumab (Campath-1H).