The Emerging Risk Factors Collaboration: analysis of individual data on lipid, inflammatory and other markers in over 1.1 million participants in 104 prospective studies of cardiovascular diseases

Many long-term prospective studies have reported on associations of cardiovascular diseases with circulating lipid markers and/or inflammatory markers. Studies have not, however, generally been designed to provide reliable estimates under different circumstances and to correct for within-person variability. The Emerging Risk Factors Collaboration has established a central database on over 1.1 million participants from 104 prospective population-based studies, in which subsets have information on lipid and inflammatory markers, other characteristics, as well as major cardiovascular morbidity and cause-specific mortality. Information on repeat measurements on relevant characteristics has been collected in approximately 340,000 participants to enable estimation of and correction for within-person variability. Re-analysis of individual data will yield up to approximately 69,000 incident fatal or nonfatal first ever major cardiovascular outcomes recorded during about 11.7 million person years at risk. The primary analyses will involve age-specific regression models in people without known baseline cardiovascular disease in relation to fatal or nonfatal first ever coronary heart disease outcomes. This initiative will characterize more precisely and in greater detail than has previously been possible the shape and strength of the age- and sex-specific associations of several lipid and inflammatory markers with incident coronary heart disease outcomes (and, secondarily, with other incident cardiovascular outcomes) under a wide range of circumstances. It will, therefore, help to determine to what extent such associations are independent from possible confounding factors and to what extent such markers (separately and in combination) provide incremental predictive value.

Intestinal microbiota balance modulates host susceptibility to infection with enteric pathogenss

Background: During our lifetimes we develop a very complex set of interactions with the multitude of microorganisms colonizing our bodies. In the gastrointestinal system, the microbiota is highly important for morphological development, nutrition, and protection against infectious diseases. The gastrointestinal pathogens, enterohemorrhagic and enteropathogenic Escherichia coli (EHEC and EPEC) and Salmonella enterica serovar Typhimurium (ST) are food-borne pathogens that cause much morbidity and mortality worldwide. Citrobacter rodentium (Cr) is a mouse pathogen that is used in small animal models to mimic EHEC and EPEC infections. Methods: We began to characterize the contribution of intestinal microbiota to the progression of these infections. Two main phyla comprise the majority of mouse intestinal microbiota: Bacteroidetes and Firmicutes. Bacteria from a number of additional phyla are also present in smaller numbers; among them γ-Proteobacteria class, belonging to Proteobacteria phylum, is note-worthy as this class harbours many intestinal pathogens, such as ST and Cr. The mouse intestinal microbiota was perturbed using tetracycline (Tet) and streptomycin (Sm) to increase the proportion of Bacteroidetes in the colonic microbiota, and using vancomycin (Vanc) to create a predominance of Firmicutes. The mice with this perturbed microbiota were infected with ST to investigate the resultant pathology and virulence characteristics, and any additional shifts in microbiota as a result of infection. Results: Treatment of mice with Sm and Vanc was found to decrease the resistance of mice to colonization with ST, while Tet-treated mice exhibited unchanged colonization resistance. Treatment of mice with gradually increasing doses of Sm, which gradually augmented the proportion of CFB bacteria in the microbiota, resulted in progressively increasing colonization of mice by ST, as well as a step-wise increase in the ST-induced typhlitis, associated with higher levels of inflammatory markers IL-6 and KC. The increasing levels of ST colonization following both Sm and Vanc treatment were associated with an increase in the proportion of γ-Proteobacteria in the cecal and colonic microbiota, as well as a decrease in the total bacterial numbers in both organs. Conclusions: It is evident that the intestinal microbiota plays a significant role in the host’s response to infection with enteric pathogens, and its composition and numbers are also affected by the offending bacteria. Elucidation of the details regarding the contribution of the microbiota to infectious disease progression will offer novel targets for the future design of superior prevention and treatment methods.

Agreement between arterial and central venous values for pH, bicarbonate, base excess, and lactate

OBJECTIVE

This study aimed to determine the extent of agreement between central venous and arterial values for pH, bicarbonate, base excess, and lactate in a group of intensive care unit (ICU) patients.

METHODS

A prospective study of a convenience sample of patients deemed by their treating doctor to require blood gas analysis as part of their clinical care in ICU. It compared pH, bicarbonate, base excess and lactate on arterial and central venous samples taken within five minutes of each other. Data were analysed using bias (Bland-Altman) methods.

RESULTS

A total of 168 matched sample pairs from 110 patients were entered into the study. All variables showed close agreement. The mean difference between arterial and venous values of pH was 0.03 pH units, for bicarbonate 0.52 mmol/l, for lactate 0.08 mmol/l, and for base excess 0.19 mmol/l. All showed acceptably narrow 95% limits of agreement.

CONCLUSION

Central venous pH, bicarbonate, base excess, and lactate values showed a high level of agreement with the respective arterial values, with narrow 95% limits of agreement. These results suggest that venous values may be an acceptable substitute for arterial measurement in this clinical setting.

Prognostic significance of clinical features and Akt activation in the survival of patients with bronchioloalveolar carcinoma (BAC)

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Background: Lung cancer is the leading cause of cancer related mortality in the world. BAC is a subset of NSCLC that has recently gained attention because of enhanced efficacy of epidermal growth factor receptor (EGFR) inhibitors in this population. Prognostic features for BAC have not been well defined. Because activation of Akt is a poor prognostic factor for other types of NSCLC, and because changes in Akt may predict outcome for EGFR inhibitors, we assessed the prognostic significance of clinical features and Akt activation in patients with BAC. Methods: 46 cases of BAC were classified according to WHO 2001 criteria. Akt activation was assessed using immunohistochemistry. Associations between ordered Akt levels and other dichotomous parameters were evaluated using an exact Cochran-Armitage test for trend. Survival was analyzed by the Kaplan-Meier method, and hazard ratios (HR) were determined based on Cox proportional hazard models. Results: Tissues from 45 patients were analyzed. Age and histology (mucinous vs. non-mucinous) were not associated with survival. Akt activation was observed in 63% of cases, but was not associated with differences in survival. Complete clinical data (except smoking) were available for 43 patients, and smoking history was available for 31 patients (8 never-smokers, 23 smokers). Cox model analysis revealed that male gender (HR 2.24, 95% CI 1.07–4.71, p = 0.032) and advanced stage (III or IV) (HR 2.17, 95% CI 1.004–4.71, p = 0.049) were associated with a worse prognosis. A model limited only to the 31 patients with smoking data demonstrated that smoking alone (HR 6.89, 95% CI 1.49–31.88, p = 0.013) was associated with a worse prognosis. Conclusions: These studies identify gender, stage, and especially smoking status as potentially important prognostic features for BAC. Akt was not prognostic. Given that the recent NSCLC clinical trials with erlotinib and gefitinib that showed varying survival benefit did not stratify by smoking status and BAC, it is possible that these characteristics could have affected the clinical outcomes. Investigators studying EGFR inhibitors should consider stratifying by smoking status and BAC to determine if there are subsets of patients who could benefit most from these therapies.

No significant financial relationships to disclose.

A case of hydatid cyst associated with postpartum maternal death

A young, apparently healthy woman from a rural area in South Africa presented in the third trimester of pregnancy with a symptomatic abdominal mass between the uterine fundus and liver. The etiology was established to be an echinococcus cyst of the liver and medical treatment was initiated. The fetal outcome was good but the mother died 3 days postpartum due to an unusual but devastating complication of the hydatid cyst.

Providing guidelines and education is not enough: an audit of gentamicin use at The Royal Melbourne Hospital

BACKGROUND

Aminoglycoside antibiotics are commonly prescribed for the treatment of Gram-negative infections. Appropriate dosing and therapeutic monitoring of aminoglycosides are important because these agents have a narrow therapeutic index.

AIM

To audit gentamicin use at our hospital, focusing on selection of the initial dose and therapeutic monitoring practices, and to compare the results against recommendations in the existing hospital aminoglycoside guidelines, which had recently been promoted to doctors.

METHODS

This audit included all inpatients receiving gentamicin at The Royal Melbourne Hospital from 1 February to 12 March 2004. The principal researcher checked the drug charts of all inpatients to identify those receiving gentamicin and collected data from the medical records and the pathology database. Doses were considered 'concordant' if the dose given was within the recommended dosing range +/-20 mg.

RESULTS

A total of 132 courses of gentamicin was included in the study. Gentamicin was prescribed for prophylaxis in 31.1% of courses. Thirty-six per cent of patients prescribed gentamicin were more than 65 years of age. Eighty-two per cent of the gentamicin used therapeutically was given as a single daily dose. Sixty-six per cent of gentamicin initial dosing was not in accordance with existing hospital guidelines. Seventy-seven per cent of gentamicin courses requiring therapeutic drug monitoring received such monitoring; however, in only 8.8% of these was the monitoring conducted according to guidelines.

CONCLUSION

Aminoglycoside prescribing practices at our hospital are suboptimal, despite ready access to prescribing guidelines. Provision of a guideline and education sessions with doctors do not necessarily lead to widespread adoption of recommended practices. We suggest that changes to hospital systems related to prescribing and monitoring of aminoglycosides are required.

Group interpersonal psychotherapy for postnatal depression: a pilot study

We conducted a pilot study to assess the potential effectiveness of group interpersonal psychotherapy (IPT-G) as a treatment for postnatal depression (PND). The study was also established to test a treatment manual for IPT-G, assess the acceptability of this format for participants and test a recruitment strategy for a randomised controlled trial. 18 mothers diagnosed with PND participated in 2 individual session and 8 sessions of group IPT. A two-hour psychoeducational session was also held for the partners of the participants. Measures of depressive symptomatology and social adjustment were administered by an independent clinician at baseline, 4 weeks, 8 weeks and 3 months post treatment. Patient satisfaction with the treatment was also evaluated. Severity scores on the BDI, EPDS and the HDRS decreased from pre- to post-treatment. This was maintained at three months follow up. No overall improvement in the Social Adjustment Scale-Self Report was noted, although there was improvement in their relationship with their significant other. The results confirm previous work that IPT-G may improve symptom severity for women suffering from postnatal depression. Limitations included the use of antidepressant therapy by 67% of subjects and the lack of a control group. There is a need for further randomised controlled trials of IPT-G with larger sample sizes to establish its effectiveness as treatment for PND.

Plasma fibrinogen level and the risk of major cardiovascular diseases and nonvascular mortality: an individual participant meta-analysis

CONTEXT

Plasma fibrinogen levels may be associated with the risk of coronary heart disease (CHD) and stroke.

OBJECTIVE

To assess the relationships of fibrinogen levels with risk of major vascular and with risk of nonvascular outcomes based on individual participant data.

DATA SOURCES

Relevant studies were identified by computer-assisted searches, hand searches of reference lists, and personal communication with relevant investigators.

STUDY SELECTION

All identified prospective studies were included with information available on baseline fibrinogen levels and details of subsequent major vascular morbidity and/or cause-specific mortality during at least 1 year of follow-up. Studies were excluded if they recruited participants on the basis of having had a previous history of cardiovascular disease; participants with known preexisting CHD or stroke were excluded.

DATA EXTRACTION

Individual records were provided on each of 154,211 participants in 31 prospective studies. During 1.38 million person-years of follow-up, there were 6944 first nonfatal myocardial infarctions or stroke events and 13,210 deaths. Cause-specific mortality was generally available. Analyses involved proportional hazards modeling with adjustment for confounding by known cardiovascular risk factors and for regression dilution bias.

DATA SYNTHESIS

Within each age group considered (40-59, 60-69, and > or =70 years), there was an approximately log-linear association with usual fibrinogen level for the risk of any CHD, any stroke, other vascular (eg, non-CHD, nonstroke) mortality, and nonvascular mortality. There was no evidence of a threshold within the range of usual fibrinogen level studied at any age. The age- and sex- adjusted hazard ratio per 1-g/L increase in usual fibrinogen level for CHD was 2.42 (95% confidence interval [CI], 2.24-2.60); stroke, 2.06 (95% CI, 1.83-2.33); other vascular mortality, 2.76 (95% CI, 2.28-3.35); and nonvascular mortality, 2.03 (95% CI, 1.90-2.18). The hazard ratios for CHD and stroke were reduced to about 1.8 after further adjustment for measured values of several established vascular risk factors. In a subset of 7011 participants with available C-reactive protein values, the findings for CHD were essentially unchanged following additional adjustment for C-reactive protein. The associations of fibrinogen level with CHD or stroke did not differ substantially according to sex, smoking, blood pressure, blood lipid levels, or several features of study design.

CONCLUSIONS

In this large individual participant meta-analysis, moderately strong associations were found between usual plasma fibrinogen level and the risks of CHD, stroke, other vascular mortality, and nonvascular mortality in a wide range of circumstances in healthy middle-aged adults. Assessment of any causal relevance of elevated fibrinogen levels to disease requires additional research.

A randomized study (WOS MM1) comparing the oral regime Z-Dex (idarubicin and dexamethasone) with vincristine, adriamycin and dexamethasone as induction therapy for newly diagnosed patients with multiple myeloma

Whilst infusional vincristine, adriamycin and dexamethasone (VAD) is an effective treatment for patients with multiple myeloma (MM), administration may be complicated by line-associated infections and thromboses. The oral regime, Z-Dex (idarubicin and dexamethasone) has been shown to be efficacious in MM. We conducted a randomized study comparing Z-Dex with VAD as induction therapy in newly diagnosed MM patients. A total of 106 patients (median age, 56 years; range: 37-73; Durie-Salmon stage II/III) were randomized to receive four to six cycles of Z-Dex or VAD. Central line complications were reported in 38 patients on 57 cycles, primarily because of infection. Neutropenia (all grades) was more common in the Z-Dex arm (P = 0.009) although grade III/IV neutropenia was not significantly different between the treatment groups (P = 0.06). Infections (all grades) were more commonly seen in the VAD arm (P = 0.001) although grade III/IV infections were not significantly different between the two groups (P = 0.081). The responses to therapy (complete/partial response) in evaluable patients were: VAD 74% vs. Z-Dex 58%, with an estimated difference in response of 16% (95% CI -2-33, P = 0.075). VAD recipients (15%) suffered early treatment-related mortality compared with 12% of Z-Dex recipients. Overall, 45 patients have died: disease progression (Z-Dex n = 13, VAD n = 10), regimen-related toxicity (Z-Dex n = 2, VAD n = 2), infection (Z-Dex n = 0, VAD n = 3), other causes (Z-Dex n = 7, VAD n = 2), unknown (Z-Dex n = 3, VAD n = 2). This study demonstrated that Z-Dex might be a suitable oral alternative to VAD for treating newly diagnosed MM patients, although definitive evidence for equivalence is not provided.

Novel P2X7 receptor antagonists

The synthesis and pharmacological evaluation of a new series of potent P2X(7) receptor antagonists is disclosed. The compounds inhibit BzATP-mediated pore formation in THP-1 cells. The distribution of the P2X(7) receptor in inflammatory cells, most notably the macrophage, mast cell and lymphocyte, suggests that P2X(7) antagonists have a significant role to play in the treatment of inflammatory disease.

Clinical features and associated psychopathology in a Tourette syndrome cohort

OBJECTIVE

This study explored in detail the association between tic symptomatology, related clinical variables, and psychopathology in 91 consecutive adult TS subjects from a UK clinic.

METHODS

Consecutive patients from a specialized Tourette clinic who met the DSM-III criteria for TS were evaluated using standardized rating scales for Tourette syndrome and other psychopathology.

RESULTS

The male female ratio in our cohort was 1.8:1. Significantly more males had an earlier age at onset of TS and history of birth complications. Obsessive compulsive behaviors in the patient was positively correlated with presence of attention deficit hyperactivity disorder and self-injurious behaviors. With regard to adult psychopathology, principal components factor analysis yielded two factors, 'obsessionality' and 'anxiety/depression', which accounted for 72% of the variance.

CONCLUSION

Our results support the high occurrence of anxiety, depression and obsessionality in adult TS subjects.