Clinical Briefs
By Louis Kuritzky, MD, Clinical Assistant Professor, University of Florida, Gainesville
Dr. Kuritzky is a retained consultant for Boehringer Ingelheim, Daiichi Sankyo, Forest Pharmaceuticals,
Janssen, Lilly, Novo Nordisk, Pfizer, and Sanofi.
Downstream Benefits of Influenza Vaccine: Cardiovascular Outcomes
Source: Udell JA, et al. Association between influenza vaccination and cardiovascular outcomes in high-risk patients: A meta-analysis. JAMA 2013;310:1711-1720.
Few clinicians would disagree that influenza (flu) vaccine has generally recognized benefits in all age groups, with senior citizens deriving the greatest risk reduction in flu-related mortality. Nonetheless, it is easy to overlook the fact that flu vaccination has important impact on other downstream clinical consequences besides upper respiratory symptoms, including otitis media and — as this report details — cardiovascular (CV) health.
The death toll from flu disproportionately affects seniors, and is recorded during the annual flu epidemic as "pneumonia and influenza" deaths. Although flu is credited as the culprit, many of the pneumonia deaths are actually due to bacterial superinfection, often with staphylococci.
In a review of data beginning as early as 1946, the authors scrutinized more than 2000 reports on flu outcomes, ultimately defining 12 randomized, clinical trials (n = 6735) within their selection criteria of flu vaccine vs placebo in midlife adults (mean age = 67) considered to be at high CV risk.
The primary outcome of interest was a composite of fatal and nonfatal myocardial infarction and stroke as well as unstable angina, heart failure, and coronary revascularization. The data indicated that flu vaccine was associated with a 36% lower risk for this primary outcome. Clinician endorsement of vaccines has a powerful impact on patient concordance. Such data as these should stimulate intensified vigor for ensuring that our highest risk citizens enjoy the opportunity for CV risk reduction afforded through the flu vaccine.
Colchicine for Acute Pericarditis
Source: Imazio M, et al. A randomized trial of colchicine for acute pericarditis. N Engl J Med 2013;369:1522-1528.
Patients who suffer recurrent pericarditis differ from the larger population who incur an initial acute pericarditis, since the former often are burdened with an immune-modulated dysfunction (e.g., familial Mediterranean fever) and the latter includes a large number of diverse infectious etiologies (bacterial and viral). Guidelines have provided some support for the role of colchicine in recurrent pericarditis based primarily on small clinical trials and expert opinion. An open-label trial in acute pericarditis also supported a role for colchicine, but no large, randomized, double-blind trial has confirmed this experience.
Imazio et al report on data from a multicenter, placebo-controlled trial of colchicine in acute pericarditis (n = 240). The primary outcome was "incessant" pericarditis (failure to remit) or recurrent pericarditis. Colchicine or placebo was administered in addition to traditional treatment of pericarditis, and was dosed according to body weight (0.5 mg/d if < 70 kg, 1.0 mg/d if > 70 kg).
The primary outcome occurred 44% less often in the colchicine treatment group, and colchicine was successful for both components (improving remission rates and reducing recurrences).
Necrobiosis Lipoidica: A Review
Source: Reid SD, et al. Update on necrobiosis lipoidica: A review of etiology, diagnosis, and treatment options. J Am Acad Dermatol 2013;69:783-791.
The dermatologic words necrobiosis lipoidica are almost always followed by the word diabeticorum, since the disorder is seen predominantly in diabetics. Readers are encouraged to view photos of necrobiosis lipoidica diabeticorum (NLD) online. Although NLD is regarded as rare, in my experience it is one of the most commonly misdiagnosed cutaneous disorders in diabetics. NLD most commonly presents as symmetrical red-to-brown discolored irregular plaque-like deposits on the lower legs. Because the etiology — aside from its association with diabetes — is unclear, it should not be surprising that treatment regimens for NLD remain under study.
There are several evidence-based treatments for NLD. Immune modulation may be a key factor, since corticosteroids (topical, intralesional, or systemic) as well as other immunomodulators (e.g., infliximab, etanercept) have each had some success. The treatment with the highest rate of NLD resolution is psoralen plus ultraviolet A; unfortunately, the treatment regimen intensity (average 47 sessions) is well beyond that of many patients, and the method is not within the typical boundaries of primary care practice. Variable results have been seen among diverse categories of intervention (e.g., cyclosporine, tacrolimus, pioglitazone, hyperbaric oxygen). Refractory cases of NLD may merit consideration of dermatologic referral. Because outcomes are often less than optimal, patients should be informed that NLD is frequently a refractory dermatologic problem.
