Elevated albuminuria associated with increased risk of recurrent venous thromboembolism: results of a population-based cohort study

This study examined the risk of recurrent venous thromboembolism (VTE) in patients with elevated albuminuria. In 1997-1998, inhabitants of Groningen, the Netherlands, aged 28-75 years (n=85,421), were invited to participate in the PREVEND (Prevention of REnal and Vascular ENd stage Disease) Study, an observational, population-based cohort study. Albuminuria was measured and VTE occurrence was monitored in responding subjects (n=40,856). Patients with first VTE between study entry and January 2009, identified through databases of the national registry of hospital discharge diagnoses, death certificates, regional anticoagulation clinic and medical records, were used for analysis. Of 351 subjects with first VTE, 37 subjects developed a recurrence during a median follow-up period of 3.3 (interquartile range, 1.1-6.4) years. The annual incidence of recurrence in subjects with elevated albuminuria (≥ 20 mg/l) was 5.00% [95% confidence interval (CI); 2.16-9.85], compared to 2.38% (95%CI; 1.59-3.41) in subjects with normal albuminuria (<20 mg/l). Hazard ratio for recurrence was 1.95 (95%CI; 0.89-4.30) after adjustment for age and sex. This hazard ratio was 3.35 (95%CI; 1.18-9.47) in patients with first unprovoked, and 1.12 (95%CI; 0.25-5.01) in those with a first provoked event. This study showed that subjects with elevated albuminuria who experience an unprovoked VTE are at an increased risk of recurrence, independent of age and sex.     

Psychological well‐being in rheumatoid arthritis: a review of the literature

The psychological well‐being of patients with rheumatoid arthritis (RA) is an important issue, and the advent of measurement tools has led to a better understanding of the mental aspects associated with this chronic illness. Patients with RA are more likely to suffer from anxiety, depression and low self‐esteem, with high levels of associated mortality and suicide. The loss of the ability to carry out daily functions owing to RA is also associated with the onset of depressive symptoms. Furthermore, the psychological effects of RA can extend to the partners, families and carers of sufferers. Conventional treatment has focused on treating the symptoms of RA and containment of disease progression, but may not necessarily address the psychological issues associated with the condition. Furthermore, patient perception of RA and of the support offered to them can cause further unnecessary psychological distress. Access to psychological support for RA patients has been shown to be inconsistent and haphazard. It is now being recognized that what is needed is a multidisciplinary team approach to treat psychological distress in RA alongside conventional treatment, involving alternative therapies tailored to the psychological needs of the patient. The benefits of treatments such as cognitive behavioural therapy, meditation and exercise are clear and these treatments should be actively encouraged, thereby enabling patients with RA to better manage the psychological burden associated with this chronic condition. Copyright © 2010 John Wiley & Sons, Ltd.     

Incidence of venous thromboembolism in patients hospitalized with cancer

Background

There are sparse data on the frequency of venous thromboembolism in patients with various types of cancer. We sought to determine the incidence and relative risk of venous thromboembolism, pulmonary embolism, and deep venous thrombosis in patients with malignancies.

Subjects and methods

The number of patients discharged with a diagnostic code for 19 types of malignancies, pulmonary embolism or deep venous thrombosis from 1979 through 1999 was obtained from the National Hospital Discharge Survey. Patients studied were men and women of all ages and races.

Results

In patients with any of the 19 malignancies studied, 827 000 of 40 787 000 (2.0%) had venous thromboembolism, which was twice the incidence in patients without these malignancies, 6 854 000 of 662 309 000 (1.0 %). The highest incidence of venous thromboembolism was in patients with carcinoma of the pancreas, 51 000 of 1 176 000 (4.3%), and the lowest incidences were in patients with carcinoma of the bladder and carcinoma of the lip, oral cavity or pharynx. The overall incidences of pulmonary embolism and deep venous thrombosis were also twice the rates in noncancer patients. Incidences with cancer were not age dependent. The incidence of venous thromboembolism in patients with cancer began to increase in the late 1980s.

Conclusion

Patients with cancer had twice the incidence of venous thromboembolism, pulmonary embolism and deep venous thrombosis as patients without cancer. The incidence of venous thromboembolism, pulmonary embolism and deep venous thrombosis associated with cancer differed according to the type of cancer, was comparable in elderly and younger patients, and increased in the late 1980s and 1990s.     

Extra-articular complications of rheumatoid arthritis: a review of recent literature

Abstract

To provide and overview of the recent advances and controversies concerning the extra-articular complications of rheumatoid arthritis (RA), we have reviewed the English and Japanese literature with emphasis on articles published within the past 5 years. Disease modifying antirheumatic drugs (DMARDs) can control synovial inflammation but they may also affect various organs such as liver, lung, kidney and bone marrow. Thus, drug-induced side effects should be included in the differential diagnosis of extra-articular manifestations of RA. Other extra-articular manifestations are due to rheumatoid activity per se and seem to represent a group of diseases distinct from synovitis. High-dose steroids and immunosuppresive agents can generally induce remissions in patients with these manifestations but they do not decrease mortality. The association of HLA-DRB1 alleles with the severity of extra-articular manifestations is still debated.     

HIV and risk of venous thromboembolism: a Danish nationwide population‐based cohort study

Objective

The association between HIV infection and the risk of venous thromboembolism (VTE) is controversial. We examined the risk of VTE in HIV‐infected individuals compared with the general population and estimated the impact of low CD4 cell count, highly active antiretroviral therapy (HAART) and injecting drug use (IDU).

Methods

We identified 4333 Danish HIV‐infected patients from the Danish HIV Cohort Study and a population‐based age‐ and gender‐matched comparison cohort of 43 330 individuals. VTE diagnoses were extracted from the Danish National Hospital Registry. Cumulative incidence curves were constructed for time to first VTE. Incidence rate ratios (IRRs) and impact of low CD4 cell count and HAART were estimated by Cox regression analyses. Analyses were stratified by IDU, adjusted for comorbidity and disaggregated by overall, provoked and unprovoked VTE.

Results

The 5‐year risk of VTE was 8.0% [95% confidence interval (CI) 5.78–10.74%] in IDU HIV‐infected patients, 1.5% (95% CI 1.14–1.95%) in non‐IDU HIV‐infected patients and 0.3% (95% CI 0.29–0.41%) in the population comparison cohort. In non‐IDU HIV‐infected patients, adjusted IRRs for unprovoked and provoked VTE were 3.42 (95% CI 2.58–4.54) and 5.51 (95% CI 3.29–9.23), respectively, compared with the population comparison cohort. In IDU HIV‐infected patients, the adjusted IRRs were 12.66 (95% CI 6.03–26.59) for unprovoked VTE and 9.38 (95% CI 1.61–54.50) for provoked VTE. Low CD4 cell count had a minor impact on these risk estimates, while HAART increased the overall risk (IRR 1.93; 95% CI 1.00–3.72).

Conclusion

HIV‐infected patients are at increased risk of VTE, especially in the IDU population. HAART and possibly low CD4 cell count further increase the risk.     

Risk of first venous thromboembolism in and around pregnancy: a population-based cohort study

Knowledge of the absolute and relative risk of venous thromboembolism (VTE) in and around pregnancy would be crucial in identifying when to commence and cease thromboprophylaxis in women who would benefit from such intervention. We addressed this hypothesis using a large prospective primary care database from the United Kingdom, containing details on 972 683 women aged 15–44 years between 1987 and 2004. Risks of a first VTE during antepartum, postpartum and outside of pregnancy were compared using Poisson regression. The rate of VTE during the third trimester antepartum was six times higher than time outside pregnancy [Incidence Rate Ratio (IRR) = 6·1; 95% confidence interval, 4·7–7·9]. In contrast, both the first (IRR = 1·6) and second (IRR = 2·1) trimesters conferred little increase in risk. The first 6 weeks postpartum was associated with a 22‐fold increase in risk, with the peak occurring in the first 3 weeks. Increased age was found to be associated with VTE during postpartum and outside of pregnancy, but not during antepartum. Our findings of a notably raised risk of VTE persisting for 3 weeks postpartum and of a raised antepartum risk constrained to the third trimester have implications for modifying the current recommendations for VTE prophylaxis in pregnancy and the puerperium.     

Management of venous thromboembolism – controversies and the future

Despite the availability of comprehensive evidence‐based guidelines there are difficult and controversial areas in the management of venous thromboembolism. Institutions and even countries disagree on the importance of calf vein thrombosis, with some rigorously detecting and treating it and others deliberately not looking for it. The need to treat proximal deep vein thrombosis and pulmonary embolism is accepted but which patients with an unprovoked first event should have long‐term anticoagulation has become a difficult clinical decision. We are uncertain how to reduce the incidence of post‐thrombotic syndrome seen in a substantial number of patients. How hard to look for an undiagnosed underlying cancer has become a contentious issue particularly in the United Kingdom following the recent publication of a guideline from the National Institute for Health and Clinical Excellence. Whilst we are wrestling with these dilemmas we are entering an era of new anticoagulants and have to solve the logistical problems of introducing them into clinical practice despite cost pressures. These issues will be explored in this review.     

Cardiovascular morbidity in rheumatoid arthritis patients in North Canterbury,New Zealand 1999–2008

Aim

Cardiovascular disease is a substantial contributor to increased morbidity and mortality in rheumatoid arthritis (RA). The aim of this audit was to determine the rate of cardiovascular events in a cohort of newly diagnosed RA patients.

Method

The inpatient clinical database from Christchurch Hospital, Christchurch, New Zealand, was searched using the International Classification of Diseases 9th Revision (ICD9) and 10 codes representing RA and cardiovascular disease between 1 January 1999 and 31 December 2008. Notes were reviewed with additional demographic and medication data sought. Outpatient data for RA patients was collated from the Rheumatology Department's letter database.

Results

Four hundred and six patients were identified with combined ICD9 or 10 codes for RA and ischemic heart disease, of whom 194 had a confirmed myocardial event. Of these, 34 were diagnosed with RA between January 1999 and December 2008 prior to their myocardial event. Kaplan–Meier analysis showed risk of a cardiovascular event at 1 and 10 years was 0.64% and 9.4%, respectively. There were 26 confirmed deaths in the study period. The risk of death at 1 and 10 years was 0.48% and 8.16%, respectively.

Conclusion

We have shown a relatively low prevalence of cardiovascular events in this RA population diagnosed within a 10 year period. This is consistent with other reports and likely reflects the short follow‐up period. Prospective longer‐term studies will be required to further investigate the relative contribution of disease activity and other parameters to cardiovascular events in patients with early RA.     

Single nucleotide polymorphisms and the risk of venous thrombosis: results from a Danish case‐cohort study

A number of single nucleotide polymorphisms (SNP) have been linked to higher risk of venous thromboembolism (VTE). We investigated the VTE risk associated with SNPs in the GP6 (rs1613662), SERPINC1 (rs2227589), F11 (rs2036914 and rs2289252), FGG (rs2066865), and F12 (rs1801020) genes. In F11, the CC genotype for rs2036914 and the CT and TT genotypes for rs2289252 were associated with a significantly higher VTE risk. A trend toward a thrombogenic effect was observed for the risk alleles of the GP6 and FGG SNPs. Risk estimates were unaffected by adjustments for blood type and F5 rs6025 (Factor V Leiden) mutation.     

Diet and rheumatoid arthritis: a review of the literature

INTRODUCTION: Rheumatoid arthritis is a common inflammatory condition. A large number of patients seek alternative or complementary therapies of which diet is an important component. This article reviews the evidence for diet in rheumatoid arthritis along with the associated concept of oral tolerization. METHODS: References were taken from Medline from 1966 to September 2004. The keywords, rheumatoid arthritis, diet, n-3 fatty acids, vitamins, and oral tolerization, were used. RESULTS: Randomized controlled trials (RCTs) indicate that dietary supplementation with n-3 fatty acids provides modest symptomatic benefit in groups of patients with rheumatoid arthritis. Epidemiological studies and RCTs show cardiovascular benefits in the broader population and patients with ischemic heart disease. A number of mechanisms through which n-3 fats may reduce inflammation have been identified. In a small number of patients with rheumatoid arthritis, other dietary manipulation such as fasting, vegan, and elimination diets may have some benefit. However, many of these diets are impractical or difficult to sustain long term. CONCLUSIONS: Dietary manipulation provides a means by which patients can a regain a sense of control over their disease. Dietary n-3 supplementation is practical and can be easily achieved with encapsulated or, less expensively, bottled fish oil.