A176 ASSOCIATIONS OF ANTIBIOTICS, HORMONAL THERAPIES, ORAL CONTRACEPTIVES, AND LONG-TERM NSAIDS WITH INFLAMMATORY BOWEL DISEASE: RESULTS FROM THE PROSPECTIVE URBAN RURAL EPIDEMIOLOGY (PURE) STUDY

Background

The pathogenesis of inflammatory bowel disease (IBD) which includes Crohn’s disease (CD) and ulcerative colitis (UC), is believed to involve activation of the intestinal immune system in response to the gut microbiome among genetically susceptible hosts. IBD has been historically regarded as a disease of developed nations, though in the past two decades there has been a reported shift in the epidemiological pattern of disease. High-income nations with known high prevalence of disease are seeing a stabilization of incident cases, while a rapid rise of incident IBD is being observed in developing nations. This suggests that environmental exposures may play a role in mediating the risk of developing IBD. The potential environmental determinants of IBD across various regions is vast, though medications have been increasingly recognized as one broad category of risk factors.

Purpose

Several medications have been considered to contribute to the etiology of IBD. This study assessed the association between medication use and risk of developing IBD using the Prospective Urban Rural Epidemiology (PURE) cohort.

Method

This was a prospective cohort study of 133,137 individuals between the ages of 20-80 from 24 countries. Country-specific validated questionnaires documented baseline and follow-up medication use. Participants were followed prospectively at least every 3 years. The main outcome was development of IBD, including CD and UC. Short-term (baseline but not follow-up use) and long-term use (baseline and subsequent follow-up use) was evaluated. Results are presented as adjusted odds ratios (aOR) with 95% confidence intervals (CI).

Result(s)

During the median follow-up of 11.0 years [interquartile range (IQR) 9.2-12.2], we recorded 571 incident cases of IBD (143 CD and 428 UC). Higher risk of incident IBD was associated with baseline antibiotic use [aOR: 2.81 (95% CI: 1.67-4.73), p=0.0001] and hormonal medication use [aOR: 4.43 (95% CI: 1.78-11.01), p=0.001]. Among females, previous or current oral contraceptive use was also associated with IBD development [aOR: 2.17 (95% CI: 1.70-2.77), p=5.02E-10]. NSAID users were also observed to have increased risk of IBD [aOR: 1.80 (95% CI: 1.23-2.64), p=0.002], which was driven by long-term users [aOR: 5.58 (95% CI: 2.26-13.80), p<0.001]. All significant results were consistent in direction for CD and UC with low heterogeneity.

Conclusion(s)

Antibiotics, hormonal medications, oral contraceptives, and long-term NSAID use were associated with increased odds of incident IBD after adjustment for covariates.

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Salim Yusuf is supported by the Heart & Stroke Foundation/Marion W. Burke Chair in Cardiovascular Disease. The PURE Study is an investigator-initiated study funded by the Population Health Research Institute, the Canadian Institutes of Health Research (CIHR), Heart and Stroke Foundation of Ontario, support from CIHR’s Strategy for Patient Oriented Research (SPOR) through the Ontario SPOR Support Unit, as well as the Ontario Ministry of Health and Long-Term Care and through unrestricted grants from several pharmaceutical companies, with major contributions from AstraZeneca (Canada), Sanofi-Aventis (France and Canada), Boehringer Ingelheim (Germany and Canada), Servier, and GlaxoSmithkline, and additional contributions from Novartis and King Pharma and from various national or local organisations in participating countries; these include: Argentina: Fundacion ECLA; Bangladesh: Independent University, Bangladesh and Mitra and Associates; Brazil: Unilever Health Institute, Brazil; Canada: Public Health Agency of Canada and Champlain Cardiovascular Disease Prevention Network; Chile: Universidad de la Frontera; China: National Center for Cardiovascular Diseases; Colombia: Colciencias, grant number 6566-04-18062; India: Indian Council of Medical Research; Malaysia: Ministry of Science, Technology and Innovation of Malaysia, grant numbers 100 -IRDC/BIOTEK 16/6/21 (13/2007) and 07-05-IFN-BPH 010, Ministry of Higher Education of Malaysia grant number 600 -RMI/LRGS/5/3 (2/2011), Universiti Teknologi MARA, Universiti Kebangsaan Malaysia (UKM-Hejim-Komuniti-15-2010); occupied Palestinian territory: the UN Relief and Works Agency for Palestine Refugees in the Near East, occupied Palestinian territory; International Development Research Centre, Canada; Philippines: Philippine Council for Health Research & Development; Poland: Polish Ministry of Science and Higher Education grant number 290/W-PURE/2008/0, Wroclaw Medical University; Saudi Arabia: the Deanship of Scientific Research at King Saud University, Riyadh, Saudi Arabia (research group number RG -1436-013); South Africa: the North-West University, SANPAD (SA and Netherlands Programme for Alternative Development), National Research Foundation, Medical Research Council of SA, The SA Sugar Association (SASA), Faculty of Community and Health Sciences (UWC); Sweden: grants from the Swedish state under the Agreement concerning research and education of doctors; the Swedish Heart and Lung Foundation; the Swedish Research Council; the Swedish Council for Health, Working Life and Welfare, King Gustaf V’s and Queen Victoria Freemasons Foundation, AFA Insurance, Swedish Council for Working Life and Social Research, Swedish Research Council for Environment, Agricultural Sciences and Spatial Planning, grant from the Swedish State under the Läkar Utbildnings Avtalet agreement, and grant from the Västra Götaland Region; Turkey: Metabolic Syndrome Society, AstraZeneca, Turkey, Sanofi Aventis, Turkey; United Arab Emirates (UAE): Sheikh Hamdan Bin Rashid Al Maktoum Award For Medical Sciences and Dubai Health Authority, Dubai UAE.

Disclosure of Interest

C. Pray: None Declared, N. Narula Grant / Research support from: Neeraj Narula holds a McMaster University Department of Medicine Internal Career Award. Neeraj Narula has received honoraria from Janssen, Abbvie, Takeda, Pfizer, Merck, and Ferring, E. C. Wong: None Declared, J. K. Marshall Grant / Research support from: John K. Marshall has received honoraria from Janssen, AbbVie, Allergan, Bristol-Meyer-Squibb, Ferring, Janssen, Lilly, Lupin, Merck, Pfizer, Pharmascience, Roche, Shire, Takeda and Teva., S. Rangarajan: None Declared, S. Islam: None Declared, A. Bahonar: None Declared, K. F. Alhabib: None Declared, A. Kontsevaya: None Declared, F. Ariffin: None Declared, H. U. Co: None Declared, W. Al Sharief: None Declared, A. Szuba: None Declared, A. Wielgosz: None Declared, M. L. Diaz: None Declared, R. Yusuf: None Declared, L. Kruger: None Declared, B. Soman: None Declared, Y. Li: None Declared, C. Wang: None Declared, L. Yin: None Declared, M. Erkin: None Declared, F. Lanas: None Declared, K. Davletov: None Declared, A. Rosengren: None Declared, P. Lopez-Jaramillo: None Declared, R. Khatib: None Declared, A. Oguz: None Declared, R. Iqbal: None Declared, K. Yeates: None Declared, Á. Avezum: None Declared, W. Reinisch Consultant of: Speaker for Abbott Laboratories, Abbvie, Aesca, Aptalis, Astellas, Centocor, Celltrion, Danone Austria, Elan, Falk Pharma GmbH, Ferring, Immundiagnostik, Mitsubishi Tanabe Pharma Corporation, MSD, Otsuka, PDL, Pharmacosmos, PLS Education, Schering-Plough, Shire, Takeda, Therakos, Vifor, Yakult, Consultant for Abbott Laboratories, Abbvie, Aesca, Algernon, Amgen, AM Pharma, AMT, AOP Orphan, Arena Pharmaceuticals, Astellas, Astra Zeneca, Avaxia, Roland Berger GmBH, Bioclinica, Biogen IDEC, Boehringer-Ingelheim, Bristol-Myers Squibb, Cellerix, Chemocentryx, Celgene, Centocor, Celltrion, Covance, Danone Austria, DSM, Elan, Eli Lilly, Ernest & Young, Falk Pharma GmbH, Ferring, Galapagos, Genentech, Gilead, Grünenthal, ICON, Index Pharma, Inova, Janssen, Johnson & Johnson, Kyowa Hakko Kirin Pharma, Lipid Therapeutics, LivaNova, Mallinckrodt, Medahead, MedImmune, Millenium, Mitsubishi Tanabe Pharma Corporation, MSD, Nash Pharmaceuticals, Nestle, Nippon Kayaku, Novartis, Ocera, Omass, Otsuka, Parexel, PDL, Periconsulting, Pharmacosmos, Philip Morris Institute, Pfizer, Procter & Gamble, Prometheus, Protagonist, Provention, Robarts Clinical Trial, Sandoz, Schering-Plough, Second Genome, Seres Therapeutics, Setpointmedical, Sigmoid, Sublimity, Takeda, Therakos, Theravance, Tigenix, UCB, Vifor, Zealand, Zyngenia, and 4SC, Advisory board member for Abbott Laboratories, Abbvie, Aesca, Amgen, AM Pharma, Astellas, Astra Zeneca, Avaxia, Biogen IDEC, Boehringer-Ingelheim, Bristol-Myers Squibb, Cellerix, Chemocentryx, Celgene, Centocor, Celltrion, Danone Austria, DSM, Elan, Ferring, Galapagos, Genentech, Grünenthal, Inova, Janssen, Johnson & Johnson, Kyowa Hakko Kirin Pharma, Lipid Therapeutics, MedImmune, Millenium, Mitsubishi Tanabe Pharma Corporation, MSD, Nestle, Novartis, Ocera, Otsuka, PDL, Pharmacosmos, Pfizer, Procter & Gamble, Prometheus, Sandoz, Schering-Plough, Second Genome, Setpointmedical, Takeda, Therakos, Tigenix, UCB, Zealand, Zyngenia, and 4SC, P. Moayyedi: None Declared, S. Yusuf: None Declared

The incidence of cancer in a population-based cohort of Canadian heart transplant recipients

To assess the long-term risk of developing cancer among heart transplant recipients compared to the Canadian general population, we carried out a retrospective cohort study of 1703 patients who received a heart transplant between 1981 and 1998, identified from the Canadian Organ Replacement Register database. Vital status and cancer incidence were determined through record linkage to the Canadian Mortality Database and Canadian Cancer Registry. Cancer incidence rates among heart transplant patients were compared to those of the general population. The observed number of incident cancers was 160 with 58.9 expected in the general population (SIR = 2.7, 95% CI = 2.3, 3.2). The highest ratios were for non-Hodgkin's lymphoma (NHL) (SIR = 22.7, 95% CI = 17.3, 29.3), oral cancer (SIR = 4.3, 95% CI = 2.1, 8.0) and lung cancer (SIR = 2.0, 95% CI = 1.2, 3.0). Compared to the general population, SIRs for NHL were particularly elevated in the first year posttransplant during more recent calendar periods, and among younger patients. Within the heart transplant cohort, overall cancer risks increased with age, and the 15-year cumulative incidence of all cancers was estimated to be 17%. There is an excess of incident cases of cancer among heart transplant recipients. The relative excesses are most marked for NHL, oral and lung cancer.

Strengthening information systems for heart health in Canada

Information plays a key role in monitoring, management, evaluation and policy development related to cardiovascular diseases. Canada currently lacks a comprehensive, integrated pan-Canadian system to address the growing burden of cardiovascular diseases, including reliable and timely data that can be used by policy-makers, health care providers, researchers and the public. Theme Working Group 1 (one of six Theme Working Groups) aimed to address different aspects of the Canadian Heart Health Strategy and Action Plan, with a focus on strengthening information systems. Members of the group, who are experts in the cardiovascular field and/or information systems, defined the scope of the issue, identified gaps and solutions, and discussed priorities. The process is described and suggestions for final recommendations are presented. These suggestions were made taking into consideration the needs of health care providers, patients and consumers, the needs for planning, innovation, evaluation and system improvement, and the needs for information on populations and environments. A sustained integrated system that meets cardiovascular information needs requires a major commitment of expertise, leadership and funding.

[Cyclophosphamide pulse therapy in patients with primary glomerulonephritis]

Cyclophosphamide is a cytostatic drug, widely used in therapy of secondary glomerulonephritis. Because pulse therapy bears less side effects than oral one we aimed to follow the cyclophosphamide effect on the course of patients with primary glomerulonephritis. We observed 20 pts (7 women and 13 men), mean age 33 +/- 10.0 yrs, age range 18-50 yrs with primary glomerulonephritis and proteinuria more than 3.5 g. 12 patients also had erythro-cyturia. In all pts kidney biopsy was performed, but in one woman the biopsy was not diagnostic. Renal biopsy revealed: FSG in 2 pts, membranous glomerulonephritis in 2 pts, in 9 pts mesangial proliferative changes and in 6--mesangiocapillary lesions. In 5 pts renal failure was observed. Cyclophosphamide was administered i.v. in the dose 0.75 g/m2 b.s., no more than 1.0 g per dose, in renal failure 0.5 g/m2. During the first six months patients received cyclophosphamide every month and then every three months. Before cyclophosphamide pulse therapy all patients were pretreated with steroids, 3 pulses of 1.0 g Methylprednisolone and then oral prednisone in the dose 20 mg/m2 body surface.

RESULTS

In 3 patients we obtained remission of proteinuria, in 11 patients decrease of proteinuria but 6 patients didn't answer to the introduced treatment. In whole group of examined patients we obtained the statistically significant decrease of proteinuria from 12.2 +/- 10.5 to 5.3 +/- 5.2 g (p < 0.05) after the treatment. The creatinine clearance did not change in the time of the treatment and any special complications during the treatment were observed. We suggest that cyclophosphamide pulse therapy could be an effective treatment in pts with primary glomerulonephritis. Our results showed that the answer of proposed treatment was independent of the type to the changes found in kidney biopsy.

Cardiovascular risk factors in supersonic pilots in Poland

Selected cardiovascular risk factors were examined in 272 active pilots of supersonic aircraft in Poland. Hypercholesterolemia was present in 72.4% and hypertriglyceridemia in 17.1% of the pilots. Decreased levels of HDL-cholesterol and increased levels of LDL-cholesterol were found in 86.9% and 69.9% of pilots, respectively. Slightly over half (52.2%) were found to be mildly overweight while 6.6% were obese. The prevalence of smoking was 25.4%. Risk factor modification included non-pharmacological treatment of hyperlipidemia supported by lipid-lowering drugs, depending on the serum lipid level. A significant improvement in lipid profiles was obtained with this strategy, at least over 3 to 6 mo of follow up. The challenge is to develop strategies that will result in maintained improvements.

High refractive errors and the accident/incident rate in Canadian medical category 1 pilots

BACKGROUND

Since 1982, the Canadian Civil Aviation Medicine Division has medically certified to Category 1 standard commercial and airline transport pilots whose visual correction was in excess of +/- 3.5 diopters (D).

METHOD

A review between the years 1982 and 1991 of the 253 pilots who had been medically certified, although they were outside the standard, was conducted. We determined if there was any difference in the accident/incident rate in this group as compared with the Canadian general aviation population standardized to a rate per 100,000 flying hours. The 253 pilots were divided into two groups with Group A having a refractive error outside the range +/- 5.7 D and Group B having a refractive error range of +/- 3.5 to +/- 5.6 D.

RESULTS

The Group A rate was within the expected range of accidents and incidents per 100,000 flying hours. The accident/incident rate in Group B was significantly lower than the expected average.

CONCLUSION

In conclusion, the Canadian Civil Aviation Medicine Division's policy on granting "flexibility" to applicants with moderate to high refractive errors has not affected adversely the accident or incident rate and therefore has not compromised aviation safety.

Angiotensin-converting enzyme inhibition in myocardial infarction--Part 1: Clinical data

There is an increasing body of clinical trial evidence to support the use of angiotensin-converting enzyme (ACE) inhibitors in the management of patients following myocardial infarction (MI). Enthusiasm for the use of ACE inhibitors in the acute phase of MI had previously been tempered by the adverse results of an early trial. However, exciting new information is available from several large, randomized studies that has not only quelled those initial concerns but also attests to the efficacy of using this class of medication in the first 24 h after an acute MI. A Canadian National Opinion Leader Symposium was held in November 1995 to review the results of the major ACE inhibitor clinical trials and to discuss key issues and controversies surrounding their use in acute MI. The focus of this paper, the first of two parts, is on the results of the major ACE inhibitor clinical trials.

Angiotensin-converting enzyme inhibition in myocardial infarction--Part 2: Clinical issues and controversies

Over the past 10 years, several clinical studies have concluded that, in patients already receiving conventional therapies, angiotensin-converting enzyme (ACE) inhibitors further reduce the risk of death following myocardial infarction (MI). Post-MI ACE inhibitors have proven to be effective as long term therapy in high risk patients as well as when used for much shorter periods in a broad patient population. However, while considerable mortality data have been collected, the effects of ACE inhibitors post-MI on other cardiovascular outcomes have not been as well documented. In addition, a number of issues regarding the most effective use of these agents remain unresolved. This paper, the second of two parts, focuses on the clinical issues and controversies surrounding the use of ACE inhibitors following acute MI. The effects of ACE inhibitors on the outcomes of sudden death, nonsudden death, recurrent angina, mitral regurgitation and left ventricular dysfunction are reviewed and potential mechanisms of action are proposed. In addition, ACE inhibitor therapy is discussed in terms of patient selection criteria, choice of agent, optimal dosing regimen, concomitant use of other therapies and relative costs of treatment. Finally, potential mechanisms of action of ACE inhibitors are proposed for each of the outcomes examined.

[Development of renal transplantation in the Gdansk center]

The kidney transplantation is one of the renal replacement therapy methods, which prolongs live of the patients with the end stage renal disease for many years. Moreover, this method is well known, safe and not so expensive as dialysotherapy. Our purpose was to present the 15-year activity of the transplantation center in Gdańsk. The first renal transplantation took place on the 31st of March 1980 and there have been 137 renal transplantations in Gdańsk until now. We can divide the time between the 31st of March 1980 and the end of 1994 into two periods: I from 31.03.80 to 31.12.89 and II from 1991 to 1994. During the first were 46, and during the second were 91 renal transplantations performed. It means that since the second half of 1991 the activity of the center in Gdańsk has increased. The graft function was noted in 29 patients (63%) during the first period and in 75 (82%) during the second. The acute graft failure was observed in the most of the cases mentioned above. The 5-year living of the transplanted patients and the dialysed patients is comparable and amounts to 90%. Infections were the main reason of death during the first period, and cardiovascular complications during the second. The 5-year graft's functioning is 60%. Nowadays the results of the kidney transplantation center in Gdańsk are good and comparable with the results of other centers in Poland and Europe. Our center, as similar ones in Poland is prepared to extend the kidney transplantation activity. So it is necessary to intensify an effort to gain more organs for transplantations.

[Development of dialysis therapy in Poland during the decade 1984-1993]

Data concerning status of dialysis therapy in Poland during decade 1984-1993 were analysed. It was found that: 1. number of dialysis units increased two times (54-105), 2. number of dialysis stations raised 2.5 times (294-812), 3. number of patients treated with maintenance dialysis was increased 3.5 times (962-3783). These data showed dynamic development of this method of renal replacement therapy in Poland. However, in Poland acceptance rate dto dialysis therapy is still not satisfactory (30-35%). The Programme of the Country Committee for the Promotion of Nephrology based on the central founding system for the renal replacement therapy provides that by the end of 1995 it will be possible to treat 50% of patients with chronic uraemia. Continuous development of different methods of renal replacement therapy (hemodialysis, continuous ambulatory peritoneal dialysis, renal transplantation) is necessary for achieving possibilities compared with developed countries.

Patterns of recurrence and survival in AMI patients in Canada

OBJECTIVE

To describe the patterns of recurrence and survival of patients following their first acute myocardial infarction (AMI).

DESIGN

A retrospective follow-up study based on the population of Nova Scotia and Saskatchewan from 1981-85.

SUBJECTS

The analyses were performed on patients aged 25 to 75 years (n = 2083) who had been admitted to hospital with their first AMI during 1981 from the provinces of Nova Scotia and Saskatchewan.

MAIN RESULTS

The rate of recurrence of AMI was 10% in men and 7% in women, regardless of age. Median time to recurrence was 13 to 15 months in men and seven months in women. After the first AMI, mortality rates were higher in women one week and one month after the initial infarction, reaching statistical significance (only in the 55- to 74-year-old age group)--P < 0.01 and P < 0.02, respectively. Five-year mortality rates were significantly higher in the older age groups (P < 0.01), but were similar in men and women.

CONCLUSIONS

Reinfarction occurs more quickly in women, who also appear to be at a higher risk of death during the first month, and especially during the first week, postinfarction.

[Clinical estimation of 1-alpha-hydroxycholecalciferol in treatment of patients with chronic renal failure]

31 adult patients (15 male and 16 female) with chronic renal failure were treated for 6 months with 1-alfa-hydroxycholecalciferol on a dose 0.25-2.0 micrograms/24 h. 15 patients with not very advanced renal failure (serum creatinine level 176.8-442 mumol/l) received conservative therapy (group I), 16 patients with serum creatinine value 884-1326 mumol/l were treated by intermittent hemodialysis (group II). The statistically significant decrease of serum alkaline phosphatase activity in group I and II (p < 0.01), the rise of serum calcium level in group I (p < 0.005) were determined. Half of the patients from both the groups stated the relief or disappearance of bone and joint pains and muscle weakness. Besides in group I significant decrease of creatinine clearance (p < 0.001) and increase of serum urea and creatinine value (p < 0.01) were noticed. On the basis of these results we can conclude that the treatment with 1-alfa-hydroxycholecalciferol, produced by "Polfa", ought to be introduced gradually with increasing doses and frequent monitoring of calcium-phosphate metabolism and renal function parameters.

Coronary artery bypass grafting in Canada: What is its rate of use? Which rate is right?

We reviewed recent reports from administrative databases and clinical registries addressing the utilization of coronary artery bypass grafting (CABG) in Canada. The Canadian CABG rate per 100,000 people increased from 31.1 to 43.2 between 1981-82 and 1986-87. Between 1981 and 1986 the rate in the United States increased from 69.9 to 95.3 per 100,000, consistently about two times the Canadian rate. Provincial data have shown particular growth in utilization among elderly people. However, in the United States the 1985 CABG rate was twice as high as the aggregated age-specific rates for Ontario and Manitoba among people 65 to 74 years of age and four times higher among those 75 years or more. Limited registry data suggest that the Canadian CABG case mix is similar to the case mix in major US centres and that, utilization growth notwithstanding, the procedure is largely applied to patients who should, in theory, benefit (i.e., those with severe angina, impaired left ventricular function and left main-stem or triple-vessel disease). However, chart audits and registry evaluations using explicit criteria are needed to compare the use of CABG in Canada and the United States. In addition, Canadian data show moderate regional and municipal variations, the 1986-87 rates per 100,000 population in major census metropolitan areas varying from 19.5 to 46.9. Areas with consistently low rates raise particular concerns about impaired access to CABG. Reasons for variations should therefore be a research priority.

[Bacterial colonization of patients treated with chronic hemodialysis]

The study was aimed at investigating the predispositions of the patients chronically treated with hemodialysis to nose and skin colonization with potentially pathogenic bacteria. The study involved 41 patients chronically hemodialysed and patients treated at the Department of Renal diseases or out-patient clinic (30 individuals). Smears from the nose and throat were taken from all patients and used for bacteriologic tests. In case of hemodialysed patients material for bacteriologic tests was additionally taken from the skin at the site of arterio-venous fistula and groin. It was found, that patients chronically treated with hemodialyses are more frequently colonized with enteric bacilli and coagulase-positive staphylococci that both hospitalized patients and those treated in out-patient clinic. No relationship between the presence of coagulase-positive staphylococci in the nose and throat and on the skin was seen despite such suggestions of other authors.

Medical education reduces inappropriate use of cimetidine in a teaching hospital

Before and after an education program to improve appropriate prescribing of cimetidine in an 810-bed teaching hospital, all new prescriptions written during a 4-week period were investigated, and information was obtained as to the indications for use, the dosage and concurrent drug therapy. The prescriptions were judged appropriate or inappropriate according to indications for cimetidine approved by the Department of National Health and Welfare's Health Protection Branch. After the program 63% of the prescriptions were deemed appropriate, compared with 40% before the program. The proportion of patients at risk of drug interactions, however, remained virtually unchanged. The results suggest that medical education can reduce the inappropriate use of cimetidine in teaching hospitals.