Epidemiology and impact of frailty in patients with atrial fibrillation in Europe

BACKGROUND

Frailty is a medical syndrome characterised by reduced physiological reserve and increased vulnerability to stressors. Data regarding the relationship between frailty and atrial fibrillation (AF) are still inconsistent.

OBJECTIVES

We aim to perform a comprehensive evaluation of frailty in a large European cohort of AF patients.

METHODS

A 40-item frailty index (FI) was built according to the accumulation of deficits model in the AF patients enrolled in the ESC-EHRA EORP-AF General Long-Term Registry. Association of baseline characteristics, clinical management, quality of life, healthcare resources use and risk of outcomes with frailty was examined.

RESULTS

Among 10,177 patients [mean age (standard deviation) 69.0 (11.4) years, 4,103 (40.3%) females], 6,066 (59.6%) were pre-frail and 2,172 (21.3%) were frail, whereas only 1,939 (19.1%) were considered robust. Baseline thromboembolic and bleeding risks were independently associated with increasing FI. Frail patients with AF were less likely to be treated with oral anticoagulants (OACs) (odds ratio 0.70, 95% confidence interval 0.55-0.89), especially with non-vitamin K antagonist OACs and managed with a rhythm control strategy, compared with robust patients. Increasing frailty was associated with a higher risk for all outcomes examined, with a non-linear exponential relationship. The use of OAC was associated with a lower risk of outcomes, except in patients with very/extremely high frailty.

CONCLUSIONS

In this large cohort of AF patients, there was a high burden of frailty, influencing clinical management and risk of adverse outcomes. The clinical benefit of OAC is maintained in patients with high frailty, but not in very high/extremely frail ones.

Assessing the efficacy of long-term administration of Tolfenamic acid in dogs undergoing femoral head and neck excision

Femoral head and neck excision (FHNE) is a salvage procedure routinely performed when severe osteoarthritis is present and clinical signs cannot be managed by conservative treatment, or when total hip replacement is cost prohibitive for the owners. The purpose of the study reported herein was to evaluate the adverse effects and efficacy of long-term administration of Tolfenamic acid in dogs undergoing FHNE. Twenty dogs admitted with clinical signs associated with bilateral hip degenerative joint disease and weighing more than 20 kg were included in the study. Ten dogs received Tolfenamic acid for four months following FHNE and 10 dogs received a placebo. At four months after surgery, the placebo group had a significant decrease, compared with pre-operative values, in peak vertical force (PVF) (60.38% BW vs 64.77% BW, p = 0.046), and a significant decrease in vertical impulse (VI) (8.38% BW x sec. vs 9.64% BW x sec., p = 0.023). There was not any significant difference between pre- and post-operative results in the Tolfenamic acid group regarding PVF (65.13% BW vs 63.31% BW, p = 0.296) and VI (8.24% BW x sec. vs 8.71% BW x sec., p = 0.945). A significant difference was not found between the two groups with regard to endoscopic evaluation of mucosal lesions. Subjectively, the owners of the dogs in the Tolfenamic acid group reported an earlier use of the limb, a more compliant dog during physical therapy and a more rapid return to a ‘normal’ gait. Long-term administration of Tolfenamic acid may therefore be recommended, following FHNE, to improve the results of the operation.

Long-term Results of Conservative Treatment, Excision Arthroplasty and Triple Pelvic Osteotomy for the Treatment of Hip Dysplasia in the Immature Dog

The efficiency of conservative treatment, excision arthroplasty of the femoral head and neck and triple pelvic osteotomy for the treatment of hip dysplasia in the immature dog were compared using locomotor, physical and radiographic examinations and owner’s evaluation. Cases selected for this study were dogs diagnosed with bilateral hip dysplasia, initially admitted with clinical signs (lameness, pain), immature at the beginning of the treatment (less than 12 months of age), with both hips subjected to the same treatment (conservative treatment, excision arthroplasty of the femoral head and neck or triple pelvic osteotomy). These dogs never showed any musculoskeletal problems other than hip dysplasia and the surgical treatment had been completed at least 20 months prior to re-evaluation time. Fourteen hips were re-evaluated in the conservative group, 16 in the triple pelvic osteotomy group and ten in the excision arthroplasty group. Locomotor, physical and owner’s evaluations demonstrated the superiority of the triple pelvic osteotomy. These evaluations also showed that excision arthroplasty was more efficient than conservative treatment. Radiographic examination demonstrated the obvious superiority of the triple pelvic osteotomy over conservative treatment.

Locomotor, physical and owner’s evaluations demonstrated the superiority of the triple pelvic osteotomy over conservative treatment and excision arthroplasty for the treatment of hip dysplasia in the immature dog. Radiographic examination demonstrated the obvious superiority of the triple pelvic osteotomy over conservative treatment for joint congruence and control of degenerative joint disease.

Long-term Results of Conservative Treatment, Excision Arthroplasty and Triple Pelvic Osteotomy for the Treatment of Hip Dysplasia in the Immature Dog

The long-term efficiency of conservative treatment, excision arthroplasty of the femoral head and neck and triple pelvic osteotomy for the treatment of hip dysplasia in the immature dog were compared using ground reaction forces analysis at the trot. Fourteen hips were re-evaluated for the conservative treatment group, 16 for the triple pelvic osteotomy group and ten for the excision arthroplasty group. Force plate analysis demonstrated that hind limbs belonging to the triple pelvic osteotomy group had, at the trot, a locomotor function similar to the one of normal hind limbs in the control group. At a “similar age”, hind limbs of the conservative group did not show any marked difference from those in the triple pelvic osteotomy and control groups. The dogs of the excision arthroplasty group showed ground reaction forces abnormalities, most probably due to the absence of a coxofemoral joint (decreased peak propulsive force and Fz impulse, compared to triple pelvic osteotomy and control groups). The forelimbs of conservative treatment, excision arthroplasty and triple pelvic osteotomy groups showed a peak propulsive force superior to the one in the control group. This could be an adaptation phenomenon in order to compensate a deficient function of the hind limbs or a habit acquired at a younger age.

Force plate analysis has demonstrated that hind limbs treated bilaterally with triple pelvic osteotomy had, at the trot, a locomotor function similar to the one of normal hind limbs from a control group. At a mean age of 4.5 ± 1 years, dogs treated conservatively did not show, at the trot, any marked difference with those treated with triple pelvic osteotomy and with normal dogs. Hind limbs treated with excision arthroplasty showed certain abnormalities most probably due to the absence of a coxofemoral joint such as a significant decrease of peak propulsive force and Fz impulse.

Palpation and dorsal acetabular rim radiographic view for early detection of canine hip dysplasia

The objectives of this study were to standardize a palpation technique and to determine within and between examiners, the repeatability in interpreting the angle of reduction, subluxation and the acetabular slope measurements. Also it was desired to ascertain the effect of pelvis positioning on the acetabular slope measurement on sixmonth- old dogs. On palpation examination fifty-three (53) dogs had their angles of reduction and subluxation measured. A radiographic examination including a standard hip-extended view, a compression and a distraction view and a dorsal acetabular rim view were performed on each dog.

The within examiner repeatability was excellent for both the angle of reduction and subluxation (r = 0.975, p = 0.82 and r = 0.977, p = 0.81 respectively). The between examiners repeatability was good for the angle of reduction (r = 0.843, p = 0.51) but only a fair correlation was found for the angle of subluxation (r = 0.652, p = 0.83). For the acetabular slope measurement, an excellent within examiner correlation was observed (r = 0.940, p = 0.52). However, though a good correlation was found between examiners, a significant difference was found in the measurements of the three examiners (r = 0.780, p < 0.0001). The under- or overrotation position slightly changed the slope measurement but a fair correlation was still observed with the perfect position (r = 0.769, p = 0.074 and r = 0.684, p = 0.061 respectively). If the pelvis is turned to one side, a correlation was not found (r = 0.090, p = 0.847). The high repeatability of the angle of reduction measurement in six-month-old dogs suggests that it may be used by multiple examiners, with the expectation of comparable and consistent results. The modified method of the acetabular slope measurement improved the correlation, but a significant difference was still observed between examiners.

Early detection in life of canine hip dysplasia is important. The angle of reduction and the acetabular slope have been evaluated as diagnostic tools. With regard to its repeatability between examiners, the use of the angle of reduction by multiple examiners will be acceptable. The correlation between examiners in the acetabular slope measurement was good but a significant difference was present. Part two is now being analyzed.

Biomechanical Properties of the Stifle Joint Lateral Collateral Ligament in Dogs

Bone/lateral collateral ligament/bone preparations were tested and structural mechanical properties compared to properties of cranial cruciate ligament in 15 dogs. The lateral collateral ligament has sufficient stiffness to provide stifle joint stability and strength to resist acute overload following fibular head transposition.

Clinical characteristics and prognostic factors of plasmablastic lymphoma patients: analysis of 135 patients from the LYSA group

Background

Plasmablastic lymphoma (PBL), initially described in 1997 in the oral cavity of HIV positive patients, is now recognized as a distinct aggressive and rare entity of diffuse large B-cells lymphoma by the World Health Organization (WHO) classification. Since the original description, others cases have been reported. However, these are largely derived from case reports or small series limiting any definitive conclusions on clinical characteristics and outcome.

Patients and methods

The clinical, biological, pathological features and outcome of a cohort including 135 patients with PBL, from LYSA centers in France and Belgium, were reported and analyzed.

Results

The median age was 58 years, with a male predominance. The cohort was divided into 56 HIV-positive patients, 17 post-transplant patients and 62 HIV-negative/non-transplanted patients. Within HIV-negative/non-transplanted, a relative immunosuppression was found in most cases (systemic inflammatory disease, history of cancer, increased age associated with weakened immune system). We have also described a new subtype, PBL arising in a chronic localized inflammatory site, without any sign of immunosuppression. At presentation, 19% of patients showed oral involvement. Immunophenotype showed CD138 positivity in 88% of cases and CD20 negativity in 90% of cases. Chemotherapy was administered to 80% of patients, with a complete response (CR) rate of 55%. The median overall survival (OS) was 32 months. In univariate analysis, HIV positive status showed better OS when compared with HIV negative status. In multivariate analysis, International Prognostic Index score, chemotherapy and CR were associated with survival benefit.

Conclusion(s)

This cohort, the largest reported to date, increases the spectrum of knowledge on PBL, rarely described. However, specific guidelines to clarify treatment are lacking, and may improve the poor prognosis of this rare disease.

Association of 25-Hydroxyvitamin D status and genetic variation in the vitamin D metabolic pathway with FEV1 in the Framingham Heart Study

BACKGROUND

Vitamin D is associated with lung function in cross-sectional studies, and vitamin D inadequacy is hypothesized to play a role in the pathogenesis of chronic obstructive pulmonary disease. Further data are needed to clarify the relation between vitamin D status, genetic variation in vitamin D metabolic genes, and cross-sectional and longitudinal changes in lung function in healthy adults.

METHODS

We estimated the association between serum 25-hydroxyvitamin D [25(OH)D] and cross-sectional forced expiratory volume in the first second (FEV1) in Framingham Heart Study (FHS) Offspring and Third Generation participants and the association between serum 25(OH)D and longitudinal change in FEV1 in Third Generation participants using linear mixed-effects models. Using a gene-based approach, we investigated the association between 241 SNPs in 6 select vitamin D metabolic genes in relation to longitudinal change in FEV1 in Offspring participants and pursued replication of these findings in a meta-analyzed set of 4 independent cohorts.

RESULTS

We found a positive cross-sectional association between 25(OH)D and FEV1 in FHS Offspring and Third Generation participants (P=0.004). There was little or no association between 25(OH)D and longitudinal change in FEV1 in Third Generation participants (P=0.97). In Offspring participants, the CYP2R1 gene, hypothesized to influence usual serum 25(OH)D status, was associated with longitudinal change in FEV1 (gene-based P<0.05). The most significantly associated SNP from CYP2R1 had a consistent direction of association with FEV1 in the meta-analyzed set of replication cohorts, but the association did not reach statistical significance thresholds (P=0.09).

CONCLUSIONS

Serum 25(OH)D status was associated with cross-sectional FEV1, but not longitudinal change in FEV1. The inconsistent associations may be driven by differences in the groups studied. CYP2R1 demonstrated a gene-based association with longitudinal change in FEV1 and is a promising candidate gene for further studies.

[A comparison of pulmonary rehabilitation delivered in the home or at a centre for patients with COPD]

AIM

There are few data showing how pulmonary rehabilitation (PR) for COPD patients carried out at home impacts on health-related quality of life (HRQL). The aim of this study was to determine if PR conducted at home improves quality of life.

METHODS

We compared the results of home-based PR versus PR performed in an outpatient center. The outcomes were the HRQL measured by the Saint-George's Hospital questionnaire and the 6-minute walk test distance (6MWT). Fifty-six COPD patients were included for PR either at home (n=27) or in the outpatient center (n=29) depending on distance from the center and patients preference. The two groups were similar for sex, age, BMI, lung function, and initial peak oxygen uptake.

RESULTS

6MWT showed a similar non-significant improvement in both groups after PR (+12±46m in home-based PR,+13±34m in outpatient center). HRQL was significantly improved in the home-based group in 2 domains : "Activity" (-8.6±6.4 vs -0.7±17.7, P<0.05), "Impact" (-8.4±6.5 vs 1.6±11.7, P<0.001) and total score (-8.2±4.0 vs 0.0±8.8, P<0.001).

CONCLUSION

Pulmonary rehabilitation at home is associated with improvements in health-related quality of life, and thus can be considered where availability of treatment in specialized centers is limited.

Rituximab, alkylating agents or combination therapy for gastric mucosa-associated lymphoid tissue lymphoma: a monocentric non-randomised observational study

BACKGROUND

There is no consensus on the standard treatment of gastric mucosa-associated lymphoid tissue (MALT) lymphoma for Helicobacter pylori-negative patients and for patients with persistent disease despite H. pylori eradication.

AIM

To evaluate the comparative efficacy and safety of alkylating agents and rituximab alone or in combination.

METHODS

In this monocentric retrospective study, which included 106 patients who had not been previously treated with anti-cancer agents, we evaluated the efficacy and safety of oral alkylating agents monotherapy (n = 48), rituximab monotherapy (n = 28) and the therapy combining both drugs (n = 30). Evaluations were performed at weeks 6 (W6), 25 (W25), and 52 (W52) and after 2 years (W104).

RESULTS

After a median follow-up period of 4.9 years (range 0.4-17.2 years), complete remission and overall response were significantly higher in patients in the combination therapy group at W104 (92% and 100% respectively) compared with patients treated with alkylating agents alone (66% and 68%) and rituximab alone (64% and 73%). The 5-year progression-free survival probabilities were 68%, 70% and 89% in patients treated with alkylating agents alone, rituximab alone and combination therapy respectively. Haematological adverse events were reported in 32 (30%) patients (mostly grade 1) and were more frequent in the two groups receiving alkylating agents (P = 0.05 and P < 0.001). No toxicity-related death was reported.

CONCLUSIONS

The use of anti-cancer systemic therapy is safe and efficient in gastric MALT lymphoma. In this retrospective study, the combination of rituximab plus chlorambucil seems more efficient than rituximab or alkylating agents alone. Rituximab has a better safety profile than regimens containing alkylating agents.

Discovery of new antagonists aimed at discriminating UII and URP-mediated biological activities: insight into UII and URP receptor activation

BACKGROUND AND PURPOSE

Recent evidence suggested that urotensin II (UII) and its paralog peptide UII-related peptide (URP) might exert common but also divergent physiological actions. Unfortunately, none of the existing antagonists were designed to discriminate specific UII- or URP-associated actions, and our understanding, on how these two endogenous peptides can trigger different, but also common responses, is limited.

EXPERIMENTAL APPROACH

Ex vivo rat and monkey aortic ring contraction as well as dissociation kinetics studies using transfected CHO cells expressing the human urotensin (UT) receptors were used in this study.

KEY RESULTS

Ex vivo rat and monkey aortic ring contraction studies revealed the propensity of [Pep(4)]URP to decrease the maximal response of human UII (hUII) without any significant change in potency, whereas no effect was noticeable on the URP-induced vasoconstriction. Dissociation experiments demonstrated the ability of [Pep(4)]URP to increase the dissociation rate of hUII, but not URP. Surprisingly, URP, an equipotent UII paralog, was also able to accelerate the dissociation rate of membrane-bound (125)I-hUII, whereas hUII had no noticeable effect on URP dissociation kinetics. Further experiments suggested that an interaction between the glutamic residue at position 1 of hUII and the UT receptor seems to be critical to induce conformational changes associated with agonistic activation. Finally, we demonstrated that the N-terminal domain of the rat UII isoform was able to act as a specific antagonist of the URP-associated actions.

CONCLUSION

Such compounds, that is [Pep(4)]URP and rUII(1-7), should prove to be useful as new pharmacological tools to decipher the specific role of UII and URP in vitro but also in vivo.

[Leg ulcer associated with type I cryoglobulinaemia due to incipient B-cell lymphoma]

BACKGROUND

Skin lesions are frequent in monoclonal cryoglobulinaemia and may be the first sign of B-cell lymphoma, especially multiple myeloma, Waldenström's macroglobulinaemia and B-cell chronic lymphocytic leukaemia.

PATIENTS AND METHODS

A 74-year-old woman with no prior medical history presented with necrotic leg ulcer. Skin biopsy showed dermal angiomatosis with numerous PAS+ thromboses, associated with monoclonal intravascular deposits of IgM kappa, indicating monoclonal cryoglobulin, which was confirmed by laboratory tests. Subsequent blood immunophenotyping revealed an inconspicuous circulating monoclonal CD5(+) B-cell population and small B-cell clusters in the bone marrow, while the B-cell count was normal and no lymphadenopathy or splenomegaly were present. Overall, these findings indicated a small B-cell lymphoma, classed as non-MALT marginal zone lymphoma on the WHO classification, at a very early stage of development. The patient was first treated by cyclophosphamide and oral steroids without success. Subsequent administration of six cycles of rituximab, cyclophosphamide, vincristine and prednisone (RCVP) led to remission of her leg ulcer, cryoglobulinaemia and lymphoma.

CONCLUSION

Skin biopsies of necrotic ulcers should undergo routine screening for intravascular deposits of type 1 cryoglobulin. Leg ulcers due to monoclonal cryoglobulinaemia may reveal incipient marginal zone B-cell lymphoma at the stage of circulating monoclonal lymphocytosis.

Transferability and fine-mapping of glucose and insulin quantitative trait loci across populations: CARe, the Candidate Gene Association Resource

AIMS/HYPOTHESIS

Hyperglycaemia disproportionately affects African-Americans (AfAs). We tested the transferability of 18 single-nucleotide polymorphisms (SNPs) associated with glycaemic traits identified in European ancestry (EuA) populations in 5,984 non-diabetic AfAs.

METHODS

We meta-analysed SNP associations with fasting glucose (FG) or insulin (FI) in AfAs from five cohorts in the Candidate Gene Association Resource. We: (1) calculated allele frequency differences, variations in linkage disequilibrium (LD), fixation indices (F(st)s) and integrated haplotype scores (iHSs); (2) tested EuA SNPs in AfAs; and (3) interrogated within ± 250 kb around each EuA SNP in AfAs.

RESULTS

Allele frequency differences ranged from 0.6% to 54%. F(st) exceeded 0.15 at 6/16 loci, indicating modest population differentiation. All iHSs were <2, suggesting no recent positive selection. For 18 SNPs, all directions of effect were the same and 95% CIs of association overlapped when comparing EuA with AfA. For 17 of 18 loci, at least one SNP was nominally associated with FG in AfAs. Four loci were significantly associated with FG (GCK, p = 5.8 × 10(-8); MTNR1B, p = 8.5 × 10(-9); and FADS1, p = 2.2 × 10(-4)) or FI (GCKR, p = 5.9 × 10(-4)). At GCK and MTNR1B the EuA and AfA SNPs represented the same signal, while at FADS1, and GCKR, the EuA and best AfA SNPs were weakly correlated (r(2) <0.2), suggesting allelic heterogeneity for association with FG at these loci.

CONCLUSIONS/INTERPRETATION

Few glycaemic SNPs showed strict evidence of transferability from EuA to AfAs. Four loci were significantly associated in both AfAs and those with EuA after accounting for varying LD across ancestral groups, with new signals emerging to aid fine-mapping.

Clinical relevance of flow cytometric immunophenotyping of the cerebrospinal fluid in patients with diffuse large B-cell lymphoma

BACKGROUND

Central nervous system (CNS) relapse is an uncommon but dramatic complication of diffuse large B-cell lymphoma (DLBCL). Several studies have demonstrated the superiority of cerebrospinal fluid (CSF) flow cytometry (FCM), as compared with conventional cytology (CC), in detecting occult leptomeningeal disease. The clinical relevance of a positive FCM still has to be clarified.

PATIENTS AND METHODS

We analyzed CSF from 114 DLBCL patients at diagnosis (n = 95) or at relapse (n = 19) by FCM and CC. Most patients received meningeal prophylaxis. FCM results did not influence treatment strategies.

RESULTS

Fourteen samples were FCM+, versus one CC+ (also FCM+). Within all patients without neurological symptoms (n = 101), four (4%) relapsed in the CNS, with a median time to relapse of 5.2 months. Only one-fourth (25%) was FCM+ before relapse. More than one extranodal disease site and elevated lactate dehydrogenase levels were associated with an increased risk of CNS relapse.

CONCLUSIONS

FCM gives far more positive results than CC. However, a positive FCM result did not translate into a significant increase in CNS relapse rate in this histologically uniform population receiving CNS prophylaxis.