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By Louis Kuritzky, MD, Clinical Assistant Professor, University of Florida, Gainesville. Dr. Kuritzky is a consultant for GlaxoSmithKline and is on the speaker's bureau of GlaxoSmithKline, 3M, Wyeth-Ayerst, Pfizer, Novartis, Bristol-Myers Squibb, AstraZeneca, Jones Pharma, and Boehringer Ingelheim.
Post-Stroke Prevention of Venous Thromboembolism
Unless prophylaxed, most post-stroke patients with hemiplegia develop deep venous thrombosis (DVT), and as many as 20% sustain pulmonary embolism (PE). Indeed, as many as 25% of early post-stroke deaths are attributable to PE.
Both low molecular weight heparin (LMWH) and unfractionated heparin (UHEP) are effective tools for prevention of venous thromboembolism, but a risk/benefit comparison of adequate size to provide conclusive evidence has been lacking.
Sherman, et al performed a study on patients (n = 1762) with acute ischemic stroke who were unable to ambulate due to the stroke. Subjects were randomly assigned to enoxaparin 40 mg SQ daily (LMWH), or UHEP 5000 U SQ every 12 hours, both administered for 10 days. The primary endpoint was a composite of DVT, and PE (fatal and nonfatal).
Compared to UHEP, LMWH reduced the primary endpoint by 43%, without any measurable difference in bleeding complications. Since enoxaparin is administered once daily, has greater efficacy than UHEP, and no greater bleeding risk, it should be preferred for prevention of venous thromboembolism.
Sherman DG, et al. Lancet. 2007;369:1347-1355.
Chronic Kidney Disease: Treatment Modality and Quality of Life
It is not surprising that chronic kidney disease (CKD) should exact a toll on quality of life (QOL). The studies on impact of treatment modality have been inconclusive, some indicating that continuous ambulatory peritoneal dialysis (CAPD) has less QOL detriment than hemodialysis (HMD), but others showing no difference. Kalender, et al evaluated CKD patients (n = 141) in comparison with healthy controls (n = 66) in reference to depression, malnutrition, inflammation (as measured by CRP and ferritin), CKD treatment modality, and their respective impact upon QOL, utilizing the SF-36 metric.
Overall, CAPD had QOL scores close to those of the control population. Depression was more common in HMD patients than CAPD also, and when depression was present in CAPD patients, the depression score was less (as measured by the Beck Depression Inventory).
Because malnutrition and inflammation were less frequent in the CAPD group, the authors posit that although HMD itself may be a culprit in detrimental QOL impact, malnutrition and inflammation may also play a role.
Kalender B, et al.Int J Clinical Practice. 2007;61(4):569-576.
Hepatitis C and Risk for Lymphoma
Although a minority of individuals who contract Hepatitis C (HEPc) spontaneously clear the virus (15-40%), most untreated individuals remain at risk for long-term consequences including chronic hepatitis, cirrhosis, and hepatic cancer.
The prevalence of HEPc in persons with nHOD is greater than the general population. Additionally, an association between HEPc and lymphoproliferative disorders has been bolstered by the observation of non-Hodgkin lymphoma (nHOD) regression subsequent to interferon treatment for HEPc.
US Veterans provide a population for studying the epidemiology of HEPc, since the prevalence of HEPc in this group is almost 5%, compared with 1.6% in the overall US population. National data from the US VA hospital system included 146,394 patients with HEPc, who were compared with 572,293 individuals negative for HEPc in this report by Giordano, et al.
The hazard ratio for nHOD among persons with HEPc was 1.28 (28% greater incidence). There was also increased risk of Waldenstrom macroglobulinemia, which is also considered a low-grade lymphoma. No other hematologic malignancies were disproportionately represented.
The authors conclude that this information supports a 20-30% increased risk for lymphoma among persons with HEPc.
Giordano T, et al. JAMA. 2007;297(18):2010-2017.