Cold-related mortality due to cardiovascular diseases, respiratory diseases and cancer: a case-crossover study

OBJECTIVES

The aim of this study was to identify the relationship between low temperatures in winter and mortality due to cancer, cardiovascular diseases and respiratory diseases.

STUDY DESIGN

Case-crossover study.

METHODS

A case-crossover study was performed in Cantabria (northern Spain) in the years 2004-2005; 3948 deaths were included. Odds ratios were estimated using conditional logistic regression, stratified by age, sex, and delay of exposure to low temperatures.

RESULTS

There was an inverse dose-response relationship between temperature and mortality in the three causes of death studied; this result was consistent across genders and age groups. The higher OR for cancer mortality was seen on the first day of exposure (OR = 4.91; 95% CI: 1.65-13.07 in the whole population), and it decreased when exposure over several days in a row was considered; people aged 75 years or more were especially susceptible to cold temperatures (OR = 17.9; 95% CI: 2.38-134.8). Cardiovascular (OR = 2.63; 95% CI: 1.88-3.67) and respiratory mortality (OR = 2.72; 95% CI: 1.46-5.08) showed a weaker effect.

CONCLUSION

There is a striking association between the extreme cold temperatures and mortality from cancer, not previously reported, which is more remarkable in the elderly. These results could be explained by a harvesting effect in which the cold acts as a trigger of death in terminally ill patients at high risk of dying a few days or weeks later.

Effects of 25-hydroxyvitamin D3 therapy on bone turnover markers and PTH levels in postmenopausal osteoporotic women treated with alendronate

OBJECTIVE

Our objective was to know the extent to which a fall in bone turnover markers is influenced by serum 25-hydroxyvitamin D (25OHD) levels in patients on alendronate (ALN) treatment.

DESIGN, PARTICIPANTS, AND SETTING

A total of 140 postmenopausal osteoporotic women were randomized to receive either ALN or ALN plus 25OHD(3) (ALN+VitD) over a 3-month period. Serum 25OHD, PTH, C-terminal telopeptide of type I collagen (CTX), and amino-terminal propeptide of type I collagen (P1NP) were measured at baseline and at the end of the 3 months.

RESULTS

25OHD rose four times above baseline levels in the ALN+VitD group, whereas no changes were seen in the ALN group. Administering ALN resulted in a significant decline in both serum CTX (53 ± 24%) and P1NP (46 ± 19%). After ALN+VitD, the fall in CTX amounted to 61 ± 20% (P = 0.06 compared with ALN) and P1NP to 50 ± 23% (P = 0.35). When patients were divided into those below and above 20 ng/ml of baseline serum 25OHD, in those below, CTX decreased by 48 ± 26% in the ALN group and by 61 ± 17% in the ALN+VitD group (P = 0.015). For P1NP, the corresponding figures were 43 ± 20 and 50 ± 23% (P = 0.2). In patients above 20 ng/ml, no differences were seen regarding CTX (58 ± 21% decrease in the ALN group and 60 ± 23% in the ALN+VitD group; P = 0.7) or P1NP (49 ± 18 and 50 ± 20%; P = 0.9).

CONCLUSIONS

Administration of 25OHD(3) is not an indispensable requirement for bisphosphonates to develop their bone antiresorptive effect. In fact, in patients with vitamin D sufficiency, no benefit is observed when the vitamin is added. However, in patients with vitamin D deficiency, an approximately 25% greater fall in the bone resorption marker CTX is seen with its administration.

TNF-alpha antagonist therapy improves insulin sensitivity in non-diabetic ankylosing spondylitis patients

OBJECTIVES

Since insulin resistance can promote endothelial dysfunction, and anti-TNF-α treatment improves endothelial function in ankylosing spondylitis (AS) patients, in the present study we sought to assess whether an infusion of the anti-TNF-α monoclonal antibody-infliximab may improve insulin sensitivity in non-diabetic AS patients.

METHODS

We assessed a series of 30 non-diabetic patients with AS attending hospital outpatient clinics who fulfilled the modified New York diagnostic criteria for AS. In all cases, the drug was given as an intravenous infusion in a saline solution over 120 minutes. Fasting blood samples were taken for determination of plasma glucose and serum insulin levels immediately before (time 0) and after infliximab infusion (time 120).

RESULTS

At the time of the study only 8 (26.7%) of the 30 patients fulfilled definitions for insulin resistance as HOMA index was in most cases less than 2.29. Nevertheless, a statistically significant reduction in the HOMA values was observed when results found at time 0 (mean±SD: 1.72±1.22) were compared with those observed immediately after infliximab infusion (1.18±0.94) (p<0.001). The reduction in HOMA values was more important in those patients with the higher values of HOMA before infliximab infusion. Also, a significant improvement of insulin sensitivity was observed in most patients when QUICKI values before (0.37±0.04) and after infusion (0.39±0.04) were compared (p=0.004).

CONCLUSIONS

The present study shows that non-diabetic patients with AS on treatment with infliximab experience a rapid improvement of insulin sensitivity following administration of this drug.

CARD8 rs2043211 (p.C10X) polymorphism is not associated with disease susceptibility or cardiovascular events in Spanish rheumatoid arthritis patients

Rheumatoid arthritis (RA) is a complex polygenic inflammatory disease associated with accelerated atherosclerosis, which is the main cause of increased cardiovascular (CV) morbidity and mortality in RA patients. CARD8 is a constituent of inflammasome, which regulates interleukin 1-beta production, and has been associated with a worse disease course in early RA. One thousand six hundred twenty-one patients fulfilling the 1987 ACR classification criteria for RA and 1300 matched controls, were genotyped for the CARD8 rs2043211 (30T>A, p.C10X) single-nucleotide polymorphism (SNP) using predesigned TaqMan SNP genotyping assay. The genotyping success rate in our study was greater than 94%. We assessed CARD8 rs2043211 gene polymorphism results in 1530 Spanish RA patients in whom information on CV disease and CV risk factors was available at the time of the study. Also, a subgroup of patients with no history of CV events (n=276) was assessed for the potential influence of the rs2043211 variant in the development of subclinical atherosclerosis, by measurement of carotid intima-media thickness (IMT) and presence of carotid plaques. No statistically significant differences in allele or genotype frequencies for the rs2043211 CARD8 gene variant between patients with RA and controls were seen. Similarly, CARD8 rs2043211 (30T>A, p.C10X) SNP did not influence the development of CV events or the risk of CV events throughout the time. Likewise, no significant association between this gene variant and carotid IMT or the presence of plaques was found. In summary, our results do not support a role of the CARD8 rs2043211 gene variant in susceptibility to RA or in the development of CV disease in patients with RA.

Analysis of the interferon gamma (rs2430561, +874T/A) functional gene variant in relation to the presence of cardiovascular events in rheumatoid arthritis

OBJECTIVE

Rheumatoid arthritis (RA) is a chronic inflammatory disease associated with increased cardiovascular (CV) morbidity and mortality. Since interferon-gamma (IFN-γ) has a direct effect on inflammation, in this study we assessed the potential association of the IFNG functional gene variant rs2430561 with CV disease in patients with RA.

METHODS

One thousand six hundred and thirty-five patients fulfilling the 1987 American College of Rheumatology classification criteria for RA were genotyped for the IFNG (rs2430561, +874T/A) gene polymorphism using TaqMan genotyping assay. Patients were stratified according to the presence of CV events or not. Logistic regression models to explain the presence of CV disease according to the IFNG rs2430561 allele distribution were performed. The potential influence of this variant in the development of subclinical atherosclerosis was also analyzed in a subgroup of patients with no history of CV events to determine carotid artery intima-media thickness (IMT) (n = 286) and presence of carotid plaques. Levels of the cytokine were determined in a subgroup of patients by ELISA.

RESULTS

Adjusted logistic regression model disclosed that presence of the minor allele A was not associated with increased risk of suffering CV events in RA patients. Besides, differences did not achieve statistical significance regarding carotid IMT and presence of carotid plaques in RA patients carrying IFNG rs2430561 variant allele. Levels of IFN-γ were higher in patients who had suffered CV events compared to patients who did not.

CONCLUSION

Our results do not support a role of IFNG rs2430561 (+874T/A) functional gene variant in the development of CV disease in RA patients.

Short-term efficacy of topical capsaicin therapy in severely affected fibromyalgia patients

The purpose of this study was to evaluate the short-term efficacy of topical capsaicin treatment in patients severely affected by fibromyalgia. One hundred and thirty fibromyalgia patients were randomly divided into two groups. The control group, 56 women and 4 men who continued their medical treatment, and the capsaicin group, 70 women who apart from continuing their medical treatment, also underwent topical capsaicin 0.075 % 3 times daily for 6 weeks. At the beginning of the program, there were no significant differences between the two groups in any of the analyzed parameters. At the end of the treatment, there were significant improvements in the capsaicin group in the myalgic score (5.21 vs 3.8, p = 0.02) and global subjective improvement (22.8 vs 5 %, p = 0.001). Six weeks after the end of the treatment, the experimental group showed significant differences in Visual Analogue Scale of depression (5.63 vs 7.35, p = 0.02), Fibromyalgia Impact Questionnaire (67.89 vs 77.7, p = 0.02), role limitations due to emotional problems (36.17 vs 17.2, p = 0.05), Fatigue Severity Scale (6.2 vs 6.6, p = 0.04), myalgic score (3.94 vs 2.66, p = 0.02) and pressure pain threshold (79.25 vs 56.71, p = 0.004). In conclusion, patients severely affected by fibromyalgia can obtain short-term improvements following topical capsaicin 0.075 % treatment three times daily for 6 weeks.

NFKB1-94ATTG ins/del polymorphism (rs28362491) is associated with cardiovascular disease in patients with rheumatoid arthritis

INTRODUCTION

Rheumatoid arthritis (RA) is an inflammatory disease associated with increased cardiovascular (CV) mortality. A recent study has disclosed association between NFKB1-94ATTG ins/del polymorphism and higher risk of coronary heart disease in healthy Caucasians. Because of that, we assessed the influence of this polymorphism in the risk of CV disease in RA patients.

MATERIAL AND METHODS

1437 Spanish patients with RA were genotyped for the NFKB1-94ATTG ins/del polymorphism. Two hundred and seventy-one of them (18.8%) had experienced CV events.

RESULTS

After adjusting for sex, age at RA diagnosis and traditional CV risk factors RA patients carrying the NFKB1 del/del genotype had higher risk of CV events than those with ins/ins genotype (Hazard ratio [HR] = 1.76, 95% CI: 1.05-2.97, p = 0.03), while heterozygous patients had an intermediate (but non-significant) risk (HR = 1.31, 95% CI: 0.90-1.92, p = 0.16).

CONCLUSION

Our results suggest that NFKB1-94ATTG ins/del polymorphism is associated with CV disease in patients with RA.

Late-onset systemic lupus erythematosus in Northwestern Spain: differences with early-onset systemic lupus erythematosus and literature review

To further investigate into the epidaemiology of systemic lupus erythematosus (SLE) in Southern Europe, we have assessed the incidence, clinical spectrum and survival of patients diagnosed with late-onset SLE (age ≥ 50 years) according to the 1982 American College of Rheumatology (ACR) classification criteria at the single hospital for a well-defined population of Lugo, Northwestern (NW) Spain. Between January 1987 and December 2006, 51 (39.3%) of the 150 patients diagnosed as having SLE fulfilled definitions for late-onset SLE. The predominance of women among late-onset SLE (4:1) was reduced when compared with that observed in early-onset SLE (7:1). However, the incidence of late-onset SLE was significantly higher in women (4.2 [95% confidence interval (CI): 3.1–5.6] per 100,000 population) than in men (1.3 [95% CI: 0.6–2.2] per 100,000 population) ( p < 0.001). As observed in early-onset SLE, the most frequent clinical manifestation in patients with late-onset SLE was arthritis (71.2%). Renal disease was less common in late-onset SLE (13.5%) than in early-onset SLE (26.4%); p = 0.07). In contrast, secondary Sjögren syndrome was more commonly found in the older age-group (27.1% versus 12.1%; p = 0.03). A non-significantly increased incidence of serositis was also observed in late-onset SLE patients (33.9% versus 22.0%; p = 0.13). Hypocomplementaemia (72.9% versus 91.2%) and positive results for anti-DNA and anti-Sm (49.2% and 6.8% versus 68.1% and 23.1, respectively) were significantly less common in late-onset SLE patients than in early-onset SLE. The probability of survival was reduced in late-onset SLE ( p < 0.001). With respect to this, the 10-year and 15-year survival probability were 74.9 % and 63.3% in the late-onset SLE group and 96.3% and 91.0% in patients with early-onset SLE, respectively. In conclusion, our results confirm that in NW Spain SLE is not uncommon in individuals 50 years and older. In keeping with earlier studies, late-onset SLE patients from NW Spain have some clinical and laboratory differences with respect to those individuals with early-onset SLE. Our data support the claim of a reduced probability of survival in the older age-group of SLE patients.

Carotid ultrasound in the cardiovascular risk stratification of patients with rheumatoid arthritis: when and for whom?

Adequate stratification of cardiovascular (CV) risk is one of the major points of interest in the management of patients with rheumatoid arthritis (RA). A task force of the European League Against Rheumatism has proposed to adapt CV risk management calculated in RA patients according to the systematic coronary risk evaluation (SCORE) function by application of a multiplier factor of 1.5 in those patients with two of the following three criteria: disease duration >10 years, rheumatoid factor (RF) or anticyclic citrullinated peptide (anti-CCP) antibody positivity, and presence of severe extra-articular manifestations. However, a major concern when using the modified SCORE is to know whether the effect of chronic inflammation on the CV risk of RA patients can be fully determined using this tool. As increased carotid intima-media thickness (IMT) and carotid plaques have been proved to predict the development of CV events in RA, the authors suggest performing carotid ultrasound when SCORE does not yield results indicating high CV risk in RA patients with extra-articular manifestations, RF or anti-CCP positivity as well as in patients with 10 years disease duration or longer. The presence of abnormal carotid IMT (>0.90 mm) or carotid plaques would lead to these patients being considered as having high CV risk regardless of the results derived from the modified SCORE.

Sex differences in adherence to highly active antiretroviral therapy: a meta-analysis

Observational studies have found that women tend to have lower adherence to highly active antiretroviral therapy (HAART) than men do, though no meta-analysis has yet investigated this trend. The aims of the current meta-analysis are to determine if and to what degree the percentage of men versus women maintaining ≥90% adherence to prescribed HAART differs, and if the external variables moderating adherence differs by gender. Eight electronic databases were searched to locate all relevant studies available by May 2011. Fifty-six observational studies were eligible for inclusion in the meta-analysis. A random effect model was assumed for the global percentage estimation and to explain the heterogeneity. Across these studies, the difference between men and women in the proportion of individuals with ≥90% adherence to HAART was marginally significant (p<0.1; 67% and 62%, respectively). A greater proportion of men maintaining ≥90% adherence to HAART was more likely in studies with higher proportions of men who have sex with men (MSM), lower proportions of male alcohol users or lower proportions of men in a methadone program. In women, higher rates of adherence were found in studies conducted in Africa, Asia, and South America, when the sample included more widows or when the sample had a lower basal CD4 count. That both the percentage of adherent individuals and the variables associated with such adherence differ between men and women are suggestive of the need for improving gender-tailored interventions for adherence to HAART.

Lack of association between carotid intima-media wall thickness and carotid plaques and markers of endothelial cell activation in rheumatoid arthritis patients undergoing anti-TNF therapy

INTRODUCTION

To determine the relationship between biomarkers of endothelial cell activation, and carotid artery intima-media wall thickness (IMT) and plaques, two surrogate markers of atherosclerosis, in a series of rheumatoid arthritis (RA) patients undergoing anti-TNF therapy.

METHODS

29 consecutive Spanish patients who fulfilled the 1987 American College of Rheumatology classification criteria for RA, had no history of cardiovascular (CV) disease, and had at least one year of follow-up after disease diagnosis were selected. All patients were undergoing anti-TNF-infliximab therapy because of severe disease refractory to conventional disease modifying antirheumatic drugs. Carotid ultrasonography was performed to determine IMT and carotid plaques. Levels of sICAM-3, sICAM-1, sVCAM-1, sPselectin and sE-selectin were assessed by ELISA immediately before an infusion of infliximab.

RESULTS

The median disease duration was 14 years. Despite infliximab, no patient experienced a disease remission (DAS28: median 4.17). Only a marginally significant correlation between sVCAM-1 and carotid IMT was observed when both total correlation using Spearman correlation coefficient (p= 0.08) or partial correlation adjusting for sex, age at the time of study, disease duration, rheumatoid factor, and classic CV risk factors was performed (p= 0.09). Also, no association between presence of carotid plaques and levels of biomarkers of endothelial cell activation was observed.

CONCLUSION

In long-standing RA patients without CV disease undergoing anti-TNF therapy no association between levels of soluble markers of endothelial cell activation and carotid ultrasonography abnormalities was observed. Further studies are needed to establish the best tools to be used in the assessment of CV risk of RA.

Prognostic value of proadrenomedullin in severe sepsis and septic shock patients with community-acquired pneumonia

PRINCIPLES

Midregional proadrenomedullin (proADM) is a novel biomarker with potential prognostic utility in patients with community-acquired pneumonia. The aim of this study was to investigate the value of proADM levels for severity assessment and outcome prediction in severe sepsis and septic shock due to CAP.

METHODS

Prospective observational study including 49 patients admitted to ICU with both a clinical and radiologic diagnosis of pneumonia and fulfilling criteria for severe sepsis or septic shock. The prognostic accuracy of proADM levels was compared with those of pneumonia severity index and of procalcitonin (PCT) and C-reactive protein (CRP).

RESULTS

49 patients with severe sepsis or septic shock due to CAP were included in the study. Mortality was 24.5% for ICU and 34.7% for hospital mortality. In all cases proADM values at ICU admission were pathological (considering normal proADM levels <4 nmol/L). ProADM consistently rose as PSI class advanced from II to V (p = 0.02). Median proADM levels were higher (p <0.01) in hospital non-survivors 5.0 (1.9-10.1) nmol/L vs. survivors 1.7 (1.3-3.1) nmol/L. These differences were also significant with respect to ICU mortality. The receiver-operating characteristic curve for proADM yielded an AUC of 0.72; better than the AUC for PCT and CRP (0.40 and 0.44 respectively) and similar to PSI (0.74).

CONCLUSIONS

In our study MR-proADM levels correlate with increasing severity of illness and death. High MR-proADM levels offer additional risk stratification in high-risk CAP patients.

The lp13.3 genomic region -rs599839- is associated with endothelial dysfunction in patients with rheumatoid arthritis

Introduction

Rheumatoid arthritis (RA) is an inflammatory disease associated with accelerated atherosclerosis and high risk of cardiovascular (CV) disease. Since genome-wide association studies demonstrated association between rs599839 polymorphism and coronary artery disease, in the present study we assessed the potential association of this polymorphism with endothelial dysfunction, an early step in atherogenesis.

Methods

A total of 128 RA patients without history of CV events were genotyped for rs599839 A/G polymorphism. The presence of endothelial dysfunction was assessed by brachial ultrasonography (brachial flow-mediated endothelium-dependent (FMD)).

Results

Patients carrying the allele G exhibited more severe endothelial dysfunction (FMD%: 4.61 ± 3.94%) than those carrying the wild allele A (FMD%: 6.01 ± 5.15%) (P = 0.08). Adjustment for gender, age at the time of study, follow-up time and classic CV risk factors disclosed a significant association between the rs599839 polymorphism and FMD (G vs. A: P = 0.0062).

Conclusions

Our results confirm an association of the rs599839 polymorphism with endothelial dysfunction in RA.

Lack of association between TLR4 rs4986790 polymorphism and risk of cardiovascular disease in patients with rheumatoid arthritis

Rheumatoid arthritis (RA) is a chronic inflammatory disease associated with increased cardiovascular (CV) mortality. Toll-like receptor-4 (TLR4) activates the innate immune response via NF-kB pathway and mitogen-activated protein kinase signaling, leading to expression of proinflammatory cytokines and chemokines. The G allele of TLR4 rs4986790 (+896A>G, Asp299Gly) gene polymorphism has been implicated in reduction of risk of atherosclerosis. In this study, 1481 RA patients fulfilling the 1987 American College of Rheumatology (ACR) criteria were genotyped for the rs4986790 TLR4 variant to determine the influence of this variant in the risk of CV events in these patients. Also, HLA-DRB1 status was determined using molecular based methods. Moreover, potential influence of rs4986790 variant in the development of subclinical atherosclerosis was assessed in a subgroup of RA patients with no history of CV events by the measurement of surrogate markers of subclinical atherosclerosis. No statistically significant differences in allele or genotype frequencies for the rs4986790 variant between RA patients who experienced CV events or not were found. Likewise, no significant association between this gene variant and any of the surrogate markers of subclinical atherosclerosis was found. In summary, results in our study do not support the hypothesis that the rs4986790 (+896A>G, Asp299Gly) TLR4 variant may influence predisposition for subclinical atherosclerosis and clinically evident CV disease in RA patients.

Lack of association between the CXCL12 rs501120 polymorphism and cardiovascular disease in Spanish patients with rheumatoid arthritis

Rheumatoid arthritis (RA) is an inflammatory disease associated with accelerated atherosclerosis. CXCL12 is a strong chemotactic signal for lymphocytes. Because previous genome-wide association studies demonstrated an association between CXCL12 rs501120 and coronary artery disease, in the present study we assessed the potential association of this polymorphism with the risk of cardiovascular (CV) disease in 1,321 Spanish patients with RA. A subgroup of patients without CV events was also studied to determine the presence of subclinical atherosclerosis by ultrasonography (brachial flow-mediated endothelium-dependent vasodilatation and carotid intima-media wall thickness). However, no significant differences in genotypic and allelic frequencies between RA patients with and without CV events were observed, as was also the case when values of surrogate markers of atherosclerosis were assessed according to CXCL12 rs501120 genotype frequencies. In conclusion, our results do not confirm an association of the CXCL12 rs501120 polymorphism with atherosclerosis or with CV disease in RA.

Influence of MHCIITA rs3087456 and rs4774 polymorphisms in the susceptibility to cardiovascular disease of patients with rheumatoid arthritis

OBJECTIVES

MHCIITA is a major regulator of MHC expression that has been reported to be involved in the susceptibility to rheumatoid arthritis (RA) and myocardial infarction. In this study we investigated the potential association of two MHCIITA gene polymorphisms with cardiovascular (CV) risk in patients with RA.

METHODS

1302 patients fulfilling the 1987 ACR classification criteria for RA were genotyped for the MHCIITA rs3087456 and rs4774 gene polymorphisms to determine the influence of MHCIITA variants in the development of CV events. The potential influence of these polymorphisms in the development of subclinical atherosclerosis was also analysed in a subgroup of patients with no history of CV events by the assessment of two surrogate markers of atherosclerosis; brachial and carotid ultrasonography to determine endothelial function and carotid artery intima-media thickness, respectively.

RESULTS

No statistically significant differences in the allele or genotype frequencies for each individual MHCIITA gene polymorphism between RA patients who experienced CV events, or not, were found. This was also the case when each polymorphism was assessed according to results obtained from surrogate markers of atherosclerosis. Also, in assessing the combined influence of both MHCIITA gene polymorphisms in the risk of CV disease after adjustment for gender, age at time of disease diagnosis, follow-up time, traditional CV risk factors, and shared epitope status, patients with CV events only showed a marginally decreased frequency of the MHCIITA rs3087456-rs4774 G-G allele combination (p=0.08; odds ratio: 0.63 [95% confidence interval: 0.37-1.05]).

CONCLUSIONS

Our data do not support an influence of MHCIITA rs3087456 and rs4774 polymorphisms in the increased risk of CV events of patients with RA.