Risk and Prognosis of Cancer in Patients with Nephrotic Syndrome

Background

Nephrotic syndrome may be a marker of occult cancer, but population-based studies of this association are lacking. Therefore, we examined the risk and prognosis of cancer in patients with nephrotic syndrome.

Methods

We conducted this population-based cohort study in Denmark, including all individuals diagnosed with nephrotic syndrome between 1980 and 2010 without a preceding cancer history. We computed the 5-year risk of cancer accounting for competing risk by death and standardized incidence ratios (SIRs) of cancer in patients with nephrotic syndrome relative to the general population. We compared the 5-year mortality for patients with cancer after nephrotic syndrome with that for a cancer cohort without a history of nephrotic syndrome using Cox regression adjusted for age, gender, and comorbidity.

Results

Of 4293 individuals with nephrotic syndrome, 338 developed an incident cancer during a median follow-up of 5.7 years. The 5-year risk of any cancer was 4.7% in patients with nephrotic syndrome, a 73% increased risk (SIR, 1.73; 95% confidence interval [CI], 1.55-1.92). The association was most pronounced for lung cancer, kidney cancer, lymphoma, and multiple myeloma. It was highest within 1 year of nephrotic syndrome diagnosis (SIR, 4.49; 95% CI, 3.68-5.42), but remained increased beyond 1 year (SIR, 1.34; 95% CI, 1.17-1.53). The 5-year mortality after cancer was 68.5% in patients with cancer with nephrotic syndrome and 63.4% in the cancer comparison cohort (adjusted hazard ratio, 1.20; 95% CI, 1.02-1.42).

Conclusions

Nephrotic syndrome is a marker of occult solid tumors and hematologic malignancies and is associated with a worsened cancer prognosis.     

High incidence of potentially virus‐induced malignancies in systemic lupus erythematosus: A long‐term followup study in a Danish cohort

Objective

Patients with systemic lupus erythematosus (SLE) seem to experience an increased prevalence of oncogenic virus infections. The aim of the present study was to investigate whether SLE patients have an increased risk of virus‐associated malignancies, defined as malignancies potentially caused by virus infection.

Methods

A hospital‐based cohort of 576 SLE patients was linked to the Danish Cancer Registry. The cohort was followed up for malignancies from the date of SLE diagnosis, and standardized incidence ratios (SIRs) were calculated for various forms of cancer.

Results

The median duration of followup was 13.2 years. Compared to the general population, the patients experienced an increased overall risk of cancer (SIR 1.6 [95% confidence interval (95% CI)] 1.2–2.0). We observed an increased risk of virus‐associated cancers combined (SIR 2.9 [95% CI 2.0–4.1]). Among human papillomavirus (HPV)–associated malignant and premalignant conditions, high risk was found for anal cancer (SIR 26.9 [95% CI 8.7–83.4]), vaginal/vulvar cancer (SIR 9.1 [95% CI 2.3–36.5]), epithelial dysplasia/carcinoma in situ of the uterine cervix (SIR 1.8 [95% CI 1.2–2.7]), and nonmelanoma skin cancer (SIR 2.0 [95% CI 1.2–3.6]). Increased SIRs were also found for other potentially virus‐induced cancer types (liver cancer SIR 9.9 [95% CI 2.5–39.8], bladder cancer SIR 3.6 [95% CI 1.4–9.7], and non‐Hodgkin's lymphoma SIR 5.0 [95% CI 1.9–13.3]).

Conclusion

The patients in this SLE cohort experienced an increased risk of HPV‐associated tumors and other potentially virus‐induced cancers during long‐term followup. Our findings call for clinical alertness to oncogenic virus infections in SLE patients.

     

Management Practices and Major Infections After Cardiac Surgery

Background

Infections are the most common noncardiac complication after cardiac surgery, but their incidence across a broad range of operations, as well as the management factors that shape infection risk, remain unknown.

Objectives

This study sought to prospectively examine the frequency of post-operative infections and associated mortality, and modifiable management practices predictive of infections within 65 days from cardiac surgery.

Methods

This study enrolled 5,158 patients and analyzed independently adjudicated infections using a competing risk model (with death as the competing event).

Results

Nearly 5% of patients experienced major infections. Baseline characteristics associated with increased infection risk included chronic lung disease (hazard ratio [HR]: 1.66; 95% confidence interval [CI]: 1.21 to 2.26), heart failure (HR: 1.47; 95% CI: 1.11 to 1.95), and longer surgery (HR: 1.31; 95% CI: 1.21 to 1.41). Practices associated with reduced infection risk included prophylaxis with second-generation cephalosporins (HR: 0.70; 95% CI: 0.52 to 0.94), whereas post-operative antibiotic duration >48 h (HR: 1.92; 95% CI: 1.28 to 2.88), stress hyperglycemia (HR: 1.32; 95% CI: 1.01 to 1.73); intubation time of 24 to 48 h (HR: 1.49; 95% CI: 1.04 to 2.14); and ventilation >48 h (HR: 2.45; 95% CI: 1.66 to 3.63) were associated with increased risk. HRs for infection were similar with either <24 h or <48 h of antibiotic prophylaxis. There was a significant but differential effect of transfusion by surgery type (excluding left ventricular assist device procedures/transplant) (HR: 1.13; 95% CI: 1.07 to 1.20). Major infections substantially increased mortality (HR: 10.02; 95% CI: 6.12 to 16.39).

Conclusions

Major infections dramatically affect survival and readmissions. Second-generation cephalosporins were strongly associated with reduced major infection risk, but optimal duration of antibiotic prophylaxis requires further study. Given practice variations, considerable opportunities exist for improving outcomes and preventing readmissions. (Management Practices and Risk of Infection Following Cardiac Surgery; NCT01089712)     

Elevated anal squamous cell carcinoma risk associated with benign inflammatory anal lesions

BACKGROUND: The association between benign anal lesions and anal cancer is still unclear. Few data from large cohort studies are available. METHODS: We conducted a register based retrospective cohort study including 45,186 patients hospitalised for inflammatory anal lesions (anal fissures, fistulas, and perianal abscesses) as well as 79,808 haemorrhoid patients, from 1965 to 2002. Multiple record linkages identified all incident anal (squamous cell carcinoma only) and colorectal cancers through to 2002. Relative risk was estimated by standardised incidence ratio (SIR), the ratio of observed number of cases divided by that expected in the age, sex, and calendar year-matched general Swedish population. RESULTS: There was a distinct incidence peak in the first three years of follow up among patients with inflammatory lesions. SIR then levelled off at around 3 and remained at this level throughout follow up (SIR during years 3-37 of follow up was 3.3 (95% confidence interval 1.8-5.7)). A similar initial incidence peak was observed among haemorrhoid patients but was confined to the first year; SIR was 2.8 in the second year, and then it decreased further and was close to unity in the following years (SIR during years 3-37 was 1.3 (95% confidence interval 0.7-2.1)). Among inflammatory lesion and haemorrhoid patients, a significantly increased risk of colorectal cancer was observed only in the first year after hospitalisation. CONCLUSIONS: Inflammatory benign anal lesions are associated with a significantly increased long term risk of anal cancer. In contrast, haemorrhoids appear not to be a risk factor for this malignancy.     

Comparative cancer risk associated with methotrexate,other non-biologic and biologic disease-modifying anti-rheumatic drugs

Objective

There is little information comparing the potential risk of cancer across conventional and biologic disease-modifying anti-rheumatic drugs (DMARDs) in patients with rheumatoid arthritis (RA). Methotrexate has not been the focus of most contemporary pharmacoepidemiologic studies of cancer.

Methods

We conducted a comparative effectiveness study with cancer as the outcome. A large observational cohort of RA was followed up from 2001 to 2010. Reports of any cancer prompted a confirmation process that included adjudication of the primary cancer records. We used a propensity score (PS) with relevant covariates and cohort trimming to improve the balance between DMARD cohorts. Cox proportional hazard regression models were constructed to estimate the risk of cancer with various DMARDs, all compared with methotrexate.

Results

We identified 6806 DMARD courses for analysis (1566 methotrexate; 904 nbDMARDs; 3761 TNF antagonists; 408 abatacept; and 167 rituximab). Non-biologic DMARDs (HR 0.17, 95% CI 0.05–0.65) and TNF antagonists (HR 0.29, 95% CI 0.05–0.65) were associated with a reduced adjusted risk of cancer compared with methotrexate. Abatacept (HR 1.55, 95% CI 0.40–5.97) and rituximab (HR 0.42, 95% CI 0.07–2.60) were similar in risk of cancer with methotrexate. These results were robust to sensitivity analyses. After controlling for DMARD exposures, risk factors for cancer included male gender, age, and alcohol consumption.

Conclusions

Cancer risk was elevated for methotrexate users compared with nbDMARDs and TNF antagonists.     

Tratamiento clínico del micronódulo pulmonar solitario: un estudio piloto

Background

Solitary pulmonary micronodules (SPMN) characteristically have a diameter of 0.1-0.5 cm.

Objective

The aim of this prospective study is to evaluate the surgical approach to SPMN in order to establish the most appropriate treatment.

Methods

Between January 2007 and June 2011, 146 SPMN patients (94 males and 52 females) were prospectively evaluated. Patients were divided into two groups based on history of malignancy (Group A, 59 patients) and generic risk factors for lung cancer (Group B, 87 patients). After gathering patient information, we proposed surgery or thin-section computed tomography (TSCT) follow-up to both Groups.

Results

Preference for surgery versus TSCT follow-up was 90% versus 10% in Group A and 78% versus 22% in Group B, respectively. In Group A, we discovered 46 metastases from previous cancer (78%), 8 primary lung cancers (14%) and 5 benign lesions (8%). In Group B, we found 5 metastases (6%), 13 non-small-cell lung cancer (15%) and 69 benign lesions (79%). Statistical analysis revealed a high positive predictive value (PPV = 0.9) between total surgical patients versus TSCT follow-up patients.

Conclusions

The indication for surgery in solitary pulmonary micronodules is aimed at establishing early diagnosis and curing malignant disease. Our study indicates that in patients with previous cancer, surgery is essential. In patients with generic risk for lung cancer, surgical indications should be contemplated more carefully, even though the pulmonary malignancy rate of 21% in Group B seems to indicate the advisability of surgery.     

Determinants of Early Readmission After Hospitalization for Heart Failure

Background

Determination of factors increasing the likelihood of early readmission after hospitalization for heart failure (HF) is fundamental for identifying potential targets for intervention. Thus, we studied the characteristics of patients readmitted within 7 and 30 days after hospitalization for HF in Alberta, Canada.

Methods

Using hospital discharge abstract data, we followed patients with incident HF discharged from April 2004-March 2012 and determined their readmission status within 7 and 30 days after an index hospitalization. Logistic regression was used to determine variables associated with readmission.

Results

Of 18,590 patients with HF (49.8% women; mean age 76.4 years), 5.6% were readmitted within 7 days and 18% were readmitted within 30 days. Readmission rates within 7 and 30 days increased significantly with age. Seven-day all-cause readmissions were associated with history of kidney disease (adjusted odds ratio [aOR], 1.28; 95% confidence interval [CI], 1.08-1.53), and 30-day all-cause readmissions were associated with cancer, pulmonary, liver, and kidney disease. Discharge with home care services at the time of discharge was a risk factor for readmission within 7 days (aOR, 1.26; 95% CI, 1.07-1.49) and 30 days (aOR, 1.23; 95% CI, 1.11-1.35). Discharge from a hospital with HF services was associated with lower readmission at both 7 days (aOR, 0.65; 95% CI, 0.57-0.74) and 30 days (aOR, 0.71; 95% CI, 0.65-0.77).

Conclusions

Several factors were associated with increased risk of readmission, whereas patients discharged from hospitals with HF services had a lower risk of readmission within 7 and 30 days of discharge. The interaction of provision of home care and higher early readmission deserves further study.     

Incidence of and Mortality from Venous Thromboembolism in a Real-world Population: The Q-VTE Study Cohort

Background

The public health burden of venous thromboembolism, which includes deep vein thrombosis and pulmonary embolism, is not fully known, and contemporary incidence and mortality estimates are needed. We determined the incidence and case fatality of venous thromboembolism in a general population.

Methods

Using the administrative health care databases of the Canadian province of Québec, we identified all incident cases of deep vein thrombosis or pulmonary embolism between 2000 and 2009 and classified them as definite or probable venous thromboembolism. We formed 2 patient cohorts, one with definite cases and the other including cases with definite or probable venous thromboembolism that were followed until December 31, 2009.

Results

We identified 67,354 definite and 35,123 probable cases of venous thromboembolism. The age- and sex-adjusted incidence rates of definite or probable venous thromboembolism, deep vein thrombosis, and pulmonary embolism were 1.22 (95% confidence interval [CI], 1.22-1.23), 0.78 (95% CI, 0.77-0.79), and 0.45 (95% CI, 0.44-0.45) per 1000 person-years, respectively, while for definite venous thromboembolism it was 0.90 (95% CI, 0.89-0.90) per 1000 person-years. The 30-day and 1-year case-fatality rates after definite or probable venous thromboembolism were 10.6% (95% CI, 10.4-10.8) and 23.0% (95% CI, 22.8-23.3), respectively, and were slightly higher among definite cases. The 1-year survival rate was 0.47 (95% CI, 0.46-0.48) for cases with definite or probable venous thromboembolism and cancer, 0.93 (95% CI, 0.93-0.94) for cases with unprovoked venous thromboembolism, and 0.84 (95% CI, 0.83-0.84) for cases with venous thromboembolism secondary to a major risk factor. Similar survival rates were seen for cases with definite venous thromboembolism.

Conclusion

The risk of venous thromboembolism in the general population remains high, and mortality, especially in cancer patients with venous thromboembolism, is substantial.     

Association of implantable defibrillator therapy risk with body mass index in systolic heart failure

Objectives

To determine whether risk for implantable cardioverter-defibrillator (ICD) therapy varies by body mass index (BMI) in systolic heart failure (HF).

Background

It is unknown whether obesity increases sudden death risk in patients with systolic HF.

Methods

Secondary analysis of patients with HF, left ventricular ejection fraction ≤0.40 and ICD (N = 464) was performed using Cox regression modeling to assess risk for first delivered ICD therapy, with patients grouped by BMI (kg/m²): normal (18.5 to <25), overweight (25 to <30), and obese (≥30).

Results

Overweight patients, compared with patients with normal BMI, had greater adjusted risk for first ICD therapy (HR 1.66; 95% CI 1.02–2.71; P = 0.04), whereas obese BMI was not associated with risk for first ICD therapy.

Conclusions

There was an inverted U-shaped relationship between BMI and risk for first ICD therapy among systolic HF patients, with highest risk in overweight BMI.     

Pioglitazone does not affect the risk of kidney cancer in patients with type 2 diabetes

Objective

To investigate whether pioglitazone treatment of patients with type 2 diabetes mellitus was associated with an increased risk of kidney cancer.

Methods

The reimbursement databases of all Taiwanese patients with type 2 diabetes who received oral anti-diabetic agents or insulin from 1996 to 2009 were retrieved from the National Health Insurance. An entry date was set at 1 January 2006, and a total of 1,093,675 patients with type 2 diabetes were followed up for kidney cancer incidence until the end of 2009. The incidences of kidney cancer among patients who had and had not received pioglitazone, as well as among subgroups of those treated with pioglitazone (sorted by time since starting pioglitazone, duration of treatment and cumulative dose) were calculated and hazard ratios (HRs) estimated by Cox regression analysis.

Results

Of the 1,093,675 patients, 58,172 (5.3%) had and 1,035,503 (94.7%) had not received pioglitazone, with incident kidney cancer developing in 208 (0.36%) and 3304 (0.32%) patients, respectively, and a respective incidence of 97.7 and 90.5 per 100,000 person-years. Pioglitazone and kidney cancer were not significantly associated in unadjusted (HR 1.04; 95% confidence interval (CI), 0.90–1.20), age-sex-adjusted (HR 1.09; 95% CI, 0.95–1.25), and fully adjusted (HR 1.09; 95% CI, 0.94–1.26) models. None of the dose-response parameters showed a significant trend of risk association, with all P-trends >0.10.

Conclusions

Pioglitazone does not affect the risk of kidney cancer.     

Lymphoma in rheumatoid arthritis: The effect of methotrexate and anti–tumor necrosis factor therapy in 18,572 patients

Objective

The risk of lymphoma is increased in patients with rheumatoid arthritis (RA), and spontaneous reporting suggests that methotrexate (MTX) and anti–tumor necrosis factor (anti‐TNF) therapy might be associated independently with an increased risk of lymphoma. However, data from clinical trials and clinical practice do not provide sufficient evidence concerning these issues because of small sample sizes and selected study populations. The objective of this study was to determine the rate of and standardized incidence ratio (SIR) for lymphoma in patients with RA and in RA patient subsets by treatment group. Additionally, we sought to determine predictors of lymphoma in RA.

Methods

We prospectively studied 18,572 patients with RA who were enrolled in the National Data Bank for Rheumatic Diseases (NDB). Patients were surveyed biannually, and potential lymphoma cases received detailed followup. The SEER (Survey, Epidemiology, and End Results) cancer data resource was used to derive the expected number of cases of lymphoma in a cohort that was comparable in age and sex with the RA cohort.

Results

The overall SIR for lymphoma was 1.9 (95% confidence interval [95% CI] 1.3–2.7). The SIR for biologic use was 2.9 (95% CI 1.7–4.9) and for the use of infliximab (with or without etanercept) was 2.6 (95% CI 1.4–4.5). For etanercept, with or without infliximab, the SIR was 3.8 (95% CI 1.9–7.5). The SIR for MTX was 1.7 (95% CI 0.9–3.2), and was 1.0 (95% CI 0.4–2.5) for those not receiving MTX or biologics. Lymphoma was associated with increasing age, male sex, and education.

Conclusion

Lymphomas are increased in RA. Although the SIR is greatest for anti‐TNF therapies, differences between therapies are slight, and confidence intervals for treatment groups overlap. The increased lymphoma rates observed with anti‐TNF therapy may reflect channeling bias, whereby patients with the highest risk of lymphoma preferentially receive anti‐TNF therapy. Current data are insufficient to establish a causal relationship between RA treatments and the development of lymphoma.

     

Worsening Renal Function and Outcome in Heart Failure Patients With Preserved Ejection Fraction and the Impact of Angiotensin Receptor Blocker Treatment

Background

Worsening renal function (WRF) associated with renin-angiotensin-aldosterone system (RAAS) inhibition does not confer excess risk in heart failure patients with reduced ejection fraction (HFrEF).

Objectives

The goal of this study was to investigate the relationship between WRF and outcomes in heart failure patients with preserved ejection fraction (HFpEF) and the interaction with RAAS blockade.

Methods

In 3,595 patients included in the I-PRESERVE (Irbesartan in Heart Failure With Preserved Ejection Fraction) trial, change in estimated glomerular filtration rate (eGFR) and development of WRF after initiation of irbesartan or placebo were examined. We examined the association between WRF and the first occurrence of cardiovascular death or heart failure hospitalization (primary outcome in this analysis) and the interaction with randomized treatment.

Results

Estimated GFR decreased early with irbesartan treatment and remained significantly lower than in the placebo group. WRF developed in 229 (6.4%) patients and occurred more frequently with irbesartan treatment (8% vs. 4%). Overall, WRF was associated with an increased risk of the primary outcome (adjusted hazard ratio [HR]: 1.43; 95% confidence interval [CI]: 1.10 to 1.85; p = 0.008). Although the risk related to WRF was greater in the irbesartan group (HR: 1.66; 95% CI: 1.21 to 2.28; p = 0.002) than with placebo (HR: 1.09; 95% CI: 0.66 to 1.79; p = 0.73), the interaction between treatment and WRF on outcome was not significant in an adjusted analysis.

Conclusions

The incidence of WRF in HFpEF was similar to that previously reported in HFrEF but more frequent with irbesartan than with placebo. WRF after initiation of irbesartan treatment in HFpEF was associated with excess risk, in contrast to WRF occurring with RAAS blockade in HFrEF.     

Fasting Levels of High-Sensitivity Growth Hormone Predict Cardiovascular Morbidity and Mortality : The Malmö Diet and Cancer Study

Background

Both pathological excess and deficiency of growth hormone (GH) are associated with cardiovascular mortality.

Objectives

The goal of this study was to test whether fasting levels of growth hormone measured with a high-sensitivity assay (hs-GH) predict cardiovascular morbidity and mortality at the population level.

Methods

We studied 4,323 participants (age 46 to 68 years; mean age 58 years; 59% women) of the Swedish, population-based Malmö Diet and Cancer study examined in 1991 to 1994. Using multivariate-adjusted Cox proportional hazards models, we related baseline levels of fasting hs-GH to incidence of coronary artery disease, stroke, congestive heart failure, all-cause mortality, and cardiovascular mortality.

Results

During a median follow-up of 16.2 years, hs-GH (hazard ratio [HR]/SD increment of natural logarithm of fasting hs-GH) was independently associated with increased risk of coronary artery disease (397 events; HR: 1.11; 95% confidence interval [CI]: 1.01 to 1.23; p = 0.04), stroke (251 events; HR: 1.18; 95% CI: 1.04 to 1.34; p = 0.01), congestive heart failure (107 events; HR: 1.25; 95% CI: 1.03 to 1.52; p = 0.02), all-cause mortality (645 events; HR: 1.17; 95% CI: 1.08 to 1.26; p < 0.001) and cardiovascular mortality (186 events; HR: 1.43; 95% CI: 1.24 to 1.66; p < 0.001). The addition of hs-GH to a model with conventional cardiovascular risk factors significantly reclassified risk, with a category-free net reclassification improvement (>0) of 0.542 (95% CI: 0.205 to 0.840) in cardiovascular mortality.

Conclusions

Higher values of hs-GH were associated with an increased risk of cardiovascular morbidity and mortality.     

Risk of tuberculosis is higher with anti–tumor necrosis factor monoclonal antibody therapy than with soluble tumor necrosis factor receptor therapy: The three‐year prospective french research axed on tolerance of biotherapies registry

Objective

Tuberculosis (TB) is associated with anti–tumor necrosis factor (anti‐TNF) monoclonal antibody (mAb) therapy, but whether this association is drug‐specific remains a concern. Our objective was to describe cases of TB associated with anti‐TNF mAb therapy, identify risk factors, and estimate the incidence.

Methods

We conducted an incidence study and a case–control analysis to investigate the risk of newly diagnosed TB associated with the use of anti‐TNF agents. As part of the French Research Axed on Tolerance of Biotherapies (RATIO) registry, for 3 years we collected cases of TB among French patients receiving anti‐TNF mAb therapy for any indication; for each case, 2 patients treated with anti‐TNF agents served as control subjects.

Results

We collected 69 cases of TB in patients treated for rheumatoid arthritis (n = 40), spondylarthritides (n = 18), inflammatory colitis (n = 9), psoriasis (n = 1) and Behçet's disease (n = 1) with infliximab (n = 36), adalimumab (n = 28), and etanercept (n = 5). None of the patients had received correct chemoprophylactic treatment. The sex‐ and age‐adjusted incidence rate of TB was 116.7 per 100,000 patient‐years. The standardized incidence ratio (SIR) was 12.2 (95% confidence interval [95% CI] 9.7–15.5) and was higher for therapy with infliximab and adalimumab than for therapy with etanercept (SIR 18.6 [95% CI 13.4–25.8] and SIR 29.3 [95% CI 20.3–42.4] versus SIR 1.8 [95% CI 0.7–4.3], respectively). In the case–control analysis, exposure to infliximab or adalimumab versus etanercept was an independent risk factor for TB (odds ratio [OR] 13.3 [95% CI 2.6–69.0] and OR 17.1 [95% CI 3.6–80.6], respectively). Other risk factors were age, the first year of anti‐TNF mAb treatment, and being born in an endemic area.

Conclusion

The risk of TB is higher for patients receiving anti‐TNF mAb therapy than for those receiving soluble TNF receptor therapy. The increased risk with early anti‐TNF treatment and the absence of correct chemoprophylactic treatment favor the reactivation of latent TB.

     

Proportion and Risk Indicators of Nonadherence to Statin Therapy: A Meta-analysis

Background

Nonadherence to chronic disease medications is important. A growing body of literature suggests that better delivery of established therapies would save more lives than would discovery of innovations. Our first objective was to quantify the proportion of adherence to statin medications. The second objective was to provide estimates of risk indicators associated with nonadherence to statin medications.

Methods

We performed a systematic literature review and meta-analysis of all studies published between database inception and June of 2011 that reviewed adherence, and risk indicators associated with nonadherence, to statin medications.

Results

In the end, 67 studies met our inclusion and exclusion criteria and passed our methodological-quality evaluation. Among observational studies, 49.0% (95% confidence interval [CI], 48.9%-49.2%) of patients were adherent to statin medications at 1 year of follow-up. Among randomized trials, 90.3% (95% CI, 89.8%-90.8%) of patients were adherent to statin medications at 1 year of follow-up. The association between 147 variables and adherence to statin medications was determined. After meta-analysis, only 6 variables were associated with nonadherence to statin medications: primary prevention (rate ratio = 1.52; 95% CI, 1.50-1.53); new statin users (rate ratio = 1.46; 95% CI, 1.33-1.61); copayment (rate ratio = 1.28; 95% CI, 1.09-1.50; lower income status (rate ratio = 1.26; 95% CI, 1.16-1.37); fewer than 2 lipid tests performed (rate ratio = 1.38; 95% CI, 1.16-1.64), and not having hypertension (rate ratio = 1.16; 95% CI, 1.12-1.21).

Conclusions

This study provides some insight into the extent of nonadherence by study type along with 6 risk indicators associated with nonadherence to statin medications.     

Association of inflammatory factors with occurrence and recurrence of atrial fibrillation: A meta-analysis

Background

The role of circulating inflammatory factors in atrial fibrillation (AF) occurrence and recurrence remains inconclusive.

Methods

We conducted a meta-analysis of observational studies evaluating the association of inflammatory factors with AF risk, postoperative AF (POAF) occurrence after coronary artery bypass grafting (CABG) surgery, and AF recurrence after electrical cardioversion (EC) or catheter ablation.

Results

Increased C-reactive protein (CRP), interleukin-6 (IL-6) and tumor necrosis factor-α were significantly associated with AF risk (standardized mean difference [SMD] [95% confidence interval (CI)]: 0.95 [0.72–1.18], 0.89 [0.64–1.15] and 2.20 [1.17–3.23], respectively). In subgroup analysis, CRP was significantly associated with persistent and permanent AF risk, but not with paroxysmal AF. Increased preoperative CRP and IL-6 were associated with greater risk of post-CABG AF (SMD [95% CI]: 0.28 [0.02–0.54] and 1.03 [0.03–2.04], respectively). Consistent significant associations between CRP and AF recurrence were found in both patient subgroups who underwent EC (SMD, 0.56; 95% CI, 0.36–0.76) and ablation (SMD, 0.48; 95% CI, 0.11–0.86). IL-6 was significantly associated with AF recurrence after ablation (SMD, 0.55; 95% CI, 0.25–0.85), but not with the recurrence after EC (SMD, 0.85; 95% CI, − 0.26–1.95).

Conclusion

Increased circulating inflammatory factors, such as CRP and IL-6, are associated with greater AF risk in general population and patients who underwent CABG, as well as with AF recurrence after EC or ablation. Future research is warranted to elucidate the roles of other inflammatory markers, such as white blood cell, IL-8, and transforming growth factor-β1, in occurrence and recurrence of well-established different clinical subtypes of AF.     

Autoimmune diseases in women with Turner's Syndrome

Objective

In terms of number of X chromosomes, women with Turner's syndrome cytogenetically resemble men. An increased risk of autoimmune diseases has been observed among women with Turner's syndrome. This study was undertaken to investigate whether the autoimmune disease profile in women with Turner's syndrome is characterized by diseases with a female or male predominance.

Methods

Using the Danish Cytogenetic Central Register, the Danish National Patient Register, and the Danish Civil Registration System, we estimated relative risk of 46 different autoimmune diseases in a cohort of 798 Danish women with Turner's syndrome followed up for 12,461 person‐years between 1980 and 2004. Standardized incidence ratios (SIRs) of first hospitalization for autoimmune disease and 95% confidence intervals (95% CIs) were used as measures of relative risk.

Results

The overall risk of autoimmune disease among women with Turner's syndrome was twice that among Danish women in general (SIR 2.1 [95% CI 1.6–2.7]). For autoimmune diseases with a female predominance, the SIR among women with Turner's syndrome was 1.7 (95% CI 1.2–2.4), whereas the SIR for autoimmune diseases with a male predominance among these women was 3.9 (95% CI 2.5–5.8). Associations were strongest for Hashimoto thyroiditis (SIR 14.6 [95% CI 6.7–27.1]), a strongly female‐predominant condition, and type 1 diabetes mellitus (SIR 4.1 [95% CI 2.5–6.3]).

Conclusion

Women with Turner's syndrome are at excess risk of autoimmune diseases, notably autoimmune diseases characterized by male predominance.

     

The association of asthma and atrial fibrillation — A nationwide population-based nested case–control study

Background

Asthma and atrial fibrillation (AF) have been reported to be related to an increased risk of cardiovascular events. However, the relationship between asthma and AF has not been fully elucidated. The purpose of this study was to examine the association between asthma and AF risk.

Methods

We conducted a population-based nested case–control study including a total of 7439 newly-diagnosed adult patients with AF and 10,075 age-, gender-, comorbidity-, and cohort entry date-matched subjects without AF from the Taiwan National Health Insurance database. Exposure to asthma as well as medications including bronchodilators and corticosteroid before the index date was evaluated to investigate the association between AF and asthma as well as concurrent medications.

Results

AF patients were 1.2 times (adjusted OR 1.2, 95% CI 1.109–1.298) more likely to be associated with a future occurrence of asthma independent of comorbidities and treatment with corticosteroids and bronchodilator. In addition, the risks of new-onset AF were significantly higher among current users of inhaled corticosteroid, oral corticosteroids, and bronchodilators. Newly users (within 6 months) have the highest risk (inhaled corticosteroid: OR, 2.13; 95% CI, 1.226–3.701, P = 0.007; oral corticosteroid: OR, 1.932; 95% CI, 1.66–2.25, P < 0.001; non-steroid bronchodilator: OR, 2.849; 95% CI, 2.48–3.273, P < 0.001). A graded association with AF risk was also observed among subjects treated with corticosteroid (inhaled and systemic administration) and bronchodilators. New users (within 6 months) of these medications had the highest risk of AF (ICS: OR, 2.13; 95% CI, 1.226–3.701, P = 0.007; oral corticosteroid: OR, 1.932; 95% CI, 1.66–2.25, P < 0.001; non-steroid bronchodilator: OR, 2.849; 95% CI, 2.48–3.273, P < 0.001). A graded association with AF risk was also observed among subjects treated with ICS or bronchodilator.

Conclusions

Asthma was associated with an increased risk of developing future AF.     

Inpatient-outpatient Transitions for Patients with Resident Primary Care Physicians: Access and Readmission

Background

Transition from hospitalization to postdischarge care is a vulnerable period for patients. How the experience of this transition differs for patients with resident primary care physicians is unknown.

Methods

In a single, large academic primary care practice, we examined an inception cohort of consecutive hospitalizations and postdischarge visits of hospitalized patients with resident or faculty primary care physicians between 2008 and 2013. We compared patient demographics, readmission risk, and access to outpatient care between resident and faculty primary care physicians by using generalized estimating equations to account for repeated hospitalizations.

Results

We documented 8161 hospitalizations among patients with resident primary care physicians and 20,844 hospitalizations among patients with faculty primary care physicians. Hospitalized patients with resident primary care physicians were generally younger, more likely to be on Medicaid, and more likely to be African American (P < .001). Patients with resident primary care physicians were less likely to be seen within 7 and 30 days of discharge (adjusted relative risk, 0.83; 95% confidence interval [CI], 0.81-0.93 at 7 days; adjusted relative risk, 0.88; 95% CI, 0.85-0.92 at 30 days) and had an increased risk of readmission within 30 days (adjusted odds ratio, 1.25; 95% CI, 1.13-1.37). They also were considerably less likely to see their own provider at first follow-up (relative risk, 0.55; 95% CI, 0.52-0.59).

Conclusions

Hospitalized patients with resident primary care physicians had lower rates of timely postdischarge follow-up, higher rates of readmission, and a lower likelihood of seeing their own provider than did patients with faculty primary care physicians. These findings highlight the challenges facing academic centers for patients with resident primary care physicians.