Chronic Kidney Disease as a Coronary Heart Disease Risk Equivalent

Tailoring therapeutic targets to patients’ risk is a fundamental principle of many coronary heart disease (CHD) treatment guidelines. Although the National Cholesterol Education Program’s guidelines do not include chronic kidney disease (CKD) as a CHD risk equivalent, the National Kidney Foundation and American Heart Association have recommended its inclusion in the highest-risk grouping for the prevention and treatment of cardiovascular disease. In three population-based studies, the risk of cardiovascular disease was higher among participants with established CHD when compared to their counterparts with CKD. Although there are other reasons for including CKD as a CHD risk equivalent in treatment guidelines (eg, higher case fatality rates from CHD and stroke), the inclusion of CKD as a CHD risk equivalent has treatment implications for a large number of US adults. Randomized trials assessing the benefits and drawbacks of aggressive CHD risk reduction among patients with CKD are needed.     

Chronic Kidney Disease as a Coronary Artery Disease Risk Equivalent

Chronic kidney disease (CKD) is associated with accelerated cardiovascular disease (CVD) risk and a higher CVD event rate. Substantial data from prospective cohort studies support the concept that dialysis patients as well as those with advanced stage (stages 3–5) CKD are associated with an increased risk for all-cause and cardiovascular mortality. The risk for coronary artery disease (CAD) increases exponentially with declining kidney function, i.e., stage 3 or higher CKD. Indeed, CVD accounts for more than 50 % of deaths in patients with CKD. CKD patients are more likely to die of CVD than to progress to end stage kidney disease. This increase in CV risk is commonly attributed to co-existence of numerous traditional and nontraditional risk factors for the development of CVD that frequently accompany reduced kidney function. Therefore, CKD itself is now considered an independent CVD risk factor and a coronary artery disease (CAD) equivalent for all-cause mortality. All patients at risk for CAD should be evaluated for kidney disease. Treatments used for management of established CAD might have similar benefits for patients with concomitant CKD.     

Smoking as a Chronic Disease

Despite remaining the leading cause of preventable death in the United States, tobacco smoking does not garner the attention it deserves in the medical and public health communities. Smoking is often referred to merely as a “bad habit” that simply requires adequate willpower to conquer effectively. Fortunately, recent attitudes regarding smoking, as illustrated by the latest US Public Health Service Clinical Practice Guidelines, call for a “chronic disease model” for treating tobacco dependence. This article underscores the importance of viewing smoking as a chronic disease by illustrating the effects on morbidity and mortality, discussing the relapsing nature of addiction, outlining the need for continuum of care for different “severities” of illness, and describing the latest research regarding effective treatment components. Tobacco dependence treatments are safe, effective, and cost-saving, and their use should be encouraged and covered by health insurance analogous to other chronic conditions.     

Peyronie's Disease as a Complication of Chronic Graft versus Host Disease

Apart from one report of phimosis, involvement of the penis has not been reported as a complication of chronic GVHD. We report a patient with recurrent chronic GVHD who developed skin discoloration of the penile shaft, together with erectile dysfunction consistent with Peyronie's disease. Histological features were consistent with sclerodermatous change. These features suggest that the penis may be a target organ in chronic GVHD.     

Economic Evaluation of a Disease Management Program for Chronic Obstructive Pulmonary Disease

Background: The data on cost savings with disease management (DM) in chronic obstructive pulmonary disease (COPD) is limited. A multicomponent DM program in COPD has recently shown in a large randomized controlled trial to reduce hospitalizations and emergency department visits compared to usual care (UC). The objectives of this study were to determine the cost of implementing the DM program and its impact on healthcare resource utilization costs compared to UC in high-risk COPD patients. Materials and Methods: This study was a post-hoc economic analysis of a multicenter randomized, adjudicator-blinded, controlled, 1-year trial comparing DM and UC at 5 Midwest region Department of Veterans Affairs (VA) medical centers. Health-care costs (hospitalizations, ED visits, respiratory medications, and the cost of the DM intervention) were compared in the COPD DM intervention and UC groups. Results: The composite outcome for all hospitalizations or ED visits were 27% lower in the DM group (123.8 mean events per 100 patient-years) compared to the UC group (170.5 mean events per 100 patient-years) (rate ratio 0.73; 0.56–0.90; p < 0.003). The cost of the DM intervention was $241,620 or $650 per patient. The total mean ± SD per patient cost that included the cost of DM in the DM group was 4491 ± 4678 compared to $5084 ± 5060 representing a $593 per patient cost savings for the DM program. Conclusions: The DM intervention program in this study was unique for producing an average cost savings of $593 per patient after paying for the cost of DM intervention.     

Difference in the Progression of a Liver Disease in a Pair of Siblings with Wilson's Disease

Wilson's hepatolenticular degeneration is a well defined disease, where copper metabolism is disturbed genetically in the liver, but its exact cause is not known. The development of the clinical symptoms varies in each individual and it is interesting to know the mechanism of the individual differences which occur in this well defined disease. We studied a pair of siblings with Wilson's disease in whom the condition of the liver disease was very much different. The 16-year-old man had the full blown liver cirrhosis characteristic of Wilson's disease, with large regenerating nodules and a deposition of copper granules in the hepatocytes. On the other hand, the liver of the 19-year-old sister, who was supposed to have the same Wilson's disease gene and who had been exposed to high concentrations of liver copper for a longer period, was fairly well preserved with a smooth liver surface. There is no study that reports in detail the differences in this liver disease in close relatives. According to the findings of our comparison of these 2 cases, we speculated that there are factors, other than the direct effect of Wilson's disease gene, which control the mode of accumulation and toxicity of copper in the liver, or factors that control the response to the accumulated copper in the liver.     

Bronchiectasis: Phenotyping a Complex Disease

ABSTRACT

Bronchiectasis is a long-neglected disease currently experiencing a surge in interest. It is a highly complex condition with numerous aetiologies, co-morbidities and a heterogeneous disease presentation and clinical course. The past few years have seen major advances in our understanding of the disease, primarily through large real-life cohort studies. The main outcomes of interest in bronchiectasis are symptoms, exacerbations, treatment response, disease progression and death. We are now more able to identify clearly the radiological, clinical, microbiological and inflammatory contributors to these outcomes. Over the past couple of years, multidimensional scoring systems such as the Bronchiectasis Severity Index have been introduced to predict disease severity and mortality. Although there are currently no licensed therapies for bronchiectasis, an increasing number of clinical trials are planned or ongoing. While this emerging evidence is awaited, bronchiectasis guidelines will continue to be informed largely by real-life evidence from observational studies and patient registries. Key developments in the bronchiectasis field include the establishment of international disease registries and characterisation of disease phenotypes using cluster analysis and biological data.     

Skin Autofluorescence Is a Predictor of Cardiovascular Disease in Chronic Kidney Disease Patients

Accelerated formation and tissue accumulation of advanced glycation end products (AGEs), reflecting cumulative glycemic and oxidative stress, occurs in age‐related and chronic diseases like diabetes mellitus (DM) and renal failure, and contributes to vascular damage. Skin autofluorescence (AFR), a noninvasive measurement method, reflects tissue accumulation of AGEs. AFR has been reported to be an independent predictor of mortality in Caucasian hemodialysis patients. We assessed the relationship between levels of AFR and the prevalence of cardiovascular disease (CVD), and clarified the prognostic usefulness of skin AFR levels in Asian (non‐Caucasian) hemodialysis (HD) patients. AFR was measured with an autofluorescence reader in 64 HD patients. Overall and cardiovascular mortality was monitored prospectively during the 3‐year follow‐up. During follow‐up, CVD events occurred in 21 patients. The deaths of 10 HD patients were associated with CVD. Multivariate logistic regression analyses showed that initial AFR was an independent risk factor for de novo CVD in HD patients with or without diabetes. When patients were classified on the basis of AFR tertiles, Cochran‐Armitage analysis demonstrated that the highest tertile of AFR level showed an increased odds ratio for the prevalence of CVD. These findings suggest that AFR levels can be used to detect the prevalence of CVD in HD patients with or without diabetes.     

Alcoholism/Addiction as a Chronic Disease

Summary

Although characterized as a chronic disease for more than 200 years, severe and persistent alcohol and other drug (AOD) problems have been treated primarily in self-contained, acute episodes of care. Recent calls for a shift from this acute treatment model to a sustained recovery management model will require rethinking the natural history of AOD disorders; pioneering new treatment and recovery support technologies; restructuring the funding of treatment services; redefining the service relationship; and altering methods of service evaluation. Recovery-oriented systems of care could offer many advantages over the current model of serial episodes of acute care, but such systems will bring with them new pitfalls in the personal and cultural management of alcohol and other drug problems.     

Ferritin, a Hodgkin''s Disease Associated Antigen

Antigens which exist in high frequency in tumor tissues of patients with Hodgkin's disease have been obtained in relatively concentrated form by gel chromatography procedures. Further purification and analysis of these antigens performed in the present study have demonstrated that the antigen of fast electrophoretic mobility (F-antigen) is normal tissue ferritin. The identification of F-antigen as ferritin has been made on the basis of comparative physicochemical and immunological analyses of purified F-antigen and normal ferritin. Thus, F-antigen was found to contain iron and to be similar to ferritin in molecular weight, amino-acid composition, electrophoretic mobility, isoelectric distribution, and immunological reactivity. Absorption of a monospecific heterologous anti-F antiserum with normal tissue ferritin completely removed all anti-F antibody activity. Moreover, the absorption of polyspecific heterologous antiserum to crude Hodgkin's extracts, which contains antibodies reacting with F-antigen, the slower migrating S-antigen, and a third specificity present in lysates of normal peripheral blood lymphocytes (PL-antigen), with ferritin, removed only anti-F activity, thus distinguishing the S- and PL-antigens from ferritin. The existence of ferritin in high quantities in serum of Hodgkin's disease patients may provide a tool of potential diagnostic and prognostic importance in the management of this disease.