Microalbuminuria: is it a predictor of ischaemic heart disease in rheumatoid arthritis?

SIR, We read with interest the article by Kitas and Erb [1],where an interesting parallel is drawn between rheumatoid arthritis(RA) and type-2 diabetes (T2D) with respect to ischaemic heartdisease (IHD). The association between RA and IHD, as with T2D,is clearly important, yet in the     

Interleukin-6 serum concentration in ankylosing spondylitis: a reliable predictor of disease progression in the subsequent year?

The aim of the present study was to evaluate whether in ankylosing spondylitis (AS), interleukin-6 (IL-6) is a reliable predictor of changes in mobility in the subsequent year. Of 261 AS patients who had been enrolled in a previous study, 128 returned for treatment at our health centre after 1 year (±3 months). The variables for mobility after 1 year (II) were compared with the findings of the previous year (I). Differences in parameters for mobility were related to the serum concentration of IL-6 in the previous year. Relation between serum concentration of IL-6 and difference (II–I) in occiput-to-wall distance (Spearman's rank correlation coefficient r _s, P value) was 0.02, 0.82; chin–chest distance −0.09, 0.31; cervical rotation −0.08, 0.39; chest expansion 0.05, 0.54; finger–floor distance −0.02, 0.84; Ott sign (flexibility of the thoracic spine) −0.11, 0.22; Schober sign 0.01, 0.94. After 1 year there was a significant improvement in cervical rotation in patients with low IL-6 serum concentration (lower quartile), but not in those with high levels of IL-6 (upper quartile). No further difference was seen between patients with high or low levels of IL-6. The present data suggest that the serum concentration of IL-6 does not allow a prediction of disease progression in the subsequent year. Received: 15 September 1999 / Accepted: 20 January 2000     

Nocturnal hypertension: Will control of nighttime blood pressure prevent progression of diabetic renal disease?

Patients with type 1 and 2 diabetes and nephropathy frequently have a blunted fall in nighttime arterial blood pressure. This abnormality is already seen in subjects with type 1 diabetes who are in the microalbuminuric phase of the disease, and we have also shown that an increase in nighttime systolic blood pressure precedes the development of microalbuminuria. These studies suggest that nocturnal hypertension may be an important early predictor of diabetic nephropathy. Various drugs have different effects on nocturnal blood pressure, and chronotherapy may be key in determining clinical outcomes. There is a compelling need for studies showing that treating nocturnal hypertension in diabetes can prevent renal disease progression.     

Coronary artery disease and periodontal disease: is there a link?

BACKGROUND: Cardiovascular disease is the number one killer worldwide. The so-called classic risk factors of coronary heart disease do not account for all of its clinical and epidemiological features. Recent evidence suggests that certain infections, among them dental infections and in particular periodontal disease, are involved in the pathogenesis of coronary artery disease. AIM: To evaluate the association between periodontal disease and coronary artery disease. PATIENTS AND METHODS: Fifty patients referred for diagnostic coronary angiography were assessed for periodontal disease. All patients underwent a thorough physical examination, routine laboratory testing, cardiac evaluation and dental examination which included pantomography x-ray evaluation. RESULTS: Pantomography x-rays and coronary angiograms of the participants were scored blindly by a dentist and cardiologists respectively. The association between periodontal disease and coronary atheromatosis remained significant after adjustment for age, smoking, blood lipids, body mass index, hypertension and the presence of diabetes. IMPLICATIONS: Periodontal disease was still significantly associated after all the known risk factors were accounted for. The implication here is that periodontal disease could be a potential risk factor for heart disease by predisposing the individual to chronic low-grade infections. If so, then dental health becomes an important parameter for medical health.     

Influenza and cardiovascular disease: is there a causal relationship?

There is mounting evidence in support of a significant role for influenza infection in the development of atherosclerosis and the triggering of its complications. Here we review the biologic basis of this relationship, with special emphasis on the pro-inflammatory and pro-thrombotic effects of influenza infection. We also discuss the related epidemiologic findings and discuss in detail the possible causal relationship between influenza and cardiovascular disease. We appraise the relationship between influenza and coronary heart disease, on the basis of Bradford Hill's criteria of causality. We show that our proposed relationship meets the following criteria: strength of association, consistency, temporal sequence, coherence, biologic plausibility, experimental evidence, and analogy. Further studies are needed to assess whether it meets the criterion of biologic gradient. Specificity is not met, but meeting that criterion is of least importance in the study of multifactorial chronic diseases such as coronary heart disease. These criteria do not yield indisputable evidence for or against cause-and-effect, but they can help researchers appraise available evidence and determine the areas that need further research. The case for expanding the research on the effect of influenza on cardiovascular disease is a strong one, for most of Hill's criteria are met.     

Cocaine and Buerger disease: is there a pathogenetic association?

A patient with a diagnosis of Buerger disease is described with peripheral limb ischemia and toe amputations, 2 recent small myocardial infarctions, and a long history of cigarette use. Peripheral angiography findings were incompatible with the clinical impression, and further workup revealed heavy recreational use of cocaine. A literature review of the clinical and pathologic manifestations of Buerger disease and of cocaine exposure shows them to have remarkable similarities. Based on our case observation and suggestive evidence from the literature, we propose that cocaine exposure may masquerade as Buerger disease, and further, that unrecognized cocaine exposure may underlie such cases, even including those originally described by Buerger in 1908.     

What is the optimal strategy to intensify blood pressure control and prevent progression of renal failure?

Recent clinical trials clearly demonstrate that patients with diabetes and hypertension, and patients with renal disease and hypertension, should have their blood pressure lowered intensively. A recent analysis of long-term clinical trials over the past 8 years clearly demonstrates that the lower the blood pressure over a range of values, the greater the preservation of renal function. It is also readily apparent that monotherapy does not suffice in attaining these more intensified goals. A review of five clinical trials in the recent National Kidney Foundation consensus report demonstrates that patients randomized to the lower level of blood pressure required an average of 3.2 different antihypertensive medications taken daily. Consequently, it is evident that the question is no longer what the initial preferred monotherapy should be, but rather what should be the optimal drug to add to an angiotensin converting enzyme inhibitor or angiotensin receptor blocker. In this paper we review data from several recent studies clearly indicating that to achieve goal blood pressure in the clinical setting of metabolic disarray and hyperglycemia, long-acting calcium antagonists constitute an excellent add-on agent for enhancing efficacy. We anticipate that the data that will accrue from the IDNT and RENAAL studies will further delineate the renal effects of dihydropyridine calcium antagonists.     

Subclinical renal tubular acidosis in patients with primary and secondary Sjögren's syndrome: a possible marker of disease progression

Abstract

To clarify the prevalence of subclinical renal tubular acidosis (RTA) and its association with clinical and laboratory parameters in primary and secondary Sjögren's syndrome (SS), an acid-loading test was conducted. Subclinical RTA was found in 32% of patients with SS. The prevalence of subclinical RTA in primary and secondary SS was about the same (31.6% and 33.3%, respectively). Significant longer duration of illness, more severely decreased salivary excretion, decreased lymphocyte number, higher serum levels of IgG and IgA, and higher frequency of anti-SS-A (Ro) and SS-B (La) antibodies were found in patients with subclinical RTA. These results suggested that subclinical RTA may be a characteristic manifestation both in primary and secondary SS, along with the progression of immunologic dysfunction, when the illness seemed to be indolent.