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Smit J, Kaasch AJ, Søgaard M, Thomsen RW, Nielsen H, Frøslev T, Schønheyder HC. Use of Glucocorticoids and Risk of Community-Acquired Staphylococcus aureus Bacteremia: A Population-Based Case-Control Study. Mayo Clin Proc 2016; 91:873-80. [PMID: 27289410 DOI: 10.1016/j.mayocp.2016.04.023] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/25/2016] [Revised: 04/07/2016] [Accepted: 04/15/2016] [Indexed: 11/23/2022]
Abstract
OBJECTIVE To investigate whether the use of systemic glucocorticoids is a risk factor for community-acquired Staphylococcus aureus bacteremia (CA-SAB). PATIENTS AND METHODS We used population-based medical registries in Northern Denmark to conduct a case-control study including all adults with first-time CA-SAB and matched population controls from January 1, 2000, through December 31, 2011. Glucocorticoid users were categorized as current users (new or long-term use), former users, and nonusers. Using conditional logistic regression, we computed odds ratios (ORs) of CA-SAB according to glucocorticoid exposure, overall and by 90-day prednisolone-equivalent cumulative dose. RESULTS We identified 2638 patients with first-time CA-SAB and 26,379 matched population controls. Current glucocorticoid users experienced considerably increased risk of CA-SAB compared with nonusers (adjusted OR=2.48; 95% CI, 2.12-2.90). The adjusted OR was 2.73 (95% CI, 2.17-3.45) in new users, 2.31 (95% CI, 1.90-2.82) in long-term users, and much lower at 1.33 (95% CI, 0.98-1.81) in former users of glucocorticoids compared with nonusers. The risk of CA-SAB increased with higher 90-day cumulative doses. Compared with nonusers of glucocorticoids, the adjusted OR was 1.32 (95% CI, 1.01-1.72) for persons with a cumulative dose of 150 mg or less, 2.42 (95% CI, 1.76-3.33) for persons whose cumulative dose was greater than 500 to 1000 mg, and 6.25 (95% CI, 4.74-8.23) for persons with a cumulative dose greater than 1000 mg. CONCLUSION Glucocorticoid use was associated with a substantially increased risk of CA-SAB. The risk increased with higher cumulative dose, revealing a distinct dose-response relation.
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Affiliation(s)
- Jesper Smit
- Department of Clinical Microbiology, Aalborg University Hospital, Aalborg, Denmark; Department of Infectious Diseases, Aalborg University Hospital, Aalborg, Denmark; Department of Clinical Epidemiology, Aarhus University Hospital, Aarhus, Denmark.
| | - Achim J Kaasch
- Institute for Medical Microbiology, Immunology, and Hygiene, University of Cologne, Cologne, Germany
| | - Mette Søgaard
- Department of Clinical Epidemiology, Aarhus University Hospital, Aarhus, Denmark
| | - Reimar W Thomsen
- Department of Clinical Epidemiology, Aarhus University Hospital, Aarhus, Denmark
| | - Henrik Nielsen
- Department of Infectious Diseases, Aalborg University Hospital, Aalborg, Denmark; Department of Clinical Medicine, Aalborg University Hospital, Aalborg, Denmark
| | - Trine Frøslev
- Department of Clinical Epidemiology, Aarhus University Hospital, Aarhus, Denmark
| | - Henrik C Schønheyder
- Department of Clinical Microbiology, Aalborg University Hospital, Aalborg, Denmark; Department of Clinical Medicine, Aalborg University Hospital, Aalborg, Denmark
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Cotton CC, Baird D, Sandler RS, Long MD. Hormonal Contraception Use is Common Among Patients with Inflammatory Bowel Diseases and an Elevated Risk of Deep Vein Thrombosis. Inflamm Bowel Dis 2016; 22:1631-8. [PMID: 27306071 PMCID: PMC5064836 DOI: 10.1097/mib.0000000000000800] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND Persons with inflammatory bowel disease (IBD) have an increased risk of venous thromboembolism. We sought to examine whether the self-report of hormonal contraception (HC), as a proxy for exposure to estrogen-based contraception, was less common for women with multiple risk factors for venous thromboembolism. METHODS We examined the prevalence of personal use of hormonal birth control in a large internet-based cohort of patients with IBD. To determine whether HC was less common among patients with IBD with increased risk of thrombosis, we estimated unadjusted and adjusted prevalence ratios (PRs) for the use of HC. RESULTS Thousand four hundred ninety-nine female survey respondents answered optional fertility questions and were included in the analysis. The prevalence of HC was 33.7% (95% CI, 30.6%-36.9%) among women with Crohn's disease and was 32.6% (95% CI, 28.6%-36.8%) for women with ulcerative colitis. Women with one risk factor for thrombosis were not significantly less likely to receive HC (PR = 0.91, 95% CI: 0.76-1.08; adjusted PR = 0.94, 95% CI: 0.80-1.11) compared with women without risk factors nor were women with 2 or more risk factors (PR = 1.10, 95% CI 0.56-1.28; adjusted PR = 1.10, 95% CI: 0.83-1.45). The use of an intrauterine device was also similar between women with and without risk factors for venous thromboembolism. CONCLUSIONS The prevalence of HC use in women with multiple risk factors was similar to that in women without risk factors, which represents an opportunity for prevention. Gastroenterologists should ask patients with IBD using HC about risk factors for thromboembolic disease to identify patients who may benefit from alternative contraception.
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Affiliation(s)
- Cary C. Cotton
- University of North Carolina at Chapel Hill, Department of Medicine, Division of Gastroenterology and Hepatology, USA; Center for Gastrointestinal Biology and Disease, Chapel Hill, NC, USA
| | - Donna Baird
- NIH, Epidemiology Branch, National Institute of Environmental Health Sciences, NC, USA
| | - Robert S. Sandler
- University of North Carolina at Chapel Hill, Department of Medicine, Division of Gastroenterology and Hepatology, USA; Center for Gastrointestinal Biology and Disease, Chapel Hill, NC, USA
| | - Millie D. Long
- University of North Carolina at Chapel Hill, Department of Medicine, Division of Gastroenterology and Hepatology, USA; Center for Gastrointestinal Biology and Disease, Chapel Hill, NC, USA
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253
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Nazir S, Sivarajah S, Fiscus V, York E. Spontaneous idiopathic bilateral adrenal haemorrhage: a rare cause of abdominal pain. BMJ Case Rep 2016; 2016:bcr-2016-215452. [PMID: 27166002 DOI: 10.1136/bcr-2016-215452] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
We describe a case of a 62-year-old woman with a history of chronic obstructive pulmonary disease and gastro-oesophageal reflux disease who presented to the emergency department with left lower quadrant abdominal pain, flank pain with nausea and no history of preceding trauma. The patient had finished a course of azithromycin and oral methylprednisolone 1 day prior to presentation. Abdominal and pelvic CT scan identified changes suggestive of bilateral adrenal haemorrhage. The patient did not show signs of acute adrenal insufficiency but was started on steroid replacement therapy because of concerns about possible disease progression. All recognised causes of adrenal haemorrhage were excluded suggesting this was a case of spontaneous idiopathic bilateral adrenal haemorrhage, a rarely reported phenomenon in the literature. The patient was discharged after clinical improvement following 6 days in hospital, taking oral steroid replacement.
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Affiliation(s)
- Salik Nazir
- Department of Internal Medicine, Reading Hospital and Medical Center, Reading, Pennsylvania, USA
| | - Surendra Sivarajah
- Department of Endocrinology and Metabolism, Reading Hospital and Medical Center, Reading, Pennsylvania, USA
| | - Valena Fiscus
- Department of Internal Medicine, Reading Hospital and Medical Center, Reading, Pennsylvania, USA
| | - Eugene York
- Department of Internal Medicine, Reading Hospital and Medical Center, Reading, Pennsylvania, USA
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Tomasiak-Lozowska MM, Rusak T, Misztal T, Bodzenta-Lukaszyk A, Tomasiak M. Reduced clot retraction rate and altered platelet energy production in patients with asthma. J Asthma 2016; 53:589-98. [PMID: 27145190 DOI: 10.3109/02770903.2015.1130151] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
OBJECTIVE Asthma enhances the risk of pulmonary embolism. The mechanism of this phenomenon is unclear. METHODS We evaluated the kinetics of clot formation, clot retraction rate (CRR), clot volume at 40 min, the rate of lactate production (a marker of aerobic glycolysis in platelets in contracting clots), blood eosinophil count (EOS), nitric oxide in exhaled breath (FENO), and spirometry (FEV1) in 50 healthy controls and in 81 allergic asthmatics (41 subjects with steroid-naïve asthma and 40 with steroid-treated asthma). RESULTS Thromboelastometry revealed that only steroid-treated asthmatics had slightly activated coagulation. Compared with healthy controls, whole asthmatics demonstrated (p < 0.05) reduced CRR, higher clot volume at 40 minutes, higher FENO, decreased FEV1, elevated EOS, and augmented lactate production in retracting clots. Reduced CRR was observed also in the absence of native plasma. In whole study population (asthmatics and healthy controls), CRR positively correlated with spirometry (rS = 0.668, p = <0.001) and negatively with FENO (rS = -0.543; p < 0.001), EOS (rS = -0.367, p < 0.002), and lactate production (rS = -0.791; p < 0.001). However, in steroid-treated asthmatics, the CRR did not correlate with FENO and EOS. In all study patients lactate production negatively correlated with FEV1 and positively with FENO. CONCLUSION Collectively, this data is consistent with the hypothesis that, in asthmatics, reactive nitrogen species produced in the lungs may reduce platelet contractility (and CRR) through the diminution of platelet energy production. CRR inhibition would predispose asthmatics to pulmonary embolism.
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Affiliation(s)
| | - Tomasz Rusak
- b Department of Physical Chemistry , Medical University of Bialystok , Bialystok , Poland
| | - Tomasz Misztal
- b Department of Physical Chemistry , Medical University of Bialystok , Bialystok , Poland
| | - Anna Bodzenta-Lukaszyk
- a Department of Allergology and Internal Diseases , Medical University of Bialystok , Bialystok , Poland
| | - Marian Tomasiak
- b Department of Physical Chemistry , Medical University of Bialystok , Bialystok , Poland
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Lieber BA, Han J, Appelboom G, Taylor BE, Han B, Agarwal N, Connolly ES. Association of Steroid Use with Deep Venous Thrombosis and Pulmonary Embolism in Neurosurgical Patients: A National Database Analysis. World Neurosurg 2016; 89:126-32. [DOI: 10.1016/j.wneu.2016.01.033] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2015] [Revised: 01/03/2016] [Accepted: 01/05/2016] [Indexed: 11/25/2022]
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Zilio M, Mazzai L, Sartori MT, Barbot M, Ceccato F, Daidone V, Casonato A, Saggiorato G, Noventa F, Trementino L, Prandoni P, Boscaro M, Arnaldi G, Scaroni C. A venous thromboembolism risk assessment model for patients with Cushing's syndrome. Endocrine 2016; 52:322-32. [PMID: 26113424 DOI: 10.1007/s12020-015-0665-z] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/24/2015] [Accepted: 06/12/2015] [Indexed: 11/28/2022]
Abstract
Cushing's syndrome (CS) is associated with an incidence of venous thromboembolism (VTE) about ten times higher than in the normal population. The aim of our study was to develop a model for identifying CS patients at higher risk of VTE. We considered clinical, hormonal, and coagulation data from 176 active CS patients and used a forward stepwise logistic multivariate regression analysis to select the major independent risk factors for thrombosis. The risk of VTE was calculated as a 'CS-VTE score' from the sum of points of present risk factors. VTE developed in 20 patients (4 pulmonary embolism). The group of CS patients with VTE were older (p < 0.001) and had more cardiovascular events (p < 0.05), infections and reduced mobility (both p < 0.001), higher midnight plasma cortisol levels (p < 0.05), and shorter APTT (p < 0.01) than those without. We identified six major independent risk factors for VTE: age ≥69 years and reduced mobility were given two points each, whereas acute severe infections, previous cardiovascular events, midnight plasma cortisol level >3.15 times the normality and shortened APTT were given one point each. A CS-VTE score <2 anticipated no risk of VTE; a CS-VTE score of two mild risk (10 %); a CS-VTE score of three moderate risk (46 %); a CS-VTE score ≥4 high risk (85 %). Considering a score ≥3 as predictive of VTE, 94 % of the patients were correctly classified. A simple score helps stratify the VTE risk in CS patients and identify those who could benefit from thromboprophylaxis.
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Affiliation(s)
- Marialuisa Zilio
- Endocrinology Unit, Department of Medicine DIMED, University-Hospital of Padova, Via Ospedale, 105 35128, Padua, Italy.
| | - Linda Mazzai
- Endocrinology Unit, Department of Medicine DIMED, University-Hospital of Padova, Via Ospedale, 105 35128, Padua, Italy
| | - Maria Teresa Sartori
- Clinical Medicine II, Department of Cardiac, Thoracic and Vascular Sciences, University-Hospital of Padova, Padua, Italy
| | - Mattia Barbot
- Endocrinology Unit, Department of Medicine DIMED, University-Hospital of Padova, Via Ospedale, 105 35128, Padua, Italy
| | - Filippo Ceccato
- Endocrinology Unit, Department of Medicine DIMED, University-Hospital of Padova, Via Ospedale, 105 35128, Padua, Italy
| | - Viviana Daidone
- Clinical Medicine II, Department of Cardiac, Thoracic and Vascular Sciences, University-Hospital of Padova, Padua, Italy
| | - Alessandra Casonato
- Clinical Medicine II, Department of Cardiac, Thoracic and Vascular Sciences, University-Hospital of Padova, Padua, Italy
| | - Graziella Saggiorato
- Clinical Medicine II, Department of Cardiac, Thoracic and Vascular Sciences, University-Hospital of Padova, Padua, Italy
| | - Franco Noventa
- Clinical Medicine V, Department of Medicine DIMED, University-Hospital of Padova, Padua, Italy
| | - Laura Trementino
- Endocrinology Unit, Polytechnic University of Marche, Ancona, Italy
| | - Paolo Prandoni
- Clinical Medicine II, Department of Cardiac, Thoracic and Vascular Sciences, University-Hospital of Padova, Padua, Italy
| | - Marco Boscaro
- Endocrinology Unit, Department of Medicine DIMED, University-Hospital of Padova, Via Ospedale, 105 35128, Padua, Italy
| | - Giorgio Arnaldi
- Endocrinology Unit, Polytechnic University of Marche, Ancona, Italy
| | - Carla Scaroni
- Endocrinology Unit, Department of Medicine DIMED, University-Hospital of Padova, Via Ospedale, 105 35128, Padua, Italy
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Majoor CJ, Sneeboer MMS, de Kievit A, Meijers JCM, van der Poll T, Lutter R, Bel EH, Kamphuisen PW. The influence of corticosteroids on hemostasis in healthy subjects. J Thromb Haemost 2016; 14:716-23. [PMID: 26791678 DOI: 10.1111/jth.13265] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2015] [Accepted: 01/07/2016] [Indexed: 11/26/2022]
Abstract
BACKGROUND Corticosteroids have been associated with an increased risk of venous thromboembolism in patients treated for inflammatory diseases. It is unclear whether the thrombotic risk is induced by the inflammation of the underlying inflammatory diseases or whether corticosteroids are prothrombotic as well. Considering the widespread use of corticosteroids in clinical practise, it is critical to know whether corticosteroids enhance coagulation. OBJECTIVE To investigate whether a 10-day prednisolone burst therapy activates hemostasis in healthy individuals. METHODS Healthy subjects received either 0.5 mg kg(-1) day(-1) of oral prednisolone or placebo. Venous blood was collected at baseline, day 1 and day 10 and tested for thrombin-antithrombin complexes (TATc), D-dimer, plasmin-alpha2-antiplasmin complexes (PAPc), plasminogen-activator inhibitor type-1 (PAI-1), von Willebrand factor (VWF) and thrombin generation (peak thrombin, velocity index and endogenous thrombin potential [ETP]). RESULTS Fifteen subjects received prednisolone and 16 placebo (median age 29 vs. 22 years, female subjects 33% vs. 56%, respectively). Peak thrombin and velocity index were higher in the placebo group at baseline. After 10 days of treatment, peak thrombin, velocity index, PAI-1 and VWF increased in the oral prednisolone group as compared with the placebo group (15.8 [SD 16.3] vs. -0.1 [SD 16.1], 41.2 [SD 41.3] vs. -2.3 [SD 42.7], 18.0 [IQR 8.0-37.0] vs. 0.5 [IQR -18.5-13.0], 4.0 [IQR -1.0-12.0] vs. 0.0 [IQR -2.5-1.5], respectively). No changes were observed for TATc, ETP, PAPc and D-dimer. CONCLUSIONS Oral prednisolone induces a procoagulant state in healthy subjects, suggesting that corticosteroid treatment may increase the thromboembolic risk in patients with inflammatory diseases.
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Affiliation(s)
- C J Majoor
- Department of Respiratory Medicine, Academic Medical Center, Amsterdam, the Netherlands
| | - M M S Sneeboer
- Department of Respiratory Medicine, Academic Medical Center, Amsterdam, the Netherlands
| | - A de Kievit
- Department of Respiratory Medicine, Academic Medical Center, Amsterdam, the Netherlands
| | - J C M Meijers
- Department of Experimental Vascular Medicine, Academic Medical Center, Amsterdam, the Netherlands
- Department of Plasma Proteins, Sanquin Research, Amsterdam, the Netherlands
| | - T van der Poll
- Center of Experimental and Molecular Medicine, Academic Medical Center, Amsterdam, the Netherlands
| | - R Lutter
- Department of Respiratory Medicine, Academic Medical Center, Amsterdam, the Netherlands
- Department of Experimental Immunology, Academic Medical Center, Amsterdam, the Netherlands
| | - E H Bel
- Department of Respiratory Medicine, Academic Medical Center, Amsterdam, the Netherlands
| | - P W Kamphuisen
- Department of Vascular Medicine, University Medical Center Groningen, Groningen, the Netherlands
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Wu M, Zhang L, Bao J, Zhao Z, Lu Q, Feng R, Song C, Zhou J, Jing Z. Postoperative glucocorticoid enhances recovery after endovascular aortic repair for chronic type B aortic dissection: a single-center experience. BMC Cardiovasc Disord 2016; 16:59. [PMID: 27013022 PMCID: PMC4807598 DOI: 10.1186/s12872-016-0234-2] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2015] [Accepted: 03/19/2016] [Indexed: 12/27/2022] Open
Abstract
Background Thoracic endovascular aortic repair (TEVAR) has been chosen as a less invasive alternative for type B aortic dissections (TBADs). However, the therapeutic effect of TEVAR has been challenged by postoperative adverse events, which were induced by inflammatory response. Glucocorticoids have been widely used because of the powerful and effective anti-inflammatory properties. Nevertheless, the prognostic effect of glucocorticoids after TBAD patients underwent TEVAR remains unclear. The objective of this study was to assess the potential effect of postoperative glucocorticoids on the prognosis of TEVAR for TBADs. Methods A total of 92 chronic TBADs patients underwent TEVAR with epidural anesthesia between June 2012 and June 2014 was retrospectively reviewed. The patients were stratified into dexamethasone (DXM) and non-dexamethasone group (N-DXM). The indications for TEVAR were as following: malperfusion (n = 28); contained or impending rupture (n = 17); persistent intractable chest/back pain (n = 32); refractory hypertension (n = 15). Results No 30-day mortality and incision infection occurred in each group. The postoperative pain score on the second day was significantly higher in N-DXM group (3.60 ± 0.21 versus 4.83 ± 0.32, P = 0.001). The differences of white blood cell, body temperature and heart rate were pronounced in both groups judged by the peak values (13.01 ± 0.58 × 109/L versus 10.04 ± 0.61 × 109/L, 37.67 ± 0.08 °C versus 37.92 ± 0.09 °C and 89.06 ± 1.21 bpm versus 95.95 ± 1.70 bpm, P = 0.002, 0.04 and 0.001, respectively). The white blood cells in DXM group significantly increased on the second and third postoperative day (P = 0.009 and 0.023), while the body temperature and heart rate showed an apparent decline on the second (P = 0.001 and 0.028), third (P = 0.007 and 0.005) and fourth postoperative days (P = 0.024 and 0.018). However, the changes of false lumen volumes and the endoleak incidence at 3-month follow-up were comparable in the two groups. No significant difference of post-implantation syndrome was observed either. Conclusions Although postoperative prophylactic glucocorticoids administration was unable to influence mortality, incision infection or the change of false lumen volumes, it enabled to enhance the recovery of vital signs and alleviate the postoperative pain. A prospective, randomized controlled trial has been registered (NCT02523300), which will be warranted before prophylactic administration of glucocorticoids after TEVAR procedure could be recommended in the clinical work. Electronic supplementary material The online version of this article (doi:10.1186/s12872-016-0234-2) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Mengtao Wu
- Department of Vascular Surgery, Changhai Hospital, Second Military Medical University, 168 Changhai Road, Shanghai, 200433, China.,Department of Vascular Surgery, General Hospital of Jinan Military Command of Chinese PLA, Jinan, China
| | - Lei Zhang
- Department of Vascular Surgery, Changhai Hospital, Second Military Medical University, 168 Changhai Road, Shanghai, 200433, China
| | - Junmin Bao
- Department of Vascular Surgery, Changhai Hospital, Second Military Medical University, 168 Changhai Road, Shanghai, 200433, China
| | - Zhiqing Zhao
- Department of Vascular Surgery, Changhai Hospital, Second Military Medical University, 168 Changhai Road, Shanghai, 200433, China
| | - Qingsheng Lu
- Department of Vascular Surgery, Changhai Hospital, Second Military Medical University, 168 Changhai Road, Shanghai, 200433, China
| | - Rui Feng
- Department of Vascular Surgery, Changhai Hospital, Second Military Medical University, 168 Changhai Road, Shanghai, 200433, China
| | - Chao Song
- Department of Vascular Surgery, Changhai Hospital, Second Military Medical University, 168 Changhai Road, Shanghai, 200433, China
| | - Jian Zhou
- Department of Vascular Surgery, Changhai Hospital, Second Military Medical University, 168 Changhai Road, Shanghai, 200433, China.
| | - Zaiping Jing
- Department of Vascular Surgery, Changhai Hospital, Second Military Medical University, 168 Changhai Road, Shanghai, 200433, China.
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Strehl C, Bijlsma JWJ, de Wit M, Boers M, Caeyers N, Cutolo M, Dasgupta B, Dixon WG, Geenen R, Huizinga TWJ, Kent A, de Thurah AL, Listing J, Mariette X, Ray DW, Scherer HU, Seror R, Spies CM, Tarp S, Wiek D, Winthrop KL, Buttgereit F. Defining conditions where long-term glucocorticoid treatment has an acceptably low level of harm to facilitate implementation of existing recommendations: viewpoints from an EULAR task force. Ann Rheum Dis 2016; 75:952-7. [DOI: 10.1136/annrheumdis-2015-208916] [Citation(s) in RCA: 193] [Impact Index Per Article: 24.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2015] [Accepted: 02/13/2016] [Indexed: 12/30/2022]
Abstract
There is convincing evidence for the known and unambiguously accepted beneficial effects of glucocorticoids at low dosages. However, the implementation of existing recommendations and guidelines on the management of glucocorticoid therapy in rheumatic diseases is lagging behind. As a first step to improve implementation, we aimed at defining conditions under which long-term glucocorticoid therapy may have an acceptably low level of harm. A multidisciplinary European League Against Rheumatism task force group of experts including patients with rheumatic diseases was assembled. After a systematic literature search, breakout groups critically reviewed the evidence on the four most worrisome adverse effects of glucocorticoid therapy (osteoporosis, hyperglycaemia/diabetes mellitus, cardiovascular diseases and infections) and presented their results to the other group members following a structured questionnaire for final discussion and consensus finding. Robust evidence on the risk of harm of long-term glucocorticoid therapy was often lacking since relevant study results were often either missing, contradictory or carried a high risk of bias. The group agreed that the risk of harm is low for the majority of patients at long-term dosages of ≤5 mg prednisone equivalent per day, whereas at dosages of >10 mg/day the risk of harm is elevated. At dosages between >5 and ≤10 mg/day, patient-specific characteristics (protective and risk factors) determine the risk of harm. The level of harm of glucocorticoids depends on both dose and patient-specific parameters. General and glucocorticoid-associated risk factors and protective factors such as a healthy lifestyle should be taken into account when evaluating the actual and future risk.
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260
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Sneeboer MMS, Hutten BA, Majoor CJ, Bel EHD, Kamphuisen PW. Oral and inhaled corticosteroid use and risk of recurrent pulmonary embolism. Thromb Res 2016; 140:46-50. [PMID: 26897283 DOI: 10.1016/j.thromres.2016.02.010] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2016] [Revised: 02/05/2016] [Accepted: 02/11/2016] [Indexed: 01/01/2023]
Abstract
INTRODUCTION Chronic inflammatory diseases predispose for development of a first pulmonary embolism (PE). Previous studies showed that corticosteroids, which are the mainstay of treatment for inflammatory diseases, enhance the risk of a first venous thromboembolism. Yet, it is unknown whether corticosteroids also predispose for recurrent events. Therefore, we investigated the association between oral and/or inhaled corticosteroid use and the risk of recurrent PE. METHODS We performed a nested case-control study using the PHARMO Database. Adult patients who had suffered from a first PE for which vitamin K antagonists were prescribed, were eligible. Of these, 384 patients with recurrent PE were matched to 1030 patients without recurrent PE. RESULTS We showed that oral or inhaled corticosteroids was ever used by 22.7% and 20.6% of patients with recurrent PE, and 23.5% and 21.5% of the patients without recurrent PE. There was an overall association between oral corticosteroid use and the risk of recurrent PE (p=0.02). Current use of oral corticosteroids increased the risk of recurrent PE (OR 3.74; 95% CI 2.04-6.87), whereas past use reduced the risk (OR 0.46; 95% CI 0.28-0.74). A similar pattern was observed for inhaled corticosteroids, although less strong (p=0.10). CONCLUSIONS Current use of oral corticosteroids is associated with increased risk of recurrent PE. Whether this increased risk is caused by oral corticosteroids themselves, or by the underlying disease, or both, needs further investigation. Nevertheless, given the frequent use of corticosteroids in clinical practice, clinicians should be aware of this risk.
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Affiliation(s)
- Marlous M S Sneeboer
- Department of Respiratory Medicine, Academic Medical Center, Amsterdam, The Netherlands.
| | - Barbara A Hutten
- Department of Clinical Epidemiology, Biostatistics and Bioinformatics, Academic Medical Center, Amsterdam, The Netherlands
| | - Christof J Majoor
- Department of Respiratory Medicine, Academic Medical Center, Amsterdam, The Netherlands
| | - Elisabeth H D Bel
- Department of Respiratory Medicine, Academic Medical Center, Amsterdam, The Netherlands
| | - Pieter W Kamphuisen
- Department of Vascular Medicine, University Medical Center Groningen, Groningen, The Netherlands
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Balancing benefits and risks of glucocorticoids in rheumatic diseases and other inflammatory joint disorders: new insights from emerging data. An expert consensus paper from the European Society for Clinical and Economic Aspects of Osteoporosis and Osteoarthritis (ESCEO). Aging Clin Exp Res 2016; 28:1-16. [PMID: 26746234 DOI: 10.1007/s40520-015-0522-1] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2015] [Accepted: 12/22/2015] [Indexed: 12/26/2022]
Abstract
PURPOSE This consensus review article considers the question of whether glucocorticoid (GC) therapy is still relevant in the treatment of rheumatic diseases, with a particular focus on rheumatoid arthritis (RA), and whether its side effects can be adequately managed. Recent basic and clinical research on the molecular, cellular and clinical effects of GCs have considerably advanced our knowledge in this field. An overview of the subject seems appropriate. METHODS This review is the result of a multidisciplinary expert working group, organised by European Society for Clinical and Economic Aspects of Osteoporosis and Osteoarthritis. The recent literature was surveyed and the salient evidence synthetized. RESULTS The pathophysiological basis of RA (and other inflammatory rheumatic diseases) now strongly implicates the adaptive immune system in addition to innate mechanisms. The molecular effect of GCs and differential GC sensitivity is better understood, although exploiting this knowledge is still in its infancy. The newer treatment strategies of early and aggressive control of RA have gr eatly improved clinical outcomes, but improvements are still possible. Newer targeted anti-inflammatory drugs have made an important impact, yet they too are associated with numerous side effects. DISCUSSION Short durations of moderate doses of GCs are generally well tolerated and have a positive benefit/risk ratio. Patients should be assessed for fracture risk and bone preserving agents and be prescribed calcium and vitamin D supplementation. CONCLUSIONS Within a strategy of a disease modifying approach to inflammatory disease, combination therapy including a GC is effective approach.
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Sundbøll J, Horváth-Puhó E, Schmidt M, Dekkers OM, Christiansen CF, Pedersen L, Bøtker HE, Sørensen HT. Preadmission Use of Glucocorticoids and 30-Day Mortality After Stroke. Stroke 2016; 47:829-35. [PMID: 26903585 DOI: 10.1161/strokeaha.115.012231] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2015] [Accepted: 12/22/2015] [Indexed: 12/23/2022]
Abstract
BACKGROUND AND PURPOSE The prognostic impact of glucocorticoids on stroke mortality remains uncertain. We, therefore, examined whether preadmission use of glucocorticoids is associated with short-term mortality after ischemic stroke, intracerebral hemorrhage (ICH), or subarachnoid hemorrhage (SAH). METHODS We conducted a nationwide population-based cohort study using medical registries in Denmark. We identified all patients with a first-time inpatient diagnosis of stroke between 2004 and 2012. We categorized glucocorticoid use as current use (last prescription redemption ≤90 days before admission), former use, and nonuse. Current use was further classified as new or long-term use. We used Cox regression to compute 30-day mortality rate ratios with 95% confidence intervals (CIs), controlling for confounders. RESULTS We identified 100 042 patients with a first-time stroke. Of these, 83 735 patients had ischemic stroke, 11 779 had ICH, and 4528 had SAH. Absolute mortality risk was higher for current users compared with nonusers for ischemic stroke (19.5% versus 10.2%), ICH (46.5% versus 34.4%), and SAH (35.0% versus 23.2%). For ischemic stroke, the adjusted 30-day mortality rate ratio was increased among current users compared with nonusers (1.58, 95% CI: 1.46-1.71), driven by the effect of glucocorticoids among new users (1.80, 95% CI: 1.62-1.99). Current users had a more modest increase in the adjusted 30-day mortality rate ratio for hemorrhagic stroke (1.26, 95% CI: 1.09-1.45 for ICH and 1.40, 95% CI: 1.01-1.93 for SAH) compared with nonusers. Former use was not substantially associated with mortality. CONCLUSIONS Preadmission use of glucocorticoids was associated with increased 30-day mortality among patients with ischemic stroke, ICH, and SAH.
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Affiliation(s)
- Jens Sundbøll
- From the Department of Clinical Epidemiology, Aarhus University Hospital, Aarhus N, Denmark (J.S., E.H.-P., M.S., C.F.C., L.P., H.T.S.); Department of Cardiology, Aarhus University Hospital, Skejby, Aarhus N, Denmark (H.E.B.); Department of Clinical Epidemiology, Leiden University Medical Centre, Leiden, The Netherlands (O.M.D.); and Department of Clinical Endocrinology and Metabolism, Leiden University Medical Centre, Leiden, The Netherlands (O.M.D.).
| | - Erzsébet Horváth-Puhó
- From the Department of Clinical Epidemiology, Aarhus University Hospital, Aarhus N, Denmark (J.S., E.H.-P., M.S., C.F.C., L.P., H.T.S.); Department of Cardiology, Aarhus University Hospital, Skejby, Aarhus N, Denmark (H.E.B.); Department of Clinical Epidemiology, Leiden University Medical Centre, Leiden, The Netherlands (O.M.D.); and Department of Clinical Endocrinology and Metabolism, Leiden University Medical Centre, Leiden, The Netherlands (O.M.D.)
| | - Morten Schmidt
- From the Department of Clinical Epidemiology, Aarhus University Hospital, Aarhus N, Denmark (J.S., E.H.-P., M.S., C.F.C., L.P., H.T.S.); Department of Cardiology, Aarhus University Hospital, Skejby, Aarhus N, Denmark (H.E.B.); Department of Clinical Epidemiology, Leiden University Medical Centre, Leiden, The Netherlands (O.M.D.); and Department of Clinical Endocrinology and Metabolism, Leiden University Medical Centre, Leiden, The Netherlands (O.M.D.)
| | - Olaf M Dekkers
- From the Department of Clinical Epidemiology, Aarhus University Hospital, Aarhus N, Denmark (J.S., E.H.-P., M.S., C.F.C., L.P., H.T.S.); Department of Cardiology, Aarhus University Hospital, Skejby, Aarhus N, Denmark (H.E.B.); Department of Clinical Epidemiology, Leiden University Medical Centre, Leiden, The Netherlands (O.M.D.); and Department of Clinical Endocrinology and Metabolism, Leiden University Medical Centre, Leiden, The Netherlands (O.M.D.)
| | - Christian F Christiansen
- From the Department of Clinical Epidemiology, Aarhus University Hospital, Aarhus N, Denmark (J.S., E.H.-P., M.S., C.F.C., L.P., H.T.S.); Department of Cardiology, Aarhus University Hospital, Skejby, Aarhus N, Denmark (H.E.B.); Department of Clinical Epidemiology, Leiden University Medical Centre, Leiden, The Netherlands (O.M.D.); and Department of Clinical Endocrinology and Metabolism, Leiden University Medical Centre, Leiden, The Netherlands (O.M.D.)
| | - Lars Pedersen
- From the Department of Clinical Epidemiology, Aarhus University Hospital, Aarhus N, Denmark (J.S., E.H.-P., M.S., C.F.C., L.P., H.T.S.); Department of Cardiology, Aarhus University Hospital, Skejby, Aarhus N, Denmark (H.E.B.); Department of Clinical Epidemiology, Leiden University Medical Centre, Leiden, The Netherlands (O.M.D.); and Department of Clinical Endocrinology and Metabolism, Leiden University Medical Centre, Leiden, The Netherlands (O.M.D.)
| | - Hans Erik Bøtker
- From the Department of Clinical Epidemiology, Aarhus University Hospital, Aarhus N, Denmark (J.S., E.H.-P., M.S., C.F.C., L.P., H.T.S.); Department of Cardiology, Aarhus University Hospital, Skejby, Aarhus N, Denmark (H.E.B.); Department of Clinical Epidemiology, Leiden University Medical Centre, Leiden, The Netherlands (O.M.D.); and Department of Clinical Endocrinology and Metabolism, Leiden University Medical Centre, Leiden, The Netherlands (O.M.D.)
| | - Henrik T Sørensen
- From the Department of Clinical Epidemiology, Aarhus University Hospital, Aarhus N, Denmark (J.S., E.H.-P., M.S., C.F.C., L.P., H.T.S.); Department of Cardiology, Aarhus University Hospital, Skejby, Aarhus N, Denmark (H.E.B.); Department of Clinical Epidemiology, Leiden University Medical Centre, Leiden, The Netherlands (O.M.D.); and Department of Clinical Endocrinology and Metabolism, Leiden University Medical Centre, Leiden, The Netherlands (O.M.D.)
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Abstract
Treatment of cancer patients with antineoplastic agents is associated with a heightened risk of thrombotic events, both arterial and venous. In this article, we review the specific agents that are implicated and the pathophysiological processes that are known to be associated with this prothrombotic state. We conclude with current recommendations for prophylactic antithrombotic therapy in these clinical situations.
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Affiliation(s)
- Peter Oppelt
- Case Western Reserve University, Cleveland, OH, USA
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264
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van der Bilt FE, Hendriksz TR, van der Meijden WAG, Brilman LG, van Bommel EFH. Outcome in patients with idiopathic retroperitoneal fibrosis treated with corticosteroid or tamoxifen monotherapy. Clin Kidney J 2016; 9:184-91. [PMID: 26985367 PMCID: PMC4792623 DOI: 10.1093/ckj/sfv148] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2015] [Accepted: 12/02/2015] [Indexed: 01/20/2023] Open
Abstract
Background Although corticosteroids (CS) are used primarily in idiopathic retroperitoneal fibrosis (iRPF), tamoxifen (TMX) may be a suitable alternative. We compared outcome with CS or TMX monotherapy for first presentation in a large group of patients with iRPF disease. Methods Of all patients with iRPF disease who were seen at our tertiary care referral centre from February 1999 to December 2011, 118 patients were eligible for this retrospective study. Treatment success was defined as the composite of (i) amelioration of symptoms, (ii) computed tomography (CT)-documented mass regression and, if applicable, (iii) definitive removal of ureteral stent or nephrostomy tube. Recurrence was defined as recurrence of signs and symptoms and/or CT-documented mass increase after initial treatment success with primary treatment. Results Presenting signs and symptoms did not differ between patients treated with CS (n = 50) or TMX (n = 68). Time to amelioration of symptoms after treatment initiation was shorter in CS-treated patients [CS, 2.0 (0.8–3.8) weeks versus TMX, 4.0 (2.0–6.0) weeks; P < 0.01]. Short-term percentual decrease in acute-phase reactant levels (P < 0.001 for both erythrocyte sedimentation rate and C-reactive protein) and serum creatinine level (P < 0.01) following treatment initiation was greater in CS-treated patients compared with that in TMX-treated patients. Mass regression at first follow-up CT scan was observed more frequently in CS-treated patients (CS, 84.0% versus TMX, 68.3%; P = 0.05) with no difference in time interval from treatment initiation to first follow-up CT between groups [CS, 5 (2–7) months versus TMX, 4 (4–5) months; P = 0.34]. Definite treatment success was non-significantly higher in CS-treated patients (CS, 72.7% versus TMX, 58.3%; P = 0.15). In patients with initial treatment success with primary treatment, recurrence rate was lower in TMX-treated patients (CS, 62.5% versus TMX, 21.4%; P < 0.01). Conclusions CS are superior to TMX in treating iRPF disease. However, in patients with initial treatment success with primary treatment, recurrence rate was lower in TMX-treated patients.
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Affiliation(s)
- Floor E van der Bilt
- Department of Nephrology , Albert Schweitzer Hospital , Dordrecht , The Netherlands
| | - Tadek R Hendriksz
- Department of Radiology , Albert Schweitzer Hospital , Dordrecht , The Netherlands
| | | | - Lisette G Brilman
- Department of Nephrology , Albert Schweitzer Hospital , Dordrecht , The Netherlands
| | - Eric F H van Bommel
- Department of Nephrology , Albert Schweitzer Hospital , Dordrecht , The Netherlands
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265
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Thawley VJ, Sánchez MD, Drobatz KJ, King LG. Retrospective comparison of thromboelastography results to postmortem evidence of thrombosis in critically ill dogs: 39 cases (2005-2010). J Vet Emerg Crit Care (San Antonio) 2016; 26:428-36. [PMID: 26749078 DOI: 10.1111/vec.12441] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2014] [Revised: 06/14/2014] [Accepted: 08/06/2014] [Indexed: 12/25/2022]
Abstract
OBJECTIVE To determine whether there is an association between thromboelastography (TEG) data and necropsy evidence of thrombosis in a cohort of critically ill dogs. DESIGN Retrospective study (2005-2010). SETTING University teaching hospital. ANIMALS Thirty-nine client-owned critically ill dogs for which TEG was performed within 7 days of complete necropsy. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Thrombi were found in 26 (67%) dogs. Spayed females (n = 20) were significantly more likely to have thrombosis (P = 0.0127). No significant association was found between presence of thrombosis and any TEG parameter, the calculated coagulation index, results of coagulation testing, type of vascular access, or clinical diagnosis. D-dimers were significantly higher in dogs with thrombosis (P = 0.0207) and a weak positive correlation was found between D-dimer value and number of sites of thrombosis (ρ = 0.18, P = 0.0045). Dogs with WBC > 16 × 10(3) /μL were more likely to have thrombosis compared to others (odds ratio 5.56, 95% confidence interval 1.2-25.7, P = 0.025). CONCLUSIONS This study found no association between any TEG parameter and the presence of thrombosis on postmortem examination.
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Affiliation(s)
- Vincent J Thawley
- Section of Critical Care, School of Veterinary Medicine, University of Pennsylvania, Philadelphia, PA, 19104
| | - Melissa D Sánchez
- Department of Clinical Studies - Philadelphia, and the Laboratory of Pathology and Toxicology, School of Veterinary Medicine, University of Pennsylvania, Philadelphia, PA, 19104
| | - Kenneth J Drobatz
- Section of Critical Care, School of Veterinary Medicine, University of Pennsylvania, Philadelphia, PA, 19104
| | - Lesley G King
- Section of Critical Care, School of Veterinary Medicine, University of Pennsylvania, Philadelphia, PA, 19104
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Gobara H, Hiraki T, Iguchi T, Fujiwara H, Kitagawa M, Hanayama N, Kanazawa S. Regression of a Pulmonary Arteriovenous Malformation after Acute Interstitial Nephritis. Intern Med 2016; 55:1487-9. [PMID: 27250058 DOI: 10.2169/internalmedicine.55.5445] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
A 68-year-old woman was scheduled to undergo percutaneous embolization of a pulmonary arteriovenous malformation (PAVM) to prevent a paradoxical embolic event. After contrast-enhanced computed tomography (CT) was performed to carefully evaluate the PAVM, she developed acute interstitial nephritis, which required steroid therapy. Moreover, her D-dimer level increased, which was suggestive of thrombus formation. After nine months, we noted that the affected vessels had markedly decreased in size, and the fistula had almost disappeared on unenhanced CT images. To our knowledge, this is the first case report to describe the regression of a PAVM, detected by CT, after the onset of acute interstitial nephritis.
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Affiliation(s)
- Hideo Gobara
- Department of Radiology, Okayama University Hospital, Japan
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267
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Myren-Svelstad S, Meisingset TW, Wesnes K. Kvinnen som ikke gjenkjente sitt eget ansikt. TIDSSKRIFT FOR DEN NORSKE LEGEFORENING 2016; 136:1815-1818. [DOI: 10.4045/tidsskr.16.0349] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022] Open
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268
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Higgins PDR. Reply. Clin Gastroenterol Hepatol 2016; 14:167-8. [PMID: 26387975 DOI: 10.1016/j.cgh.2015.09.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Affiliation(s)
- Peter D R Higgins
- Division of Gastroenterology, Department of Medicine, University of Michigan, Ann Arbor, Michigan
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269
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Sneeboer MMS, Majoor CJ, de Kievit A, Meijers JCM, van der Poll T, Kamphuisen PW, Bel EH. Prothrombotic state in patients with severe and prednisolone-dependent asthma. J Allergy Clin Immunol 2015; 137:1727-1732. [PMID: 26714414 DOI: 10.1016/j.jaci.2015.10.038] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2015] [Revised: 10/18/2015] [Accepted: 10/30/2015] [Indexed: 12/13/2022]
Abstract
BACKGROUND Epidemiologic studies have shown that asthmatic patients, in particular those with severe disease, have increased risk of pulmonary embolism. It is unknown whether these patients have a prothrombotic state under stable conditions. OBJECTIVE We sought to compare coagulation and fibrinolysis parameters between healthy subjects and patients with mild, severe, and prednisolone-dependent asthma under stable conditions and to investigate whether hemostatic markers correlate with airway inflammation. METHODS In 126 adults (33 healthy control subjects, 31 patients with mild asthma, 32 patients with severe asthma, and 30 patients with prednisolone-dependent asthma) parameters of inflammation (peripheral blood eosinophils and neutrophils) and markers of hemostasis (endogenous thrombin potential [ETP], thrombin-antithrombin complex, plasmin-α2-antiplasmin complex, plasminogen activator inhibitor type 1 [PAI-1], D-dimer, and von Willebrand factor [vWF]) were measured in plasma. One-way ANOVA with the post hoc Bonferroni test was used for group comparison, and linear regression analysis was used for correlations. RESULTS We observed increased ETP (121% vs 99%, overall P < .01), plasmin-α2-antiplasmin complex (520 vs 409 μg/L, overall P = .04), PAI-1 (10 vs 7 ng/mL, overall P = .02), and vWF (142% vs 87%, overall P < .01) levels in asthmatic patients compared with healthy control subjects. ETP, PAI-1, and vWF levels increased with increasing asthma severity. In addition, we found a correlation between ETP and vWF with neutrophil but not eosinophil counts. CONCLUSION Asthmatic patients have a prothrombotic state that increases with asthma severity. This might explain why patients with asthma, in particular those with severe disease, have an increased risk of venous thromboembolism.
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Affiliation(s)
- Marlous M S Sneeboer
- Department of Respiratory Medicine, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands.
| | - Christof J Majoor
- Department of Respiratory Medicine, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
| | - Anne de Kievit
- Department of Respiratory Medicine, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
| | - Joost C M Meijers
- Department of Experimental Vascular Medicine, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands; Department of Plasma Proteins, Sanquin Research, Amsterdam, The Netherlands
| | - Tom van der Poll
- Center of Experimental and Molecular Medicine, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
| | - Pieter W Kamphuisen
- Department of Vascular Medicine, University Medical Center Groningen, Groningen, The Netherlands
| | - Elisabeth H Bel
- Department of Respiratory Medicine, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
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270
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Venous thromboembolism in patients with chronic lymphocytic leukemia. Thromb Res 2015; 136:1082-6. [DOI: 10.1016/j.thromres.2015.05.010] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2015] [Revised: 05/04/2015] [Accepted: 05/12/2015] [Indexed: 11/24/2022]
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Coelho MCA, Santos CV, Vieira Neto L, Gadelha MR. Adverse effects of glucocorticoids: coagulopathy. Eur J Endocrinol 2015; 173:M11-21. [PMID: 25971647 DOI: 10.1530/eje-15-0198] [Citation(s) in RCA: 61] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/19/2015] [Accepted: 05/11/2015] [Indexed: 11/08/2022]
Abstract
Hypercortisolism is associated with various systemic manifestations, including central obesity, arterial hypertension, glucose intolerance/diabetes mellitus, dyslipidemia, nephrolithiasis, osteoporosis, gonadal dysfunction, susceptibility to infections, psychiatric disorders, and hypercoagulability. The activation of the hemostatic system contributes to the development of atherosclerosis and subsequent cardiovascular morbidity and mortality. Previous studies have identified an increased risk of both unprovoked and postoperative thromboembolic events in patients with endogenous and exogenous Cushing's syndrome (CS). The risk for postoperative venous thromboembolism in endogenous CS is comparable to the risk after total hip or knee replacement under short-term prophylaxis. The mechanisms that are involved in the thromboembolic complications in hypercortisolism include endothelial dysfunction, hypercoagulability, and stasis (Virchow's triad). It seems that at least two factors from Virchow's triad must be present for the occurrence of a thrombotic event in these patients. Most studies have demonstrated that this hypercoagulable state is explained by increased levels of procoagulant factors, mainly factors VIII, IX, and von Willebrand factor, and also by an impaired fibrinolytic capacity, which mainly results from an elevation in plasminogen activator inhibitor 1. Consequently, there is a shortening of activated partial thromboplastin time and increased thrombin generation. For these reasons, anticoagulant prophylaxis might be considered in patients with CS whenever they have concomitant prothrombotic risk factors. However, multicenter studies are needed to determine which patients will benefit from anticoagulant therapy and the dose and time of anticoagulation.
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Affiliation(s)
- Maria Caroline Alves Coelho
- Neuroendocrinology Research Center/Endocrinology SectionMedical School and Hospital Universitário Clementino Fraga Filho, Universidade Federal do Rio de Janeiro, Rua Prof. Rodolpho Paulo Rocco, 255, 9th Floor, Ilha do Fundo, Rio de Janeiro 21941-913, BrazilEndocrine SectionHospital Pedro Ernesto, Rio de Janeiro, BrazilEndocrine SectionInstituto Estadual de Diabetes e Endocrinologia Luiz Capriglione (IEDE), Rio de Janeiro, BrazilEndocrine SectionHospital Federal da Lagoa, Rio de Janeiro, Brazil Neuroendocrinology Research Center/Endocrinology SectionMedical School and Hospital Universitário Clementino Fraga Filho, Universidade Federal do Rio de Janeiro, Rua Prof. Rodolpho Paulo Rocco, 255, 9th Floor, Ilha do Fundo, Rio de Janeiro 21941-913, BrazilEndocrine SectionHospital Pedro Ernesto, Rio de Janeiro, BrazilEndocrine SectionInstituto Estadual de Diabetes e Endocrinologia Luiz Capriglione (IEDE), Rio de Janeiro, BrazilEndocrine SectionHospital Federal da Lagoa, Rio de Janeiro, Brazil Neuroendocrinology Research Center/Endocrinology SectionMedical School and Hospital Universitário Clementino Fraga Filho, Universidade Federal do Rio de Janeiro, Rua Prof. Rodolpho Paulo Rocco, 255, 9th Floor, Ilha do Fundo, Rio de Janeiro 21941-913, BrazilEndocrine SectionHospital Pedro Ernesto, Rio de Janeiro, BrazilEndocrine SectionInstituto Estadual de Diabetes e Endocrinologia Luiz Capriglione (IEDE), Rio de Janeiro, BrazilEndocrine SectionHospital Federal da Lagoa, Rio de Janeiro, Brazil
| | - Camila Vicente Santos
- Neuroendocrinology Research Center/Endocrinology SectionMedical School and Hospital Universitário Clementino Fraga Filho, Universidade Federal do Rio de Janeiro, Rua Prof. Rodolpho Paulo Rocco, 255, 9th Floor, Ilha do Fundo, Rio de Janeiro 21941-913, BrazilEndocrine SectionHospital Pedro Ernesto, Rio de Janeiro, BrazilEndocrine SectionInstituto Estadual de Diabetes e Endocrinologia Luiz Capriglione (IEDE), Rio de Janeiro, BrazilEndocrine SectionHospital Federal da Lagoa, Rio de Janeiro, Brazil Neuroendocrinology Research Center/Endocrinology SectionMedical School and Hospital Universitário Clementino Fraga Filho, Universidade Federal do Rio de Janeiro, Rua Prof. Rodolpho Paulo Rocco, 255, 9th Floor, Ilha do Fundo, Rio de Janeiro 21941-913, BrazilEndocrine SectionHospital Pedro Ernesto, Rio de Janeiro, BrazilEndocrine SectionInstituto Estadual de Diabetes e Endocrinologia Luiz Capriglione (IEDE), Rio de Janeiro, BrazilEndocrine SectionHospital Federal da Lagoa, Rio de Janeiro, Brazil
| | - Leonardo Vieira Neto
- Neuroendocrinology Research Center/Endocrinology SectionMedical School and Hospital Universitário Clementino Fraga Filho, Universidade Federal do Rio de Janeiro, Rua Prof. Rodolpho Paulo Rocco, 255, 9th Floor, Ilha do Fundo, Rio de Janeiro 21941-913, BrazilEndocrine SectionHospital Pedro Ernesto, Rio de Janeiro, BrazilEndocrine SectionInstituto Estadual de Diabetes e Endocrinologia Luiz Capriglione (IEDE), Rio de Janeiro, BrazilEndocrine SectionHospital Federal da Lagoa, Rio de Janeiro, Brazil Neuroendocrinology Research Center/Endocrinology SectionMedical School and Hospital Universitário Clementino Fraga Filho, Universidade Federal do Rio de Janeiro, Rua Prof. Rodolpho Paulo Rocco, 255, 9th Floor, Ilha do Fundo, Rio de Janeiro 21941-913, BrazilEndocrine SectionHospital Pedro Ernesto, Rio de Janeiro, BrazilEndocrine SectionInstituto Estadual de Diabetes e Endocrinologia Luiz Capriglione (IEDE), Rio de Janeiro, BrazilEndocrine SectionHospital Federal da Lagoa, Rio de Janeiro, Brazil
| | - Mônica R Gadelha
- Neuroendocrinology Research Center/Endocrinology SectionMedical School and Hospital Universitário Clementino Fraga Filho, Universidade Federal do Rio de Janeiro, Rua Prof. Rodolpho Paulo Rocco, 255, 9th Floor, Ilha do Fundo, Rio de Janeiro 21941-913, BrazilEndocrine SectionHospital Pedro Ernesto, Rio de Janeiro, BrazilEndocrine SectionInstituto Estadual de Diabetes e Endocrinologia Luiz Capriglione (IEDE), Rio de Janeiro, BrazilEndocrine SectionHospital Federal da Lagoa, Rio de Janeiro, Brazil
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272
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Ostenfeld EB, Erichsen R, Baron JA, Thorlacius-Ussing O, Iversen LH, Riis AH, Sørensen HT. Preadmission glucocorticoid use and anastomotic leakage after colon and rectal cancer resections: a Danish cohort study. BMJ Open 2015; 5:e008045. [PMID: 26408282 PMCID: PMC4593143 DOI: 10.1136/bmjopen-2015-008045] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
OBJECTIVE To examine whether preadmission glucocorticoid use increases the risk of anastomotic leakage after colon and rectal cancer resections. DESIGN A population-based cohort study. SETTING Denmark (2001-2011). PARTICIPANTS We identified patients who had undergone a primary anastomosis after a colorectal cancer resection by linking medical registries. Participants who filled their most recent glucocorticoid prescription ≤90, 91-365 and >365 days before their surgery date were categorised as current, recent and former users, respectively. MAIN OUTCOME MEASURES We calculated 30-day absolute risk of anastomotic leakage and computed ORs using logistic regression models with adjustment for potential confounders. RESULTS Of the 18,190 patients with colon cancer, anastomotic leakage occurred in 1184 (6.5%). Glucocorticoid use overall was not associated with an increased risk of leakage (6.4% vs 6.9% among never-users; OR 1.05; 95% CI 0.89 to 1.23). Categories of oral, inhaled or intestinal-acting glucocorticoids did not greatly affect risk of leakage. Anastomotic leakage occurred in 695 (13.2%) of 5284 patients with rectal cancer. Glucocorticoid use overall slightly increased risk of leakage (14.6% vs 12.8% among never-users; OR 1.36, 95% CI 1.08 to 1.72). Results did not differ significantly within glucocorticoid categories. CONCLUSIONS Preadmission glucocorticoids modestly increased the risk of anastomotic leakage mainly after rectal cancer resection. However, absolute risk differences were small and the clinical impact of glucocorticoid use may therefore be limited.
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Affiliation(s)
- Eva Bjerre Ostenfeld
- Department of Clinical Epidemiology, Aarhus University Hospital, Aarhus, Denmark
- Department of Gastrointestinal Surgery, Aalborg University Hospital, Aalborg, Denmark
| | - Rune Erichsen
- Department of Clinical Epidemiology, Aarhus University Hospital, Aarhus, Denmark
| | - John A Baron
- Department of Clinical Epidemiology, Aarhus University Hospital, Aarhus, Denmark
- Department of Medicine, University of North Carolina, School of Medicine, Chapel Hill, North Carolina, USA
| | - Ole Thorlacius-Ussing
- Department of Gastrointestinal Surgery, Aalborg University Hospital, Aalborg, Denmark
| | | | - Anders H Riis
- Department of Clinical Epidemiology, Aarhus University Hospital, Aarhus, Denmark
| | - Henrik Toft Sørensen
- Department of Clinical Epidemiology, Aarhus University Hospital, Aarhus, Denmark
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273
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Kantar RS, Haddad AG, Tamim H, Jamali F, Taher AT. Venous thromboembolism and preoperative steroid use: analysis of the NSQIP database to evaluate risk in surgical patients. Eur J Intern Med 2015; 26:528-33. [PMID: 26148433 DOI: 10.1016/j.ejim.2015.06.005] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/03/2015] [Revised: 06/12/2015] [Accepted: 06/12/2015] [Indexed: 12/31/2022]
Abstract
BACKGROUND Despite several prophylactic strategies, postoperative venous thromboembolism (VTE) remains a major cause of morbidity and mortality. Therefore, the search for modifiable preoperative risk factors is crucial. Few reports have explored this issue but the direct relationship between preoperative steroid use and postoperative VTE in surgical patients remains unexplored. METHODS We used The American College of Surgeons' National Surgical Quality Improvement Program (NSQIP) database in our study. After analyzing patient characteristics, we used multivariate logistic regression to assess the crude and adjusted effect of steroids on VTE, our primary outcome. RESULTS Data was obtained for 1,921,901 patients, 58,667 of whom were on glucocorticoids for at least 30days preoperatively. VTE was higher in patients on steroids with an adjusted odds ratio of 1.54, 95% confidence interval (CI) 1.45-1.64. The adjusted odds ratio for the secondary outcomes: mortality, urinary tract occurrences, wound occurrences, sepsis, cardiac and respiratory adverse events were 1.42 (CI 1.35-1.49), 1.40 (CI 1.30-1.50), 1.58 (CI 1.51-1.66), 1.51 (CI 1.42-1.60), 1.19 (CI 1.11-1.29) and 1.302 (CI 1.301-1.303) respectively. CONCLUSIONS Our results suggest that surgical patients with prolonged preoperative glucocorticoid intake are at a higher risk of developing postoperative VTE as well as other secondary outcomes including: all-cause mortality, urinary tract occurrences, sepsis, wound occurrences, cardiac and respiratory adverse events. These are important findings since preoperative glucocorticoid use is a modifiable factor.
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Affiliation(s)
- Rami S Kantar
- Experimental Therapeutics and Molecular Imaging Laboratory, Massachusetts General Hospital, Boston, USA
| | - Anthony G Haddad
- Department of Internal Medicine, American University of Beirut Medical Center, Beirut, Lebanon; Department of Surgery, Brigham and Women's Hospital, Boston, USA
| | - Hani Tamim
- Department of Internal Medicine, American University of Beirut Medical Center, Beirut, Lebanon
| | - Faek Jamali
- Department of Surgery, American University of Beirut Medical Center, Beirut, Lebanon
| | - Ali T Taher
- Experimental Therapeutics and Molecular Imaging Laboratory, Massachusetts General Hospital, Boston, USA.
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274
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Isidori AM, Minnetti M, Sbardella E, Graziadio C, Grossman AB. Mechanisms in endocrinology: The spectrum of haemostatic abnormalities in glucocorticoid excess and defect. Eur J Endocrinol 2015; 173:R101-13. [PMID: 25987566 DOI: 10.1530/eje-15-0308] [Citation(s) in RCA: 66] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/19/2015] [Accepted: 05/14/2015] [Indexed: 12/28/2022]
Abstract
Glucocorticoids (GCs) target several components of the integrated system that preserves vascular integrity and free blood flow. Cohort studies on Cushing's syndrome (CS) have revealed increased thromboembolism, but the pathogenesis remains unclear. Lessons from epidemiological data and post-treatment normalisation time suggest a bimodal action with a rapid and reversible effect on coagulation factors and an indirect sustained effect on the vessel wall. The redundancy of the steps that are potentially involved requires a systematic comparison of data from patients with endogenous or exogenous hypercortisolism in the context of either inflammatory or non-inflammatory disorders. A predominant alteration in the intrinsic pathway that includes a remarkable rise in factor VIII and von Willebrand factor (vWF) levels and a reduction in activated partial thromboplastin time appears in the majority of studies on endogenous CS. There may also be a rise in platelets, thromboxane B2, thrombin-antithrombin complexes and fibrinogen (FBG) levels and, above all, impaired fibrinolytic capacity. The increased activation of coagulation inhibitors seems to be compensatory in order to counteract disseminated coagulation, but there remains a net change towards an increased risk of venous thromboembolism (VTE). Conversely, GC administered in the presence of inflammation lowers vWF and FBG, but fibrinolytic activity is also reduced. As a result, the overall risk of VTE is increased in long-term users. Finally, no studies have assessed haemostatic abnormalities in patients with Addison's disease, although these may present as a consequence of bilateral adrenal haemorrhage, especially in the presence of antiphospholipid antibodies or anticoagulant treatments. The present review aimed to provide a comprehensive overview of the complex alterations produced by GCs in order to develop better screening and prevention strategies against bleeding and thrombosis.
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Affiliation(s)
- Andrea M Isidori
- Department of Experimental MedicineSapienza University of Rome, Viale del Policlinico 155, Rome 00161, ItalyOxford Centre for DiabetesEndocrinology and Metabolism, Churchill Hospital, University of Oxford, Headington, Oxford OX3 7LE, UK
| | - Marianna Minnetti
- Department of Experimental MedicineSapienza University of Rome, Viale del Policlinico 155, Rome 00161, ItalyOxford Centre for DiabetesEndocrinology and Metabolism, Churchill Hospital, University of Oxford, Headington, Oxford OX3 7LE, UK Department of Experimental MedicineSapienza University of Rome, Viale del Policlinico 155, Rome 00161, ItalyOxford Centre for DiabetesEndocrinology and Metabolism, Churchill Hospital, University of Oxford, Headington, Oxford OX3 7LE, UK
| | - Emilia Sbardella
- Department of Experimental MedicineSapienza University of Rome, Viale del Policlinico 155, Rome 00161, ItalyOxford Centre for DiabetesEndocrinology and Metabolism, Churchill Hospital, University of Oxford, Headington, Oxford OX3 7LE, UK
| | - Chiara Graziadio
- Department of Experimental MedicineSapienza University of Rome, Viale del Policlinico 155, Rome 00161, ItalyOxford Centre for DiabetesEndocrinology and Metabolism, Churchill Hospital, University of Oxford, Headington, Oxford OX3 7LE, UK
| | - Ashley B Grossman
- Department of Experimental MedicineSapienza University of Rome, Viale del Policlinico 155, Rome 00161, ItalyOxford Centre for DiabetesEndocrinology and Metabolism, Churchill Hospital, University of Oxford, Headington, Oxford OX3 7LE, UK
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275
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Ording AG, Horváth-Puhó E, Lash TL, Ehrenstein V, Borre M, Vyberg M, Sørensen HT. Prostate cancer, comorbidity, and the risk of venous thromboembolism: A cohort study of 44,035 Danish prostate cancer patients, 1995-2011. Cancer 2015; 121:3692-9. [PMID: 26149752 DOI: 10.1002/cncr.29535] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2015] [Revised: 04/16/2015] [Accepted: 04/22/2015] [Indexed: 11/07/2022]
Abstract
BACKGROUND Venous thromboembolism (VTE) is a serious complication of cancer. It is unknown whether comorbidity interacts clinically with prostate cancer (PC) to increase the VTE rate beyond that explained by PC and comorbidity alone, for example, by delaying diagnosis or precluding treatment. METHODS A nationwide, registry-based cohort study of all 44,035 Danish patients diagnosed with PC from 1995 to 2011 and 213,810 men from the general population matched 5:1 on age, calendar time, and comorbidities. The authors calculated VTE rate ratios and the interaction contrast as a measure on the additive scale of the excess VTE rate explained by synergy between PC and comorbidity. RESULTS In total, 849 patients in the PC cohort and 2360 men from the general population had VTE during 5 years of follow-up, and their risk of VTE was 2.2% and 1.3%, respectively. The 1-year VTE standardized rate among PC patients who had high comorbidity levels was 15 per 1000 person-years (PYs) (95% confidence interval, 6.8-24 per 1000 PYs), and 29% of that rate was explained by an interaction between PC and comorbidity. The VTE risk was increased among older patients, those with metastases, those with high Gleason scores, those in the D'Amico high-risk group, and those who underwent surgery. CONCLUSIONS PC interacted clinically with high comorbidity levels and increased the VTE rate. Because of the large PC burden, reducing VTEs associated with comorbidities may have an impact on VTE risk and the potential to improve prognosis. Clinical interactions between high levels of comorbidity and PC on the risk of VTE were observed. Almost 30% of all episodes of VTE occurred among patients who had high levels of comorbidity.
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Affiliation(s)
- Anne G Ording
- Department of Clinical Epidemiology, Aarhus University Hospital, Aarhus, Denmark
| | | | - Timothy L Lash
- Department of Clinical Epidemiology, Aarhus University Hospital, Aarhus, Denmark.,Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, Georgia
| | - Vera Ehrenstein
- Department of Clinical Epidemiology, Aarhus University Hospital, Aarhus, Denmark
| | - Michael Borre
- Department of Urology, Aarhus University Hospital, Aarhus, Denmark
| | - Mogens Vyberg
- Institute of Pathology, Aalborg University Hospital, Aalborg, Denmark
| | - Henrik T Sørensen
- Department of Clinical Epidemiology, Aarhus University Hospital, Aarhus, Denmark
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276
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Venous thromboembolism (VTE) and glioblastoma. J Neurooncol 2015; 124:87-94. [PMID: 25985958 DOI: 10.1007/s11060-015-1805-2] [Citation(s) in RCA: 62] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2014] [Accepted: 05/06/2015] [Indexed: 01/19/2023]
Abstract
The risk of venous thromboembolism (VTE) is high for patients with brain tumors (11-20 %). Glioblastoma (GBM) patients, in particular, have the highest risk of VTE (24-30 %). The Khorana scale is the most commonly used clinical scale to evaluate the risk of VTE in cancer patients but its efficacy in patients with GBM remains unclear. The aim of this study is to estimate the frequency of VTE in GBM patients and identify potential risk factors for the development of VTE during adjuvant chemotherapy. Furthermore, we intend to examine whether the Khorana scale accurately predicts the risk of VTE in GBM patients. We retrospectively reviewed the medical records of GBM patients treated at MD Anderson during the years 2005-2011. The study cohort included 440 patients of which 64 (14.5 %) developed VTE after the start of adjuvant treatment. The median time to develop VTE was 6.5 months from the start of adjuvant treatment. On multivariate analysis male sex, BMI ≥ 35, KPS ≤ 80, history of VTE and steroid therapy were significantly associated with the development of VTE. The Khorana scale was found to be an invalid VTE predictive model in GBM patients due to poor specificity. Of the 64 patients who developed a VTE, 36 were treated with anticoagulation, 2 with an IVC filter, and 21 with both. Complications (intracranial hemorrhage, bleeding in other organs and thrombocytopenia) secondary to anticoagulation were reported in 16 % (n = 10). VTE is common in patients with GBM. Our results did not validate the Khorana scale in GBM patients. Additional studies identifying which GBM patients are at highest risk for VTE are needed to enable further evaluation of VTE preventive measures in this selected group.
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277
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Yusuf HR, Hooper WC, Beckman MG, Zhang QC, Tsai J, Ortel TL. Risk of venous thromboembolism among hospitalizations of adults with selected autoimmune diseases. J Thromb Thrombolysis 2015; 38:306-13. [PMID: 24464552 DOI: 10.1007/s11239-014-1050-0] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Previous research has suggested autoimmune diseases are risk factors for developing venous thromboembolism (VTE). We assessed whether having diagnoses of selected autoimmune diseases associated with antiphospholipid antibodies--autoimmune hemolytic anemia (AIHA), immune thrombocytopenic purpura (ITP), rheumatoid arthritis (RA), and systemic lupus erythematosus (SLE)--were associated with having a VTE diagnosis among US adult hospitalizations. A cross-sectional study was conducted using the 2010 Nationwide Inpatient Sample of the Healthcare Cost and Utilization Project, Agency for Healthcare Research and Quality. VTE and autoimmune diseases were identified using International Classification of Diseases, Ninth Revision, Clinical Modification coded diagnoses information. The percentages of hospitalizations with a VTE diagnosis among all non-maternal adult hospitalizations without any of the four autoimmune diseases of interest and among those with AIHA, ITP, RA, and SLE diagnoses were 2.28, 4.46, 3.35, 2.65 and 2.77%, respectively. The adjusted odds ratios (OR) for having a diagnosis of VTE among non-maternal adult hospitalizations with diagnoses of AIHA, ITP, RA, and SLE were 1.25 [95% confidence interval (CI) 1.05-1.49], 1.20 (95% CI 1.07-1.34), 1.17 (95% CI 1.13-1.21), and 1.23 (95% CI 1.15-1.32), respectively, when compared to those without the corresponding conditions. The adjusted OR for a diagnosis of VTE associated with a diagnosis of any of the four autoimmune diseases was 1.20 (95% CI 1.16-1.24). The presence of a diagnosis of AIHA, ITP, RA, and SLE was associated with an increased likelihood of having a VTE diagnosis among the group of all non-maternal adult hospitalizations.
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Affiliation(s)
- Hussain R Yusuf
- Division of Blood Disorders, National Center on Birth Defects and Developmental Disabilities, Centers for Disease Control and Prevention, 1600 Clifton Rd., N.E., MS-E64, Atlanta, GA, 30333, USA,
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278
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Abstract
Thrombosis in inflammatory bowel disease (IBD) is an increasingly noted extraintestinal manifestation with high morbidity and mortality. While controlling the activity of the disease with the appropriate therapy, thromboembolism prophylaxis should be applied to all patients. All common risk factors for thromboembolism are also valid for patients with IBD; however, it is clear that uncontrolled disease and hospitalization are major disease-specific risk factors for venous thromboembolism in patients with IBD. Pharmacological thromboprophylaxis with currently available anticoagulants does not increase the risk of further bleeding in patients with IBD with mild-to-moderate bleeding. In severe bleeding or with increased risk of further bleeding due to other comorbid conditions, thromboprophylaxy with mechanical methods should be the treatment option. Whether thrombosis is the cause or the result of intestinal inflammation remains to be elucidated, and other issues in the etiology, such as the role of intestinal flora in thrombosis pathogenesis, will be the subject of future studies.
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279
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Dieckmann KP, Anheuser P, Gehrckens R, Aries SP, Ikogho R, Hollburg W. Factor V Leiden mutation triggering four major complications to standard dose cisplatin-chemotherapy for testicular seminoma: a case report. BMC Urol 2015; 15:21. [PMID: 25887618 PMCID: PMC4374368 DOI: 10.1186/s12894-015-0011-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2014] [Accepted: 02/20/2015] [Indexed: 12/21/2022] Open
Abstract
Background Major life-threatening complications secondary to cisplatin-based chemotherapy are rare in patients with testicular germ cell tumour (GCT). The incidence of complications increases with dosage of chemotherapy and with a variety of patient-related as well as disease-related conditions. We here report the first case of GCT experiencing as many as four major complications most of which can be explained by the conjunction of several predispositions. Case presentation A 48 year old patient with testicular seminoma and bulky retroperitoneal and mediastinal metastases underwent cisplatin based chemotherapy. During the third cycle of chemotherapy, he developed thrombosis of the central venous port device, subtotal splenic infarction, and Bleomycin induced pneumonitis (BIP). Three months after completion of therapy, he was struck by thalamic infarction. Genetic testing then revealed heterozygote mutation of Factor V Leiden (FVL). He received full-dose warfarin anticoagulation treatment and steroid treatment for BIP. 18 months thereafter, the patient is still disease-free, oncologically. Neurological symptoms have disappeared, but pulmonary dysfunction persists with a vital capacity of 50%. Conclusion The unique co-incidence of four major complications occurring in this patient were obviously triggered by the genetically determined predisposition of the patient to thrombotic events (FVL). Additionally, several patient-related and disease-related conditions contributed to the unique pattern of complications, i.e. (1) the slightly advanced age (48 years), (2) the prothrombotic condition caused by the disease of cancer, (3) the central venous port device, (4) retroperitoneal bulky metastasis, and (5) cisplatin chemotherapy. Whether or not FVL contributed to the pulmonary fibrosis as well, remains elusive. Practically, in the case of one major vascular complication during cisplatin chemotherapy at standard dose, genetic testing for hereditary thrombophilia should be considered. Thus, precautions for preventing further complications could be initiated.
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Affiliation(s)
- Klaus-Peter Dieckmann
- Albertinen-Krankenhaus, Department of Urology, Suentelstrasse 11a, D-22457, Hamburg, Germany.
| | - Petra Anheuser
- Albertinen-Krankenhaus, Department of Urology, Suentelstrasse 11a, D-22457, Hamburg, Germany.
| | - Ralf Gehrckens
- Albertinen-Krankenhaus, Department of Diagnostic Radiology, Hamburg, Germany.
| | | | - Raphael Ikogho
- Albertinen-Krankenhaus, Department of Urology, Suentelstrasse 11a, D-22457, Hamburg, Germany.
| | - Wiebke Hollburg
- Hämatologisch-onkologische Praxis Altona (HOPA), Mörkenstrasse 47, D-22767, Hamburg, Germany.
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280
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Koutroubakis IE. The relationship between coagulation state and inflammatory bowel disease: current understanding and clinical implications. Expert Rev Clin Immunol 2015; 11:479-88. [PMID: 25719625 DOI: 10.1586/1744666x.2015.1019475] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Inflammatory bowel disease (IBD) is associated with a hypercoagulable state and subsequently with an increased risk for venous thromboembolism (VTE). VTE in IBD is characterized by a high recurrence rate and is associated with the disease activity. Acquired endothelial dysfunction, abnormalities of platelets, activation of coagulation system and impaired fibrinolysis are the main changes in the coagulation state in IBD. The development of VTE in IBD has been considered to be the result of multiple interactions between acquired and inherited risk factors. The treatment of VTE in IBD patients is recommended to be similar and to follow the same protocols as for non-IBD patients. In the clinical practice, the management of IBD patients and especially the hospitalized patients should include thromboprophylaxis.
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Affiliation(s)
- Ioannis E Koutroubakis
- Department of Gastroenterology, University Hospital Heraklion, P.O. Box 1352, 71110 Heraklion, Crete, Greece
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281
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Glassock RJ. Thrombo-prevention in membranous nephropathy: a new tool for decision making? Kidney Int 2015; 85:1265-6. [PMID: 24875548 DOI: 10.1038/ki.2013.541] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Thromboembolic events occur in primary membranous nephropathy, especially when serum albumin is less than 2.8 g/dl. In such patients, a conundrum arises concerning anticipated benefits and risks when a prophylactic oral anticoagulant is considered. Lee et al. describe a flexible Markov decision tree program to aid decision making. Its application to individual patients will probably be useful, but physicians will need to assess patients' tolerance for the benefit-to-risk ratio, considering the many factors bearing on the risk of thromboembolic events and/or serious bleeding.
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Affiliation(s)
- Richard J Glassock
- Department of Medicine, Geffen School of Medicine at UCLA, Los Angeles, California, USA
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282
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Gribsholt SB, Svensson E, Thomsen RW, Richelsen B, Sørensen HT. Preoperative glucocorticoid use and risk of postoperative bleeding and infection after gastric bypass surgery for the treatment of obesity. Surg Obes Relat Dis 2015; 11:1212-7. [PMID: 26001556 DOI: 10.1016/j.soard.2015.01.017] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2014] [Revised: 01/19/2015] [Accepted: 01/26/2015] [Indexed: 10/24/2022]
Abstract
BACKGROUND Previous research suggests that patients using glucocorticoids may be at increased risk of postoperative bleeding and infection after major surgery. The objective was to investigate the association between preoperative glucocorticoid use and risk of bleeding and infection after Roux-en-Y gastric bypass surgery (RYGB). SETTING Nationwide cohort study of 13,195 patients, who underwent RYGB 2006-2012 using Danish population-based medical databases. METHODS Information was obtained on current (redeemed prescription<60 d before surgery), recent (prescription 60-180 d before surgery), or no glucocorticoid use, and postoperative bleeding or infection within 30 days of surgery. We computed risk differences and odds ratios (ORs) as a measure of relative risk with 95% confidence intervals (95% CIs) for the association between glucocorticoid use and bleeding or infection, adjusting for gender, age, and co-morbidities by logistic regression. RESULTS Among RYGB patients, 325 (2.5%) were current glucocorticoid users, and 365 (2.8%) were recent users. The risk of bleeding was increased in current users: 2.8% versus 1.6% among nonusers (risk difference: 1.2%, 95% CI: -.6, 3.0) corresponding to an adjusted OR of 1.5 (95% CI: .8, 3.0). For recent users, the adjusted OR for bleeding was 1.2 (95% CI: .5, 2.5). The risk of infection did not differ materially between current (1.8%), recent (1.0%) and nonusers (1.7%), corresponding to an adjusted OR of .9 (95% CI: .4, 2.1) among current versus nonusers. CONCLUSIONS Current use of glucocorticoids is associated with a slightly increased risk of postoperative bleeding, but not infection, after RYGB. No increased risks were found for recent users.
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Affiliation(s)
- Sigrid Bjerge Gribsholt
- Department of Endocrinology and Internal Medicine, Aarhus University Hospital; Department of Clinical Epidemiology, Aarhus University Hospital.
| | | | | | - Bjørn Richelsen
- Department of Endocrinology and Internal Medicine, Aarhus University Hospital
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283
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Activation of endothelium, coagulation and fibrinolysis is enhanced and associates with renal anti-neutrophil cytoplasmic antibody-associated vasculitis†. Nephrol Dial Transplant 2014; 30 Suppl 1:i53-9. [DOI: 10.1093/ndt/gfu379] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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284
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Mozaffarian D, Benjamin EJ, Go AS, Arnett DK, Blaha MJ, Cushman M, de Ferranti S, Després JP, Fullerton HJ, Howard VJ, Huffman MD, Judd SE, Kissela BM, Lackland DT, Lichtman JH, Lisabeth LD, Liu S, Mackey RH, Matchar DB, McGuire DK, Mohler ER, Moy CS, Muntner P, Mussolino ME, Nasir K, Neumar RW, Nichol G, Palaniappan L, Pandey DK, Reeves MJ, Rodriguez CJ, Sorlie PD, Stein J, Towfighi A, Turan TN, Virani SS, Willey JZ, Woo D, Yeh RW, Turner MB. Heart disease and stroke statistics--2015 update: a report from the American Heart Association. Circulation 2014; 131:e29-322. [PMID: 25520374 DOI: 10.1161/cir.0000000000000152] [Citation(s) in RCA: 4448] [Impact Index Per Article: 444.8] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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285
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Nguyen GC, Elnahas A, Jackson TD. The impact of preoperative steroid use on short-term outcomes following surgery for inflammatory bowel disease. J Crohns Colitis 2014; 8:1661-7. [PMID: 25107847 DOI: 10.1016/j.crohns.2014.07.007] [Citation(s) in RCA: 83] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/08/2014] [Revised: 07/13/2014] [Accepted: 07/22/2014] [Indexed: 02/08/2023]
Abstract
BACKGROUND Inflammatory bowel disease (IBD) patients are frequently treated with steroids prior to surgery. We characterized the association between preoperative steroid use and postoperative complications in a large prospective cohort. METHODS We identified patients who underwent major IBD-related abdominal surgery in the American College of Surgeon's National Surgical Quality Improvement Program (ACS-NSQIP) between 2005 and 2012. We compared the risk of postoperative complications and 30-day mortality between preoperative steroid users and non-users. RESULTS We identified 8260 Crohn's disease (CD) and 7235 ulcerative colitis (UC) patients who underwent major abdominal surgery. Preoperative steroid use was associated with higher risk of postoperative complications, excluding death, in both CD (22.6% vs. 18.5%, P<0.0001) and UC (30.1% vs. 22.5%, P<0.0001). The adjusted odds ratio for any postoperative complication associated with steroids was 1.26 (95% CI: 1.12-1.41) for CD and 1.44 (95% CI: 1.28-1.61) for UC. Infectious complications were more frequent with steroid use in both CD (15.2% vs. 12.9%, P=0.004) and UC (19.4% vs. 15.6%, P<0.0001), specifically intra-abdominal infections and sepsis. Steroid use was associated with increased risk of venous thromboembolism (VTE) in both CD (OR, 1.66; 95% CI: 1.17-2.35) and UC (OR, 2.66; 95% CI: 2.01-3.53). 30-day mortality did not differ among steroid users and non-users (6.8/1000 vs. 5.8/1000, P=0.58 for CD; 13.5/1000 vs. 15.2/1000, P=0.55 for UC). CONCLUSIONS Preoperative steroids are associated with higher risk of postoperative sepsis and VTE in IBD. Increased infectious control measures and VTE prophylaxis may reduce adverse events.
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Affiliation(s)
- Geoffrey C Nguyen
- Mount Sinai Hospital Centre for Inflammatory Bowel Disease, University of Toronto, Canada; Institute for Health Policy Management and Evaluation, University of Toronto, Canada.
| | - Ahmad Elnahas
- University Health Network, Division of General Surgery, Department of Surgery, University of Toronto, Canada
| | - Timothy D Jackson
- University Health Network, Division of General Surgery, Department of Surgery, University of Toronto, Canada
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286
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Ananthakrishnan AN, Cagan A, Gainer VS, Cheng SC, Cai T, Scoville E, Konijeti GG, Szolovits P, Shaw SY, Churchill S, Karlson EW, Murphy SN, Kohane I, Liao KP. Thromboprophylaxis is associated with reduced post-hospitalization venous thromboembolic events in patients with inflammatory bowel diseases. Clin Gastroenterol Hepatol 2014; 12:1905-10. [PMID: 24632349 PMCID: PMC4162859 DOI: 10.1016/j.cgh.2014.02.034] [Citation(s) in RCA: 54] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/09/2013] [Revised: 01/21/2014] [Accepted: 02/19/2014] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Patients with inflammatory bowel diseases (IBDs) have increased risk for venous thromboembolism (VTE); those who require hospitalization have particularly high risk. Few hospitalized patients with IBD receive thromboprophylaxis. We analyzed the frequency of VTE after IBD-related hospitalization, risk factors for post-hospitalization VTE, and the efficacy of prophylaxis in preventing post-hospitalization VTE. METHODS In a retrospective study, we analyzed data from a multi-institutional cohort of patients with Crohn's disease or ulcerative colitis and at least 1 IBD-related hospitalization. Our primary outcome was a VTE event. All patients contributed person-time from the date of the index hospitalization to development of VTE, subsequent hospitalization, or end of follow-up. Our main predictor variable was pharmacologic thromboprophylaxis. Cox proportional hazard models adjusting for potential confounders were used to estimate hazard ratios (HRs) and 95% confidence intervals (CIs). RESULTS From a cohort of 2788 patients with at least 1 IBD-related hospitalization, 62 patients developed VTE after discharge (2%). Incidences of VTE at 30, 60, 90, and 180 days after the index hospitalization were 3.7/1000, 4.1/1000, 5.4/1000, and 9.4/1000 person-days, respectively. Pharmacologic thromboprophylaxis during the index hospital stay was associated with a significantly lower risk of post-hospitalization VTE (HR, 0.46; 95% CI, 0.22-0.97). Increased numbers of comorbidities (HR, 1.30; 95% CI, 1.16-1.47) and need for corticosteroids before hospitalization (HR, 1.71; 95% CI, 1.02-2.87) were also independently associated with risk of VTE. Length of hospitalization or surgery during index hospitalization was not associated with post-hospitalization VTE. CONCLUSIONS Pharmacologic thromboprophylaxis during IBD-related hospitalization is associated with reduced risk of post-hospitalization VTE.
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Affiliation(s)
- Ashwin N Ananthakrishnan
- Division of Gastroenterology, Massachusetts General Hospital, Boston, Massachusetts; Harvard Medical School, Boston, Massachusetts.
| | - Andrew Cagan
- Research IS and Computing, Partners HealthCare, Charlestown, Massachusetts
| | - Vivian S Gainer
- Research IS and Computing, Partners HealthCare, Charlestown, Massachusetts
| | - Su-Chun Cheng
- Department of Biostatistics, Harvard School of Public Health, Boston, Massachusetts
| | - Tianxi Cai
- Department of Biostatistics, Harvard School of Public Health, Boston, Massachusetts
| | - Elizabeth Scoville
- Division of Gastroenterology, Massachusetts General Hospital, Boston, Massachusetts
| | - Gauree G Konijeti
- Division of Gastroenterology, Massachusetts General Hospital, Boston, Massachusetts
| | - Peter Szolovits
- Massachusetts Institute of Technology, Cambridge, Massachusetts
| | - Stanley Y Shaw
- Harvard Medical School, Boston, Massachusetts; Center for Systems Biology, Massachusetts General Hospital, Boston, Massachusetts
| | - Susanne Churchill
- i2b2 National Center for Biomedical Computing, Brigham and Women's Hospital, Boston, Massachusetts
| | - Elizabeth W Karlson
- Harvard Medical School, Boston, Massachusetts; Division of Rheumatology, Allergy and Immunology, Brigham and Women's Hospital, Boston, Massachusetts
| | - Shawn N Murphy
- Harvard Medical School, Boston, Massachusetts; Research IS and Computing, Partners HealthCare, Charlestown, Massachusetts; Department of Neurology, Massachusetts General Hospital, Boston, Massachusetts
| | - Isaac Kohane
- Harvard Medical School, Boston, Massachusetts; i2b2 National Center for Biomedical Computing, Brigham and Women's Hospital, Boston, Massachusetts; Children's Hospital Boston, Boston, Massachusetts
| | - Katherine P Liao
- Harvard Medical School, Boston, Massachusetts; Division of Rheumatology, Allergy and Immunology, Brigham and Women's Hospital, Boston, Massachusetts
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287
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Sonstein L, Clark C, Seidensticker S, Zeng L, Sharma G. Improving adherence for management of acute exacerbation of chronic obstructive pulmonary disease. Am J Med 2014; 127:1097-1104. [PMID: 24927911 PMCID: PMC4592184 DOI: 10.1016/j.amjmed.2014.05.033] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/01/2013] [Revised: 04/29/2014] [Accepted: 05/26/2014] [Indexed: 12/21/2022]
Abstract
BACKGROUND Clinical practice guidelines recommend 40-60 mg of prednisone equivalent for 10-14 days for patients with acute exacerbations of chronic obstructive pulmonary disease (COPD). However, the amount of corticosteroid prescribed varies widely in clinical practice. Using the electronic health record, we implemented an evidence-based order set to standardize treatment of patients hospitalized with acute exacerbations of COPD. METHODS This is a pre- and post-intervention study on patients hospitalized between January 1, 2009 and September 30, 2012 with primary discharge diagnosis of COPD (International Classification of Diseases, 9(th) Revision code: 491.xx, 492.xx, and 496) and receipt of at least one dose of corticosteroid at our tertiary care hospital. Data on baseline demographics, dose of corticosteroid in prednisone equivalent administered during the first 48 hours and during the entire hospitalizations were collected from the electronic health record. Evidence-based guidelines were used to build and implement acute exacerbations of COPD management electronic ordersets in our electronic health record, Epic (Verona, WI). We divided the study into 2 time periods (January 1, 2009 through February 28, 2011 as pre- [n = 203] and March 1, 2011 through September 30, 2012 as post-intervention periods [n = 217]). The primary outcome measure was corticosteroid dose administered in the first 48 hours. Secondary outcome measures were corticosteroid dosage during the entire hospitalization, length of stay, hospital follow-up rates, and 30-day readmission rates. RESULTS A total of 420 patients with acute exacerbations of COPD were included in the study. In the post-intervention period, the median amount of corticosteroid used in the first 48 hours was significantly reduced (306.2 mg vs 156.25 mg, P < .0001), as was that used during the entire hospitalization (352.5 mg vs 175 mg, P < .0001). There was no difference in hospital follow-up rates, length of stay, or 30-day readmission rates between the 2 periods. CONCLUSIONS Evidence-based electronic ordersets improve compliance with clinical practice guidelines and reduce the total dose of corticosteroid administered in patients hospitalized with acute exacerbations of COPD.
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Affiliation(s)
- Lindsay Sonstein
- Department of Internal Medicine, University of Texas Medical Branch, Galveston.
| | - Carlos Clark
- Department of Internal Medicine, University of Texas Medical Branch, Galveston
| | - Susan Seidensticker
- Department of Quality and Patient Safety, University of Texas Medical Branch, Galveston
| | - Li Zeng
- Department of Industrial and Manufacturing Systems Engineering, University of Texas, Arlington
| | - Gulshan Sharma
- Department of Internal Medicine, University of Texas Medical Branch, Galveston
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Epler GR, Kelly EM. Systematic review of postradiotherapy bronchiolitis obliterans organizing pneumonia in women with breast cancer. Oncologist 2014; 19:1216-26. [PMID: 25361622 DOI: 10.1634/theoncologist.2014-0041] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND Radiation therapy for breast cancer has been implicated in the development of bronchiolitis obliterans organizing pneumonia (BOOP). This inflammatory lung disorder was first noted in 1983, and there have been numerous reports of BOOP occurring in women who have had radiation therapy for breast cancer since 1995. This study was undertaken to perform a systematic review of postradiotherapy BOOP to determine the occurrence, presentation, treatment, and outcome. MATERIALS AND METHODS A systematic literature review was conducted according to the guidelines provided by the Preferred Reporting Items for Systematic Reviews and Meta-Analyses report. RESULTS The literature search yielded 10 Japanese epidemiological reports with 129 women, 4 case series reports with 36 women, and 24 case reports with 34 women. Common symptoms included fever, cough, and shortness of breath. Most patients received corticosteroid therapy, and duration of treatment ranged from 6 months to 1 year, although some patients received steroids for longer than 1 year because of relapse, which occurred in approximately one half of patients. No deaths have been reported. CONCLUSION BOOP is a rare but significant complication from radiation therapy for breast cancer. Chest radiographic studies for women who report new respiratory symptoms during the postradiation period can be beneficial for early diagnosis and for guiding appropriate management.
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Affiliation(s)
- Gary R Epler
- Pulmonary and Critical Care Medicine, Harvard Medical School, Brigham and Women's Hospital, Boston, Massachusetts, USA; Kelly Research and Consulting, Smithtown, New York, USA
| | - Eileen M Kelly
- Pulmonary and Critical Care Medicine, Harvard Medical School, Brigham and Women's Hospital, Boston, Massachusetts, USA; Kelly Research and Consulting, Smithtown, New York, USA
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289
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Yusuf HR, Hooper WC, Grosse SD, Parker CS, Boulet SL, Ortel TL. Risk of venous thromboembolism occurrence among adults with selected autoimmune diseases: a study among a U.S. cohort of commercial insurance enrollees. Thromb Res 2014; 135:50-7. [PMID: 25456001 DOI: 10.1016/j.thromres.2014.10.012] [Citation(s) in RCA: 61] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2014] [Revised: 10/09/2014] [Accepted: 10/14/2014] [Indexed: 10/24/2022]
Abstract
OBJECTIVE This study assessed the risk of venous thromboembolism (VTE) among privately insured adults in the U.S. with one or more of the following autoimmune diseases: autoimmune hemolytic anemia (AIHA), immune thrombocytopenic purpura (ITP), rheumatoid arthritis (RA), and systemic lupus erythematosus (SLE). MATERIALS AND METHODS Using the Truven Health MarketScan® Databases, patients 18-64 years of age with a diagnosis of AIHA, ITP, RA, or SLE in 2007 and a sex and age-group matched comparison group of enrollees were followed up through 2010 to identify VTE events. Survival curve and Cox proportional hazards analyses were conducted to assess differences between groups. RESULTS Among patients with AIHA, ITP, RA, or SLE, or >1 of these diseases, the risk of at least one VTE event was 19.74, 7.72, 4.90, 9.89, and 13.35 per 1,000 person-years, respectively; among the comparison group, the risk was 1.91 per 1,000 person-years. The adjusted hazard ratios (aHRs) for VTE among patients with AIHA, ITP, RA, or SLE, or >1 of these diseases (when compared with the comparison group) tended to decline over follow-up time; at 1year, the aHRs were 6.30 (95% confidence interval [CI]: 4.44-8.94), 2.95 (95% CI: 2.18-4.00), 2.13 (95% CI: 1.89-2.40), 4.68 (95% CI: 4.10-5.33), and 5.11 (95% CI: 4.26-6.14), respectively. CONCLUSION Having AIHA, ITP, RA, or SLE, or >1 of these diseases was associated with an increased likelihood of a VTE event. More research is necessary to develop better understanding of VTE occurrence among people with autoimmune diseases.
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Affiliation(s)
- Hussain R Yusuf
- Office of Science and Public Health Practice, Office of Public Health Preparedness and Response, Centers for Disease Control and Prevention, 1600 Clifton Rd., N.E., MS-K72, Atlanta, GA 30333.
| | - W Craig Hooper
- Division of Blood Disorders, National Center on Birth Defects and Developmental Disabilities, Centers for Disease Control and Prevention, 1600 Clifton Rd., N.E., MS-E64, Atlanta, GA 30333
| | - Scott D Grosse
- Division of Blood Disorders, National Center on Birth Defects and Developmental Disabilities, Centers for Disease Control and Prevention, 1600 Clifton Rd., N.E., MS-E64, Atlanta, GA 30333
| | - Christopher S Parker
- Division of Blood Disorders, National Center on Birth Defects and Developmental Disabilities, Centers for Disease Control and Prevention, 1600 Clifton Rd., N.E., MS-E64, Atlanta, GA 30333
| | - Sheree L Boulet
- Division Of Reproductive Health, National Center on Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, 1600 Clifton Rd., N.E., MS-F74, Atlanta, GA 30333
| | - Thomas L Ortel
- Hemostasis and Thrombosis Center, Duke University Medical Center, 40 Duke Medicine Circle, Durham, NC 27710
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Roth P, Happold C, Weller M. Corticosteroid use in neuro-oncology: an update. Neurooncol Pract 2014; 2:6-12. [PMID: 26034636 DOI: 10.1093/nop/npu029] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2014] [Indexed: 01/10/2023] Open
Abstract
Because of the lack of curative approaches for most patients with malignant brain tumors, supportive therapy, which aims at maintaining quality of life and functional independence, has a central role in the treatment of many patients. Steroids are particularly important in the setting of supportive therapy. They are commonly used to treat tumor-associated edema, and their administration is typically associated with rapid symptom relief, such as the resolution of headaches. Besides their antiedema activity, corticosteroids are characterized by their potent antilymphoma properties and their effects against acute or delayed emesis caused by systemic chemotherapy in cancer patients. Accordingly, steroids are among the most frequently used drugs in oncology. These desirable properties of steroids are counterbalanced by cardiovascular, muscular, and psychiatric side effects. On the cellular level, corticosteroids exert various effects that translate into the desired clinical activity, but they also evoke significant toxicity that may outweigh the beneficial effects. The mode of action and the limitations of steroid treatment are summarized in this review article. Interactions between steroids and other drugs must be considered. A particular challenge to the ongoing use of glucocorticoids is that newer therapeutic approaches are being introduced in neuro-oncology for which concomitant steroids are likely to be contraindicated. These include the emergence of various immunotherapeutic approaches including vaccination strategies and treatment with immune checkpoint inhibitors. Since the administration of steroids may interfere with the activity of these novel therapies, an even more critical evaluation of their use will be required.
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Affiliation(s)
- Patrick Roth
- Department of Neurology and Brain Tumor Center , University Hospital Zurich , Switzerland
| | - Caroline Happold
- Department of Neurology and Brain Tumor Center , University Hospital Zurich , Switzerland
| | - Michael Weller
- Department of Neurology and Brain Tumor Center , University Hospital Zurich , Switzerland
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291
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Aviña-Zubieta JA, Bhole VM, Amiri N, Sayre EC, Choi HK. The risk of deep venous thrombosis and pulmonary embolism in giant cell arteritis: a general population-based study. Ann Rheum Dis 2014; 75:148-54. [PMID: 25265937 DOI: 10.1136/annrheumdis-2014-205665] [Citation(s) in RCA: 46] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2014] [Accepted: 09/13/2014] [Indexed: 01/24/2023]
Abstract
IMPORTANCE Patients with giant cell arteritis (GCA) may have an increased risk of pulmonary embolism (PE), similar to other systemic vasculitidies; however, no relevant population data are available to date. OBJECTIVE To evaluate the future risk and time trends of new venous thromboembolism (VTE) in individuals with incident GCA at the general population level. DESIGN Observational cohort study. SETTING General population of British Columbia. PARTICIPANTS 909 patients with incident GCA and 9288 age-matched, sex-matched and entry-time-matched control patients without a history of VTE. MAIN OUTCOME MEASURES We calculated incidence rate ratios (IRR) overall, and stratified by GCA duration. We calculated HR of PE and deep vein thrombosis (DVT), adjusting for potential VTE risk factors. RESULTS Among 909 individuals with GCA (mean age 76 years, 73% women), 18 developed PE and 20 developed DVT. Incidence rates (IR) of VTE, PE and DVT were 13.3, 7.7 and 8.5 per 1000 person-years (PY) in GCA cohort, versus 3.7, 1.9 and 2.2 per 1000 PY in the comparison cohort. The corresponding IRRs (95% CI) for VTE, PE and DVT were 3.58 (2.33 to 5.34), 3.98 (2.22 to 6.81) and 3.82 (2.21 to 6.34) with the highest IRR observed in the first year of GCA diagnosis (7.03, 7.23 and 7.85, respectively). Corresponding fully adjusted HRs (95% CI) were 2.49 (1.45 to 4.30), 2.71 (1.32 to 5.56) and 2.78 (1.39 to 5.54). CONCLUSIONS AND SIGNIFICANCE These findings provide general population-based evidence that patients with GCA have an increased risk of VTE, calling for increased vigilance in preventing this serious, but preventable complication, especially within months after GCA diagnosis.
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Affiliation(s)
- J Antonio Aviña-Zubieta
- Arthritis Research Centre of Canada, Richmond, British Columbia, Canada Division of Rheumatology, Department of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - Vidula M Bhole
- Arthritis Research Centre of Canada, Richmond, British Columbia, Canada
| | - Neda Amiri
- Division of Rheumatology, Department of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - Eric C Sayre
- Arthritis Research Centre of Canada, Richmond, British Columbia, Canada
| | - Hyon K Choi
- Arthritis Research Centre of Canada, Richmond, British Columbia, Canada Department of Rheumatology, Division of Rheumatology, Allergy and Immunology, Harvard Medical School, Boston, USA
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292
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Carruthers EC, Choi HK, Sayre EC, Aviña-Zubieta JA. Risk of deep venous thrombosis and pulmonary embolism in individuals with polymyositis and dermatomyositis: a general population-based study. Ann Rheum Dis 2014; 75:110-6. [PMID: 25193998 DOI: 10.1136/annrheumdis-2014-205800] [Citation(s) in RCA: 56] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2014] [Accepted: 08/14/2014] [Indexed: 11/04/2022]
Abstract
BACKGROUND/OBJECTIVE Patients with polymyositis (PM) and dermatomyositis (DM) may have an increased risk of venous thromboembolism (VTE); however, no general population data are available to date. The purpose of this study was to estimate the future risk and time trends of new VTE (deep venous thrombosis (DVT) or pulmonary embolism (PE)) in individuals with incident PM/DM at the general population level. METHODS We assembled a retrospective cohort of all patients with incident PM/DM in British Columbia and a corresponding comparison cohort of up to 10 age-matched, sex-matched and entry-time-matched individuals from the general population. We calculated incidence rate ratios (IRR) for VTE, DVT and PE and stratified by disease duration. We calculated HRs adjusting for relevant confounders. RESULTS Among 752 cases with inflammatory myopathies, 443 had PM (58% female, mean age 60 years) and 355 had DM (65% female, mean age 56 years); 46 subjects developed both diseases. The corresponding IRRs (95% CI) for VTE, DVT and PE in PM were 8.14 (4.62 to 13.99), 6.16 (2.50 to 13.92) and 9.42 (4.59 to 18.70), respectively. Overall, the highest IRRs for VTE, DVT and PE were observed in the first year after PM diagnosis (25.25, 9.19 and 38.74, respectively). Fully adjusted HRs for VTE, DVT and PE remained statistically significant (7.0 (3.34 to 14.64), 6.16 (2.07 to 18.35), 7.23 (2.86 to 18.29), respectively). Similar trends were seen in DM. CONCLUSIONS These findings provide the first general population-based evidence that patients with PM/DM have an increased risk of VTE. Increased vigilance of this serious but preventable complication is recommended.
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Affiliation(s)
- Erin C Carruthers
- Arthritis Research Centre of Canada, Richmond, British Columbia, Canada
| | - Hyon K Choi
- Arthritis Research Centre of Canada, Richmond, British Columbia, Canada Division of Rheumatology, Allergy and Immunology, Department of Rheumatology, Harvard Medical School, Boston, Massachusetts, USA Division of Rheumatology, Department of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - Eric C Sayre
- Arthritis Research Centre of Canada, Richmond, British Columbia, Canada
| | - J Antonio Aviña-Zubieta
- Arthritis Research Centre of Canada, Richmond, British Columbia, Canada Division of Rheumatology, Department of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
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294
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Ording AG, Horváth-Puhó E, Garne JP, Nyström PW, Vyberg M, Sørensen HT, Lash TL. Impact of comorbidity on risk of venous thromboembolism in patients with breast cancer: a Danish population-based cohort study. BMJ Open 2014; 4:e005082. [PMID: 24902734 PMCID: PMC4054647 DOI: 10.1136/bmjopen-2014-005082] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
OBJECTIVES To assess the interaction between comorbidity and breast cancer (BC) on the rate of venous thromboembolism (VTE) beyond what can be explained by the independent effects of BC and comorbidity. DESIGN Population-based matched cohort study. SETTING Denmark. PARTICIPANTS Danish patients with BC (n=62 376) diagnosed in 1995-2010 and a comparison cohort of women without BC (n=304 803) from the general population were matched to the patients with BC on year of birth in 5-year intervals and on the specific diseases included in the Charlson Comorbidity Index (CCI) and atrial fibrillation and obesity. MEASURES The rate ratios of VTE per 1000 person-years (PY) were computed by comorbidity levels using the CCI, and interaction contrasts (IC) were calculated as a measure of the excess or deficit VTE rate not explained by the independent effects of BC and comorbidity. RESULTS Among patients with BC with a CCI score of 1, the 0-1 year VTE rate was 12/1000 PY, and interaction accounted for 10% of the rate (IC=3.2, 95% CI 0.5 to 5.9). Among patients with BC with CCI ≥4, the VTE rate was 17, and interaction accounted for 8% of the rate (IC=1.2, 95% CI -1.8 to 4.2). There was no interaction during 2-5 years of follow-up. CONCLUSIONS There was only little interaction between BC and the CCI score on the rate of VTE.
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Affiliation(s)
- Anne Gulbech Ording
- Department of Clinical Epidemiology, Aarhus University Hospital, Aarhus, Denmark
| | | | | | | | - Mogens Vyberg
- Institute of Pathology, Aalborg University Hospital, Aalborg, Denmark
| | - Henrik Toft Sørensen
- Department of Clinical Epidemiology, Aarhus University Hospital, Aarhus, Denmark
| | - Timothy L Lash
- Department of Clinical Epidemiology, Aarhus University Hospital, Aarhus, Denmark Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, Georgia, USA
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296
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Peeters PJHL, Bazelier MT, Uitdehaag BMJ, Leufkens HGM, De Bruin ML, de Vries F. The risk of venous thromboembolism in patients with multiple sclerosis: the Clinical Practice Research Datalink. J Thromb Haemost 2014; 12:444-51. [PMID: 24502649 DOI: 10.1111/jth.12523] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2013] [Accepted: 01/28/2014] [Indexed: 10/25/2022]
Abstract
BACKGROUND In patients with multiple sclerosis (MS), disability and autoinflammatory processes may result in an increased risk of venous thromboembolism (VTE) OBJECTIVE: To evaluate the risk of VTE associated with MS. METHODS We conducted an observational-cohort study within the Clinical Practice Research Datalink (1987-2009) linked to the National Registry of Hospitalizations (1997-2008). At the time of MS diagnosis, a comparison cohort (N = 33 370) without a recorded MS diagnosis during the study period was matched (6:1) to the MS cohort (n = 5566) by birth year, sex, and practice. Subjects were followed from the index date until the occurrence of VTE, end of data collection, migration, or death, whichever came first. Cox proportional-hazards models were used to derive adjusted hazard ratios and 95% confidence intervals for VTE associated with MS and VTE risk factors within the MS cohort. Time-dependent adjustments were made for age, comorbidity, and medication use. RESULTS Compared with the comparison cohort, a 2.6-fold increased risk of VTE was observed for MS patients (adjusted hazard ratio 2.56, 95% confidence interval 2.06-3.20). A prior VTE event, varicose veins, obesity, and major trauma were found to be associated with an increased risk of VTE within the MS population. Moreover, the risk of VTE was increased in MS patients with recent records indicating immobility, spasticity, glucocorticoid use, or disability. CONCLUSIONS Patients with MS had an increased risk of VTE. Furthermore, our results provide evidence that this association is, at least in part, mediated through an increased prevalence of VTE risk factors in MS patients.
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Affiliation(s)
- P J H L Peeters
- Utrecht Institute of Pharmaceutical Sciences, Utrecht University, Utrecht, The Netherlands
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Go AS, Mozaffarian D, Roger VL, Benjamin EJ, Berry JD, Blaha MJ, Dai S, Ford ES, Fox CS, Franco S, Fullerton HJ, Gillespie C, Hailpern SM, Heit JA, Howard VJ, Huffman MD, Judd SE, Kissela BM, Kittner SJ, Lackland DT, Lichtman JH, Lisabeth LD, Mackey RH, Magid DJ, Marcus GM, Marelli A, Matchar DB, McGuire DK, Mohler ER, Moy CS, Mussolino ME, Neumar RW, Nichol G, Pandey DK, Paynter NP, Reeves MJ, Sorlie PD, Stein J, Towfighi A, Turan TN, Virani SS, Wong ND, Woo D, Turner MB. Heart disease and stroke statistics--2014 update: a report from the American Heart Association. Circulation 2014; 129:e28-e292. [PMID: 24352519 PMCID: PMC5408159 DOI: 10.1161/01.cir.0000441139.02102.80] [Citation(s) in RCA: 3516] [Impact Index Per Article: 351.6] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
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299
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Owczarek D, Cibor D, Głowacki MK, Rodacki T, Mach T. Inflammatory bowel disease: epidemiology, pathology and risk factors for hypercoagulability. World J Gastroenterol 2014; 20:53-63. [PMID: 24415858 PMCID: PMC3886032 DOI: 10.3748/wjg.v20.i1.53] [Citation(s) in RCA: 58] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/03/2013] [Revised: 11/19/2013] [Accepted: 12/05/2013] [Indexed: 02/06/2023] Open
Abstract
Hypercoagulability observed in patients with inflammatory bowel diseases (IBD) may lead to thromboembolic events (TE), which affect the venous and arterial systems alike and are an important factor in patients' morbidity and mortality. The risk of TE in IBD patients has been demonstrated to be approximately three-fold higher as compared to the general population. The pathogenesis of thrombosis in IBD patients is multifactorial and not fully explained. The most commonly listed factors include genetic and immune abnormalities, disequilibrium between procoagulant and anticoagulant factors, although recently, the role of endothelial damage as an IBD-triggering factor is underlined. Several studies report that the levels of some coagulation enzymes, including fibrinogen, factors V, VII, VIII, active factor XI, tissue factor, prothrombin fragment 1 + 2 and the thrombin-antithrombin complex, are altered in IBD patients. It has been demonstrated that there is a significant decrease of tissue plasminogen activator level, a marked increase of plasminogen activator inhibitor type 1 and thrombin-activable fibrinolysis inhibitor, a significantly lower level of antithrombin III and tissue factor pathway inhibitor. IBD patients have been also observed to produce an increased amount of various anticoagulant antibodies. Hyperhomocysteinemia, which is a potential risk factor for TE was also observed in some IBD patients. Further studies are necessary to assess the role of coagulation abnormalities in IBD etiology and to determine indications for thromboprophylactic treatment in patients at high risk of developing TE.
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