Prognostic factors in patients with hepatitis C virus infection and systemic vasculitis.

OBJECTIVE: Hepatitis C virus (HCV)-related systemic vasculitis can cause significant morbidity and mortality. Most studies of the prognosis of patients with HCV-related systemic vasculitis are based on heterogeneous studies performed before the era of antiviral therapy. The aim of this study was to analyze the clinical, biologic, and therapeutic factors associated with prognosis in a homogeneous series of patients with HCV-related systemic vasculitis who were followed up during the era of antiviral therapy. METHODS: One hundred fifty-one consecutive HCV RNA-positive patients with vasculitis were prospectively followed up between 1993 and 2009 and were analyzed for clinical, biologic, and therapeutic factors associated with survival. RESULTS: After a median followup period of 54 months, 32 patients (21%) had died, mainly of infection and end-stage liver disease. The 1-year, 3-year, 5-year, and 10-year survival rates were 96%, 86%, 75%, and 63%, respectively. Baseline factors associated with a poor prognosis were the presence of severe liver fibrosis (hazard ratio [HR] 5.31), central nervous system involvement (HR 2.74), kidney involvement (HR 1.91), and heart involvement (HR 4.2). The Five-Factors Score (FFS), a vasculitis scoring system, was significantly associated with outcome. In multivariate analysis, severe fibrosis (HR 10.8) and the FFS (HR 2.49) were significantly associated with a poor prognosis. Treatment with the combination of PEGylated interferon plus ribavirin was associated with a good prognosis (HR 0.34), whereas treatment with immunosuppressive agents was associated with a poor outcome, after adjustment for the severity of vasculitis (HR 4.05). Among patients without severe fibrosis, the FFS was a good predictor of outcome, while among those with severe fibrosis, the severity of vasculitis had no prognostic value. CONCLUSION: At the time of the diagnosis of HCV-related systemic vasculitis, severe liver fibrosis and the severity of vasculitis were the main prognostic factors. Use of antiviral agents was associated with a good prognosis, whereas treatment with immunosuppressant agents had a negative impact.

Surrogate markers of B cell non-Hodgkin's lymphoma in patients with hepatitis C virus-related cryoglobulinaemia vasculitis.

OBJECTIVE: To evaluate clinical and biological surrogate markers associated with the presence of B cell non-Hodgkin's lymphoma (B-NHL) in patients with hepatitis C virus (HCV) with mixed cryoglobulinaemia (MC) vasculitis. METHODS: A total of 104 patients with HCV-MC vasculitis (including 20 with B-NHL) were included. The main clinical and biological markers associated with the presence of B-NHL were evaluated. RESULTS: Patients with B-NHL compared to those without showed higher rates of poor general status (40% vs 16.7%; p = 0.032), purpura (90% vs 66.7%; p = 0.05), renal (50% vs 28.6%; p = 0.11) and cardiac involvement (15% vs 0%; p = 0.0006), higher cryoglobulin levels (1.44 g/litre vs 0.67 g/litre; p = 0.0004), and lower C4 (0.025 g/litre vs 0.06 g/litre; p=0.001) and γ-globulin levels (5.3 g/litre vs 13.3 g/litre; p < 0.0001). The free light chain κ/λ ratio was more frequently abnormal in patients with than without B-NHL (64.3% vs 33.3%, p = 0.10). On multivariate analysis, only γ-globulin level was associated with the presence of B-NHL (OR 0.77 (95% CI -0.44 to -0.13), p = 0.0006). The optimal cut-off value for γ-globulin level was 9 g/litre, with sensitivity, specificity, positive and negative predictive values for the presence of B-NHL of 75%, 82%, 50% and 93%, respectively. CONCLUSIONS: In patients with HCV-MC, a low γ-globulin level (< 9 g/litre) is strongly associated with the presence of B-NHL.

Psychotropic Drug Consumption Among Older People Enrolled in a French Private Health Insurance Plan.

BACKGROUND: In France, little information exists on psychotropic drug consumption in the elderly. OBJECTIVE: This study aimed to describe the patterns of psychotropic drug consumption, including the extent of inappropriate prescribing, in elderly subjects enrolled in a large health insurance plan in France (MGEN). METHODS: In 2011, 5840 MGEN affiliates aged at least 65 years were randomly selected. Reimbursement claims were organized into a 1-year cross-sectional data set. The EphMRA (European Pharmaceutical Market Research Association) classification was used to identify prescriptions of psychotropic drugs, and the Laroche criteria to identify potentially inappropriate medications (PIMs). Treatment duration was estimated using WHO defined daily doses (DDDs). A multivariate analysis was performed to identify factors associated with the prescription of PIMs. RESULTS: In 2011, 2213 subjects (37.9 %) made at least one reimbursement claim for a psychotropic drug, with the claims rate increasing with age. The mean annual volume of prescriptions per user was 193 DDDs. General practitioners were found to generate most of these prescriptions (81.8 %). Of these 2213 users, only 137 (6.2 %) had consulted a mental health specialist, and this rate decreased with age. Moreover, 1428 (64.5 %) subjects were prescribed at least one PIM, rising to 1711 (77.3 %) when including concomitant use of psychotropic drugs. Finally, the number of psychotropic drugs prescribed was associated with a higher odds ratio (OR) of PIM prescription. CONCLUSIONS: Efforts should be made to reduce psychotropic drug prescriptions in elderly patients. This may contribute to reduce the amount of PIM prescriptions and the occurrence of iatrogenic side effects.

High burden of non-influenza viruses in influenza-like illness in the early weeks of H1N1v epidemic in France.

BACKGROUND: Influenza-like illness (ILI) may be caused by a variety of pathogens. Clinical observations are of little help to recognise myxovirus infection and implement appropriate prevention measures. The limited use of molecular tools underestimates the role of other common pathogens. OBJECTIVES: During the early weeks of the 2009-2010 flu pandemic, a clinical and virological survey was conducted in adult and paediatric patients with ILI referred to two French University hospitals in Paris and Tours. Aims were to investigate the different pathogens involved in ILI and describe the associated symptoms. METHODS: H1N1v pandemic influenza diagnosis was performed with real time RT-PCR assay. Other viral aetiologies were investigated by the molecular multiplex assay RespiFinder19®. Clinical data were collected prospectively by physicians using a standard questionnaire. RESULTS: From week 35 to 44, endonasal swabs were collected in 413 patients. Overall, 68 samples (16.5%) were positive for H1N1v. In 13 of them, other respiratory pathogens were also detected. Among H1N1v negative samples, 213 (61.9%) were positive for various respiratory agents, 190 in single infections and 23 in mixed infections. The most prevalent viruses in H1N1v negative single infections were rhinovirus (62.6%), followed by parainfluenza viruses (24.2%) and adenovirus (5.3%). 70.6% of H1N1v cases were identified in patients under 40 years and none after 65 years. There was no difference between clinical symptoms observed in patients infected with H1N1v or with other pathogens. CONCLUSION: Our results highlight the high frequency of non-influenza viruses involved in ILI during the pre-epidemic period of a flu alert and the lack of specific clinical signs associated with influenza infections. Rapid diagnostic screening of a large panel of respiratory pathogens may be critical to define and survey the epidemic situation and to provide critical information for patient management.

Plasma neutrophil gelatinase-associated lipocalin in kidney transplantation and early renal function prediction.

BACKGROUND: This prospective observational study aimed to assess the relevance of serial postoperative plasma neutrophil gelatinase-associated lipocalin (NGAL) measurements on prediction of early renal transplant function. METHODS: Plasma NGAL (pNGAL) was measured (Triage NGAL Test; Biosite Inc., Inverness Medical) in 41 patients scheduled for kidney transplantation from deceased or living donors, immediately before and after surgery, and at 12 hr, day 1, day 3, and day 7. A delayed graft function (DGF) was defined as the need for dialysis during the first week. The results were expressed as median (Q1, Q3). RESULTS: Of the 41 consecutive patients enrolled, all had a high preoperative pNGAL level: 453 ng/mL (382, 595). Fifteen (36.6%) presented a DGF. In patients with DGF, pNGAL was significantly higher at 12 hr (571 [467, 634] vs. 242 [158, 299] ng/mL, P<0.0001) and at day 1 (466 [356, 627] vs. 165 [91, 248] ng/mL, P<0.0001). A pNGAL higher than 400 ng/mL 12 hr after transplantation predicted DGF with a sensitivity of 93.3%, a specificity of 88.5%, and an odds ratio of 63.2 (P=0.0004). This predictive performance was higher than for plasma creatinine. CONCLUSIONS: pNGAL level early and accurately predicted DGF after renal transplantation. pNGAL measurements allowed monitoring of the renal function in this striking situation of ischemia-reperfusion aggression. Early identification of patients at risk of DGF, before graft lesions are consolidated, opens the field of a precise monitoring of renal injury and the impact of future protective therapeutics.