Clinical Briefs by Louis Kuritzky, MD
Clinical Briefs
By Louis Kuritzky, MD, Clinical Assistant Professor, University of Florida, Gainesville. Dr. Kuritzky is a consultant for Sucampo Pharmaceuticals, Takeda, Boehringer Ingelheim; and is a consultant and on the speaker's bureau for Novo Nordisk, Lilly, Daiichi Sankyo, Forest Pharmaceuticals, Cephalon, Novartis, and Sanofi Aventis.
Getting a handle on hidradenitis suppurativa
Source: Canoui-Poitrine F, et al. Clinical characteristics of a series of 302 French patients with hidradenitis suppurativa, with an analysis of factors associated with disease severity. J Am Acad Dermatol 2009;61:51-57.
Hidradenitis suppurativa (HSP) is regarded both in the dermatology and primary care communities as a "heart sink" diagnosis: Patients are generally chronically burdened, we have little successful treatment, the pathophysiology is poorly understood, and the consequences often have an important negative impact on quality of life. As far as is understood at this point, HSP is a recurrent disorder characterized by recurrent, deep, painful abscesses at tissue sites containing apocrine glands (i.e., axillae, breasts, perineum, gluteal area). Since the currently quoted prevalence rate approaches 1%, all primary care clinicians who treat adults or adolescents are likely to encounter the disorder many times.
The Sartorius score is a recognized HSP severity score. It includes number of regions of the body involved, number of lesions (including abscesses, fistulas, scars, pustules), and presence/ absence of healthy skin between multiple lesions.
An assessment of 302 HSP patients from a dermatology clinic in Paris provided the opportunity to determine associations between Sartorius score (i.e., disease severity) and risk factors. In this population, BMI and severe acne were associated with a higher Sartorius score. Some of the treatments for acne have been shown to provide improvement in HSP, but it is unknown whether weight loss improves outcomes in HSP. Chronic lesions sometimes motivate patients to resort to surgical solutions for HSP. We continue to look forward to better insight into the pathophysiology of HSP, and more sustainable and effective interventions.
Is a prolonged PR interval innocent?
Source: Cheng S, et al. Long-term outcomes in individuals with prolonged PR interval or first-degree atrio-ventricular block. JAMA 2009;301: 2571-2577.
Apr interval prolonged beyond 200 milliseconds or first-degree heart block (FDHB) can be associated with cardiac pathology, inflammatory diseases, and medications. On the other hand, in ostensibly healthy ambulatory adults without risk factors for or evidence of coronary artery disease (and in the absence of culprit medications), FDHB is often summarily dismissed as being innocent. Well, maybe that designation needs to be reassessed.
Cheng et al evaluated data from the Framingham Heart Study. A population of adults (n = 7575) had a baseline EKG performed at age 47 (in the 1968-1974 time interval); follow-up data obtained in 2007 included incidence of pacemaker implantation, atrial fibrillation, and all-cause mortality.
There was a 2-fold or greater risk for atrial fibrillation, a 3-fold greater incidence of pacemaker implantation, and a 1.4 relative increase in all-cause mortality in persons with FDHB. This risk was linearly related to the degree of PR prolongation: For instance, for every 20 millisecond increment increase in PR interval, there was an 11% greater incidence of atrial fibrillation.
Previous data supporting the benign nature of FDHB were primarily based on data from younger adults. This long-term follow-up indicates that FDHB is indeed associated with adverse CV outcomes. The appropriate interval for follow-up or indicated evaluation (if any) was not suggested by the authors.
Migraine and ischemic brain lesions
Source: Scher AI, et al. Migraine headache in middle age and late- life brain infarcts. JAMA 2009;301: 2563-2570.
The relationship noted between migraine headaches (MIG) and an increased, albeit small, stroke risk has long been an issue of concern. Indeed, classic migraine (migraine with aura), which affects about one-third of migraineurs, has been associated with both stroke and CAD. A 2004 study reported that migraine was associated with increased risk (7-fold) for cerebellar infarcts, especially for persons with frequent migraine.
Scher et al performed a population-based study of midlife adult (mean age, 51 years) men and women (total n = 4689) in Reykjavik, Iceland, who were followed for more than 25 years. Detailed information about headaches including frequency, unilaterality, photophobia, nausea, and aura was obtained. Additionally, all subjects underwent MRI. Mean age at the time of MRI was 76 years.
Study subjects who reported midlife migraine with aura had a 40% greater incidence of late-life infarct on MRI. This increased risk was dominantly driven by an almost 2-fold greater risk of cerebellar infarcts in women. For men, there was no demonstrable increased risk. The risk of cerebellar infarct was independent of traditional risk factors for atherosclerosis. In women, midlife migraine may emerge as an important cerebrovascular risk factor.
Hidradenitis suppurativa (HSP) is regarded both in the dermatology and primary care communities as a "heart sink" diagnosis: Patients are generally chronically burdened, we have little successful treatment, the pathophysiology is poorly understood, and the consequences often have an important negative impact on quality of life.Subscribe Now for Access
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