Donor Electrocardiogram Associations With Cardiac Dysfunction, Heart Transplant Use, and Survival: The Donor Heart Study

BACKGROUND

Potential organ donors often exhibit abnormalities on electrocardiograms (ECGs) after brain death, but the physiological and prognostic significance of such abnormalities is unknown.

OBJECTIVES

This study sought to characterize the prevalence of ECG abnormalities in a nationwide cohort of potential cardiac donors and their associations with cardiac dysfunction, use for heart transplantation (HT), and recipient outcomes.

METHODS

The Donor Heart Study enrolled 4,333 potential cardiac organ donors at 8 organ procurement organizations across the United States from 2015 to 2020. A blinded expert reviewer interpreted all ECGs, which were obtained once hemodynamic stability was achieved after brain death and were repeated 24 ± 6 hours later. ECG findings were summarized, and their associations with other cardiac diagnostic findings, use for HT, and graft survival were assessed using univariable and multivariable regression.

RESULTS

Initial ECGs were interpretable for 4,136 potential donors. Overall, 64% of ECGs were deemed clinically abnormal, most commonly as a result of a nonspecific St-T-wave abnormality (39%), T-wave inversion (19%), and/or QTc interval >500 ms (17%). Conduction abnormalities, ectopy, pathologic Q waves, and ST-segment elevations were less common (each present in ≤5% of donors) and resolved on repeat ECGs in most cases. Only pathological Q waves were significant predictors of donor heart nonuse (adjusted OR: 0.39; 95% CI: 0.29-0.53), and none were associated with graft survival at 1 year post-HT.

CONCLUSIONS

ECG abnormalities are common in potential heart donors but often resolve on serial testing. Pathologic Q waves are associated with a lower likelihood of use for HT, but they do not portend worse graft survival.

Estimating the association between systemic Interleukin-6 and mortality in the dialysis population. Re-analysis of the global fluid study, systematic review and meta-analysis

BACKGROUND

Systemic inflammation, measured as circulating Interleukin-6 (IL-6) levels, is associated with cardiovascular and all-cause mortality in chronic kidney disease. However, this has not been convincingly demonstrated in a systematic review or a meta-analysis in the dialysis population. We provide such evidence, including a re-analysis of the GLOBAL Fluid Study.

METHODS

Mortality in the GLOBAL fluid study was re-analysed using Cox proportional hazards regression with IL-6 levels as a covariate using a continuous non-logarithmic scale. Literature searches of the association of IL-6 levels with mortality were conducted on MEDLINE, EMBASE, PyschINFO and CENTRAL. All studies were assessed for risk of bias using the QUIPS tool. To calculate a pooled effect size, studies were grouped by use of IL-6 scale and included in the meta-analysis if IL-6 was analysed as a continuous linear covariate, either per unit or per 10 pg/ml, in both unadjusted or adjusted for other patient characteristics (e.g. age, comorbidity) models. Funnel plot was used to identify potential publication bias.

RESULTS

Of 1886 citations identified from the electronic search, 60 were included in the qualitative analyses, and 12 had sufficient information to proceed to meta-analysis after full paper screening. Random effects meta-analysis of 11 articles yielded a pooled hazard ratio (HR) per pg/ml of 1.03, (95% CI 1.01, 1.03), [Formula: see text]= 81%. When the analysis was confined to seven articles reporting a non-adjusted HR the result was similar: 1.03, per pg/ml (95% CI: 1.03, 1.06), [Formula: see text]=92%. Most of the heterogeneity could be attributed to three of the included studies. Publication bias could not be determined due to the limited number of studies.

CONCLUSION

This systematic review confirms the adverse association between systemic IL-6 levels and survival in people treated with dialysis. The heterogeneity that we observed may reflect differences in study case mix.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO - CRD42020214198.

Left Ventricular Dysfunction Associated With Brain Death: Results From the Donor Heart Study

BACKGROUND

Left ventricular dysfunction in potential donors meeting brain death criteria often results in nonuse of donor hearts for transplantation, yet little is known about its incidence or pathophysiology. Resolving these unknowns was a primary aim of the DHS (Donor Heart Study), a multisite prospective cohort study.

METHODS

The DHS enrolled potential donors by neurologic determination of death (n=4333) at 8 organ procurement organizations across the United States between February 2015 and May 2020. Data included medications administered, serial diagnostic tests, and transthoracic echocardiograms (TTEs) performed: (1) within 48 hours after brain death was formally diagnosed; and (2) 24±6 hours later if left ventricular (LV) dysfunction was initially present. LV dysfunction was defined as an LV ejection fraction <50% and was considered reversible if LV ejection fraction was >50% on the second TTE. TTEs were also examined for presence of LV regional wall motion abnormalities and their reversibility. We assessed associations between LV dysfunction, donor heart acceptance for transplantation, and recipient 1-year survival.

RESULTS

An initial TTE was interpreted for 3794 of the 4333 potential donors by neurologic determination of death. A total of 493 (13%) of these TTEs showed LV dysfunction. Among those donors with an initial TTE, LV dysfunction was associated with younger age, underweight, and higher NT-proBNP (N-terminal pro-B-type natriuretic peptide) and troponin levels. A second TTE was performed within 24±6 hours for a subset of donors (n=224) with initial LV dysfunction; within this subset, 130 (58%) demonstrated reversibility. Sixty percent of donor hearts with normal LV function were accepted for transplant compared with 56% of hearts with reversible LV dysfunction and 24% of hearts with nonreversible LV dysfunction. Donor LV dysfunction, whether reversible or not, was not associated with recipient 1-year survival.

CONCLUSIONS

LV dysfunction associated with brain death occurs in many potential heart donors and is sometimes reversible. These findings can inform decisions made during donor evaluation and help guide donor heart acceptance for transplantation.

Bio-impedance spectroscopy added to a fluid management protocol does not improve preservation of residual kidney function in incident hemodialysis patients in a randomized controlled trial

Avoiding excessive dialysis-associated volume depletion may help preserve residual kidney function (RKF). To establish whether knowledge of the estimated normally hydrated weight from bioimpedance measurements (BI-NHW) when setting the post-hemodialysis target weight (TW) might mitigate rate of loss of RKF, we undertook an open label, randomized controlled trial in incident patients receiving HD, with clinicians and patients blinded to bioimpedance readings in controls. A total of 439 patients with over 500 ml urine/day or residual GFR exceeding 3 ml/min/1.73m2 were recruited from 34 United Kingdom centers and randomized 1:1, stratified by center. Fluid assessments were made for up to 24 months using a standardized proforma in both groups, supplemented by availability of BI-NHW in the intervention group. Primary outcome was time to anuria, analyzed using competing-risk survival models adjusted for baseline characteristics, by intention to treat. Secondary outcomes included rate of RKF decline (mean urea and creatinine clearance), blood pressure and patient-reported outcomes. There were no group differences in cause-specific hazard rates of anuria (0.751; 95% confidence interval (0.459, 1.229)) or sub-distribution hazard rates (0.742 (0.453, 1.215)). RKF decline was markedly slower than anticipated, pooled linear rates in year 1: -0.178 (-0.196, -0.159)), year 2: -0.061 (-0.086, -0.036)) ml/min/1.73m2/month. Blood pressure and patient-reported outcomes did not differ by group. The mean difference agreement between TW and BI-NHW was similar for both groups, Bioimpedance: -0.04 kg; Control: -0.25 kg. Thus, use of a standardized clinical protocol for fluid assessment when setting TW is associated with excellent preservation of RKF. Hence, bioimpedance measurements are not necessary to achieve this.

Factors associated with change in health-related quality of life in people with gout: a 3-year prospective cohort study in primary care

OBJECTIVE

To describe factors associated with change in health-related quality of life (HRQOL) in people living with gout in primary care.

METHODS

In a UK prospective cohort study, adults with a diagnosis of gout registered with 20 general practices completed the Gout Impact Scale (GIS; scale 0-100), 36-item Short Form Physical Function subscale (PF-10; 0-100) and HAQ Disability Index (HAQ-DI; 0-3) via postal questionnaires at baseline and 6, 12, 24 and 36 months. Linear mixed modelling was used to investigate factors associated with changes in HRQOL over 3 years.

RESULTS

A total of 1184 participants responded at baseline (adjusted response 65.6%); 990 (83.6%) were male, with a mean age of 65.6 years (s.d. 12.5). A total of 818, 721, 696 and 605 responded at 6, 12, 24 and 36 months, respectively. Factors associated with worse disease-specific and generic HRQOL over 3 years were flare frequency (five or more flares; GIS subscales, PF-10), oligo/polyarticular flares (GIS subscales, PF-10, HAQ-DI), worse pain (GIS subscales, PF-10, HAQ-DI), body pain (GIS subscales, PF-10, HAQ-DI) and more severe depression (GIS subscales, PF-10, HAQ-DI) (P ≤ 0.05). More severe anxiety was associated with worse disease-specific HRQOL only (GIS subscales). Older age (PF-10), being female (PF-10, HAQ-DI) and BMI (HAQ-DI) were associated with worse generic HRQOL (P ≤ 0.05).

CONCLUSION

Gout-specific, comorbid and sociodemographic factors were associated with change in HRQOL over a 3-year period, highlighting people at risk of worse outcomes who could be targeted for interventions.

Monitoring residual kidney function in haemodialysis patients using timed urine collections: validation of the use of estimated blood results to calculate GFR

OBJECTIVE

With growing recognition of the benefits of preserving residual kidney function (RKF) and use of incremental treatment regimes, the incentive to measure residual clearance in haemodialysis patients is increasing. Interdialytic urine collections used to monitor RKF in research studies are considered impractical in routine care, partly due to the requirement for blood samples before and after the collection. Plasma solute levels can be estimated if patients are in 'steady state', where urea and creatinine concentrations increase at a constant rate between dialysis sessions and are reduced by a constant ratio at each session. Validation of the steady state assumption would allow development of simplified protocols for urine collections in HD patients.

APPROACH

Equations were derived for estimating plasma urea and creatinine at the start or end of the interdialytic interval for patients in steady state. Data collected during the BISTRO study was used to assess the agreement between measured and estimated plasma levels and the effect of using estimated levels on the calculated glomerular filtration rate (GFR).

MAIN RESULTS

The mean difference between GFR calculated with estimated plasma levels for the HD session after the collection and a full set of measured levels was 2.0% (95% limits of agreement -10.7% to +14.7%, N = 316). Where plasma levels for the session before the collection were estimated, the mean difference was 1.2% (limits of agreement -10.3% to +7.9%, N = 275).

SIGNIFICANCE

Using estimated levels for one session led to a clinically significant difference in the calculated GFR for less than 3% of the collections studied. This indicates that the steady state assumption can be used to estimate solute levels when determining GFR from timed urine collections. A pragmatic approach to monitoring RKF in HD would be for patients to collect for approximately 24 hours before routine bloods are taken.

Challenges encountered in conducting donor-based research: Lessons learned from the Donor Heart Study

Solid organ transplantation continues to be constrained by a lack of suitable donor organs. Advances in donor management and evaluation are needed to address this shortage, but the performance of research studies in deceased donors is fraught with challenges. Here we discuss several of the major obstacles we faced in the conduct of the Donor Heart Study-a prospective, multi-site, observational study of donor management, evaluation, and acceptance for heart transplantation. These included recruitment and engagement of participating organ procurement organizations, ambiguities related to study oversight, obtaining authorization for donor research, logistical challenges encountered during donor management, sustaining study momentum, and challenges related to study data management. By highlighting these obstacles encountered, as well as the solutions implemented, we hope to stimulate further discussion and actions that will facilitate the design and execution of future donor research studies.

Longitudinal assessment of lung clearance index to monitor disease progression in children and adults with cystic fibrosis

Background

Lung clearance index (LCI) is a valuable research tool in cystic fibrosis (CF) but clinical application has been limited by technical challenges and uncertainty about how to interpret longitudinal change. In order to help inform clinical practice, this study aimed to assess feasibility, repeatability and longitudinal LCI change in children and adults with CF with predominantly mild baseline disease.

Methods

Prospective, 3-year, multicentre, observational study of repeated LCI measurement at time of clinical review in patients with CF >5 years, delivered using a rapid wash-in system.

Results

112 patients completed at least one LCI assessment and 98 (90%) were still under follow-up at study end. The median (IQR) age was 14.7 (8.6–22.2) years and the mean (SD) FEV₁ z-score was −1.2 (1.3). Of 81 subjects with normal FEV₁ (>−2 z-scores), 63% had raised LCI (indicating worse lung function). For repeat stable measurements within 6 months, the mean (limits of agreement) change in LCI was 0.9% (−18.8% to 20.7%). A latent class growth model analysis identified four discrete clusters with high accuracy, differentiated by baseline LCI and FEV₁. Baseline LCI was the strongest factor associated with longitudinal change. The median total test time was under 19 min.

Conclusions

Most patients with CF with well-preserved lung function show stable LCI over time. Cluster behaviours can be identified and baseline LCI is a risk factor for future progression. These results support the use of LCI in clinical practice in identifying patients at risk of lung function decline.

Non-invasive ventilation is associated with long-term improvements in lung function and gas exchange in cystic fibrosis adults with hypercapnic respiratory failure

BACKGROUND

Non-invasive ventilation (NIV) is an established treatment option for cystic fibrosis (CF) patients with type 2 respiratory failure but the benefits of this therapy remain unclear. This study examined the long-term outcomes and response to NIV in a large adult CF cohort.

METHODS

All patients attending a UK adult CF Centre receiving NIV as treatment for hypercapnic respiratory failure over a nine-year period were studied prospectively. Detailed clinical data was recorded and longitudinal data measurements were examined for the three years pre and post NIV initiation to assess effect of this intervention.

RESULTS

94 patients, mean age 29.9 (SD 9.7) years, percent predicted FEV₁ 21.5 (7.3), received NIV. All patients commenced NIV in a hospital setting. 21 remain alive, 24 received double lung transplant, 49 died without lung transplantation. NIV use was associated with a stabilisation and improvement in both FEV₁ and FVC from NIV set up to three years post follow-up, in addition to an increase in body mass index and attenuation of PCO₂ (all p<0.001). No single parameter was found to predict long-term NIV response but baseline PCO₂ (p=0.005), CRP (p=0.004) and age (p=0.009) were identified as independent predictors of mortality.

CONCLUSIONS

NIV use in CF adults is associated with improvements in lung function and attenuation of hypercapnia which is maintained for up to three years post NIV initiation. Outcomes for CF patients with severe pulmonary disease commenced on NIV have significantly improved with fifty percent of patients expected to survive for approximately five years.

Longitudinal clusters of pain and stiffness in polymyalgia rheumatica: 2-year results from the PMR Cohort Study

Objectives

To investigate potential subgroups of primary care–diagnosed patients with PMR based on self-reported pain and stiffness severity over time.

Methods

A total of 652 people with an incident PMR diagnosis were recruited from English general practices and completed a baseline postal questionnaire. They were followed up with a further six questionnaires over a 2 year period. A total of 446 people completed the 2 year follow-up. Pain and stiffness were reported on a 0–10 numerical rating scale. Latent class growth analysis was used to estimate the joint trajectories of pain and stiffness over time. A combination of statistical and clinical considerations was used to choose the number of clusters. Characteristics of the classes were described.

Results

Five clusters were identified. One cluster represented the profile of ‘classical’ PMR symptoms and one represented sustained symptoms that may not be PMR. The other three clusters displayed a partial recovery, a recovery followed by worsening and a slow, but sustained recovery. Those displaying classical PMR symptoms were in better overall health at diagnosis than the other groups.

Conclusion

PMR is a heterogeneous condition, with a number of phenotypes. The spectrum of presentation, as well as varying responses to treatment, may be related to underlying health status at diagnosis. Future research should seek to stratify patients at diagnosis to identify those likely to have a poor recovery and in need of an alternative treatment pathway. Clinicians should be aware of the different experiences of patients and monitor symptoms closely, even where there is initial improvement.

The Effect of Pain Conditioning on Experimentally Evoked Cough: Evidence of Impaired Endogenous Inhibitory Control Mechanisms in Refractory Chronic Cough

The pathophysiology of refractory chronic cough (RCC) is unclear. We hypothesised that endogenous inhibitory control mechanisms, such as those activated by noxiousstimuli inducing pain (conditioned pain modulation (CPM)), may be capable of inhibiting coughing and urge to cough evoked by inhaled capsaicin. Furthermore, these mechanisms may be impaired in patients with RCC.The objective was to investigate the effects of pain on cough and urge to cough (UTC) in healthy volunteers (HV) and RCC. HV and RCC patients underwent a randomised, controlled, 4-way cross-over study comparing the effect of 4 interventions on capsaicin evoked coughing and UTC. The interventions comprised immersing a hand in i) noxious cold-water, ii) warm water, iii) warm water but instructed to voluntarily supress coughing and iv) no intervention. The co-primary outcomes were numbers of evoked coughs and UTC scores.Twenty HV (mean age 50.1(±SD14.2), M:F 10:10) and 20 RCC (age 60.1(±7.9), M:F 9:11) participated. Overall, noxious cold water reduced capsaicin evoked UTC scores and cough numbers compared with warm water (1.6 (95% C.I. 1.3-2.0) versus 2.2 (1.8-2.6) p<0.001; 4.8 coughs (3.7-6.2) versus 7.9 coughs (6.7-9.5) p<0.001, respectively). HV and RCC demonstrated similar reductions in the UTC during noxious cold-water immersion, but noxious cold water and voluntary suppression interventions were less effective in RCC than HV in reducing capsaicin evoked cough (p=0.041).Endogenous inhibitory control mechanisms, specifically those activated by pain, can reduce both coughing and the UTC. Impairment of endogenous inhibitory control mechanisms may contribute to excessive coughing in RCC.

P142 Factors associated with change in health-related quality of life in people living with gout: a three-year prospective cohort study in primary care

Background

Gout affects 2.5% of adults in the UK but is often poorly managed. It can impair health-related quality of life (HRQOL), yet little is known about which people with gout are at risk of worse outcomes. We investigated factors associated with change in HRQOL over a three-year period in people living with gout in primary care.

Methods

People with gout registered with 20 general practices in the West Midlands completed the Gout Impact Scale (GIS), Short-Form-36 Physical Function subscale (PF10) and health assessment questionnaire disability index (HAQ-DI) at five time-points (baseline & 6, 12, 24 and 36 months) via postal questionnaire. Linear mixed modelling (LMM) with multivariate adjustment for baseline and time-varying covariates was used to investigate gout-specific, comorbid and socio-demographic factors associated with change in the Concern Overall (GIS-CO), PF10 and HAQ-DI over three years. Higher scores are worse for GIS-CO and HAQ-DI, but better for PF10.

Results

Of 1,184 baseline respondents, 818 (80%), 721 (73%), 696 (75%), 605 (68%) responded at 6, 12, 24 and 36 months respectively. Mean age (SD) at baseline was 65.6 (12.5) years. 990 (84%) were male, 494 (42%) reported &gt;2 gout flares in the previous year, 624 (54%) were taking allopurinol and 318 (27%) had an eGFR&lt;60mL/min/1.73m2. Factors identified as being associated with a deterioration in HRQOL over three years (table), were gout flare frequency (GIS-CO, PF10), history of oligo/polyarticular flares (GIS-CO, HAQ-DI), having a flare currently (GIS-CO), allopurinol use (PF10), having body pain (GIS-CO, PF10, HAQ-DI), higher pain severity (GIS-CO, PF10, HAQ-DI), number of comorbidities (PF10), eGFR &lt;60mL/min/1.73m2 (PF10, HAQ-DI), anxiety (GIS-CO), depression (PF10, HAQ-DI), and older age (PF10, HAQ-DI). Factors associated with an improvement in HRQOL were longer gout duration (GIS-CO), older age (GIS-CO), lower socioeconomic deprivation (PF10, HAQ-DI) and more frequent alcohol consumption (PF10, HAQ-DI).

Conclusion

Gout-specific, comorbid and socio-demographic factors associated with change in HRQOL over a three-year period in people living with gout in primary care were identified, highlighting people at risk of worse outcomes over three years and at greatest need of urate-lowering therapy and other targeted interventions.

Disclosures

L. Watson None. J. Belcher None. E. Nicholls None. P. Chandratre None. M. Blagojevic-Bucknall None. S. Hider None. S.A. Lawton None. C.D. Mallen None. S. Muller None. K. Rome None. E. Roddy None.

Estimating risk of encapsulating peritoneal sclerosis accounting for the competing risk of death

Background

Risk of encapsulating peritoneal sclerosis (EPS) is strongly associated with the duration of peritoneal dialysis (PD), such that patients who have been on PD for some time may consider elective transfer to haemodialysis to mitigate the risk of EPS. There is a need to determine this risk to better inform clinical decision making, but previous studies have not allowed for the competing risk of death.

Methods

This study included new adult PD patients in Australia and New Zealand (ANZ; 1990–2010) or Scotland (2000–08) followed until 2012. Age, time on PD, primary renal disease, gender, data set and diabetic status were evaluated as predictors at the start of PD, then at 3 and 5 years after starting PD using flexible parametric competing risks models.

Results

In 17 396 patients (16 162 ANZ, 1234 Scotland), EPS was observed in 99 (0.57%) patients, less frequently in ANZ patients (n = 65; 0.4%) than in Scottish patients (n = 34; 2.8%). The estimated risk of EPS was much lower when the competing risk of death was taken into account (1 Kaplan–Meier = 0.0126, cumulative incidence function = 0.0054). Strong predictors of EPS included age, primary renal disease and time on PD. The risk of EPS was reasonably discriminated at the start of PD (C-statistic = 0.74–0.79) and this improved at 3 and 5 years after starting PD (C-statistic = 0.81–0.92).

Conclusions

EPS risk estimates are lower when calculated using competing risk of death analyses. A patient’s estimated risk of EPS is country-specific and can be predicted using age, primary renal disease and duration of PD.

Interstitial lung disease is a risk factor for ischaemic heart disease and myocardial infarction

Objectives

Despite many shared risk factors and pathophysiological pathways, the risk of ischaemic heart disease (IHD) and myocardial infarction (MI) in interstitial lung disease (ILD) remains poorly understood. This lack of data could be preventing patients who may benefit from screening for these cardiovascular diseases from receiving it.

Methods

A population-based cohort study used electronic patient records from the Clinical Practice Research Datalink and linked Hospital Episode Statistics to identify 68 572 patients (11 688 ILD exposed (mean follow-up: 3.8 years); 56 884 unexposed controls (mean follow-up: 4.0 years), with 349 067 person-years of follow-up. ILD-exposed patients (pulmonary sarcoidosis (PS) or idiopathic pulmonary fibrosis (PF)) were matched (by age, sex, registered general practice and available follow-up time) to patients without ILD or IHD/MI. Rates of incident MI and IHD were estimated. HRs were modelled using multivariable Cox proportional hazards regression accounting for potential confounders.

Results

ILD was independently associated with IHD (HR 1.85, 95% CI 1.56 to 2.18) and MI (HR 1.74, 95% CI 1.44 to 2.11). In all disease categories, risk of both IHD and MI peaked between ages 60 and 69 years, except for the risk of MI in PS which was greatest <50 years. Men with PF were at greatest risk of IHD, while women with PF were at greatest risk of MI.

Conclusions

ILD, particularly PF, is independently associated with MI and IHD after adjustment for established cardiovascular risk factors. Our results suggest clinicians should prioritise targeted assessment of cardiovascular risk in patients with ILD, particularly those aged 60–69 years. Further research is needed to understand the impact of such an approach to risk management.

Characteristics of patients with giant cell arteritis who experience visual symptoms

Permanent vision loss is one of the most serious complications of giant cell arteritis (GCA) and therefore prompt diagnosis is paramount. However, diagnosis of GCA remains challenging due to its frequently non-specific presentation. Our aim was to identify differences in the characteristics of GCA patients with, and without, current visual symptoms. A cross-sectional survey was mailed to patients with a GCA Read code entered in their GP electronic medical record. Responders were categorised as those currently reporting a visual symptom or not. We compared general and GCA-specific characteristics in these two groups. The association of diagnostic delay with subsequent experience of visual symptoms was examined using unadjusted and adjusted linear regression analysis. 318 GCA patients responded to the survey (59.6%). Responders were predominantly female (69.8%), with a mean age of 73.7 years (SD 8.2). 28% reported current visual symptoms. There was no statistically significant difference in the general characteristics between those with and without visual symptoms. Of GCA-specific characteristics, pre-GCA diagnosis of diplopia (p = 0.018), temporary (p ≤ 0.001) or permanent visual problems (p = 0.001) and hoarseness (p = 0.004) were more common among those reporting current visual symptoms. There was no association between the extent of diagnostic delay and reporting of current visual symptoms. Though we found few characteristics to distinguish between GCA patients with or without current visual symptoms, diagnostic delay was not associated with current visual symptoms. Our findings highlighted the continued difficulty for clinicians to identify GCA patients at the highest risk of visual complications.

Gender-specific risk factors for gout: a systematic review of cohort studies

BACKGROUND

Though gout is more prevalent in men than women, it remains unclear whether gender influences risk factors for incident gout. We aimed to systematically review all cohort studies examining risk factors for the development of gout by gender.

METHODS

MEDLINE, EMBASE, CINAHL and the Cochrane Library were searched from inception to March 2019. Risk factors for gout examined were: age, ethnicity, consumption of alcohol, meat, seafood, dairy products, purine-rich vegetables, coffee and fructose, vitamin C intake, the Dietary Approaches to Stop Hypertension (DASH) diet, metabolic syndrome, BMI, waist and chest circumference, waist-to-hip ratio, weight change, diabetes mellitus, dyslipidaemias, renal disease, psoriasis, hypertension, diuretic use and anti-diabetic medication. Cohort studies were included if examining (at least) one of these risk factors for gout in either gender in the general population or primary care. Sample characteristics from included articles and their reported risk estimates were described using narrative synthesis.

RESULTS

Thirty-three articles were included, 20 (60.6%)directly compared risk factors by gender, 10 (30.3%) used men-only samples, 3 (9.1%) used women-only samples. Articles comparing risk across genders found similar increases in most risk factors. However, in men, metabolic syndrome (Hazard Ratio (95% CI) 1.37(1.20-1.58)) presented a risk of incident gout compared to none in women (> 50 years 1.15(0.85-1.54); ≤50 years 1.29(0.76-2.17)). Compared to men, women showed greater associated risk with higher consumption of fish and shellfish (HR (95% CI) Men: 1.02 (0.86-1.22); Women 1.36 (1.12-1.65)).

CONCLUSIONS

Risk factors for developing gout did not typically differ between genders and therefore similar preventative advice can be provided. Exceptions were metabolic syndrome in men and excessive seafood consumption in women, but these singular articles need further examination and in general more research into the risk factors for gout which includes women is required.

Cost-Utility Analysis of Routine Anxiety and Depression Screening in Patients Consulting for Osteoarthritis: Results From a Clinical, Randomized Controlled Trial

OBJECTIVE

To investigate the cost-effectiveness (cost-utility) of introducing general practitioner screening for anxiety and depression in patients consulting for osteoarthritis (OA).

METHODS

A cluster-randomized trial-based economic evaluation to assess general practitioners screening for anxiety and depression symptoms in patients consulting for OA compared to usual care (screening for pain intensity) was undertaken over a 12-month period from a UK National Health Service and societal perspective. Patient-level mean costs and mean quality-adjusted life years (QALYs) were estimated, and cost-effectiveness acceptability curves controlling for cluster-level data were constructed. The base-case analysis used the net benefit regressions approach. The 2-stage nonparametric sampling technique was explored in a sensitivity analysis.

RESULTS

The base-case analysis demonstrated that the intervention was as costly as, and less effective than, the control (QALY differential -0.029 [95% confidence interval -0.062, 0.003]). In the base-case analyses, general practitioner screening for anxiety and depression was unlikely to be a cost-effective option (probability <5% at £20,000/QALY). Similar results were observed in all sensitivity analyses.

CONCLUSION

Prompting general practitioners to routinely screen and manage comorbid anxiety and depression in patients presenting with OA is unlikely to be cost-effective. Further research is needed to explore clinically effective and cost-effective models of managing anxiety and depression in patients presenting with clinical OA.

Risk of chronic kidney disease in patients with gout and the impact of urate lowering therapy: a population-based cohort study

Background

An association between gout and renal disease is well-recognised but few studies have examined whether gout is a risk factor for subsequent chronic kidney disease (CKD). Additionally, the impact of urate-lowering therapy (ULT) on development of CKD in gout is unclear. The objective of this study was to quantify the risk of CKD stage ≥ 3 in people with gout and the impact of ULT.

Methods

This was a retrospective cohort study using data from the Clinical Practice Research Datalink (CPRD). Patients with incident gout were identified from general practice medical records between 1998 and 2016 and randomly matched 1:1 to patients without a diagnosis of gout based on age, gender, available follow-up time and practice. Primary outcome was development of CKD stage ≥ 3 based on estimated glomerular filtration rate (eGFR) or recorded diagnosis. Absolute rates (ARs) and adjusted hazard ratios (HRs) were calculated using Cox regression models. Risk of developing CKD was assessed among those prescribed ULT within 1 and 3 years of gout diagnosis.

Results

Patients with incident gout (n = 41,446) were matched to patients without gout. Development of CKD stage ≥ 3 was greater in the exposed group than in the unexposed group (AR 28.6 versus 15.8 per 10,000 person-years). Gout was associated with an increased risk of incident CKD (adjusted HR 1.78 95% CI 1.70 to 1.85). Those exposed to ULT had a greater risk of incident CKD, but following adjustment this was attenuated to non-significance in all analyses (except on 3-year analysis of women (adjusted HR 1.31 95% CI 1.09 to 1.59)).

Conclusions

This study has demonstrated gout to be a risk factor for incident CKD stage ≥ 3. Further research examining the mechanisms by which gout may increase risk of CKD and whether optimal use of ULT can reduce the risk or progression of CKD in gout is suggested.

Electronic supplementary material

The online version of this article (10.1186/s13075-018-1746-1) contains supplementary material, which is available to authorized users.

Measurement error and timing of predictor values for multivariable risk prediction models are poorly reported

OBJECTIVE

Measurement error in predictor variables may threaten the validity of clinical prediction models. We sought to evaluate the possible extent of the problem. A secondary objective was to examine whether predictors are measured at the intended moment of model use.

METHODS

A systematic search of Medline was used to identify a sample of articles reporting the development of a clinical prediction model published in 2015. After screening according to a predefined inclusion criteria, information on predictors, strategies to control for measurement error, and intended moment of model use were extracted. Susceptibility to measurement error for each predictor was classified into low and high risks.

RESULTS

Thirty-three studies were reviewed, including 151 different predictors in the final prediction models. Fifty-one (33.7%) predictors were categorized as high risk of error; however, this was not accounted for in the model development. Only 8 (24.2%) studies explicitly stated the intended moment of model use and when the predictors were measured.

CONCLUSION

Reporting of measurement error and intended moment of model use is poor in prediction model studies. There is a need to identify circumstances where ignoring measurement error in prediction models is consequential and whether accounting for the error will improve the predictions.

Public priorities for osteoporosis and fracture research: results from a general population survey

This is the first national study of public and patient research priorities in osteoporosis and fracture. We have identified new research areas of importance to members of the public, particularly 'access to information from health professionals'. The findings are being incorporated into the research strategy of the National Osteoporosis Society.

PURPOSE

This study aimed to prioritise, with patients and public members, research topics for the osteoporosis research agenda.

METHODS

An e-survey to identify topics for research was co-designed with patient representatives. A link to the e-survey was disseminated to supporters of the UK National Osteoporosis Society (NOS) in a monthly e-newsletter. Responders were asked to indicate their top priority for research across four topics (understanding and preventing osteoporosis, living with osteoporosis, treating osteoporosis and treating fractures) and their top three items within each topic. Descriptive statistics were used to describe demographics and item ranking. A latent class analysis was applied to identify a substantive number of clusters with different combinations of binary responses.

RESULTS

One thousand one hundred eighty-eight (7.4%) respondents completed the e-survey. The top three items overall were 'Having easy access to advice and information from health professionals' (63.8%), 'Understanding further the safety and benefit of osteoporosis drug treatments' (49.9%) and 'Identifying the condition early by screening' (49.2%). Latent class analysis revealed distinct clusters of responses within each topic including primary care management and self-management. Those without a history of prior fracture or aged under 70 were more likely to rate items within the cluster of self-management as important (21.0 vs 12.9 and 19.8 vs 13.3%, respectively).

CONCLUSION

This is the first study of public research priorities in osteoporosis and has identified new research areas of importance to members of the public including access to information. The findings are being incorporated into the research strategy of the National Osteoporosis Society.

Factors Influencing Allopurinol Initiation in Primary Care

Despite guidance on appropriate initiation, urate-lowering therapy is prescribed for only a minority of patients with gout. Electronic health records for 8,142 patients with gout were used to investigate the effect of age, sex, comorbidities, number of consultations, and meeting internationally agreed eligibility criteria on time to allopurinol initiation. Time to first prescription was modeled using multilevel Cox proportional hazards regression. Allopurinol initiation was positively associated with meeting eligibility criteria at diagnosis of gout, but negatively associated with becoming eligible after diagnosis. Managing gout as a chronic disease, with regular reviews to discuss allopurinol treatment, may reduce barriers to treatment.

Clinical Significance of Medial Versus Lateral Compartment Patellofemoral Osteoarthritis: Cross-Sectional Analyses in an Adult Population With Knee Pain

OBJECTIVE

To determine the comparative prevalence, associations with selected patient characteristics, and clinical outcomes of medial and lateral compartment patellofemoral (PF) joint osteoarthritis (OA).

METHODS

Information was collected by questionnaires, clinical assessment, and radiographs from 745 eligible community-dwelling symptomatic adults age ≥50 years. PF joint space narrowing (JSN) and osteophytes were scored from skyline radiographs using the Osteoarthritis Research Society International atlas. Multilevel models were used to assess associations of compartmental PF joint OA with age, sex, body mass index (BMI) and varus-valgus malalignment, while median regression was used to examine associations with clinical outcomes (current pain intensity on a numeric rating scale [0-10] and the function subscale of the Western Ontario and McMaster Universities Osteoarthritis Index [0-68]).

RESULTS

Isolated lateral PF joint OA was more common than isolated medial PF joint OA, particularly at higher severity thresholds. Irrespective of severity threshold, age (≥2 odds ratio [OR] 1.19 [95% confidence interval (95% CI) 1.12, 1.26]), BMI (≥2 OR 1.15 [95% CI 1.07, 1.24]), and valgus malalignment (≥2 OR 2.58 [95% CI 1.09, 6.07]) were associated with increased odds of isolated lateral JSN, but isolated medial JSN was only associated with age (≥2 OR 1.20 [95% CI 1.14, 1.27]). The pattern of association was less clear for PF joint osteophytes. Isolated lateral PF joint OA, defined by JSN or osteophytes, was associated with higher pain scores than isolated medial PF joint OA, but these differences were modest and were not significant. A similar pattern of association was seen for functional limitation but only when PF joint OA was defined by JSN.

CONCLUSION

Isolated lateral PF joint OA is more common than isolated medial PF joint OA, and it is more consistently associated with established OA risk factors. It is also associated with higher, but clinically nonsignificant, pain and function scores than isolated medial PF joint OA, particularly when PF joint OA is defined using JSN.

Diagnostic delay for giant cell arteritis - a systematic review and meta-analysis

BACKGROUND

Giant cell arteritis (GCA), if untreated, can lead to blindness and stroke. The study's objectives were to (1) determine a new evidence-based benchmark of the extent of diagnostic delay for GCA and (2) examine the role of GCA-specific characteristics on diagnostic delay.

METHODS

Medical literature databases were searched from inception to November 2015. Articles were included if reporting a time-period of diagnostic delay between onset of GCA symptoms and diagnosis. Two reviewers assessed the quality of the final articles and extracted data from these. Random-effects meta-analysis was used to pool the mean time-period (95% confidence interval (CI)) between GCA symptom onset and diagnosis, and the delay observed for GCA-specific characteristics. Heterogeneity was assessed by I ² and by 95% prediction interval (PI).

RESULTS

Of 4128 articles initially identified, 16 provided data for meta-analysis. Mean diagnostic delay was 9.0 weeks (95% CI, 6.5 to 11.4) between symptom onset and GCA diagnosis (I ² = 96.0%; P < 0.001; 95% PI, 0 to 19.2 weeks). Patients with a cranial presentation of GCA received a diagnosis after 7.7 (95% CI, 2.7 to 12.8) weeks (I ² = 98.4%; P < 0.001; 95% PI, 0 to 27.6 weeks) and those with non-cranial GCA after 17.6 (95% CI, 9.7 to 25.5) weeks (I ² = 96.6%; P < 0.001; 95% PI, 0 to 46.1 weeks).

CONCLUSIONS

The mean delay from symptom onset to GCA diagnosis was 9 weeks, or longer when cranial symptoms were absent. Our research provides an evidence-based benchmark for diagnostic delay of GCA and supports the need for improved public awareness and fast-track diagnostic pathways.

Symptom Recognition and Perceived Urgency of Help-Seeking for Rheumatoid Arthritis and Other Diseases in the General Public: A Mixed Method Approach

OBJECTIVE

Clinical outcomes in rheumatoid arthritis (RA) are improved if the disease is treated early. However, treatment is often significantly delayed as a result of delayed help-seeking by patients who fail to recognize its symptoms or the need for rapid medical attention. Two studies were conducted to investigate the role of symptom recognition in help-seeking for the symptoms of RA, and compared this to symptom recognition and help-seeking in angina and bowel cancer.

METHODS

A qualitative interview study with 31 individuals and a survey of 1,088 members of the general public (all without RA) were conducted. Both studies used vignettes describing the symptoms of RA, bowel cancer, and angina. Participants made causal attributions and rated the perceived seriousness of the symptoms and the urgency with which they would seek medical help if confronted with these symptoms.

RESULTS

Only a small proportion of participants in both studies recognized the symptoms of RA, whereas the symptoms of bowel cancer and angina were readily recognized by many participants and considered to be more serious and to require more rapid medical attention (Z = 14.7-34.2, P < 0.001).

CONCLUSION

Accurate symptom attribution and the perception that symptoms are indicative of a serious underlying condition are both important drivers for rapid help-seeking. In the case of angina and bowel cancer, recent campaigns have promoted not only recognition of symptoms and their seriousness, but also emphasized the consequences of not seeking timely help. Our results suggest that these consequences should also be addressed in any public health campaign for RA.

The effects of implementing a point-of-care electronic template to prompt routine anxiety and depression screening in patients consulting for osteoarthritis (the Primary Care Osteoarthritis Trial): A cluster randomised trial in primary care

BACKGROUND

This study aimed to evaluate whether prompting general practitioners (GPs) to routinely assess and manage anxiety and depression in patients consulting with osteoarthritis (OA) improves pain outcomes.

METHODS AND FINDINGS

We conducted a cluster randomised controlled trial involving 45 English general practices. In intervention practices, patients aged ≥45 y consulting with OA received point-of-care anxiety and depression screening by the GP, prompted by an automated electronic template comprising five questions (a two-item Patient Health Questionnaire-2 for depression, a two-item Generalized Anxiety Disorder-2 questionnaire for anxiety, and a question about current pain intensity [0-10 numerical rating scale]). The template signposted GPs to follow National Institute for Health and Care Excellence clinical guidelines for anxiety, depression, and OA and was supported by a brief training package. The template in control practices prompted GPs to ask the pain intensity question only. The primary outcome was patient-reported current pain intensity post-consultation and at 3-, 6-, and 12-mo follow-up. Secondary outcomes included pain-related disability, anxiety, depression, and general health. During the trial period, 7,279 patients aged ≥45 y consulted with a relevant OA-related code, and 4,240 patients were deemed potentially eligible by participating GPs. Templates were completed for 2,042 patients (1,339 [31.6%] in the control arm and 703 [23.1%] in the intervention arm). Of these 2,042 patients, 1,412 returned questionnaires (501 [71.3%] from 20 intervention practices, 911 [68.0%] from 24 control practices). Follow-up rates were similar in both arms, totalling 1,093 (77.4%) at 3 mo, 1,064 (75.4%) at 6 mo, and 1,017 (72.0%) at 12 mo. For the primary endpoint, multilevel modelling yielded significantly higher average pain intensity across follow-up to 12 mo in the intervention group than the control group (adjusted mean difference 0.31; 95% CI 0.04, 0.59). Secondary outcomes were consistent with the primary outcome measure in reflecting better outcomes as a whole for the control group than the intervention group. Anxiety and depression scores did not reduce following the intervention. The main limitations of this study are two potential sources of bias: an imbalance in cluster size (mean practice size 7,397 [intervention] versus 5,850 [control]) and a difference in the proportion of patients for whom the GP deactivated the template (33.6% [intervention] versus 27.8% [control]).

CONCLUSIONS

In this study, we observed no beneficial effect on pain outcomes of prompting GPs to routinely screen for and manage comorbid anxiety and depression in patients presenting with symptoms due to OA, with those in the intervention group reporting statistically significantly higher average pain scores over the four follow-up time points than those in the control group.

TRIAL REGISTRATION

ISRCTN registry ISRCTN40721988.

Illness perceptions of gout patients and the use of allopurinol in primary care: baseline findings from a prospective cohort study

BACKGROUND

Patients' perceptions of their illness are dynamic and can directly influence aspects of management. Our aim was to examine the illness perceptions of gout patients in UK primary care and associations with allopurinol use.

METHODS

A health questionnaire was sent to 1805 people with gout aged ≥18 years identified by a gout diagnosis or prescriptions for allopurinol or colchicine in their primary care medical records in the preceding 2 years. The questionnaire included selected items from the revised illness perception questionnaire (IPQ-R). Associations between illness perceptions and use of allopurinol were calculated using multinomial logistic regression adjusted for age, gender, deprivation status, body mass index, alcohol consumption, comorbidities and gout characteristics.

RESULTS

One thousand one hundred eighty-four participants responded to the baseline questionnaire (65.6 %). Approximately half of responders perceived that they were able to control (51.2 %) or affect their gout through their own actions (44.8 %). Three quarters perceived treatments to be effective (76.4 %) and agreed that gout is a serious condition (76.4 %). Patients who agreed that they could control their gout (Relative Risk Ratio, 95 % confidence interval 1.66 (1.12 to 2.45)) and that treatments were effective (2.24 (1.32 to 3.81)) were more likely to currently be using allopurinol than not using allopurinol. However, this significance was attenuated after adjustment for self-reported gout characteristics (1.39 (0.89 to 2.17) & 1.78 (0.96 to 3.29) respectively).

CONCLUSIONS

Patients who perceive that they can control their gout and that treatments are effective are more likely to be using allopurinol, this suggests that better information is needed for the patient from GPs and rheumatologist to reassure and support their use of ULT.

Widespread pain and depression are key modifiable risk factors associated with reduced social participation in older adults: A prospective cohort study in primary care

In older adults, reduced social participation increases the risk of poor health-related quality of life, increased levels of inflammatory markers and cardiovascular disease, and increased mortality. Older adults frequently present to primary care, which offers the potential to deliver interventions at the point of care to increase social participation. The aim of this prospective study was to identify the key modifiable exposures that were associated with reduced social participation in a primary care population of older adults.The study was a population-based prospective cohort study. Participants (n = 1991) were those aged ≥65 years who had completed questionnaires at baseline, and 3 and 6-year follow-ups. Generalized linear mixed modeling framework was used to test for associations between exposures and decreasing social participation over 6 years.At baseline, 44% of participants reported reduced social participation, increasing to 49% and 55% at 3 and 6-year follow-up. Widespread pain and depression had the strongest independent association with reduced social participation over the 6-year follow-up period. The prevalence of reduced social participation for those with widespread pain was 106% (adjusted incidence rate ratio 2.06, 95% confidence interval 1.72, 2.46), higher than for those with no pain. Those with depression had an increased prevalence of 82% (adjusted incidence rate ratio 1.82, 95% confidence interval 1.62, 2.06). These associations persisted in multivariate analysis.Population ageing will be accompanied by increasing numbers of older adults with pain and depression. Future trials should assess whether screening for widespread pain and depression, and targeting appropriate treatment in primary care, increase social participation in older people.

Clustering of pain and its associations with health in people aged 50 years and older: cross-sectional results from the North Staffordshire Osteoarthritis Project

OBJECTIVE

Most pain in patients aged ≥50 years affects multiple sites and yet the predominant mode of presentation is single-site syndromes. The aim of this study was to investigate if pain sites form clusters in this population and if any such clusters are associated with health factors other than pain.

SETTING

Six general practices in North Staffordshire, UK.

DESIGN

Cross-sectional, postal questionnaire, study.

PARTICIPANTS

Community-dwelling adults aged ≥50 years registered at the general practices.

MAIN OUTCOMES MEASURES

Number of pain sites was measured by asking participants to shade sites of pain lasting ≥1 day in the past 4 weeks on a blank body manikin. Health factors measured included anxiety and depression (Hospital and Anxiety Depression Scale), cognitive complaint (Sickness Impact Profile) and sleep. Pain site clustering was investigated using latent class analysis. Association of clusters with health factors, adjusted for age, sex, body mass index and morbidities, was analysed using multinomial regression models.

RESULTS

13 986 participants (adjusted response 70.6%) completed a questionnaire, of whom 12 408 provided complete pain data. Four clusters of participants were identified: (1) low number of pain sites (36.6%), (2) medium number of sites with no back pain (31.5%), (3) medium number of sites with back pain (17.9%) and (4) high number of sites (14.1%). Compared to Cluster 1, other clusters were associated with poor health. The strongest associations (relative risk ratios, 95% CI) were with Cluster 4: depression (per unit change in score) 1.11 (1.08 to 1.14); cognitive complaint 2.60 (2.09 to 3.24); non-restorative sleep 4.60 (3.50 to 6.05).

CONCLUSIONS

These results indicate that in a general population aged ≥50 years, pain forms four clusters shaped by two dimensions-number of pain sites (low, medium, high) and, within the medium cluster, the absence or presence of back pain. The usefulness of primary care treatment approaches based on this simple classification should be investigated.

Exhaled breath hydrogen cyanide as a marker of early Pseudomonas aeruginosa infection in children with cystic fibrosis

Hydrogen cyanide is readily detected in the headspace above Pseudomonas aeruginosa cultures and in the breath of cystic fibrosis (CF) patients with chronic (P. aeruginosa) infection. We investigated if exhaled breath HCN is an early marker of P. aeruginosa infection. 233 children with CF who were free from P. aeruginosa infection were followed for 2 years. Their median (interquartile range) age was 8.0 (5.0-12.2) years. At each study visit, an exhaled breath sample was collected for hydrogen cyanide analysis. In total, 2055 breath samples were analysed. At the end of the study, the hydrogen cyanide concentrations were compared to the results of routine microbiology surveillance. P. aeruginosa was isolated from 71 children during the study with an incidence (95% CI) of 0.19 (0.15-0.23) cases per patient-year. Using a random-effects logistic model, the estimated odds ratio (95% CI) was 3.1 (2.6-3.6), which showed that for a 1- ppbv increase in exhaled breath hydrogen cyanide, we expected a 212% increase in the odds of P. aeruginosa infection. The sensitivity and specificity were estimated at 33% and 99%, respectively. Exhaled breath hydrogen cyanide is a specific biomarker of new P. aeruginosa infection in children with CF. Its low sensitivity means that at present, hydrogen cyanide cannot be used as a screening test for this infection.

Measurement of C-reactive protein, procalcitonin and neutrophil elastase in saliva of COPD patients and healthy controls: correlation to self-reported wellbeing parameters

BACKGROUND

Saliva is increasingly promoted as an alternative diagnostic bio-sample to blood; however its role in respiratory disease requires elucidation. Our aim was to investigate whether C-reactive protein (CRP), procalcitonin (PCT) and neutrophil elastase (NE) could be measured in unstimulated whole saliva, and to explore differences between COPD patients and controls with normal lung function. We also determined the relationship between these salivary biomarkers and self-reported COPD-relevant metrics.

METHODS

Salivary CRP, PCT and NE levels were measured at each of 3 visits over a 14-day period alongside spirometry and a daily self-assessment dairy in 143 subjects: 20 never-smokers and 25 smokers with normal spirometry; 98 COPD patients [GOLD Stage I, 16; Stage II, 32; Stage III, 39; Stage IV, 11]. Twenty-two randomly selected subjects provided simultaneous blood samples.

RESULTS

Levels of each salivary biomarker could distinguish between the above cohorts. Significant differences remained for salivary CRP and NE (p < 0.05) following adjustment for age, gender, sampling time, gum disease and total co-morbidities; but not for BMI except for salivary NE, which remained higher in smokers compared to non-smokers and stable COPD subjects (p < 0.001). Patients with acute COPD exacerbations had a median increase in all 3 salivary biomarkers (p < 0.001); CRP: median 5.74 ng/ml, [interquartile range (IQR) 2.86-12.25], PCT 0.38 ng/ml, [IQR 0.22-0.94], and NE 539 ng/ml, [IQR 112.25-1264]. In COPD patients, only salivary CRP and PCT levels correlated with breathing scores (r = 0.14, p < 0.02; r = 0.13, p < 0.03 respectively) and sputum features but not with activities of daily living. Salivary CRP and PCT concentrations strongly correlated with serum counterparts [r = 0.82, (95% CI: 0.72-0.87), p < 0.001 by Spearman's; and r = 0.53, (95% CI: 0.33-0.69), p < 0.006 respectively]; salivary NE did not.

CONCLUSIONS

CRP, PCT and NE were reliably and reproducibly measured in saliva, providing clinically-relevant information on health status in COPD; additionally NE distinguished smoking status. All 3 salivary biomarkers increased during COPD exacerbations, with CRP and PCT correlating well with patient-derived clinical metrics. These results provide the conceptual basis for further development of saliva as a viable bio-sample in COPD monitoring and exacerbation management.

Gout and risk of chronic kidney disease and nephrolithiasis: meta-analysis of observational studies

Introduction

To determine the prevalence of chronic kidney disease and nephrolithiasis in people with gout, and the association between gout and prevalent or incident chronic kidney disease and nephrolithiasis.

Methods

Systematic review and meta-analysis of epidemiological studies. Data sources; MEDLINE, EMBASE and CINAHL databases, hand-searched reference lists, citation history and contact with authors. Eligibility criteria: cohort, case–control or cross-sectional studies which examined the occurrence of chronic kidney disease or nephrolithiasis amongst adults with gout (with or without a non-gout comparator group) in primary care or general population samples. Prevalence and risk estimate meta-analyses were performed using a random-effects model.

Results

Seventeen studies were included in the meta-analysis (chronic kidney disease n = 7, nephrolithiasis n = 8, both n = 2). Pooled prevalence estimates of chronic kidney disease stage ≥3 and self-reported lifetime nephrolithiasis in people with gout were 24% (95% confidence interval 19% to 28%) and 14% (95% CI 12% to 17%) respectively. Gout was associated with both chronic kidney disease (pooled adjusted odds ratio 2.41, 95% confidence interval 1.86 to 3.11) and self-reported lifetime nephrolithiasis (1.77, 1.43 to 2.19).

Conclusions

Chronic kidney disease and nephrolithiasis are commonly found amongst patients with gout. Gout is independently associated with both chronic kidney disease and nephrolithiasis. Patients with gout should be actively screened for chronic kidney disease and its consequences.