Mary A. De Vera

Serum uric acid levels and the risk of type 2 diabetes: a prospective study.

PURPOSE To evaluate the impact of serum uric acid levels on the future risk of developing type 2 diabetes independent of other factors. METHODS We used prospective data from the Framingham Heart Study original (n=4883) and offspring (n=4292) cohorts to examine the association between serum uric acid levels and the incidence of diabetes. We used Cox proportional hazards models to estimate the relative risk of incident diabetes adjusting for age, sex, physical activity, alcohol consumption, smoking, hypertension, body mass index, and blood levels of glucose, cholesterol, creatinine, and triglycerides. RESULTS We identified 641 incident cases of diabetes in the original cohort and 497 cases in the offspring cohort. The incidence rates of diabetes per 1000 person-years for serum uric acid levels <5.0, 5.0-5.9, 6.0-6.9, 7.0-7.9 and ≥8.0 mg/dL were 3.3, 6.1, 8.7, 11.5, and 15.9, respectively, in the original cohort; and 2.9, 5.0, 6.6, 8.7, and 10.9, respectively, in the offspring cohort (P-values for trends <.001). Multivariable relative risks per mg/dL increase in serum uric acid levels were 1.20 (95% confidence interval; 1.11-1.28) for the original cohort and 1.15 (95% confidence interval; 1.06-1.23) for the offspring cohort. CONCLUSIONS These prospective data from 2 generations of the Framingham Heart Study provide evidence that individuals with higher serum uric acid; including younger adults, are at a higher future risk of type 2 diabetes independent of other known risk factors. These data expand on cross-sectional associations between hyperuricemia and the metabolic syndrome, and extend the link to the future risk of type 2 diabetes.

Immediate and past cumulative effects of oral glucocorticoids on the risk of acute myocardial infarction in rheumatoid arthritis: a population-based study

OBJECTIVES To determine the effect of glucocorticoids (GCs) on acute myocardial infarction (MI) risk in patients with RA. METHODS Using administrative health data, we conducted a population-based cohort study of 8384 incident RA cases (1997-2006). Primary exposure was incident GC use. MI events were ascertained using hospitalization and vital statistics data. We used Cox proportional-hazards models and modelled GC use as four alternative time-dependent variables (current use, current dose, cumulative dose and cumulative duration), adjusting for demographics, comorbidities, cardiovascular drug use, propensity score and RA characteristics. Sensitivity analyses explored potential effects of unmeasured confounding. RESULTS Within 50 238 person-years in 8384 RA cases, we identified 298 incident MI events. Multivariable models showed that current GC use was associated with 68% increased risk of MI [Hazard ratio (HR) = 1.68, 95% CI 1.14, 2.47]. Similarly, separate multivariable models showed that current daily dose (HR = 1.14, 95% CI 1.05, 1.24 per each 5 mg/day increase), cumulative duration of use (HR = 1.14, 95% CI 1.00, 1.29 per year of GC use) and total cumulative dose (HR = 1.06, 95% CI 1.02, 1.10 per gram accumulated in the past) were also associated with increased risk of MI. Furthermore, in the same multivariable model, current dose and cumulative use were independently associated with an increased risk of MI (10% per additional year on GCs and 13% per 5 mg/day increase). CONCLUSION GCs are associated with an increased risk of MI in RA. Our results suggest a dual effect of GCs on MI risk, an immediate effect mediated through current dosage and a long-term effect of cumulative exposure.

Independent impact of gout on the risk of acute myocardial infarction among elderly women: a population-based study

Background Men with gout have been found to have an increased risk of acute myocardial infarction (AMI), but no corresponding data are available among women. Objective To evaluate the potential independent association between gout and the risk of AMI among elderly women, aged ≥65 years. Methods A population-based cohort study was conducted using the British Columbia Linked Health Database and compared incidence rates of AMI between 9642 gout patients and 48 210 controls, with no history of ischaemic heart disease. Cox proportional hazards models stratified by gender were used to estimate the relative risk (RR) for AMI, adjusting for age, comorbidities and prescription drug use. Results Over a 7-year median follow-up, 3268 incident AMI cases, were identified, 996 among women. Compared with women without gout, the multivariate RRs among women with gout were 1.39 (95% CI 1.20 to 1.61) for all AMI and 1.41 (95% CI 1.19 to 1.67) for non-fatal AMI. These RRs were significantly larger than those among men (multivariate RRs for all AMI and non-fatal AMI, 1.11 and 1.11; p values for interaction, 0.003 and 0.005, respectively). Conclusion These population-based data suggest that women with gout have an increased risk for AMI and the magnitude of excess risk is higher than in men.

Impact of statin adherence on cardiovascular disease and mortality outcomes: a systematic review

While suboptimal adherence to statin medication has been quantified in real‐world patient settings, a better understanding of its impact is needed, particularly with respect to distinct problems of medication taking. Our aim was to synthesize current evidence on the impacts of statin adherence, discontinuation and persistence on cardiovascular disease and mortality outcomes.

Gout and the risk of parkinson's disease: A cohort study

OBJECTIVE Several studies have suggested that higher serum uric acid levels lead to a lower risk of Parkinsons disease (PD) because uric acid exerts antioxidant effects on neurons. Our objective was to examine the relationship between gout and the risk of PD in persons age > or = 65 years. METHODS We conducted a population-based cohort study using the British Columbia Linked Health Database and PharmaCare data (i.e., prescription drug data for those age > or = 65 years). We compared incidence rates of PD between 11,258 gout patients and 56,199 controls matched on age, sex, date of gout diagnosis, and length of medical record. Cox proportional hazards models were used to estimate the relative risk (RR) of PD, adjusting for age, sex, prior comorbid conditions, and use of diuretics and nonsteroidal antiinflammatory drugs. RESULTS Over an 8-year median followup, we identified 1,182 new cases of PD. Compared with individuals without gout, the multivariate RR of PD among those with gout was 0.70 (95% confidence interval [95% CI] 0.59-0.83). In subgroup analyses, the inverse association was similarly present in both sexes and was evident among those who did not use diuretics (RR 0.66, 95% CI 0.54-0.81), but not among diuretic users (RR 0.80, 95% CI 0.58-1.10, P for interaction 0.35). CONCLUSION Our population-based data provide evidence for a protective effect of gout on the risk of PD and support the purported protective role of uric acid.

Medication Adherence in Gout: A Systematic Review

Recent data suggesting the growing problem of medication nonadherence in gout have called for the need to synthesize the burden, determinants, and impacts of the problem. Our objective was to conduct a systematic review of the literature examining medication adherence among patients with gout in real‐world settings.

Statin discontinuation and risk of acute myocardial infarction in patients with rheumatoid arthritis: a population-based cohort study

Objectives Screening for cardiovascular risk factors and treating hyperlipidaemia with statins are recommended to reduce the increased cardiovascular risk in individuals with rheumatoid arthritis (RA). However, poor compliance with statins may limit their therapeutic benefit. Our objective was to evaluate the impact of statin discontinuation on risk of acute myocardial infarction (AMI) among RA patients. Methods The authors conducted a population-based cohort study of RA patients with incident statin use followed from May 1996 to March 2006 using administrative health data. Primary exposure was statin discontinuation for ≥3 months at any time during therapy course. The authors used Coxs proportional hazards models and modelled statin discontinuation as a time-dependent variable, while adjusting for age, sex, comorbidities, use of other medications influencing cardiac risk, and proxy indicators of RA severity. Results During 15 669 person-years of follow-up in 4102 incident-statin users with RA, the authors identified 264 AMI events. Statin discontinuation was associated with 67% increased risk of AMI (adjusted HR 1.67; 95% CI 1.24 to 2.25). There was a 2% increase in risk of AMI with each 1-month increase in the duration of discontinuation (adjusted HR 1.02; 95% CI 1.01 to 1.03). These associations were not modified by timing of first statin prescription, prior AMI status, sex and age (p values for interactions >0.17). Conclusions These population-based data indicate that RA patients who discontinue statins have increased risk of AMI. Findings emphasise the need to raise awareness, among health professionals and people with RA, of the importance of compliance with statin therapy in RA.

Treatment of idiopathic clubfoot utilizing botulinum A toxin: a new method and its short-term outcomes.

A pivotal point in most clubfoot management protocols is Achilles tendon lengthening or tenotomy to address hindfoot deformity. The effectiveness of botulinum A toxin (BTX-A) in attenuating the function of the triceps surae muscle complex as an alternative to tenotomy was investigated. Fifty-one patients with 73 idiopathic clubfeet were recruited. Outcome measures included surgical rate, Pirani clubfoot score, ankle dorsiflexion with knee in flexion and extension, and recurrences. Patients were divided according to age: group 1 (<30 days old) and group 2 (>30 days and <8 months old). Ankle dorsiflexion in knee flexion and extension remained above 20 degrees and 15 degrees, respectively, and Pirani scores below 0.5 following BTX-A injection for both groups. One of the 51 patients required limited posterior release and 9 patients required repeat manipulation and casting plus or minus BTX-A injection. The use of BTX-A as an adjunctive therapy in the noninvasive approach of manipulation and casting in idiopathic clubfoot is a safe and effective treatment.

Impact of statin discontinuation on mortality in patients with rheumatoid arthritis: A population-based study

To evaluate the impact of statin discontinuation on cardiovascular disease (CVD) mortality and all‐cause mortality in a population‐based cohort of patients with rheumatoid arthritis (RA).

Normative data for the dynamic pedobarographic profiles of children

In order to establish the clinical utility of pedobarography in the treatment of childhood foot pathology, a reliable set of pedobarograph data describing non-pathologic feet is required. The purpose of this study was to describe the pedobarographic profiles of normal children across all ages, with specific focus on young children and explore age-related differences in foot pressure patterns. The Tekscan HR Mat pressure measurement system was used in a protocol involving a dynamic test at self-selected speed and walking pattern of 146 normal children (age range 1.6-14.9 years). Relative force and timing data were obtained across five foot segments (heel, lateral midfoot, medial midfoot, lateral forefoot, and medial forefoot). Analysis of variance (ANOVA) techniques were applied to determine if there were any age-related differences in foot pressure profiles in children across four a priori pedobarograph variables: % of stance at initiation at the heel, % of stance at initiation at the medial midfoot, maximum % force at the heel, maximum % force at the medial midfoot. Differences in foot pressure profiles were distinguished across three age groups: (1) Group 1: <2 years; (2) Group 2: 2-5 years; and (3) Group 3: >5 years. Age-related differences in initiation patterns, force transmission, and the amount of time spent on each foot segment provide evidence for maturation of childrens foot pressure profiles from a flatfoot pattern in the young child to a curvilinear pattern in the older child.