Giant cell arteritis with low erythrocyte sedimentation rate: Frequency of occurrence in a population‐based study

Objective

To determine the frequency of a low erythrocyte sedimentation rate (ESR) in patients with giant cell arteritis (GCA) and evaluate their clinical features in a defined population.

Methods

A total of 167 patients with GCA were identified in the population of Olmsted County, Minnesota, between the years 1950 and 1998 using methods described in previous studies. All fulfilled American College of Rheumatology criteria for GCA.

Results

In 9 of the 167 patients the ESR was less than 40 mm/hour (Westergren method) at diagnosis. These patients had less frequent systemic symptoms and visual symptoms than the others. No patient with low ESR developed blindness. Other manifestations were similar in those with low and those with high ESR. The response of symptoms to prednisone treatment was within 1 week, and after a median of 25 days of therapy the median ESR dropped from 19 mm/hour to 3 mm/hour. The median duration of glucocorticoid therapy in the 9 patients was 21.5 months and median followup after diagnosis was 12.5 years. Over a long period of observation (median 44 years) in the 9 patients with low ESR, 9 inflammatory events other than GCA were observed in 7 patients. The ESR was normal in 7 of these 9 other events.

Conclusion

A low ESR in active GCA is not a rare occurrence. Causes may include localized arteritis in some patients and an inability to mount an acute phase serologic response in others.

     

Erythrocyte sedimentation rate: a possible marker of atherosclerosis and a strong predictor of coronary heart disease mortality.

AIMS: Since atherosclerosis is a chronic inflammation and the erythrocyte sedimentation rate is an appropriate test for monitoring chronic inflammatory responses, we wanted to investigate whether the erythrocyte sedimentation rate might carry prognostic information on the risk of sustaining coronary heart disease events. METHOD: The erythrocyte sedimentation rate was determined in 2014 apparently healthy men aged 40-60 years during an extensive cardiovascular survey in 1972-75, and the test was repeated in an identical follow-up examination 7 years later. Cause-specific mortality and rates of non-fatal myocardial infarction were followed for 23 years. RESULTS: The erythrocyte sedimentation rate was strongly correlated with age, haemoglobin level, smoking status, total cholesterol level and systolic blood pressure. After adjusting for all these associations in multivariate Cox regression analyses, the erythrocyte sedimentation rate emerged as a strong short- and long-term predictor of coronary heart disease mortality, particularly in men who had developed angina pectoris and/or had a positive exercise ECG test at the second survey. Increases in non-coronary heart disease deaths and in non-fatal myocardial infarctions were only seen in the upper erythrocyte sedimentation rate range. CONCLUSIONS: The erythrocyte sedimentation rate is a strong predictor of coronary heart disease mortality, and appears to be a marker of aggressive forms of coronary heart disease. The erythrocyte sedimentation rate probably gives substantial information in addition to that given by fibrinogen on the risk of coronary heart disease death.     

Comorbidity is an independent prognostic factor in patients with advanced‐stage diffuse large B‐cell lymphoma treated with R‐CHOP: a population‐based cohort study

An observational population‐based cohort study was performed to investigate the role of comorbidity on outcome and treatment‐related toxicity in patients with newly diagnosed advanced‐stage diffuse large B‐cell lymphoma (DLBCL) treated with R‐CHOP (rituximab, cyclophosphamide, doxorubicin, vincristine, prednisone). Data for the clinical characteristics of 154 patients (median age 69 years), including Charlson Comorbidity Index (CCI), treatment, toxicity and outcome were evaluated. Forty‐five percent of the patients had an International Prognistic index ≥3 and 16% had a CCI ≥2. The planned R‐CHOP schedule was completed by 84% and 75% reached complete remission (CR). In those with CCI ≥2, 67% completed treatment with 46% CR. In patients with a CCI <2, overall survival (OS) after 1, 2 and 5 years was 84%, 79% and 65% respectively and it was 64%, 48% and 48% for those with CCI ≥2. Grade III/IV toxicity was documented in 53%, most frequently febrile neutropenia (27%) and infections (23%). In multivariate analysis CCI ≥2 and IPI ≥3 were independent risk indicators for OS and grade III/IV toxicity. In conclusion, comorbidity is an independent risk indicator for worse OS in patients with advanced DLBCL treated with R‐CHOP by interference with intensive treatment schedules and more grade III/IV toxicity. Future studies are warranted to determine the optimal treatment approach in patients with significant comorbidities.     

The clinical and prognostic significance of erythrocyte sedimentation rate (ESR), serum interleukin‐6 (IL‐6) and acute phase protein levels in multiple myeloma

Summary Interleukin‐6 (IL‐6) and acute phase proteins are commonly increased in patients with multiple myeloma. Several of these acute phase proteins are believed to predict prognosis and influence survival. We measured interleukin‐6 (IL‐6), C‐reactive protein (CRP), alpha‐1‐antitrypsin (a₁AT), acid alpha‐1‐glycoprotein (a₁AG), haptoglobin (HAP), transferrin (TRF), hemoglobin (Hb), beta‐2‐microglobulin (β₂M) and erythrocyte sedimentation rate (ESR) in 42 newly diagnosed multiple myeloma patients and 25 normal controls. At the time of blood collection, nine patients were at stage I of disease, 14 at stage II, and 19 at stage III according to the Durie and Salmon myeloma staging system. Mean ± SD values of IL‐6, CRP, a₁AT, a₁AG, HAP, β₂M, and ESR were significantly higher and Hb significantly lower than those found in the controls. Univariate analysis, using the log‐rank test, showed that among the acute phase proteins, serum CRP (P < 0.002), a₁AT (P < 0.008) and ESR (P < 0.008) were significantly correlated with survival. However, when a multivariate Cox proportional hazard model was performed, ESR, CRP, a₁AT, a₁AG and β₂M were identified as independent prognostic factors, while the others were not. We conclude that ESR, a simple and easily performed marker, was found to be an independent prognostic factor for survival in patients with multiple myeloma.     

Trends in the epidemiology,diagnosed age and mortality rate of haemophiliacs in Taiwan: a population‐based study, 1997–2009

Many studies on epidemiology and mortality in haemophiliacs have been published in Western countries. However, few have been conducted in Asian countries. The purpose of our study was to investigate the nationwide epidemiology and mortality of haemophiliacs in Taiwan. Population‐based data from the National Health Insurance Research Database between 1997 and 2009 were analysed using SAS version 9.3. The annual prevalence of haemophilia A (HA) and haemophilia B (HB) increased steadily to 7.30 and 1.34 cases per 100000 males, respectively, in 2009. The annual crude incidence of HA and HB averaged 8.73 and 1.73 per 100000 male births respectively. During the study period, the proportion of paediatric haemophiliacs decreased from 41.5% to 28.2% and the proportion of geriatric haemophiliacs increased from 2.5% to 5.7%. Among 493 newly diagnosed cases, the peak diagnostic ages were before 3 and between ages 10 and 40. Of the 76 cases of mortality, most patients died between the ages of 18 and 60. However, an increase in the age of mortality was noted after 2005 (P = 0.033). The overall standardized crude death rate of haemophiliacs was 10.2 per 1000 people, and the standard mortality ratio was 1.98. The annual prevalence of human immunodeficiency virus infection in haemophiliacs grossly declined from 1998 to 2009, with an average of 32.2 per 1000 haemophiliacs. This was a rare population‐based study on the epidemiology and mortality of haemophilia in a Chinese population and Asian countries. The 13‐year trends showed advances in haemophilia care in Taiwan.     

All‐cause mortality in people with cirrhosis compared with the general population: a population‐based cohort study

Background: Mortality due to cirrhosis has tripled over the last 30 years in the UK. However, we lack adequate, contemporary, population‐based estimates of the excess mortality patients who are at risk compared with the general population. Aim: To determine the overall survival in patients with cirrhosis compared with the general population taking into account the effects of severity and aetiology of disease and comorbidity. Methods: In a cohort study, we identified 4537 people with cirrhosis and a control cohort of 44 403 patients, matched by age, sex and general practice from the UK General Practice Research Database between June 1987 and April 2002. Results: Patients with compensated cirrhosis had a nearly five‐fold [hazard ratio (HR) 4.7, 95% confidence interval (CI) 4.4–5.0] increased risk of death, while those with decompensated cirrhosis had a near 10‐fold (HR 9.7, 95% CI 8.9–10.6) increased risk compared with the general population. Alcoholic cirrhosis conferred a worse prognosis than non‐alcohol‐related cirrhosis both in the first year following diagnosis and subsequently. Conclusion: Having a diagnosis of cirrhosis confers a substantial increased mortality risk compared with the general population, even for those with compensated disease, with 5‐year survival between that seen for breast and colorectal cancer.     

Impact of injecting drug use on mortality in Danish HIV‐infected patients: a nation‐wide population‐based cohort study

Objectives To estimate the impact of injecting drug use (IDU) on mortality in HIV‐infected patients in the highly active antiretroviral therapy (HAART) era. Design Population‐based, nation‐wide prospective cohort study in Denmark (the Danish HIV Cohort Study). Methods A total of 4578 HIV‐infected patients were followed from 1 January 1997 or date of HIV diagnosis. We calculated mortality rates stratified on IDU. One‐, 5‐ and 10‐year survival probabilities were estimated by Kaplan–Meier methods, and Cox regression analyses were used to estimate mortality rate ratios (MRR). Results Of the patients, 484 (10.6%) were categorized as IDUs and 4094 (89.4%) as non‐IDUs. IDUs were more likely to be women, Caucasian, hepatitis C virus (HCV) co‐infected and younger at baseline; 753 patients died during observation (206 IDUs and 547 non‐IDUs). The estimated 10‐year survival probabilities were 53.2% [95% confidence interval (CI): 48.1–58.3] in the IDU group and 82.1% (95% CI: 80.7–83.6) in the non‐IDU group. IDU as route of HIV infection more than tripled the mortality in HIV‐infected patients (MRR: 3.2; 95% CI: 2.7–3.8). Adjusting for potential confounders did not change this estimate substantially. The risk of HIV‐related death was not increased in IDUs compared to non‐IDUs (MRR 1.1; 95% CI 0.7–1.7). Conclusions Although Denmark's health care system is tax paid and antiretroviral therapy is provided free of charge, HIV‐infected IDUs still suffer from substantially increased mortality in the HAART era. The increased risk of death seems to be non‐HIV‐related and is due probably to the well‐known risk factors associated with intravenous drug abuse.     

Lower life expectancy among people with an HCV notification: a population‐based linkage study

Among people with hepatitis C virus (HCV) infection, liver disease‐related deaths have risen over the last 20 years. Life expectancy has not been estimated in this population. HCV notifications (mandatory notification of anti‐HCV‐positive serology since 1991) reported to the New South Wales Health Department from 1992 to 2006 were linked to cause of death data. Abridged life tables were constructed from age‐specific mortality rates. Life expectancy from ages 18–70 years for non‐drug‐related mortality causes was estimated using competing risk methods and compared to the general population of Australia. The cohort comprised 81 644 individuals with an HCV notification, with median follow‐up of 7.6 years. Median age at notification was 34 years [interquartile range (IQR) 28–42] and 63% were male. Between 1992 and 2006, 4607 deaths occurred. Median age at liver‐ and drug‐related death among males was 51 (IQR 45–66) and 36 (IQR 31–42) years, respectively, and among females was 63 (IQR 49–74) and 36 (IQR 30–41) years, respectively. In each year of follow‐up before 2000, 15–21% of deaths were liver‐ and 30–39% were drug‐related. After 2000, liver‐related deaths increased to 20–26% of deaths in each year and drug‐related deaths decreased to 13–19%. Excluding drug‐related causes of death, life expectancy was lowered by an average of 4.2 (SD ± 1.0) and 5.4 (SD ± 0.7) years for males and females, respectively. Among people with an HCV notification, an increasing proportion of deaths are liver‐related. Following removal of drug‐related mortality, life expectancy in this population remained considerably lower, compared with the general population.     

Maternal adiposity as an independent risk factor for pre‐eclampsia: a meta‐analysis of prospective cohort studies

Studies investigating the association between maternal adiposity and risk of pre‐eclampsia showed contradictory results. Therefore, we performed a meta‐analysis of prospective cohort studies to estimate the effect of maternal adiposity on pre‐eclampsia. We reviewed 1,286 abstracts and finally included 29 prospective cohort studies with 1,980,761 participants and 67,075 pre‐eclampsia events. We pooled data with a random‐effects model, and obtained risk estimates for five predetermined bodyweight groups: low, normal‐weight (reference), overweight, obese and severely obese. In the cohort studies that unadjusted for pre‐eclampsia risk factors, the pooled unadjusted relative risks (RR) with 95% confidence intervals (95%CI) for pre‐eclampsia of overweight, obese and severely obese women were 1.58 (95% CI 1.44–1.72, P < 0.001), 2.68 (95% CI 2.39–3.01, P < 0.001) and 3.12 (95% CI 2.24–4.36, P < 0.001), respectively. In those cohorts that adjusted for pre‐eclampsia risk factors, the pooled unadjusted RRs for pre‐eclampsia of overweight, obese and severely obese women were 1.70 (95% CI 1.60–1.81, P < 0.001), 2.93 (95% CI 2.58–3.33, P < 0.001) and 4.14 (95% CI 3.61–4.75, P < 0.001), respectively. Sensitivity analysis showed maternal adiposity was associated with increased risk of pre‐eclampsia in both nulliparous and multiparas women. In conclusion, overweight or obese pregnant women have a substantially increased risk of pre‐eclampsia, and maternal adiposity is an independent risk factor of pre‐eclampsia.     

Plasma procalcitonin and the risk of cardiovascular events and death: a prospective population‐based study

Abstract. Schiopu A, Hedblad B, Engström G, Struck J, Morgenthaler NG, Melander O (Lund University, Skåne University Hospital Malmö, Malmö, Sweden; BRAHMS GmbH/Thermo Fisher Scientific, Hennigsdorf, Germany). Plasma procalcitonin and the risk of cardiovascular events and death: a prospective population‐based study. J Intern Med 2012; 272: 484–491. Objectives: A number of inflammatory biomarkers such as C‐reactive protein (CRP) are independent predictors of cardiovascular risk. The inflammatory biomarker procalcitonin (PCT) has previously been shown to be associated with coronary atherosclerosis and the metabolic syndrome. We evaluated the ability of PCT to predict future cardiovascular events in a population of apparently healthy individuals. Design: We measured plasma PCT levels in 3713 subjects with no previous history of cardiovascular disease, randomly selected from the Malmö Diet and Cancer cohort. The correlation between PCT concentration and the incidence of coronary events, stroke and cardiovascular death over a median follow‐up period of 13.7 years was studied using a Cox regression analysis corrected for age, sex, CRP level, traditional risk factors and renal function. Results: Age and sex were strong determinants of PCT; the concentration of PCT was significantly higher in men than in women. PCT was associated with several of the established cardiovascular risk factors (CRP, hypertension, diabetes and renal function) as determined by multivariate linear regression. Of note, PCT was inversely correlated with HDL and smoking. We found significant correlations between PCT levels, coronary events and cardiovascular death. However, these relationships lost statistical significance when the analysis was corrected for CRP and the traditional risk factors. Conclusions: This is the largest population‐based prospective study to demonstrate a positive association between plasma PCT levels and cardiovascular risk in subjects with no previous history of acute cardiovascular events. However, the high degree of covariation between PCT and other cardiovascular risk factors limits the value of PCT as an independent cardiovascular risk predictor.     

Phase angle as a prognostic marker after percutaneous endoscopic gastrostomy (PEG) in a prospective cohort study

Objective: The phase angle identifies changes in tissue’s electrical properties assessed by bioelectrical impedance measurement and it can predict prognosis in some conditions. Percutaneous endoscopic gastrostomy (PEG) is commonly used in patients with severe nutritional problems, but there is a need to improve the clinical decision-making for using PEG. We examined if a decreased phase angle predicts complications, short-term mortality (within 60 days of PEG insertion), or inflammatory markers (high C-reactive protein [CRP] levels or low albumin levels) following PEG insertion.

Material and methods: The phase angle was assessed from body resistance and reactance as measured by bioelectrical impedance in 131 patients admitted for PEG. Anthropometrics and clinical biochemical measures were collected at the time of PEG insertion, while complications and mortality were assessed at clinical follow-ups. Multivariable logistic regression analysis provided odds ratios (ORs) with 95% confidence intervals (CIs) adjusted for sex, age, body mass index, and comorbidity.

Results: A decreased phase angle did not statistically significantly increase the probability of acute complications or short-term mortality, but predicted increased inflammatory markers (CRP?≥10?mg/L [OR 1.63, 95% CI 1.02–2.60], albumin?<30?g/L [OR 2.10, 95% CI 1.24–3.57] and a combination of CRP?≥10?mg/L and albumin?<30?g/L [OR 3.06, 95% CI 1.51–6.19]).

Conclusions: A decreased phase angle did not predict acute complications or short-term mortality after PEG insertion, but predicted increased levels of inflammatory markers.