ID: 41: THROMBOTIC RAMIFICATIONS OF OPHTHALMOLOGIC DIAGNOSIS OF FAMILIAL AND ACQUIRED THROMBOPHILIA AS PATHOETIOLOGY FOR OTHERWISE UNEXPLAINED UVEITIS

Purpose

The diagnosis of uveitis prompts investigation into a long list of infectious, systemic autoimmune, and primary ocular conditions. Familial and acquired thrombophilia are rarely considered in the assessment of the pathoetiology of uveitis. We assessed three patients with uveitis who were referred to a thrombosis center by their retinologists-ophthalmologists after the search for an etiology among the common causes of uveitis did not yield a diagnosis, who were subsequently found to have familial thrombophilia and extra-ocular thrombotic events.

Methods

We prospectively measured familial and acquired thrombophilias in 3 patients, along with a thorough review of other known etiologies for uveitis.

Results

Of the three patients, one experienced 3 recurrent unexplained first trimester miscarriages and was found to have familial thrombophilia (high factor VIII, 158%, UNL 150%, and factor XI, 168%, UNL 150%) and familial hypofibrinolysis with 4G/4G homozygosity of the plasminogen activator inhibitor type 1 (PAI-1) gene. Enoxaparin, 40 mg twice/day was started at inception of her 4th pregnancy, which is now at 20 weeks gestation. The second patient developed deep venous thrombosis in both legs with pulmonary emboli, and 2 months later, was diagnosed with uveitis. She was found to have familial protein C deficiency (30%, laboratory lower normal limit 60%) and antiphospholipid syndrome. The third patient, whose son had an ischemic stroke at 1 month of age, was found to have thrombophilic compound heterozygous mutations in the methylenetetrahydrofolate reductase (MTHFR) gene as well as hypofibrinolytic 4G4G homozygosity in the PAI-1 gene.

Conclusion

When the usual pathoetiologies of uveitis are not found, ophthalmologists should screen for thrombophilia, often being the first to illuminate treatable etiologies for other thrombotic events. In our 3 patients, when the pathoetiology of uveitis could not be discerned, screening for familial and acquired thrombophilia had important therapeutic ramifications in the probands and their first degree relatives. .

ID: 19: ELIGIBILITY FOR PCSK9 TREATMENT IN 734 HYPERCHOLESTEROLEMIC PATIENTS REFERRED TO A REGIONAL CHOLESTEROL TREATMENT CENTER WITH LDL CHOLESTEROL ≥70 MG/DL DESPITE MAXIMAL TOLERATED CHOLESTEROL LOWERING THERAPY

Background

LDL cholesterol (LDLC) lowering has been revolutionized by PCSK9 inhibitors, Alirocumab (Praluent) and Evolocumab (Repatha), which have approved indications as an adjunct to diet-maximally tolerated cholesterol lowering therapy in heterozygous (HeFH) or homozygous (HoFH) familial hypercholesterolemia, and/or clinical atherosclerotic cardiovascular disease (CVD) where LDLC lowering is insufficient despite maximal tolerated therapy.

Methods

We applied FDA approved and commercial insurance eligibility criteria for PCSK9 inhibitor use in 734 patients serially referred over 3 years who then received ≥2 months maximally tolerated LDLC lowering diet-drug therapy with follow up LDLC ≥70 mg/dl, as well as in 37 patients approved by commercial insurance for PCSK9 inhibitors. We obtained estimates of the percentage of patients with HeFH and/or CVD who meet FDA and commercial insurance eligibility for PCSK9 inhibitors using LDLC goal-based guidelines.

Results

Of the 734 patients with LDLC ≥70 mg/dl after ≥2 months maximally tolerated LDLC lowering therapy, 220 (30%) had HeFH and/or CVD events with LDLC >100 mg/dl, meeting both FDA and commercial insurance criteria for PCSK9 inhibitor therapy. Sixty-six (9%) patients were statin intolerant, without HeFH or CVD events. Of the 37 patients whose PCSK9 inhibitor therapy was approved for coverage by medical insurance carriers, 34 (92%) had LDLC>100 mg/dl after ≥2 months on maximally tolerated LDLC lowering therapy. Sixteen (43%) of these 37 patients had HeFH without CVD (LDLC on maximally tolerated conventional treatment 181±48 mg/dl), 11 (30%) had CVD without HeFH (LDLC on maximally tolerated conventional treatment 122±22 mg/dl), and 8 (22%) had both HeFH and CVD (LDLC on maximally tolerated conventional treatment 204±56 mg/dl).

Conclusion

Of the 734 patients referred for high LDLC treatment, with LDLC ≥70 mg/dl after ≥2 months on maximally tolerated therapy, 220 (30%) had HeFH and/or CVD with LDLC >100 mg/dl, meeting both FDA and insurance criteria for PCSK9 inhibitor therapy. If 30% of patients with high LDLC and HeFH-CVD are eligible for PCSK9 inhibitors, then specialty pharmaceutical pricing models (∼$14,300/year) will collide with an estimated 16–21 million HeFH-CVD patients. Although the costs for PCSK9 inhibitors given to an estimated 16 to 21 million patients are extraordinary ($228–300 billion), we speculate that, when weighed against direct and indirect costs of CVD, on balance, the cost to society might be either none, or that society would, in fact, save money by an anticipated 50% reduction of CVD events with PCSK9 inhibitors. Whether the health care savings arising from the anticipated reduction of CVD on the PCSK9 inhibitors justify the broad population use of these agents remains to be determined.

ID: 20: HOSPITALIZATION FOR PULMONARY EMBOLISM ASSOCIATED WITH ANTECEDENT TESTOSTERONE OR ESTROGEN THERAPY IN PATIENTS FOUND TO HAVE FAMILIAL THROMBOPHILIA

Background

In patients hospitalized over a 4 year period for pulmonary embolism (PE), and subsequently found to have familial-acquired thrombophilia, we assessed relationships of thrombophilia with testosterone (TT) and estrogen therapy (ET) anteceding PE.

Methods

From 2011 through 2014, 347 patients were hospitalized in Cincinnati Mercy Hospitals with PE. Retrospective chart review was used to document TT or ET anteceding PE in patients subsequently found to have familial or acquired thrombophilia.

Results

Preceding hospitalization for PE, of the 154 men and 193 women, 8 men (5% of men) used TT, 24 women (12% of women) used ET (16 birth control pills, 6 hormone replacement therapy, 2 progesterone). Median age in the 8 men was 56 and for the 24 women 38. After excluding 45 women with cancer preceding PE, 24 of 148 (16%) women with PE had used ET, and after excluding 33 men with cancer, 8/121 men (7%) used TT. Of these 8 men, 6 used TT gels, 50 mg/day, and 2 had intra muscular TT 50 mg/week.

Of the 8 men, 5 (63%) smoked, 2 had a history of thrombotic events, and 2 had type 2 diabetes. The median number of months from the initiation of TT to development of PE was 7 months.

Coagulation evaluations were done in 6 of the 8 men. All 6 had ≥1 thrombophilia; 1 heterozygous for the G20210A prothrombin gene (PTG) mutation, 1 with high factor VIII, 3 with high homocysteine (1 of whom had MTHFR C677T homozygosity), 2 with low protein C, 2 with low protein S, and 2 with low free protein S. Two of 8 men had Klinefelter's syndrome.

Of the 24 women, 2 were diabetic, 1 had a history of thrombosis, and 7 (29%) smoked. The median time between initiation of ET and the PE was 18 months.

In 18 out of the 24 women, coagulation evaluations were performed. 15 had ≥1 thrombophilia; 4 were factor V Leiden heterozygotes, 1 PTG heterozygote, 2 high Factor VIII, 1 high Factor XI, 2 with the lupus anticoagulant, 3 low protein S, 2 low Free S, 3 low antithrombin III, 3 high anticardiolipin antibodies.

Conclusion

After excluding antecedent cancer, 24/148 women (16%) had ET before PE, and TT was taken by 8/121 (7%) men. PE is an important complication of TT in men and ET in women, in part reflecting an interaction between familial and acquired thrombophilia and exogenous hormone use.

ID: 86: SAFETY OF 50,000-100,000 UNITS OF VITAMIN D3 PER WEEK IN VITAMIN D DEFICIENT, HYPERCHOLESTEROLEMIC PATIENTS, WITH STATIN INTOLERANCE

Background

In ∼85–90% of statin intolerant patients, vitamin D deficiency (serum 25 (OH) D <32 ng/ml) is a reversible cause of statin intolerance, usually requiring 50,000 to 100,000 units of vitamin D/week continuously to normalize serum vitamin D, and thus successfully allow reinstitution of statins which previously could not be tolerated because of myalgia-myositis.

Specific Aim

In 274 statin intolerant patients, all with low entry serum vitamin D (<32 ng/ml, median 21 ng/ml), we assessed safety and efficacy of vitamin D supplementation (50,000–100,000 units/week) over treatment periods of 3 months (n=274), 3 and 6 months (n=161), 3, 6, and 9 months (n=58), and 3, 6, 9, and 12 months (n=22).

Results

In the 385 patients with 3 month follow-up, taking mean 61,000 and median 50,000 IU of vitamin D3/week, median serum vitamin D rose from 20 to 42 ng/ml (p<0.0001); vitamin D became high (>100 ng/ml) but not toxic-high (>150 ng/ml) in 4 patients (1.0%) (101, 102, 106, 138 ng/ml). Median serum calcium was unchanged from entry (9.6 mg/dl) to 9.6 at 3 months. On vitamin D supplementation, the trend of change in serum calcium from normal-to-high or from high-to-normal did not significantly differ (McNemar S=1.0, p=0.32), and there was no significant trend in change of the calculated glomerular filtration rate (eGFR) from entry to follow-up (McNemar S=2.6, p=0.11).

In the 161 patients with 3 and 6 month follow-up, taking mean 67,000 and median 50,000 IU of vitamin D3/week, median entry serum vitamin D rose from 21 to 42 to 44 ng/ml (p<0.0001), serum vitamin D was high (>100 but <150 ng/ml) in 2 patients at 3 months (1.2%, 101, 102 mg/ml) and in 3 (1.9%) at 6 months (101, 140, 140 ng/ml). Median serum calcium was unchanged from entry (9.7 mg/dl), at 3 and 6 months (9.7, 9.6 mg/dl, p>0.05). On vitamin D supplementation, the change in serum calcium from normal-to-high or high-to-normal was no significant trend (McNemar S=0.7, p=0.41), and no trend in change of eGFR (McNemar S=1.3, p=0.26).

In the 58 patients with 3, 6, and 9 month follow-up on mean and median 71,000 and 100,000 IU of D3/week, median entry vitamin D rose from 20 to 37, 41, and 44 ng/ml (p<0.0001), with 1 (1.7%, 102 ng/ml), 2 (3.5%, 140, 140 ng/ml), and 0 (0%) patients high. Median serum calcium was unchanged from entry, median 9.7, 9.8, 9.6, and 9.6 mg/dl. On vitamin D supplementation, the trend of change in serum calcium from normal-to-high or high-to-normal was not significant (McNemar S=1.8, p=0.18), and no trend in change of eGFR (McNemar S=2, p=0.16).

In the 22 patients with follow-up at 3, 6, 9, and 12 months on mean and median 70,000 and 75,000 IU of D3/week, median serum vitamin D rose from 20 to 37, to 41, to 44, and to 43 ng/ml (p<0.0001), with 1 (5%, 102 ng/ml) high, 2 (9%, 140, 140) high, 0 (0%) high, and 1 (5%, 126 ng/ml) high. Serum calcium was unchanged, median at entry 9.6, and then at 3, 6, 9, and 12 months 9.7, 9.7, 9.5, and 9.7 mg/ml. At entry serum calcium was normal in 21, none high, and one became high at 12 month follow-up. The trend of change in eGFR was insignificant, McNemar S=1.0, p=0.32.

When serum D rose above 100 ng/ml in the few cases, as above, it fell into the normal range within 2 weeks by reducing the vitamin D dose by 50%.

Conclusions

When 50,000–100,000 units of vitamin D/week are given to reverse statin intolerance in statin intolerant patients with low entry vitamin D (<32 ng/ml), it appears to be safe over up to 1 year follow-up, without toxic high serum vitamin D levels >150 ng/ml, and levels rarely >100 ng/ml, and without changes in serum calcium or eGFR.

ID: 47: TESTOSTERONE-HCG THERAPY ASSOCIATED WITH RECURRENT DEEP VENOUS THROMBOSIS-PULMONARY EMBOLISM DESPITE ANTICOAGULATION IN A 55 YEAR OLD MAN WITH THROMBOPHILIA

Background

When exogenous testosterone or treatments to elevate testosterone (human chorionic gonadotropin [HCG] or Clomid) are given to men with underlying familial and/or acquired thrombophilia, deep venous thrombosis and pulmonary embolism often occur, and may recur despite adequate anticoagulation if testosterone therapy is continued.

Case Presentation

In a 55 year old white male, referred to us because of 4 thrombotic events, 3 despite adequate anticoagulation over a 5 year period, we assessed interactions between thrombophilia, exogenous testosterone therapy, and recurrent thrombosis. In 2009, despite low-normal serum testosterone 334 ng/dl (lower normal limit [LNL] 300 ng/dl.), he was given testosterone (TT) cypionate (50 mg/week) and HCG (500 units/week) for presumed hypogonadism. Ten months later, with supranormal serum T (1385 ng/dl, UNL 827 ng/dl) and estradiol (E2) 45 pg/ml (UNL 41 pg/ml), he had a pulmonary embolus (PE), and was then anticoagulated for 2 years (enoxaparin, then Coumadin). Four years later, on TT-HCG, he had his first deep venous thrombosis (DVT). TT was stopped, HCG continued; he was anticoagulated (enoxaparin, then Coumadin, then apixaban (Eliquis), then fondaparinux (Arixtra)). One year after his first DVT, on HCG, still on Arixtra, he had a second DVT (5/2015), was anticoagulated (enoxaparin+Coumadin), with a Greenfield filter placed, but 8 days later had a second PE. The Lupus anticoagulant was found to be present. After stopping HCG, and maintained on Coumadin, he has been free of further DVT-PE for 6 months.

Conclusion

When DVT- PE occur on TT or HCG, in the presence of thrombophilia, TT- HCG should be stopped, lest DVT-PE reoccur despite concurrent anticoagulation.

ID: 40: OPHTHALMOLOGISTS SHOULD ASSESS FOR THROMBOPHILIA, A MAJOR CAUSE OF CENTRAL RETINAL ARTERY AND CENTRAL RETINAL VEIN OCCLUSION

Background

Thrombotic retinal vascular occlusive disease, central retinal vein occlusion (CRVO) and central retinal artery occlusion (CRAO), are well known causes of visual loss. They are often associated with familial thrombophilia, which may predispose to other thrombotic events.

Abstract ID: 40 Table 1

Coagulation disorders in 77 women with retinal thrombosis (16 CRAO, 61 CRVO).

 Factor V LeidenPTGMTHFRPAIGHomocys- teine1Factor VIIIFactor XIProtein CProtein SFree SAntithrombin IIIAbnormal rangeTC,TTTC, TTTT4G4Gumol/L>150%>150%<73%<63%<66%<8062 Normal female controlsAge 44±12, med=432/61(3%)2/62(3%)21/61(34%)13/56(23%)0/62(0%)6/57(11%)2/55(4%)2/53(4%)4/53(8%)2/53(4%)1/52(2%)16 CRAO womenAge 52±19, med=542/16(13%)0/16(0%)7/16(44%)3/13(23%)2/16(13%)*6/16(38%)†4/16(25%)†0/16(0%)1/15(7%)4/15(27%)†0/15(0%)61 CRVO womenAge 64±17, med=638/60(13%)6/57(11%)19/61(31%)19/58(33%)16/61(26%)§§24/56(43%)§12/54(22%)††2/57(4%)1/57(2%)4/51(8%)1/54(2%)All 77 Ocular thrombosisAge 61±18, med=6110/76(13%)6/73(8%)26/77(34%)22/71(31%)18/77(23%)§§30/72(42%)§§16/70(23%)††2/73(3%)2/72(3%)8/66(12%)1/69(2%)

1 dated cut point for Homocysteine high: ≥15 (11/15/08–12/2/14); ≥10.4 (after 2/3/14). *p<.05, †p<.025, ††p<.01, §p<.001, §§p<.0001, comparing with 62 normal female controls by Fisher's test.

Specific aim

We compared measures of thrombophilia in 77 women with retinal vascular occlusion, 16 with CRAO (mean±SD age 52±19) and 61 with CRVO (mean±SD age 64±17), compared to 62 healthy female controls (mean±SD age 44±12) without ocular thrombosis to better delineate the role of thrombophilia in retinal vascular occlusion.

Results

Of 11 measures of thrombophilia, the 77 women with retinal vascular occlusion were more likely to have ≥1 abnormal level (90%) when compared to 62 normal female controls (44%, p<0.0001). Among the 77 women with RVO, homocysteine was elevated in 23%, compared to 0% in 62 normal female controls (p<0.0001). Factor VIII was elevated in 42%, compared to 11% in normal female controls (p<0.0001). Factor XI was elevated in 23%, compared to 4% in normal female controls (p=0.0020). Further analysis based on diagnosis of CRAO or CRVO in 77 total women with retinal vascular occlusion revealed that homocysteine was elevated in 13% of women with CRAO and in 26% of women with CRVO compared to 0% of 62 healthy normal female controls (p=0.04, <0.0001). Factors VIII and XI were elevated in 16 women with CRAO (38%, 25% [p=0.019, 0.021]) and in 61 women with CRVO (43%, 22% [p=0.0001, 0.0041]) compared to normal female controls (11%, 4%). The 16 women with CRAO were significantly more likely than normal female controls (27% vs 4%, p=0.019) to have low free protein S (<66%).

Conclusion

By screening for thrombophilia in women with CRAO and CRVO who have early onset of disease, severe phenotypes, or lack typical risk factors of retinal vascular occlusion, ophthalmologists may assist in diagnosis of common familial thrombophilias. Appropriate diagnosis has relevance not only for retinal vascular occlusion, but also for obstetric and thrombotic outcomes in the probands and in their first-degree relatives.

ID: 39: RETINAL VASCULAR OCCLUSION: A WINDOW TO DIAGNOSIS OF FAMILIAL AND ACQUIRED THROMBOPHILIA AND HYPOFIBRINOLYSIS, WITH IMPORTANT RAMIFICATIONS FOR OCULAR AND NON-OCULAR THROMBOSIS

Purpose

Investigation for familial and acquired thrombophilia and hypofibrinolysis in 77 women with retinal vascular occlusion (either central retinal artery [CRAO] or central retinal vein occlusion [CRVO]), reinforced the importance of obtaining measures of thrombophilia and hypofibrinolysis in the evaluation of underlying causes of CRAO and CRVO, which pose risk for other thrombotic events, particularly obstetric complications.

Abstract ID: 39 Table 1

Coagulation disorders in 16 women with retinal vascular occlusion, compared with 62 normal healthy women.

 Factor V LeidenPTGMTHFRPAIGHomocys- teine1Factor VIIIFactor XIProtein CProtein SFree SAntithrombin IIIAbnormal rangeTC,TTTC,TTTT4G4Gumol/l>150%>150%<73%<63%<66%<8062 Normal controlsAge 44±12, med=432/61(3%)2/62(3%)21/61(34%)13/56(23%)0/62(0%)6/57(11%)2/55(4%)2/53(4%)4/53(8%)2/53(4%)1/52(2%)16 RVO casesAge 61±13, med=633/16(19%)2/15(13%)6/16(38%)5/15(33%)5/16(31%)§6/15(40%)†3/13(23%)*0/15(0%)1/15(7%)2/14(14%)0/15(0%)

1 dated cut point for Homocysteine high: ≥15 (11/15/08–12/2/14); ≥10.4 (after 2/3/14). * p<.05, †p<.025, §p<.001, comparing with 62 normal female controls by Fisher's test.

Methods

In 77 women with CRAO or CRVO referred by retinologists for hematologic evaluation, we performed a detailed evaluation of familial and acquired thrombophilia, with focus on thrombotic events, particularly pregnancy complications, including unexplained miscarriage, pre-eclampsia, eclampsia, and HELLP syndrome. We evaluated thrombophilia measurements in 16 (of the total 77) women with CRAO or CRVO who had 2 or more unexplained pregnancy losses compared to 62 healthy normal women without retinal vascular occlusion.

Results

Of the 77 women, 24 (39%) had at least 1 miscarriage, and 16 (26%) had 2 or more miscarriages, pre-eclampsia, or eclampsia. Of these 16 women, 8 had 2 miscarriages, 3 had 4 miscarriages, one woman had 6 miscarriages, and one woman had 8 miscarriages. Of the 16 women with retinal vascular occlusion and pregnancy complications, they were significantly more likely to have elevated Factor VIII (40% vs 11%, p=0.014), elevated Factor XI (23% vs 4%, p=0.045), elevated serum homocysteine (31% vs 0%, p=0.0002), compared with 62 healthy normal female controls without history of retinal vascular occlusion. These 16 women were marginally (p=0.058) more likely than the 62 normal controls to have Factor V Leiden heterozygosity (19% vs 3%).

Conclusion

Women of childbearing age who presented with retinal vascular occlusion (CRAO or CRVO) had elevated serum factors associated with thrombophilia, which may pose increased risk for deep vein thrombosis, pulmonary embolism, and obstetric complications. Retinologists are important gatekeepers in the diagnosis of heritable ocular thrombosis through the evaluation of early age of onset for retinal vascular occlusion.

ID: 15: ELIGIBILITY FOR PCSK9 THERAPY IN CHOLESTEROL CENTER PATIENTS WITH INITIAL LDL CHOLESTEROL ≥130 BUT <160 MG/DL

Background

By lowering LDL cholesterol (LDLC) ∼60% beyond statins, PCSK9s have the potential to profoundly improve primary and secondary prevention of atherosclerotic coronary artery (CAD), peripheral (PAD), and carotid artery disease.

Purpose

In 189 patients referred to a regional Cholesterol Center for diagnosis and treatment of hypercholesterolemia, who had initial LDL cholesterol (LDLC) ≥130 but <160 mg/dl, our specific aim was to determine how many would be eligible for PCSK9 therapy by extant preferred commercial insurance criteria.

Methods

Current preferred commercial insurance criterion for PCSK9 therapy consisted of ≥1 of the following 3 conditions:

Heterozygous familial hypercholesterolemia (previous LDLC >190 mg/dl and Tendon Xanthomas),

Atherosclerotic cerebral-cardio-peripheral vascular disease.

Failure to tolerate 2 or more statins.

Results

At entry, in the 189 patients, mean±SD and median LDLC were 144±9 mg/dl and 143 mg/dl respectively. Of the 189 patients (96 female and 93 male with median age 53) 16 (8%) were diagnosed as having heterozygous FH, with median LDLC of 139 mg/dl, and 32 (17%) had sustained a cerebral-cardio- peripheral vascular event with median LDLC on treatment of 146 mg/dl. Of the 189 patients, in 44 (23%) the maximum tolerated statin dose was zero (complete statin intolerant), with median LDLC of 145 mg/dl. Of the 44 statin intolerant patients, 18 (41%) had either HeFH or an atherosclerotic event, and 26 (59%) had neither positive. Altogether 73 of 189 (39% of patients with entry LDLC ≥130 but <160 were eligible for PCSK9 therapy from commercial carriers.

Conclusion

Of 189 patients referred to a regional Cholesterol diagnosis and treatment center with initial LDLC ≥130 but <160 mg/dl, 73 (39%) met current commercial insurance carrier preferred criteria for PCSK9 drug coverage.

Metformin-diet ameliorates coronary heart disease risk factors and facilitates resumption of regular menses in adolescents with polycystic ovary syndrome

BACKGROUND

In 35 adolescent females (17 +/- 2 years) with polycystic ovary syndrome (PCOS), median body mass index (BMI) 30.8 kg/m2, we assessed effeicacy of metformin-diet for 1 year for reduction of weight, insulin, HOMA insulin resistance (IR), cholesterol, triglycerides, and resumption of regular menses.

METHODS

Calories (26% protein, 44% carbohydrate) were targeted to 1,500-1,800/day if BMI was <25 or to 1,200-1,500/day if BMI was > or = 25, along with 2,550 mg metformin.

RESULTS

Median weight fell from 82.7 to 79.1 kg (p = 0.009), insulin 16.7 to 13.3 microU/ml (p <0.0001), HOMA IR 3.41 to 2.74 (p = 0.0004), total cholesterol 164 to 151 mg/dl (p = 0.002), and triglyceride 103 to 85 mg/dl (p = 0.006). The percentage of cycles with normal menses rose from a pre-treatment mean of 22% to 74%, p < 0.0001.

CONCLUSIONS

In adolescents with PCOS, metformin-diet reduces weight, insulin, IR, cholesterol, and triglycerides, and facilitates resumption of regular menses.

Amaurosis fugax: associations with heritable thrombophilia

The aim of this study was to prospectively assess associations between amaurosis fugax, inherited thrombophilia, and acquired thrombophilia. Thrombophilia and hypofibrinolysis were studied in 11 cases (eight women, three men; all white) with amaurosis fugax, 57 +/- 17 years old, selected by the absence of abnormal brain magnetic resonance imaging (MRI), magnetic resonance angiography (MRA), magnetic resonance venography (MRV), ipsilateral internal carotid artery plaque, atrial fibrillation, or cardiac thrombus. Cases were compared to 78 healthy adult white controls (53 +/- 18 years old) for serologic measures, and by polymerase chain reaction to 248 healthy white controls (78 adults, 170 children) for gene mutations. All 11 cases had one or more familial thrombophilic coagulation disorder including one heterozygous for the G1691A factor V Leiden mutation, two with low free protein S, four with high factor VIII, three with resistance to activated protein C, three homozygous for the C677T methylenetetrahydrofolate reductase (MTHFR) mutation, two compound C677T-A1298C MTHFR heterozygotes, and three with hypofibrinolytic 4G4G homozygosity for the PAI-1 gene. The case with factor VIII of 160% had two other thrombophilias (compound MTHFR C677T-A1298C heterozygosity, resistance to activated protein C), and hypofibrinolytic high Lp(a). Thrombophilic C677T MTHFR homozygosity or compound C677T-A1298C heterozygosity was present in five of 10 (50%) cases vs. 30 of 248 (12%) controls, Fisher's p (p(f)) = .005. Thrombophilic factor VIII was high in four of 10 (40%) cases vs. 0 of 38 controls, p(f) = .001. Thrombophilic hyperestrogenemia in five of the eight women (four exogenous estrogen, one pregnant) may have interacted with inherited thrombophilia-hypofibrinolysis, promoting thrombus formation. In cases selected by the absence of abnormal brain magnetic resonance imaging, significant ipsilateral internal carotid artery plaque, atrial fibrillation, or cardiac thrombus, we speculate that amaurosis fugax can be caused by reversible (by anticoagulation) retinal artery thrombi associated with heritable thrombophilia and/or hypofibrinolysis, often augmented by estrogen-driven acquired thrombophilia.

The Cincinnati lipid research clinic family study: Analysis of commingling and family resemblance for fasting blood glucose

Our specific aim in this study was to investigate commingling and family resemblance for fasting blood glucose in 160 randomly selected white families from the Princeton School District Lipid Research Clinics Family Study. Adjustment of fasting blood glucose for the influence of age, sex, and the use of oral contraceptives and construction of indices were performed simultaneously using multiple regression methods. Path analysis was carried out, constructing an environmental index based on special diet usage, hematocrit, and obesity, which was also adjusted for the influences of age and sex. Commingling analysis and segregation analysis using the mixed model were also performed. Nearly 16% of the variance of fasting blood glucose was accounted for by age and sex. Obesity itself, which constituted the index, explained an additional 4% of the variance of fasting blood glucose. Significant genetic heritability for fasting blood glucose was documented by both path analysis and segregation analysis. In aggregate, we conclude that though there was a major familial vector accounting for within-family aggregation of blood glucose, it was probably generated by a multifactorial component as compared to a major locus. Under the most parsimonious model, path analysis estimated the genetic and cultural heritabilities as h2 = .39 +/- .08 and c2 = .06 +/- .03., respectively.

A Genetic study of hypoalphalipoproteinemia

Complex segregation analysis under the unified mixed model of inheritance (major gene and multifactorial) is performed on families ascertained through 23 probands with hypoalphalipoproteinemia (depressed HDL-cholesterol, denoted HDL-c). Evidence for segregation of a recessive major gene for depressed HDL-c with frequency q = 0.116, in addition to multifactorial transmission (H = 0.572), is found in these families. Reanalysis of a subset of families with severely depressed HDL-c confirms the conclusions based on the original analysis, except that different definitions of "affection" give rise to different estimates of gene frequency. Our finding of a recessive mode of inheritance differs from previous claims for a dominant gene because previous analyses did not use a mixed model for segregation analysis of hypoalphalipoproteinemia. When the significant multifactorial background is neglected, we also find evidence for the invalid claim of a dominant gene. This demonstrates the necessity of using mixed models for determining the mode of inheritance of a given phenotype.

Metformin, pre-eclampsia, and pregnancy outcomes in women with polycystic ovary syndrome

AIMS

Was metformin during pregnancy in women with polycystic ovary syndrome (PCOS) associated with pre-eclampsia, and was it safe for mother and neonate?

METHODS

In the current study, pre-eclampsia and other pregnancy outcomes were prospectively studied in 90 women with PCOS who conceived on metformin 1.5-2.55 g/day, and had > or = 1 live birth (97 pregnancies, 100 live births) compared with 252 healthy women (not known to have PCOS) with > or = 1 live birth, consecutively delivered in a community obstetrics practice.

RESULTS

Women with PCOS were older than controls (33 +/- 5 vs. 29 +/- 6 years, P < 0.0001), more likely to be > 35 years old at conception (23 vs. 13%, P = 0.028), much heavier (93 +/- 23 vs. 72 +/- 18 kg, P < 0.0001, BMI 33.8 +/- 7.8 kg/m2 vs. 25.6 +/- 5.9, P < 0.0001), and more likely to be Caucasian (97 vs. 90%, P = 0.05), but there were similar numbers with preconception Type 2 diabetes mellitus [2/90 (2.2%) vs. 1/252 (0.4%), P = 0.17]. Pre-eclampsia in PCOS (5/97 pregnancies, 5.2%), did not differ (P = 0.5) from controls (9/252, 3.6%), nor did it differ (P = 1.0) in PCOS vs. control primigravidas [2/45 (4.4%) vs. 4/91 (4.4%)]. Development of gestational diabetes in PCOS did not differ from controls [9/95 pregnancies (9.5%) vs. 40/251 (15.9%), P = 0.12]. Of the 100 live births to 90 women with PCOS, there were no major birth defects. Mean +/- sd birth weight of the 80 live births > or = 37 weeks gestation in women with PCOS (3414 +/- 486 g) did not differ from controls' 206 live births > or = 37 weeks (3481 +/- 555 g), P = 0.34, nor did the percentage of > or = 37 week gestation neonates > or = 4000 g (12.5 vs. 17.5%, P = 0.3) or > or = 4500 g (1.3 vs. 2.9%, P = 0.7).

CONCLUSIONS

Metformin is not associated with pre-eclampsia in pregnancy in women with PCOS, and appears to be safe for mother and fetus.

Height, weight, and motor-social development during the first 18 months of life in 126 infants born to 109 mothers with polycystic ovary syndrome who conceived on and continued metformin through pregnancy

BACKGROUND

We prospectively assessed growth and motor-social development during the first 18 months of life in 126 live births (122 pregnancies) to 109 women with polycystic ovary syndrome (PCOS) who conceived on and continued metformin (1.5-2.55 g/day) through pregnancy.

METHODS

The lengths and weights of PCOS neonates were compared with gender-specific Centers for Disease Control and Prevention (CDC) infant data. Gestational diabetes (GD) and pre-eclampsia in women with PCOS were compared with 252 healthy women without PCOS who had >or=1 live birth (262 live births).

RESULTS

There were 101 out of 126 (80%) term (>or=37 gestational weeks) PCOS births, which was not significantly different (P = 0.7) from controls, 206 out of 252 (81.7%). There were two (1.6%) birth defects. GD occurred in nine out of 119 PCOS pregnancies (7.6%) versus 40 out of 251 (15.9%) controls, P = 0.027. The prevalence of pre-eclampsia did not differ in PCOS versus control pregnancies (4.1 versus 3.6%, P = 0.8). The birth length and weight of the 52 male neonates did not differ (P > 0.05) from those of CDC males; the 74 female neonates were shorter than CDC females (48.9 +/- 5.4 versus 50.6 +/- 2.7 cm, P = 0.006) and weighed less (3.09 +/- 0.85 versus 3.29 +/- 0.52 kg, P = 0.04). There were no systematic differences in growth between PCOS and CDC infants over 18 months. At 3, 6, 9, 12 and 18 months, of a potential 100% motor-social development score, scores (+/-SD) were 95 +/- 13, 98 +/- 8%, 95 +/- 10, 97 +/- 8 and 94 +/- 16%; no infants had motor-social developmental delays.

CONCLUSIONS

Metformin reduced development of GD, was not teratogenic and did not adversely affect birth length and weight, growth or motor-social development in the first 18 months of life.