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Marijuana smoking is an independent risk factor for lung disease in HIV+
Long-term marijuana smoking was associated with lung disease in HIV-infected (HIV+) but not HIV uninfected (HIV–) men who have sex with men (MSM), according to the results of a large, prospective cohort study.
“There were no significant interactions between marijuana and tobacco smoking in any multivariable model tested for HIV+ participants, indicating independent effects of these factors,” wrote David R. Lorenz, PhD, of the Dana-Farber Cancer Institute, Boston, and his colleagues.
These findings are especially important given that the proportion of HIV+ individuals who frequently smoke marijuana is higher than in the general population in the United States, and has increased in recent years, according to the report, published online in EClinicalMedicine.
The study examined 2,704 MSM who met eligibility criteria (1,352 HIV+ and 1,352 HIV− individuals), with a median age of 44 years at baseline and a median follow-up of 10.5 years. A total of 27% of HIV+ participants reported daily or weekly marijuana smoking for 1 year or more during follow-up, compared with 18% of the HIV− participants.
HIV+ participants who smoked marijuana were more likely to report one or more pulmonary diagnoses, versus nonsmoking HIV+ individuals during follow-up (41.0% vs. 30.0% infectious, and 24.8% vs. 19.0% noninfectious), according to the authors. In contrast, there was no association between marijuana smoking and either an infectious or noninfectious pulmonary diagnosis among HIV− participants (24.2% vs. 20.9%, and 14.8% vs. 17.7%, respectively).
For HIV+ individuals, each 10 days/month increase in marijuana smoking in the prior 2-year period was found to be associated with a 6% increased risk of infectious pulmonary diagnosis (hazard risk 1.06 [95% confidence interval 1.00-1.11]; P = .041). Overall, they found that from the 53,000 person-visits in the study, marijuana smoking was associated with increased risk of both infectious and noninfectious pulmonary diagnoses among the 1,352 HIV-infected participants independent of CD4 count, antiretroviral therapy (ART) adherence, and demographic factors as well.
In particular, viral suppression did not seem to interfere with this association between marijuana smoking and infectious pulmonary diagnoses, as it remained significant in models restricted to those person-visits with suppressed HIV viral load (HR 1.41 [1.03-1.91], P = .029).
The authors suggested that HIV-specific factors such as lung immune cell depletion and dysfunction, persistent immune cell activation, systemic inflammation, respiratory microbiome alterations, and oxidative stress, or a combination of these effects, may interact with the alveolar macrophage dysfunction seen in both humans and mouse models exposed to marijuana smoke. Thus, “a potential additive risk of marijuana smoking and HIV disease may explain the increased prevalence of infectious pulmonary diagnoses in our adjusted analyses,” Dr. Lorenz and his colleagues stated.
“These findings suggest that marijuana smoking is a modifiable risk factor that healthcare providers should consider when seeking to prevent or treat lung disease in people infected with HIV, particularly those with other known risk factors including heavy tobacco smoking, and low CD4 T cell count or advanced HIV disease,” they concluded.
The National Institutes of Health funded the study. The authors reported that they had no relevant disclosures.
SOURCE: Lorenz DR et al. EClinicalMedicine. 2019 Jan 24. doi: 10.1016/j.eclinm.2019.01.003.
Long-term marijuana smoking was associated with lung disease in HIV-infected (HIV+) but not HIV uninfected (HIV–) men who have sex with men (MSM), according to the results of a large, prospective cohort study.
“There were no significant interactions between marijuana and tobacco smoking in any multivariable model tested for HIV+ participants, indicating independent effects of these factors,” wrote David R. Lorenz, PhD, of the Dana-Farber Cancer Institute, Boston, and his colleagues.
These findings are especially important given that the proportion of HIV+ individuals who frequently smoke marijuana is higher than in the general population in the United States, and has increased in recent years, according to the report, published online in EClinicalMedicine.
The study examined 2,704 MSM who met eligibility criteria (1,352 HIV+ and 1,352 HIV− individuals), with a median age of 44 years at baseline and a median follow-up of 10.5 years. A total of 27% of HIV+ participants reported daily or weekly marijuana smoking for 1 year or more during follow-up, compared with 18% of the HIV− participants.
HIV+ participants who smoked marijuana were more likely to report one or more pulmonary diagnoses, versus nonsmoking HIV+ individuals during follow-up (41.0% vs. 30.0% infectious, and 24.8% vs. 19.0% noninfectious), according to the authors. In contrast, there was no association between marijuana smoking and either an infectious or noninfectious pulmonary diagnosis among HIV− participants (24.2% vs. 20.9%, and 14.8% vs. 17.7%, respectively).
For HIV+ individuals, each 10 days/month increase in marijuana smoking in the prior 2-year period was found to be associated with a 6% increased risk of infectious pulmonary diagnosis (hazard risk 1.06 [95% confidence interval 1.00-1.11]; P = .041). Overall, they found that from the 53,000 person-visits in the study, marijuana smoking was associated with increased risk of both infectious and noninfectious pulmonary diagnoses among the 1,352 HIV-infected participants independent of CD4 count, antiretroviral therapy (ART) adherence, and demographic factors as well.
In particular, viral suppression did not seem to interfere with this association between marijuana smoking and infectious pulmonary diagnoses, as it remained significant in models restricted to those person-visits with suppressed HIV viral load (HR 1.41 [1.03-1.91], P = .029).
The authors suggested that HIV-specific factors such as lung immune cell depletion and dysfunction, persistent immune cell activation, systemic inflammation, respiratory microbiome alterations, and oxidative stress, or a combination of these effects, may interact with the alveolar macrophage dysfunction seen in both humans and mouse models exposed to marijuana smoke. Thus, “a potential additive risk of marijuana smoking and HIV disease may explain the increased prevalence of infectious pulmonary diagnoses in our adjusted analyses,” Dr. Lorenz and his colleagues stated.
“These findings suggest that marijuana smoking is a modifiable risk factor that healthcare providers should consider when seeking to prevent or treat lung disease in people infected with HIV, particularly those with other known risk factors including heavy tobacco smoking, and low CD4 T cell count or advanced HIV disease,” they concluded.
The National Institutes of Health funded the study. The authors reported that they had no relevant disclosures.
SOURCE: Lorenz DR et al. EClinicalMedicine. 2019 Jan 24. doi: 10.1016/j.eclinm.2019.01.003.
Long-term marijuana smoking was associated with lung disease in HIV-infected (HIV+) but not HIV uninfected (HIV–) men who have sex with men (MSM), according to the results of a large, prospective cohort study.
“There were no significant interactions between marijuana and tobacco smoking in any multivariable model tested for HIV+ participants, indicating independent effects of these factors,” wrote David R. Lorenz, PhD, of the Dana-Farber Cancer Institute, Boston, and his colleagues.
These findings are especially important given that the proportion of HIV+ individuals who frequently smoke marijuana is higher than in the general population in the United States, and has increased in recent years, according to the report, published online in EClinicalMedicine.
The study examined 2,704 MSM who met eligibility criteria (1,352 HIV+ and 1,352 HIV− individuals), with a median age of 44 years at baseline and a median follow-up of 10.5 years. A total of 27% of HIV+ participants reported daily or weekly marijuana smoking for 1 year or more during follow-up, compared with 18% of the HIV− participants.
HIV+ participants who smoked marijuana were more likely to report one or more pulmonary diagnoses, versus nonsmoking HIV+ individuals during follow-up (41.0% vs. 30.0% infectious, and 24.8% vs. 19.0% noninfectious), according to the authors. In contrast, there was no association between marijuana smoking and either an infectious or noninfectious pulmonary diagnosis among HIV− participants (24.2% vs. 20.9%, and 14.8% vs. 17.7%, respectively).
For HIV+ individuals, each 10 days/month increase in marijuana smoking in the prior 2-year period was found to be associated with a 6% increased risk of infectious pulmonary diagnosis (hazard risk 1.06 [95% confidence interval 1.00-1.11]; P = .041). Overall, they found that from the 53,000 person-visits in the study, marijuana smoking was associated with increased risk of both infectious and noninfectious pulmonary diagnoses among the 1,352 HIV-infected participants independent of CD4 count, antiretroviral therapy (ART) adherence, and demographic factors as well.
In particular, viral suppression did not seem to interfere with this association between marijuana smoking and infectious pulmonary diagnoses, as it remained significant in models restricted to those person-visits with suppressed HIV viral load (HR 1.41 [1.03-1.91], P = .029).
The authors suggested that HIV-specific factors such as lung immune cell depletion and dysfunction, persistent immune cell activation, systemic inflammation, respiratory microbiome alterations, and oxidative stress, or a combination of these effects, may interact with the alveolar macrophage dysfunction seen in both humans and mouse models exposed to marijuana smoke. Thus, “a potential additive risk of marijuana smoking and HIV disease may explain the increased prevalence of infectious pulmonary diagnoses in our adjusted analyses,” Dr. Lorenz and his colleagues stated.
“These findings suggest that marijuana smoking is a modifiable risk factor that healthcare providers should consider when seeking to prevent or treat lung disease in people infected with HIV, particularly those with other known risk factors including heavy tobacco smoking, and low CD4 T cell count or advanced HIV disease,” they concluded.
The National Institutes of Health funded the study. The authors reported that they had no relevant disclosures.
SOURCE: Lorenz DR et al. EClinicalMedicine. 2019 Jan 24. doi: 10.1016/j.eclinm.2019.01.003.
FROM ECLINICALMEDICINE
Key clinical point: HIV+ but not HIV– marijuana smokers had an increased rate of pulmonary diagnoses.
Major finding: HIV+ marijuana smokers were more likely to report one or more infectious or noninfectious pulmonary diagnoses, compared with nonsmoking HIV+ individuals (41.0% vs. 30.0%, and 24.8% vs. 19.0%, respectively).
Study details: A prospective cohort study of 1,352 HIV+ vs. 1,352 HIV– men who have sex with men.
Disclosures: The National Institutes of Health funded the study. The authors reported that they had no relevant disclosures.
Source: Lorenz DR et al. EClinicalMedicine. 2019 Jan 24. doi: 10.1016/j.eclinm.2019.01.003.
Arterial stiffness index may be potent tool for PAD risk stratification
An increased peripheral arterial stiffness index was associated with an increased rate of major adverse cardiac events (MACEs), independent of age, coronary artery disease, and Rutherford category, according to the results of a study of patients with peripheral arterial disease (PAD) presenting to the vascular surgery outpatient clinic at the San Francisco Veterans Affairs Medical Center.
Seventy-two patients with PAD were recruited during 2011-2016 and each had baseline radial artery applanation tonometry performed at a baseline visit. Their central radial artery augmentation index (AIX), normalized to 75 beats/min, and the peripheral AIX were calculated using pulse wave analysis. Subsequent MACEs were identified by chart review in the Journal of Surgical Research.
The cohort was predominately male (96%) and white (69%), with an average age of 69.4 years.
During a median follow-up period of 34 months, 14 patients experienced a MACE (19%). These events included eight myocardial infarctions or coronary revascularizations, four deaths from a cardiac cause, one stroke, and one transient ischemic attack. Unadjusted Cox proportional hazards models identified a significant association between the peripheral AIX and rate of MACE (hazard ratio, 1.54; 95% confidence interval, 1.06-2.22; P less than .02).
the researchers concluded.
The study was funded by public institutions including the National Institutes of Heath, the University of California, San Francisco, and a Society for Vascular Surgery Seed Grant and Career Development Award. The authors reported that they had no disclosures.
SOURCE: Ramirez JL et al. J Surg Res 2019;235:250-7.
An increased peripheral arterial stiffness index was associated with an increased rate of major adverse cardiac events (MACEs), independent of age, coronary artery disease, and Rutherford category, according to the results of a study of patients with peripheral arterial disease (PAD) presenting to the vascular surgery outpatient clinic at the San Francisco Veterans Affairs Medical Center.
Seventy-two patients with PAD were recruited during 2011-2016 and each had baseline radial artery applanation tonometry performed at a baseline visit. Their central radial artery augmentation index (AIX), normalized to 75 beats/min, and the peripheral AIX were calculated using pulse wave analysis. Subsequent MACEs were identified by chart review in the Journal of Surgical Research.
The cohort was predominately male (96%) and white (69%), with an average age of 69.4 years.
During a median follow-up period of 34 months, 14 patients experienced a MACE (19%). These events included eight myocardial infarctions or coronary revascularizations, four deaths from a cardiac cause, one stroke, and one transient ischemic attack. Unadjusted Cox proportional hazards models identified a significant association between the peripheral AIX and rate of MACE (hazard ratio, 1.54; 95% confidence interval, 1.06-2.22; P less than .02).
the researchers concluded.
The study was funded by public institutions including the National Institutes of Heath, the University of California, San Francisco, and a Society for Vascular Surgery Seed Grant and Career Development Award. The authors reported that they had no disclosures.
SOURCE: Ramirez JL et al. J Surg Res 2019;235:250-7.
An increased peripheral arterial stiffness index was associated with an increased rate of major adverse cardiac events (MACEs), independent of age, coronary artery disease, and Rutherford category, according to the results of a study of patients with peripheral arterial disease (PAD) presenting to the vascular surgery outpatient clinic at the San Francisco Veterans Affairs Medical Center.
Seventy-two patients with PAD were recruited during 2011-2016 and each had baseline radial artery applanation tonometry performed at a baseline visit. Their central radial artery augmentation index (AIX), normalized to 75 beats/min, and the peripheral AIX were calculated using pulse wave analysis. Subsequent MACEs were identified by chart review in the Journal of Surgical Research.
The cohort was predominately male (96%) and white (69%), with an average age of 69.4 years.
During a median follow-up period of 34 months, 14 patients experienced a MACE (19%). These events included eight myocardial infarctions or coronary revascularizations, four deaths from a cardiac cause, one stroke, and one transient ischemic attack. Unadjusted Cox proportional hazards models identified a significant association between the peripheral AIX and rate of MACE (hazard ratio, 1.54; 95% confidence interval, 1.06-2.22; P less than .02).
the researchers concluded.
The study was funded by public institutions including the National Institutes of Heath, the University of California, San Francisco, and a Society for Vascular Surgery Seed Grant and Career Development Award. The authors reported that they had no disclosures.
SOURCE: Ramirez JL et al. J Surg Res 2019;235:250-7.
FROM THE JOURNAL OF SURGICAL RESEARCH
Key clinical point: An increased peripheral arterial stiffness index was associated with an increased rate of MACEs.
Major finding: There was significant association between peripheral arterial stiffness and the rate of MACE (P less than .02).
Study details: Chart review study of 72 patients with PAD over time.
Disclosures: The study was funded by various public institutions. The authors reported that they had no disclosures.
Source: Ramirez JL et al. J Surg Res 2019 Mar;235:250-7.
Life’s Simple 7 tied to lowered PAD risk in long-term study
Adherence to the American Heart Association’s Life’s Simple 7 is associated with lower incidence of peripheral artery disease and less decline in ankle brachial index, according to the results of a retrospective analysis of patients in the Multi-Ethnic Study of Atherosclerosis (MESA) trial.
“These results support the use of LS7 to prevent PAD and decline in ABI in multiple racial/ethnic groups,” according to Jonathan T. Unkart, MD, of the department of medicine and public health, University of California, San Diego, and his colleagues.
MESA recruited 6,814 men and women aged 45-84 years who were free of clinical cardiovascular disease. The cohort comprised 53% women and had the following racial/ethnic composition: 38% non-Hispanic white; 28% African American; 23% Hispanic, and 11% Asian. MESA consisted of six exams, with the baseline exam occurring from 2000 to 2002, including assessment of all LS7 components and PAD assessment using ABI calculated on both left and right sides. The final exam was performed from 2010 to 2012.
As background, the metrics for Life’s Simple 7 consist of total cholesterol, blood pressure, blood glucose, smoking status, body mass index, physical activity, and adherence to a healthy diet score. Each element can be scored 2 points for optimum, 1 for average, and 0 for inadequate. The investigators assessed overall LS7 scores on a continuous 0-14 scale, as well as the overall categorical indications of inadequate, average, and optimum. Cox proportional hazard models were used to assess the association of individual LS7 components by overall LS7 with incident PAD, according to the researchers.
Interactions of race/ethnicity by LS7 score were assessed on a multiplicative scale for both incident PAD and decline in ABI outcomes, adjusted for age, sex, education, and income (Am J Prev Med. 2019;56:262-70).
A total of 5,529 participants had complete LS7 information and met inclusion criteria to assess incident PAD. Over a median follow-up of 9.2 years, 251 (4.5%) participants developed incident PAD and 419 (9.8%) participants had a decline of at least 0.15 in ABI. In addition, each point higher on the continuous LS7 scale was associated with 0.94-fold lower odds of decline in ABI (odds ratio, 0.94; 95% confidence interval, 0.87-0.97; P =.003).
Each point higher on the continuous LS7 scale was associated with a 17% lower rate of incident PAD (HR, 0.83; 95% CI, 0.78-0.88; P less than .001), according to the researchers.
The study showed that there was a significant prospective association between LS7 score and incident PAD in African Americans, Hispanics, and non-Hispanic whites. Although the association was not statistically significant for the Chinese Americans in MESA, this was likely because of the low number of incident PAD cases (only 18) in this group, according to the authors.
Analysis by individual LS7 components showed that more optimal levels of smoking, physical activity, glucose, and blood pressure were significantly associated with lower rates of incident PAD. Similarly, after adjustment for age, sex, race/ethnicity, income, education, and baseline ABI, more optimal levels of smoking, and glucose were significantly associated with lower odds of decline. These results for the decline in ABI did not appear to differ across race/ethnicity, according to Dr. Unkart and his colleagues.
In contrast, BMI, diet, and cholesterol were not associated with incident PAD or decline in ABI.
“Higher scores on the AHA LS7 were associated with lower incident PAD and less decline in ABI. Preventive measures targeting LS7 components could assist with reducing PAD-related morbidity and mortality,” the researchers concluded.
The work was supported by the National, Heart, Lung, and Blood Institute. Dr. Unkart and his colleagues reported that they had no disclosures.
SOURCE: Unkart JT et al. Am J Prev Med 2019;56:262-270.
Adherence to the American Heart Association’s Life’s Simple 7 is associated with lower incidence of peripheral artery disease and less decline in ankle brachial index, according to the results of a retrospective analysis of patients in the Multi-Ethnic Study of Atherosclerosis (MESA) trial.
“These results support the use of LS7 to prevent PAD and decline in ABI in multiple racial/ethnic groups,” according to Jonathan T. Unkart, MD, of the department of medicine and public health, University of California, San Diego, and his colleagues.
MESA recruited 6,814 men and women aged 45-84 years who were free of clinical cardiovascular disease. The cohort comprised 53% women and had the following racial/ethnic composition: 38% non-Hispanic white; 28% African American; 23% Hispanic, and 11% Asian. MESA consisted of six exams, with the baseline exam occurring from 2000 to 2002, including assessment of all LS7 components and PAD assessment using ABI calculated on both left and right sides. The final exam was performed from 2010 to 2012.
As background, the metrics for Life’s Simple 7 consist of total cholesterol, blood pressure, blood glucose, smoking status, body mass index, physical activity, and adherence to a healthy diet score. Each element can be scored 2 points for optimum, 1 for average, and 0 for inadequate. The investigators assessed overall LS7 scores on a continuous 0-14 scale, as well as the overall categorical indications of inadequate, average, and optimum. Cox proportional hazard models were used to assess the association of individual LS7 components by overall LS7 with incident PAD, according to the researchers.
Interactions of race/ethnicity by LS7 score were assessed on a multiplicative scale for both incident PAD and decline in ABI outcomes, adjusted for age, sex, education, and income (Am J Prev Med. 2019;56:262-70).
A total of 5,529 participants had complete LS7 information and met inclusion criteria to assess incident PAD. Over a median follow-up of 9.2 years, 251 (4.5%) participants developed incident PAD and 419 (9.8%) participants had a decline of at least 0.15 in ABI. In addition, each point higher on the continuous LS7 scale was associated with 0.94-fold lower odds of decline in ABI (odds ratio, 0.94; 95% confidence interval, 0.87-0.97; P =.003).
Each point higher on the continuous LS7 scale was associated with a 17% lower rate of incident PAD (HR, 0.83; 95% CI, 0.78-0.88; P less than .001), according to the researchers.
The study showed that there was a significant prospective association between LS7 score and incident PAD in African Americans, Hispanics, and non-Hispanic whites. Although the association was not statistically significant for the Chinese Americans in MESA, this was likely because of the low number of incident PAD cases (only 18) in this group, according to the authors.
Analysis by individual LS7 components showed that more optimal levels of smoking, physical activity, glucose, and blood pressure were significantly associated with lower rates of incident PAD. Similarly, after adjustment for age, sex, race/ethnicity, income, education, and baseline ABI, more optimal levels of smoking, and glucose were significantly associated with lower odds of decline. These results for the decline in ABI did not appear to differ across race/ethnicity, according to Dr. Unkart and his colleagues.
In contrast, BMI, diet, and cholesterol were not associated with incident PAD or decline in ABI.
“Higher scores on the AHA LS7 were associated with lower incident PAD and less decline in ABI. Preventive measures targeting LS7 components could assist with reducing PAD-related morbidity and mortality,” the researchers concluded.
The work was supported by the National, Heart, Lung, and Blood Institute. Dr. Unkart and his colleagues reported that they had no disclosures.
SOURCE: Unkart JT et al. Am J Prev Med 2019;56:262-270.
Adherence to the American Heart Association’s Life’s Simple 7 is associated with lower incidence of peripheral artery disease and less decline in ankle brachial index, according to the results of a retrospective analysis of patients in the Multi-Ethnic Study of Atherosclerosis (MESA) trial.
“These results support the use of LS7 to prevent PAD and decline in ABI in multiple racial/ethnic groups,” according to Jonathan T. Unkart, MD, of the department of medicine and public health, University of California, San Diego, and his colleagues.
MESA recruited 6,814 men and women aged 45-84 years who were free of clinical cardiovascular disease. The cohort comprised 53% women and had the following racial/ethnic composition: 38% non-Hispanic white; 28% African American; 23% Hispanic, and 11% Asian. MESA consisted of six exams, with the baseline exam occurring from 2000 to 2002, including assessment of all LS7 components and PAD assessment using ABI calculated on both left and right sides. The final exam was performed from 2010 to 2012.
As background, the metrics for Life’s Simple 7 consist of total cholesterol, blood pressure, blood glucose, smoking status, body mass index, physical activity, and adherence to a healthy diet score. Each element can be scored 2 points for optimum, 1 for average, and 0 for inadequate. The investigators assessed overall LS7 scores on a continuous 0-14 scale, as well as the overall categorical indications of inadequate, average, and optimum. Cox proportional hazard models were used to assess the association of individual LS7 components by overall LS7 with incident PAD, according to the researchers.
Interactions of race/ethnicity by LS7 score were assessed on a multiplicative scale for both incident PAD and decline in ABI outcomes, adjusted for age, sex, education, and income (Am J Prev Med. 2019;56:262-70).
A total of 5,529 participants had complete LS7 information and met inclusion criteria to assess incident PAD. Over a median follow-up of 9.2 years, 251 (4.5%) participants developed incident PAD and 419 (9.8%) participants had a decline of at least 0.15 in ABI. In addition, each point higher on the continuous LS7 scale was associated with 0.94-fold lower odds of decline in ABI (odds ratio, 0.94; 95% confidence interval, 0.87-0.97; P =.003).
Each point higher on the continuous LS7 scale was associated with a 17% lower rate of incident PAD (HR, 0.83; 95% CI, 0.78-0.88; P less than .001), according to the researchers.
The study showed that there was a significant prospective association between LS7 score and incident PAD in African Americans, Hispanics, and non-Hispanic whites. Although the association was not statistically significant for the Chinese Americans in MESA, this was likely because of the low number of incident PAD cases (only 18) in this group, according to the authors.
Analysis by individual LS7 components showed that more optimal levels of smoking, physical activity, glucose, and blood pressure were significantly associated with lower rates of incident PAD. Similarly, after adjustment for age, sex, race/ethnicity, income, education, and baseline ABI, more optimal levels of smoking, and glucose were significantly associated with lower odds of decline. These results for the decline in ABI did not appear to differ across race/ethnicity, according to Dr. Unkart and his colleagues.
In contrast, BMI, diet, and cholesterol were not associated with incident PAD or decline in ABI.
“Higher scores on the AHA LS7 were associated with lower incident PAD and less decline in ABI. Preventive measures targeting LS7 components could assist with reducing PAD-related morbidity and mortality,” the researchers concluded.
The work was supported by the National, Heart, Lung, and Blood Institute. Dr. Unkart and his colleagues reported that they had no disclosures.
SOURCE: Unkart JT et al. Am J Prev Med 2019;56:262-270.
FROM THE AMERICAN JOURNAL OF PREVENTIVE MEDICINE
Key clinical point: Life’s Simple 7 appears to be a valid tool for modifying PAD risk.
Major finding: Each point higher for the overall Life’s Simple 7 score was associated with a 17% lower rate of incident PAD (HR, 0.83; P less than .001).
Study details: Retrospective analysis of 5,529 individuals from the Multi-Ethnic Study of Atherosclerosis who were followed more than 10 years.
Disclosures: The work was supported by the National, Heart, Lung, and Blood Institute. The authors reported that they had no disclosures..
Source: Unkart JT et al. Am J Prev Med. 2019;56:262-70.
Residential HCV program improves veterans’ diagnosis and care
Integrating comprehensive and collaborative hepatitis C virus (HCV) care within a Veterans Affairs residential treatment program can substantially increase diagnosis and treatment of HCV-infected veterans with substance use disorder (SUD), according to the results of an evaluation study for the period from December 2014 to April 2018.
A total of 97.5% (582/597) of patient admissions to the program were screened for HCV infection, and 12.7% (74/582) of the cases were confirmed to be HCV positive. All of the positive cases were sent to an infectious disease (ID) clinic for further evaluation and, if appropriate, to begin HCV pharmacotherapy, according to the report, published in the Journal of Substance Abuse Treatment.
Of the HCV-positive cases, 78.4% (58/74) received pharmacotherapy, with a sustained virologic response rate of 82.8% (48/58), wrote Mary Jane Burton, MD, of the G.V. (Sonny) Montgomery VA Medical Center, Jackson, Miss., and her colleagues.
As part of the program, all veterans admitted to the SUD residential program were offered screening for HCV. Veterans with negative screening results received education about how to remain HCV negative via handouts and veterans who screened positive received brief supportive counseling and were referred to the ID clinic via a consult. Veterans confirmed to have chronic HCV infection receive education and evaluation in the HCV clinic while they attend the residential SUD program. Treatment for HCV is instituted as early as feasible and prescribing is in accordance with VA guidelines (Department of Veterans Affairs, 2018), with the goal of initiating pharmacotherapy treatment for HCV while the veteran is still in the residential program, according to the researchers.
Following discharge from the program, veterans on HCV treatment are scheduled for follow-up every 2 weeks in the HCV treatment clinic for the remainder of their pharmacotherapy, the researchers added.
Patient-level barriers to HCV treatment among the SUD population include reduced health literacy, low health care utilization, comorbid mental health conditions, and poor social support, according to the literature. Because multidisciplinary approaches to HCV treatment that mitigate these barriers have been shown to increase treatment uptake among these patients, the VA program was initiated, the researchers stated. Dr. Burton and her colleagues reported that 18.9% (14/74) of the HCV-positive cases were newly diagnosed and would have likely gone undetected without this program (J Substance Abuse Treatment. 2019;98:9-14).
“We have demonstrated that integrating a comprehensive HCV screening, education, referral, and treatment program within residential SUD treatment is feasible and effective in diagnosing previously unrecognized HCV infections, transitioning veterans into HCV care, and promoting treatment initiation,” the researchers concluded.
The Department of Veterans Affairs and the VA Center for Innovation supported the study. Dr. Burton reported research support from Merck Sharpe & Dohme.
Integrating comprehensive and collaborative hepatitis C virus (HCV) care within a Veterans Affairs residential treatment program can substantially increase diagnosis and treatment of HCV-infected veterans with substance use disorder (SUD), according to the results of an evaluation study for the period from December 2014 to April 2018.
A total of 97.5% (582/597) of patient admissions to the program were screened for HCV infection, and 12.7% (74/582) of the cases were confirmed to be HCV positive. All of the positive cases were sent to an infectious disease (ID) clinic for further evaluation and, if appropriate, to begin HCV pharmacotherapy, according to the report, published in the Journal of Substance Abuse Treatment.
Of the HCV-positive cases, 78.4% (58/74) received pharmacotherapy, with a sustained virologic response rate of 82.8% (48/58), wrote Mary Jane Burton, MD, of the G.V. (Sonny) Montgomery VA Medical Center, Jackson, Miss., and her colleagues.
As part of the program, all veterans admitted to the SUD residential program were offered screening for HCV. Veterans with negative screening results received education about how to remain HCV negative via handouts and veterans who screened positive received brief supportive counseling and were referred to the ID clinic via a consult. Veterans confirmed to have chronic HCV infection receive education and evaluation in the HCV clinic while they attend the residential SUD program. Treatment for HCV is instituted as early as feasible and prescribing is in accordance with VA guidelines (Department of Veterans Affairs, 2018), with the goal of initiating pharmacotherapy treatment for HCV while the veteran is still in the residential program, according to the researchers.
Following discharge from the program, veterans on HCV treatment are scheduled for follow-up every 2 weeks in the HCV treatment clinic for the remainder of their pharmacotherapy, the researchers added.
Patient-level barriers to HCV treatment among the SUD population include reduced health literacy, low health care utilization, comorbid mental health conditions, and poor social support, according to the literature. Because multidisciplinary approaches to HCV treatment that mitigate these barriers have been shown to increase treatment uptake among these patients, the VA program was initiated, the researchers stated. Dr. Burton and her colleagues reported that 18.9% (14/74) of the HCV-positive cases were newly diagnosed and would have likely gone undetected without this program (J Substance Abuse Treatment. 2019;98:9-14).
“We have demonstrated that integrating a comprehensive HCV screening, education, referral, and treatment program within residential SUD treatment is feasible and effective in diagnosing previously unrecognized HCV infections, transitioning veterans into HCV care, and promoting treatment initiation,” the researchers concluded.
The Department of Veterans Affairs and the VA Center for Innovation supported the study. Dr. Burton reported research support from Merck Sharpe & Dohme.
Integrating comprehensive and collaborative hepatitis C virus (HCV) care within a Veterans Affairs residential treatment program can substantially increase diagnosis and treatment of HCV-infected veterans with substance use disorder (SUD), according to the results of an evaluation study for the period from December 2014 to April 2018.
A total of 97.5% (582/597) of patient admissions to the program were screened for HCV infection, and 12.7% (74/582) of the cases were confirmed to be HCV positive. All of the positive cases were sent to an infectious disease (ID) clinic for further evaluation and, if appropriate, to begin HCV pharmacotherapy, according to the report, published in the Journal of Substance Abuse Treatment.
Of the HCV-positive cases, 78.4% (58/74) received pharmacotherapy, with a sustained virologic response rate of 82.8% (48/58), wrote Mary Jane Burton, MD, of the G.V. (Sonny) Montgomery VA Medical Center, Jackson, Miss., and her colleagues.
As part of the program, all veterans admitted to the SUD residential program were offered screening for HCV. Veterans with negative screening results received education about how to remain HCV negative via handouts and veterans who screened positive received brief supportive counseling and were referred to the ID clinic via a consult. Veterans confirmed to have chronic HCV infection receive education and evaluation in the HCV clinic while they attend the residential SUD program. Treatment for HCV is instituted as early as feasible and prescribing is in accordance with VA guidelines (Department of Veterans Affairs, 2018), with the goal of initiating pharmacotherapy treatment for HCV while the veteran is still in the residential program, according to the researchers.
Following discharge from the program, veterans on HCV treatment are scheduled for follow-up every 2 weeks in the HCV treatment clinic for the remainder of their pharmacotherapy, the researchers added.
Patient-level barriers to HCV treatment among the SUD population include reduced health literacy, low health care utilization, comorbid mental health conditions, and poor social support, according to the literature. Because multidisciplinary approaches to HCV treatment that mitigate these barriers have been shown to increase treatment uptake among these patients, the VA program was initiated, the researchers stated. Dr. Burton and her colleagues reported that 18.9% (14/74) of the HCV-positive cases were newly diagnosed and would have likely gone undetected without this program (J Substance Abuse Treatment. 2019;98:9-14).
“We have demonstrated that integrating a comprehensive HCV screening, education, referral, and treatment program within residential SUD treatment is feasible and effective in diagnosing previously unrecognized HCV infections, transitioning veterans into HCV care, and promoting treatment initiation,” the researchers concluded.
The Department of Veterans Affairs and the VA Center for Innovation supported the study. Dr. Burton reported research support from Merck Sharpe & Dohme.
FROM THE JOURNAL OF SUBSTANCE ABUSE TREATMENT
Prescribed opioids increase pneumonia risk in patients with, without HIV
Prescribed opioids were associated with an increase in community-acquired pneumonia in patients with and without HIV infection, according to results of a large database study.
People living with HIV (PLWH) appeared to have a greater community-acquired pneumonia (CAP) risk at lower opioid doses and particularly with immunosuppressive opioids compared with uninfected patients, although the difference was not significant, E. Jennifer Edelman, MD, of Yale University, New Haven, Conn., and her colleagues wrote in JAMA Internal Medicine.
The researchers performed a nested case-control study comprising 25,392 participants (98.9% men; mean age, 55 years) in the Veterans Aging Cohort Study from Jan. 1, 2000, through Dec. 31, 2012.
Dr. Edelman and her colleagues compared the characteristics of 4,246 CAP cases with those of 21,146 uninfected controls in the sample. They also compared cases and controls by HIV status. They ran bivariate and multivariate analysis to estimate odds ratios for CAP risk associated with opioid exposure. In addition, the researchers ran models stratified by HIV status and formally checked for an interaction between prescribed opioid characteristics and HIV status.
In unadjusted logistic regression, prescribed opioids were associated with increased odds of CAP, with the greatest risk observed with currently prescribed opioids, compared with past prescribed opioids or no opioids.
Prescribed opioids remained associated with CAP in the adjusted models for past unknown or nonimmunosuppressive (adjusted OR, 1.24; 95% confidence interval, 1.09-1.40) and past immunosuppressive opioid use (aOR, 1.42; 95% CI, 1.21-1.67).
For currently prescribed opioids, nonimmunosuppressive or unknown, the aOR was 1.23 (95% CI, 1.03-1.48). For currently prescribed immunosuppressive opioids, the aOR was 3.18 (95% CI, 2.44-4.14).
The researchers also found evidence of a dose-response effect such that currently prescribed high-dose opioids were associated with the greatest CAP risk, followed by medium- and then by low-dose opioids, whether immunosuppressive or not.
With regard to the effect of HIV status in stratified, adjusted analyses, CAP risk tended to be greater among PLWH with current prescribed opioids, especially immunosuppressive opioids, compared with uninfected patients. However, the overall interaction term for opioid × HIV status was not significant (P = .36).
Although the researchers stated that a limitation of their study was an inability to prove causality or rule out respiratory depression (vs. immunosuppression) as the cause of the increased CAP risk, “the observed effects of opioid immunosuppressive properties and CAP risk lend support to our hypothesis that opioids have clinically relevant immunosuppressive properties.”
Dr. Edelman and her colleagues cited several limitations. For example, they were not able to determine whether patients took their prescribed medications appropriately and assess whether the patients took nonmedically prescribed opioids. Also, because men made up such a large portion of the study population, it is unclear whether the results are generalizable to women.
Nevertheless, the study “adds to growing evidence of potential medical harms associated with prescribed opioids,” they wrote.
“Health care professionals should be aware of this additional CAP risk when they prescribe opioids, and future studies should investigate the effects of opioids prescribed for longer durations and on other immune-related outcomes,” wrote Dr. Edelman and her colleagues. “Understanding whether mitigating the risk of prescribed opioids for CAP is possible by using a lower dose and nonimmunosuppressive opioids awaits further study.”
However, without such data, when prescribed opioids are warranted, physicians should attempt to modify other factors known to affect CAP risk, including smoking and lack of vaccination, Dr. Edelman and her colleagues concluded.
Several U.S. government agencies and Yale University provided funding for the study. The authors reported that they had no conflicts.
SOURCE: Edelman EJ et al. JAMA Intern Med. 2019 Jan 7. doi: 10.1001/jamainternmed.2018.6101.
Prescribed opioids were associated with an increase in community-acquired pneumonia in patients with and without HIV infection, according to results of a large database study.
People living with HIV (PLWH) appeared to have a greater community-acquired pneumonia (CAP) risk at lower opioid doses and particularly with immunosuppressive opioids compared with uninfected patients, although the difference was not significant, E. Jennifer Edelman, MD, of Yale University, New Haven, Conn., and her colleagues wrote in JAMA Internal Medicine.
The researchers performed a nested case-control study comprising 25,392 participants (98.9% men; mean age, 55 years) in the Veterans Aging Cohort Study from Jan. 1, 2000, through Dec. 31, 2012.
Dr. Edelman and her colleagues compared the characteristics of 4,246 CAP cases with those of 21,146 uninfected controls in the sample. They also compared cases and controls by HIV status. They ran bivariate and multivariate analysis to estimate odds ratios for CAP risk associated with opioid exposure. In addition, the researchers ran models stratified by HIV status and formally checked for an interaction between prescribed opioid characteristics and HIV status.
In unadjusted logistic regression, prescribed opioids were associated with increased odds of CAP, with the greatest risk observed with currently prescribed opioids, compared with past prescribed opioids or no opioids.
Prescribed opioids remained associated with CAP in the adjusted models for past unknown or nonimmunosuppressive (adjusted OR, 1.24; 95% confidence interval, 1.09-1.40) and past immunosuppressive opioid use (aOR, 1.42; 95% CI, 1.21-1.67).
For currently prescribed opioids, nonimmunosuppressive or unknown, the aOR was 1.23 (95% CI, 1.03-1.48). For currently prescribed immunosuppressive opioids, the aOR was 3.18 (95% CI, 2.44-4.14).
The researchers also found evidence of a dose-response effect such that currently prescribed high-dose opioids were associated with the greatest CAP risk, followed by medium- and then by low-dose opioids, whether immunosuppressive or not.
With regard to the effect of HIV status in stratified, adjusted analyses, CAP risk tended to be greater among PLWH with current prescribed opioids, especially immunosuppressive opioids, compared with uninfected patients. However, the overall interaction term for opioid × HIV status was not significant (P = .36).
Although the researchers stated that a limitation of their study was an inability to prove causality or rule out respiratory depression (vs. immunosuppression) as the cause of the increased CAP risk, “the observed effects of opioid immunosuppressive properties and CAP risk lend support to our hypothesis that opioids have clinically relevant immunosuppressive properties.”
Dr. Edelman and her colleagues cited several limitations. For example, they were not able to determine whether patients took their prescribed medications appropriately and assess whether the patients took nonmedically prescribed opioids. Also, because men made up such a large portion of the study population, it is unclear whether the results are generalizable to women.
Nevertheless, the study “adds to growing evidence of potential medical harms associated with prescribed opioids,” they wrote.
“Health care professionals should be aware of this additional CAP risk when they prescribe opioids, and future studies should investigate the effects of opioids prescribed for longer durations and on other immune-related outcomes,” wrote Dr. Edelman and her colleagues. “Understanding whether mitigating the risk of prescribed opioids for CAP is possible by using a lower dose and nonimmunosuppressive opioids awaits further study.”
However, without such data, when prescribed opioids are warranted, physicians should attempt to modify other factors known to affect CAP risk, including smoking and lack of vaccination, Dr. Edelman and her colleagues concluded.
Several U.S. government agencies and Yale University provided funding for the study. The authors reported that they had no conflicts.
SOURCE: Edelman EJ et al. JAMA Intern Med. 2019 Jan 7. doi: 10.1001/jamainternmed.2018.6101.
Prescribed opioids were associated with an increase in community-acquired pneumonia in patients with and without HIV infection, according to results of a large database study.
People living with HIV (PLWH) appeared to have a greater community-acquired pneumonia (CAP) risk at lower opioid doses and particularly with immunosuppressive opioids compared with uninfected patients, although the difference was not significant, E. Jennifer Edelman, MD, of Yale University, New Haven, Conn., and her colleagues wrote in JAMA Internal Medicine.
The researchers performed a nested case-control study comprising 25,392 participants (98.9% men; mean age, 55 years) in the Veterans Aging Cohort Study from Jan. 1, 2000, through Dec. 31, 2012.
Dr. Edelman and her colleagues compared the characteristics of 4,246 CAP cases with those of 21,146 uninfected controls in the sample. They also compared cases and controls by HIV status. They ran bivariate and multivariate analysis to estimate odds ratios for CAP risk associated with opioid exposure. In addition, the researchers ran models stratified by HIV status and formally checked for an interaction between prescribed opioid characteristics and HIV status.
In unadjusted logistic regression, prescribed opioids were associated with increased odds of CAP, with the greatest risk observed with currently prescribed opioids, compared with past prescribed opioids or no opioids.
Prescribed opioids remained associated with CAP in the adjusted models for past unknown or nonimmunosuppressive (adjusted OR, 1.24; 95% confidence interval, 1.09-1.40) and past immunosuppressive opioid use (aOR, 1.42; 95% CI, 1.21-1.67).
For currently prescribed opioids, nonimmunosuppressive or unknown, the aOR was 1.23 (95% CI, 1.03-1.48). For currently prescribed immunosuppressive opioids, the aOR was 3.18 (95% CI, 2.44-4.14).
The researchers also found evidence of a dose-response effect such that currently prescribed high-dose opioids were associated with the greatest CAP risk, followed by medium- and then by low-dose opioids, whether immunosuppressive or not.
With regard to the effect of HIV status in stratified, adjusted analyses, CAP risk tended to be greater among PLWH with current prescribed opioids, especially immunosuppressive opioids, compared with uninfected patients. However, the overall interaction term for opioid × HIV status was not significant (P = .36).
Although the researchers stated that a limitation of their study was an inability to prove causality or rule out respiratory depression (vs. immunosuppression) as the cause of the increased CAP risk, “the observed effects of opioid immunosuppressive properties and CAP risk lend support to our hypothesis that opioids have clinically relevant immunosuppressive properties.”
Dr. Edelman and her colleagues cited several limitations. For example, they were not able to determine whether patients took their prescribed medications appropriately and assess whether the patients took nonmedically prescribed opioids. Also, because men made up such a large portion of the study population, it is unclear whether the results are generalizable to women.
Nevertheless, the study “adds to growing evidence of potential medical harms associated with prescribed opioids,” they wrote.
“Health care professionals should be aware of this additional CAP risk when they prescribe opioids, and future studies should investigate the effects of opioids prescribed for longer durations and on other immune-related outcomes,” wrote Dr. Edelman and her colleagues. “Understanding whether mitigating the risk of prescribed opioids for CAP is possible by using a lower dose and nonimmunosuppressive opioids awaits further study.”
However, without such data, when prescribed opioids are warranted, physicians should attempt to modify other factors known to affect CAP risk, including smoking and lack of vaccination, Dr. Edelman and her colleagues concluded.
Several U.S. government agencies and Yale University provided funding for the study. The authors reported that they had no conflicts.
SOURCE: Edelman EJ et al. JAMA Intern Med. 2019 Jan 7. doi: 10.1001/jamainternmed.2018.6101.
FROM JAMA INTERNAL MEDICINE
Key clinical point: Prescribed opioids, especially those with immunosuppressive properties, are associated with increased community-acquired pneumonia risk.
Major finding: For currently prescribed immunosuppressive opioids, the adjusted odds ratio for community-acquired pneumonia was 3.18 (95% confidence interval, 2.44-4.14).
Study details: A nested case-control study of 25,392 patients in the Veterans Aging Cohort Study from Jan. 1, 2000, through Dec. 31, 2012.
Disclosures: Funding was provided by a variety of government organizations and Yale University, New Haven, Conn. The authors reported that they had no conflicts.
Source: Edelman EJ et al. JAMA Intern Med. 2019 Jan 7. doi: 10.1001/jamainternmed.2018.6101.
COPD linked to higher in-hospital death rates in patients with PAD
A growing body of evidence suggests that, along with other vascular beds, smoking and chronic obstructive pulmonary disease (COPD) affect the arteries of the lower limbs in terms of the development of peripheral arterial disease (PAD), reported Karsten Keller, MD, of the Johannes Gutenberg-University Mainz (Germany) and his colleagues.
This provided the rationale for their large database analysis of inpatients with concomitant COPD and PAD. They found that the additional presence of COPD was associated with increased in-hospital mortality in patients with PAD.
“Our data suggest that COPD increased the mortality of PAD patients by the factor 1.2-fold,” they wrote in Respiratory Medicine. “Unexpectedly, this increase was not driven by [myocardial infarction] as the life-threatening acute presentation of [coronary artery disease], but rather related to an increased risk for [pulmonary embolism] and a higher coprevalence of cancer.”
Dr. Keller and his colleagues inspected the German inpatient national database based on ICD codes. They identified 5,611,827 adult inpatients (64.8% men) diagnosed with PAD between January 2005 and December 2015, and of those, 13.6% also were coded for COPD. Overall, 277,894 PAD patients (5.0%) died in the hospital, Dr. Keller and his colleagues wrote.
The all-cause, in-hospital mortality was significantly higher in PAD patients with COPD, compared with those without COPD (6.5% vs. 4.7%, respectively; P less than .001), and cardiovascular events comprising pulmonary embolism (PE), deep vein thrombosis (DVT), and myocardial infarction (MI) occurred more often in coprevalence with PAD and COPD than in PAD without COPD.
In PAD patients, COPD was an independent predictor of in-hospital death (odds ratio, 1.16; 95% confidence interval, 1.15-1.17; P less than .001) as well as an independent predictor for PE (OR, 1.44; 95% CI, 1.40-1.49; P less than .001).
Overall, PAD patients with COPD were of similar age as (73 years), but stayed slightly longer in the hospital than (9 vs. 8 days), those without COPD. PAD patients without COPD revealed more often cardiovascular risk factors like essential arterial hypertension and diabetes, but the prevalence of cardiovascular diseases such as coronary artery disease and heart failure were more often found in PAD patients with COPD. In addition, cancer and renal insufficiency also were more common in PAD patients with COPD, according to the authors.
“Remarkably, PAD patients with COPD showed more frequently lower PAD stages than those without COPD. Especially, PAD stage IV was more prevalent in PAD patients without COPD (19.6% vs. 13.8%; P less than 0.001),” the authors stated. In addition, amputations were more often performed in PAD patients without COPD.
Dr. Keller and his colleagues had the following conclusions regarding the clinical implications of their study: “I) PAD patients with long-standing tobacco use might benefit from COPD screening and treatment. II) PAD patients with additional COPD should be monitored more intensively, and the treatment for COPD should be optimized. III) COPD increases the risk for PE, and it is critical not to overlook this life-threatening disease. IV) MI and PE are important causes of in-hospital death in PAD patients with and without COPD.”
The German Federal Ministry of Education and Research funded the study, and the authors reported having no conflicts.
SOURCE: Keller K et al. Respir Med. 2019 Feb;147:1-6.
A growing body of evidence suggests that, along with other vascular beds, smoking and chronic obstructive pulmonary disease (COPD) affect the arteries of the lower limbs in terms of the development of peripheral arterial disease (PAD), reported Karsten Keller, MD, of the Johannes Gutenberg-University Mainz (Germany) and his colleagues.
This provided the rationale for their large database analysis of inpatients with concomitant COPD and PAD. They found that the additional presence of COPD was associated with increased in-hospital mortality in patients with PAD.
“Our data suggest that COPD increased the mortality of PAD patients by the factor 1.2-fold,” they wrote in Respiratory Medicine. “Unexpectedly, this increase was not driven by [myocardial infarction] as the life-threatening acute presentation of [coronary artery disease], but rather related to an increased risk for [pulmonary embolism] and a higher coprevalence of cancer.”
Dr. Keller and his colleagues inspected the German inpatient national database based on ICD codes. They identified 5,611,827 adult inpatients (64.8% men) diagnosed with PAD between January 2005 and December 2015, and of those, 13.6% also were coded for COPD. Overall, 277,894 PAD patients (5.0%) died in the hospital, Dr. Keller and his colleagues wrote.
The all-cause, in-hospital mortality was significantly higher in PAD patients with COPD, compared with those without COPD (6.5% vs. 4.7%, respectively; P less than .001), and cardiovascular events comprising pulmonary embolism (PE), deep vein thrombosis (DVT), and myocardial infarction (MI) occurred more often in coprevalence with PAD and COPD than in PAD without COPD.
In PAD patients, COPD was an independent predictor of in-hospital death (odds ratio, 1.16; 95% confidence interval, 1.15-1.17; P less than .001) as well as an independent predictor for PE (OR, 1.44; 95% CI, 1.40-1.49; P less than .001).
Overall, PAD patients with COPD were of similar age as (73 years), but stayed slightly longer in the hospital than (9 vs. 8 days), those without COPD. PAD patients without COPD revealed more often cardiovascular risk factors like essential arterial hypertension and diabetes, but the prevalence of cardiovascular diseases such as coronary artery disease and heart failure were more often found in PAD patients with COPD. In addition, cancer and renal insufficiency also were more common in PAD patients with COPD, according to the authors.
“Remarkably, PAD patients with COPD showed more frequently lower PAD stages than those without COPD. Especially, PAD stage IV was more prevalent in PAD patients without COPD (19.6% vs. 13.8%; P less than 0.001),” the authors stated. In addition, amputations were more often performed in PAD patients without COPD.
Dr. Keller and his colleagues had the following conclusions regarding the clinical implications of their study: “I) PAD patients with long-standing tobacco use might benefit from COPD screening and treatment. II) PAD patients with additional COPD should be monitored more intensively, and the treatment for COPD should be optimized. III) COPD increases the risk for PE, and it is critical not to overlook this life-threatening disease. IV) MI and PE are important causes of in-hospital death in PAD patients with and without COPD.”
The German Federal Ministry of Education and Research funded the study, and the authors reported having no conflicts.
SOURCE: Keller K et al. Respir Med. 2019 Feb;147:1-6.
A growing body of evidence suggests that, along with other vascular beds, smoking and chronic obstructive pulmonary disease (COPD) affect the arteries of the lower limbs in terms of the development of peripheral arterial disease (PAD), reported Karsten Keller, MD, of the Johannes Gutenberg-University Mainz (Germany) and his colleagues.
This provided the rationale for their large database analysis of inpatients with concomitant COPD and PAD. They found that the additional presence of COPD was associated with increased in-hospital mortality in patients with PAD.
“Our data suggest that COPD increased the mortality of PAD patients by the factor 1.2-fold,” they wrote in Respiratory Medicine. “Unexpectedly, this increase was not driven by [myocardial infarction] as the life-threatening acute presentation of [coronary artery disease], but rather related to an increased risk for [pulmonary embolism] and a higher coprevalence of cancer.”
Dr. Keller and his colleagues inspected the German inpatient national database based on ICD codes. They identified 5,611,827 adult inpatients (64.8% men) diagnosed with PAD between January 2005 and December 2015, and of those, 13.6% also were coded for COPD. Overall, 277,894 PAD patients (5.0%) died in the hospital, Dr. Keller and his colleagues wrote.
The all-cause, in-hospital mortality was significantly higher in PAD patients with COPD, compared with those without COPD (6.5% vs. 4.7%, respectively; P less than .001), and cardiovascular events comprising pulmonary embolism (PE), deep vein thrombosis (DVT), and myocardial infarction (MI) occurred more often in coprevalence with PAD and COPD than in PAD without COPD.
In PAD patients, COPD was an independent predictor of in-hospital death (odds ratio, 1.16; 95% confidence interval, 1.15-1.17; P less than .001) as well as an independent predictor for PE (OR, 1.44; 95% CI, 1.40-1.49; P less than .001).
Overall, PAD patients with COPD were of similar age as (73 years), but stayed slightly longer in the hospital than (9 vs. 8 days), those without COPD. PAD patients without COPD revealed more often cardiovascular risk factors like essential arterial hypertension and diabetes, but the prevalence of cardiovascular diseases such as coronary artery disease and heart failure were more often found in PAD patients with COPD. In addition, cancer and renal insufficiency also were more common in PAD patients with COPD, according to the authors.
“Remarkably, PAD patients with COPD showed more frequently lower PAD stages than those without COPD. Especially, PAD stage IV was more prevalent in PAD patients without COPD (19.6% vs. 13.8%; P less than 0.001),” the authors stated. In addition, amputations were more often performed in PAD patients without COPD.
Dr. Keller and his colleagues had the following conclusions regarding the clinical implications of their study: “I) PAD patients with long-standing tobacco use might benefit from COPD screening and treatment. II) PAD patients with additional COPD should be monitored more intensively, and the treatment for COPD should be optimized. III) COPD increases the risk for PE, and it is critical not to overlook this life-threatening disease. IV) MI and PE are important causes of in-hospital death in PAD patients with and without COPD.”
The German Federal Ministry of Education and Research funded the study, and the authors reported having no conflicts.
SOURCE: Keller K et al. Respir Med. 2019 Feb;147:1-6.
FROM RESPIRATORY MEDICINE
Key clinical point:
Major finding: All-cause, in-hospital mortality was significantly higher in PAD patients with COPD, compared with those without (6.5% vs. 4.7%; P less than 0.001).
Study details: Database analysis of 5.6 million German PAD inpatients stratified for COPD.
Disclosures: The German Federal Ministry of Education and Research funded the study, and the authors reported having no conflicts.
Source: Keller K et al. Respir Med. 2019 Feb;147:1-6.
Host stress response may be a factor in early-stage HCV clearance
The cellular stress response in hepatocytes may play a major role in controlling hepatitis C virus (HCV). This response may be an important host factor for virus clearance during the early stages of HCV infection, according to a review of acute and chronic HCV infection by W. Alfredo Ríos-Ocampo, MD, and his colleagues (Virus Res. 2019. doi: 10.1016/j.virusres.2018.12.013).
The reviewers examined the mechanisms of induction and modulation of oxidative stress and endoplasmic-reticular stress with regard to viral persistence and cell survival. The accumulated research indicates that the activation of the eIF2-alpha/ATF4 pathway and selective autophagy induction are involved in the elimination of harmful viral proteins after oxidative stress induction. This all suggests a negative role of autophagy upon HCV infection or a negative regulation of viral replication.
“We conclude from published studies and our own research that viral protein synthesis activates adaptive responses, including autophagy pathways, that act to limit viral protein load and thereby reduce oxidative stress and cell death. Exploitation of these pathways to reduce viral replication will be the next goal and might be a valuable addition to antiviral therapy,” the reviewers concluded.
The authors reported that they had no conflicts of interest.
SOURCE: Ríos-Ocampo, WA, et al. Virus Res. 2019. doi: 10.1016/j.virusres.2018.12.013).
The cellular stress response in hepatocytes may play a major role in controlling hepatitis C virus (HCV). This response may be an important host factor for virus clearance during the early stages of HCV infection, according to a review of acute and chronic HCV infection by W. Alfredo Ríos-Ocampo, MD, and his colleagues (Virus Res. 2019. doi: 10.1016/j.virusres.2018.12.013).
The reviewers examined the mechanisms of induction and modulation of oxidative stress and endoplasmic-reticular stress with regard to viral persistence and cell survival. The accumulated research indicates that the activation of the eIF2-alpha/ATF4 pathway and selective autophagy induction are involved in the elimination of harmful viral proteins after oxidative stress induction. This all suggests a negative role of autophagy upon HCV infection or a negative regulation of viral replication.
“We conclude from published studies and our own research that viral protein synthesis activates adaptive responses, including autophagy pathways, that act to limit viral protein load and thereby reduce oxidative stress and cell death. Exploitation of these pathways to reduce viral replication will be the next goal and might be a valuable addition to antiviral therapy,” the reviewers concluded.
The authors reported that they had no conflicts of interest.
SOURCE: Ríos-Ocampo, WA, et al. Virus Res. 2019. doi: 10.1016/j.virusres.2018.12.013).
The cellular stress response in hepatocytes may play a major role in controlling hepatitis C virus (HCV). This response may be an important host factor for virus clearance during the early stages of HCV infection, according to a review of acute and chronic HCV infection by W. Alfredo Ríos-Ocampo, MD, and his colleagues (Virus Res. 2019. doi: 10.1016/j.virusres.2018.12.013).
The reviewers examined the mechanisms of induction and modulation of oxidative stress and endoplasmic-reticular stress with regard to viral persistence and cell survival. The accumulated research indicates that the activation of the eIF2-alpha/ATF4 pathway and selective autophagy induction are involved in the elimination of harmful viral proteins after oxidative stress induction. This all suggests a negative role of autophagy upon HCV infection or a negative regulation of viral replication.
“We conclude from published studies and our own research that viral protein synthesis activates adaptive responses, including autophagy pathways, that act to limit viral protein load and thereby reduce oxidative stress and cell death. Exploitation of these pathways to reduce viral replication will be the next goal and might be a valuable addition to antiviral therapy,” the reviewers concluded.
The authors reported that they had no conflicts of interest.
SOURCE: Ríos-Ocampo, WA, et al. Virus Res. 2019. doi: 10.1016/j.virusres.2018.12.013).
FROM VIRUS RESEARCH
Chronic infections such as HCV, HIV, and TB cause unique problems for psoriasis patients
In a review of therapeutic issues for psoriasis patients who have such chronic infections as hepatitis, HIV, or latent tuberculosis infection (LTBI) or those who fall into the category of special populations (pregnant women or children), significant concerns were directly tied to the mode of action of the drugs involved.
In particular, “Most systemic agents for psoriasis are immunosuppressive, which poses a unique treatment challenge in patients with psoriasis with chronic infections because they are already immunosuppressed,” according to Shivani B. Kaushik, MD, a resident in the department of dermatology at the Icahn School of Medicine at Mount Sinai, New York, and her colleague Mark G. Lebwohl, MD, professor and system chair of the department.
For example, the reviewers detailed a report of hepatitis B virus (HBV) and hepatitis C virus (HCV) reactivation in patients with psoriasis who were taking biologics. Virus reactivation was noted in 2/175 patients who were positive for anti-HBc antibody, 3/97 patients with HCV infection, and 8/40 patients who were positive for HBsAg (the surface antigen of HBV). From this, they concluded that “biologics pose minimal risk for viral reactivation in patients with anti-HCV or anti-HBc antibodies, but they are of considerable risk in HBsAg-positive patients.” (J Amer Acad Derm. 2019 Jan;80:43-53).
Giving a specific example, Dr. Kaushik and her colleague pointed out that the safety of ustekinumab in patients with psoriasis with concurrent HCV and HBV infection was not clear. Viral reactivation and hepatocellular cancer were reported in one of four patients with HCV and in two of seven HBsAg-positive patients; and yet, another study showed that the successful use of ustekinumab for psoriasis had no impact on liver function or viral load in a patient with coexisting HCV.
Overall, “Patients should not be treated with immunosuppressive therapies during the acute stage. However, biologic treatment can be initiated in patients with chronic or resolved hepatitis under close monitoring and collaboration with a gastroenterologist,” the researchers stated.
In addition, they pointed out that methotrexate, another commonly prescribed drug for psoriasis, is absolutely contraindicated, although the use of cyclosporine remains controversial for those patients who are HCV-antibody positive.
“Most systemic agents used in psoriasis are immunosuppressive and require appropriate screening, monitoring, and prophylaxis when used in [psoriasis] patients with chronic infections, such as hepatitis, HIV, and LTBI,” the authors concluded.
The authors reported receiving funding from a number of pharmaceutical companies.
SOURCE: Kaushik BS et al. J Amer Acad Derm. 2019;80:43-53.
In a review of therapeutic issues for psoriasis patients who have such chronic infections as hepatitis, HIV, or latent tuberculosis infection (LTBI) or those who fall into the category of special populations (pregnant women or children), significant concerns were directly tied to the mode of action of the drugs involved.
In particular, “Most systemic agents for psoriasis are immunosuppressive, which poses a unique treatment challenge in patients with psoriasis with chronic infections because they are already immunosuppressed,” according to Shivani B. Kaushik, MD, a resident in the department of dermatology at the Icahn School of Medicine at Mount Sinai, New York, and her colleague Mark G. Lebwohl, MD, professor and system chair of the department.
For example, the reviewers detailed a report of hepatitis B virus (HBV) and hepatitis C virus (HCV) reactivation in patients with psoriasis who were taking biologics. Virus reactivation was noted in 2/175 patients who were positive for anti-HBc antibody, 3/97 patients with HCV infection, and 8/40 patients who were positive for HBsAg (the surface antigen of HBV). From this, they concluded that “biologics pose minimal risk for viral reactivation in patients with anti-HCV or anti-HBc antibodies, but they are of considerable risk in HBsAg-positive patients.” (J Amer Acad Derm. 2019 Jan;80:43-53).
Giving a specific example, Dr. Kaushik and her colleague pointed out that the safety of ustekinumab in patients with psoriasis with concurrent HCV and HBV infection was not clear. Viral reactivation and hepatocellular cancer were reported in one of four patients with HCV and in two of seven HBsAg-positive patients; and yet, another study showed that the successful use of ustekinumab for psoriasis had no impact on liver function or viral load in a patient with coexisting HCV.
Overall, “Patients should not be treated with immunosuppressive therapies during the acute stage. However, biologic treatment can be initiated in patients with chronic or resolved hepatitis under close monitoring and collaboration with a gastroenterologist,” the researchers stated.
In addition, they pointed out that methotrexate, another commonly prescribed drug for psoriasis, is absolutely contraindicated, although the use of cyclosporine remains controversial for those patients who are HCV-antibody positive.
“Most systemic agents used in psoriasis are immunosuppressive and require appropriate screening, monitoring, and prophylaxis when used in [psoriasis] patients with chronic infections, such as hepatitis, HIV, and LTBI,” the authors concluded.
The authors reported receiving funding from a number of pharmaceutical companies.
SOURCE: Kaushik BS et al. J Amer Acad Derm. 2019;80:43-53.
In a review of therapeutic issues for psoriasis patients who have such chronic infections as hepatitis, HIV, or latent tuberculosis infection (LTBI) or those who fall into the category of special populations (pregnant women or children), significant concerns were directly tied to the mode of action of the drugs involved.
In particular, “Most systemic agents for psoriasis are immunosuppressive, which poses a unique treatment challenge in patients with psoriasis with chronic infections because they are already immunosuppressed,” according to Shivani B. Kaushik, MD, a resident in the department of dermatology at the Icahn School of Medicine at Mount Sinai, New York, and her colleague Mark G. Lebwohl, MD, professor and system chair of the department.
For example, the reviewers detailed a report of hepatitis B virus (HBV) and hepatitis C virus (HCV) reactivation in patients with psoriasis who were taking biologics. Virus reactivation was noted in 2/175 patients who were positive for anti-HBc antibody, 3/97 patients with HCV infection, and 8/40 patients who were positive for HBsAg (the surface antigen of HBV). From this, they concluded that “biologics pose minimal risk for viral reactivation in patients with anti-HCV or anti-HBc antibodies, but they are of considerable risk in HBsAg-positive patients.” (J Amer Acad Derm. 2019 Jan;80:43-53).
Giving a specific example, Dr. Kaushik and her colleague pointed out that the safety of ustekinumab in patients with psoriasis with concurrent HCV and HBV infection was not clear. Viral reactivation and hepatocellular cancer were reported in one of four patients with HCV and in two of seven HBsAg-positive patients; and yet, another study showed that the successful use of ustekinumab for psoriasis had no impact on liver function or viral load in a patient with coexisting HCV.
Overall, “Patients should not be treated with immunosuppressive therapies during the acute stage. However, biologic treatment can be initiated in patients with chronic or resolved hepatitis under close monitoring and collaboration with a gastroenterologist,” the researchers stated.
In addition, they pointed out that methotrexate, another commonly prescribed drug for psoriasis, is absolutely contraindicated, although the use of cyclosporine remains controversial for those patients who are HCV-antibody positive.
“Most systemic agents used in psoriasis are immunosuppressive and require appropriate screening, monitoring, and prophylaxis when used in [psoriasis] patients with chronic infections, such as hepatitis, HIV, and LTBI,” the authors concluded.
The authors reported receiving funding from a number of pharmaceutical companies.
SOURCE: Kaushik BS et al. J Amer Acad Derm. 2019;80:43-53.
FROM THE JOURNAL OF THE AMERICAN ACADEMY OF DERMATOLOGY
Opioid clinic physicians report lack of competency in managing patients with HCV
A survey of clinicians who provide opioid agonist therapy (OAT) to people who inject drugs (PWID), showed several areas where self-reported competency in the management and treatment of hepatitis C virus (HCV) could be improved.
The C-SCOPE study consisted of a self-administered survey among physicians practicing at clinics providing OAT in Australia, Canada, Europe, and the United States during April-May of 2017. Among 203 physicians – 40% in the United States, 45% in Europe, and 14% in Australia/Canada – 21% were addiction medicine specialists, and 29% were psychiatrists.
The majority reported that HCV testing (86%) and treatment (82%) among PWID were important.
The minority reported less than average competence with respect to regular screening (12%) and interpretation of HCV test results (14%), while greater proportions reported less than average competence in advising patients about new HCV therapies (28%), knowledge of new treatments (37%), and treatment/management of HCV (40%). Although a minority of participants self-reported average or less competency related to the ability to ensure regular screening for HCV (34%) and in the ability to interpret HCV test results (39%), more than half of the participants self-reported average or less competency in other areas. These areas included the ability to assess liver disease (52%), the ability to treat HCV and manage side effects (65%), and knowledge of new HCV treatments (64%). This trend was consistent with findings from previous studies among competency related to HCV infection among primary care providers, according to the authors (Int J Drug Policy. 2019;63:29-38).
“These low levels of reported competency in HCV management and treatment highlight a critical need for improved HCV education and training in how to manage and treat HCV among PWID,” the researchers concluded.
The authors reported grant funding and consultancy with a number of pharmaceutical companies. Funding was provided by Merck Sharp & Dohme and the Australian government.
SOURCE: Grebely J et al. Int J Drug Policy. 2019;63:29-38.
A survey of clinicians who provide opioid agonist therapy (OAT) to people who inject drugs (PWID), showed several areas where self-reported competency in the management and treatment of hepatitis C virus (HCV) could be improved.
The C-SCOPE study consisted of a self-administered survey among physicians practicing at clinics providing OAT in Australia, Canada, Europe, and the United States during April-May of 2017. Among 203 physicians – 40% in the United States, 45% in Europe, and 14% in Australia/Canada – 21% were addiction medicine specialists, and 29% were psychiatrists.
The majority reported that HCV testing (86%) and treatment (82%) among PWID were important.
The minority reported less than average competence with respect to regular screening (12%) and interpretation of HCV test results (14%), while greater proportions reported less than average competence in advising patients about new HCV therapies (28%), knowledge of new treatments (37%), and treatment/management of HCV (40%). Although a minority of participants self-reported average or less competency related to the ability to ensure regular screening for HCV (34%) and in the ability to interpret HCV test results (39%), more than half of the participants self-reported average or less competency in other areas. These areas included the ability to assess liver disease (52%), the ability to treat HCV and manage side effects (65%), and knowledge of new HCV treatments (64%). This trend was consistent with findings from previous studies among competency related to HCV infection among primary care providers, according to the authors (Int J Drug Policy. 2019;63:29-38).
“These low levels of reported competency in HCV management and treatment highlight a critical need for improved HCV education and training in how to manage and treat HCV among PWID,” the researchers concluded.
The authors reported grant funding and consultancy with a number of pharmaceutical companies. Funding was provided by Merck Sharp & Dohme and the Australian government.
SOURCE: Grebely J et al. Int J Drug Policy. 2019;63:29-38.
A survey of clinicians who provide opioid agonist therapy (OAT) to people who inject drugs (PWID), showed several areas where self-reported competency in the management and treatment of hepatitis C virus (HCV) could be improved.
The C-SCOPE study consisted of a self-administered survey among physicians practicing at clinics providing OAT in Australia, Canada, Europe, and the United States during April-May of 2017. Among 203 physicians – 40% in the United States, 45% in Europe, and 14% in Australia/Canada – 21% were addiction medicine specialists, and 29% were psychiatrists.
The majority reported that HCV testing (86%) and treatment (82%) among PWID were important.
The minority reported less than average competence with respect to regular screening (12%) and interpretation of HCV test results (14%), while greater proportions reported less than average competence in advising patients about new HCV therapies (28%), knowledge of new treatments (37%), and treatment/management of HCV (40%). Although a minority of participants self-reported average or less competency related to the ability to ensure regular screening for HCV (34%) and in the ability to interpret HCV test results (39%), more than half of the participants self-reported average or less competency in other areas. These areas included the ability to assess liver disease (52%), the ability to treat HCV and manage side effects (65%), and knowledge of new HCV treatments (64%). This trend was consistent with findings from previous studies among competency related to HCV infection among primary care providers, according to the authors (Int J Drug Policy. 2019;63:29-38).
“These low levels of reported competency in HCV management and treatment highlight a critical need for improved HCV education and training in how to manage and treat HCV among PWID,” the researchers concluded.
The authors reported grant funding and consultancy with a number of pharmaceutical companies. Funding was provided by Merck Sharp & Dohme and the Australian government.
SOURCE: Grebely J et al. Int J Drug Policy. 2019;63:29-38.
FROM THE INTERNATIONAL JOURNAL OF DRUG POLICY
PAD community forum provides insight into patient care, concerns
A developing feature of modern health care is the formation of eHealth communities based upon particular disease conditions. An analysis of one such forum dedicated to peripheral arterial disease indicated that this form of communications outlet can provide “a rich source of information related to the experiences of patients with PAD, their treatment preferences, questions they consider important, and terminology that they use,” according to a study published in Annals of Vascular Surgery.
The researchers collected 103 posts from an online open access PAD Medical Support Community forum (MedHelp) based in the United States. Posts were selected from PAD-specific threads and were analyzed for thematic content, common vernacular, and self-reported characteristics of the participants using a qualitative analysis software program. In addition, the investigators assessed disease-specific comments with regard to their match to contemporary PAD treatment guidelines, according to Peris Castaneda, a medical student, and her colleagues at the University of Michigan, Ann Arbor.
They found that, among original posts, the most common themes included PAD diagnosis and differential (25%), epidemiology and pathophysiology (21%), disease symptoms and effects on activities of daily living (15%), and health-care provider recommendations (13%). Negative posts related to experiences with health-care providers were identified in 10 of 18 (55.6%), while overall, 15.9% of posts mentioned medical advice that was inconsistent with clinical treatment guidelines.
“This information can be used to understand unmet patient needs, develop educational resources, and improve communication,” the authors wrote. “We hope that the results of this analysis can be applied to the development of additional resources targeting unmet patient and family needs and improved communication,” they concluded.
The were no disclosures reported in the article.
SOURCE: Castaneda P et al. Ann Vasc Surg. 2019;54:92-102.
A developing feature of modern health care is the formation of eHealth communities based upon particular disease conditions. An analysis of one such forum dedicated to peripheral arterial disease indicated that this form of communications outlet can provide “a rich source of information related to the experiences of patients with PAD, their treatment preferences, questions they consider important, and terminology that they use,” according to a study published in Annals of Vascular Surgery.
The researchers collected 103 posts from an online open access PAD Medical Support Community forum (MedHelp) based in the United States. Posts were selected from PAD-specific threads and were analyzed for thematic content, common vernacular, and self-reported characteristics of the participants using a qualitative analysis software program. In addition, the investigators assessed disease-specific comments with regard to their match to contemporary PAD treatment guidelines, according to Peris Castaneda, a medical student, and her colleagues at the University of Michigan, Ann Arbor.
They found that, among original posts, the most common themes included PAD diagnosis and differential (25%), epidemiology and pathophysiology (21%), disease symptoms and effects on activities of daily living (15%), and health-care provider recommendations (13%). Negative posts related to experiences with health-care providers were identified in 10 of 18 (55.6%), while overall, 15.9% of posts mentioned medical advice that was inconsistent with clinical treatment guidelines.
“This information can be used to understand unmet patient needs, develop educational resources, and improve communication,” the authors wrote. “We hope that the results of this analysis can be applied to the development of additional resources targeting unmet patient and family needs and improved communication,” they concluded.
The were no disclosures reported in the article.
SOURCE: Castaneda P et al. Ann Vasc Surg. 2019;54:92-102.
A developing feature of modern health care is the formation of eHealth communities based upon particular disease conditions. An analysis of one such forum dedicated to peripheral arterial disease indicated that this form of communications outlet can provide “a rich source of information related to the experiences of patients with PAD, their treatment preferences, questions they consider important, and terminology that they use,” according to a study published in Annals of Vascular Surgery.
The researchers collected 103 posts from an online open access PAD Medical Support Community forum (MedHelp) based in the United States. Posts were selected from PAD-specific threads and were analyzed for thematic content, common vernacular, and self-reported characteristics of the participants using a qualitative analysis software program. In addition, the investigators assessed disease-specific comments with regard to their match to contemporary PAD treatment guidelines, according to Peris Castaneda, a medical student, and her colleagues at the University of Michigan, Ann Arbor.
They found that, among original posts, the most common themes included PAD diagnosis and differential (25%), epidemiology and pathophysiology (21%), disease symptoms and effects on activities of daily living (15%), and health-care provider recommendations (13%). Negative posts related to experiences with health-care providers were identified in 10 of 18 (55.6%), while overall, 15.9% of posts mentioned medical advice that was inconsistent with clinical treatment guidelines.
“This information can be used to understand unmet patient needs, develop educational resources, and improve communication,” the authors wrote. “We hope that the results of this analysis can be applied to the development of additional resources targeting unmet patient and family needs and improved communication,” they concluded.
The were no disclosures reported in the article.
SOURCE: Castaneda P et al. Ann Vasc Surg. 2019;54:92-102.
FROM THE ANNALS OF VASCULAR SURGERY