Interesting article from Journal Watch: Large case study on a greatly overlooked impairment. We looked at various underwriting manuals and CAD was not even highlighted as a risk factor. Also, the diagnosis of this disorder has really only come to the forefront in the past 10 years, with our elderly patients there continues to be a lack of quick diagnosis, and as such the cardiac factor may have already had time to develop into a highly overlooked risk factor.
Article:
Villous atrophy, intraepithelial lymphocytosis, and latent celiac disease were all associated with excess mortality.
Celiac disease is associated with an elevated risk for mortality. To more broadly assess celiac-specific mortality according to small-intestinal histopathology, investigators conducted a retrospective, case-control study involving more than 46,000 Swedish patients for whom duodenal or jejunal biopsy samples were available.
Patients were divided into three groups by diagnosis: 29,096 had overt celiac disease (biopsy showed villous atrophy); 13,306 had small-intestinal inflammation only (biopsy showed intraepithelial lymphocytosis or excess numbers of lymphocytes in the duodenal or jejunal epithelium, considered to be early but not diagnostic histological findings of celiac disease); and 3719 had latent celiac disease (duodenal biopsy was normal, but celiac serology was positive). Five controls were matched to each patient by age, sex, county, and calendar period through a Swedish population registry.
During the first year of follow-up, risks for mortality were highest for all three groups compared with controls (hazard ratios, 2.80 for overt celiac disease, 4.66 for inflammation only, and 1.81 for latent celiac disease). Between years 1 and 5, mortality risks remained higher for all groups (HRs, 1.26 for overt celiac disease, 1.41 for inflammation only, and 1.27 for latent celiac disease). After 5 years, patients with overt celiac disease and inflammation only had persistently higher mortality risks (HRs, 1.27 and 1.30, respectively), but those with latent celiac disease had nonsignificantly higher risk (HR, 1.11). Mortality risks were highest in patients who received diagnosis of celiac disease before age 20; some decline in the magnitude of excess risk occurred with increasing age. Overall, patients had increased risk for death from cardiovascular disease, malignancy, respiratory disease, and other causes. Cardiovascular disease and malignancy were the most common causes of death.
Comment: Results of this well-done study confirm previous observations of a modest increase in risk for death in patients with celiac disease and extend previous observations to comparable risks in patients with only intraepithelial lymphocytosis and positive serologies. The excess risk for cardiovascular death in these patients might be related to chronic inflammation, given that other data have associated markers of chronic inflammation with cardiovascular risk. The increased risk for malignancy in celiac disease has recently been associated with non-Hodgkin lymphoma. This study did not address which specific cancers result in increased mortality in the three study groups.
The cause of the increasing prevalence of celiac disease is unclear. Clinicians should maintain a high index of suspicion and consider screening for celiac disease in patients who have osteoporosis, unexplained anemia, peripheral neuropathy, irritable bowel syndrome or nonulcer dyspepsia (severe enough to require referral to a gastroenterologist), type 1 diabetes, autoimmune diseases, or family members with established celiac disease. Intraepithelial lymphocytosis alone in patients with positive serologies is probably celiac disease and might warrant a trial of a gluten-free diet. Patients with intraepithelial lymphocytosis alone and asymptomatic patients with positive serologies seem to warrant observation as well as attention to and treatment of cardiovascular and pulmonary disease risk factors.
— Douglas K. Rex,
Underwriting Term Du Jour: CBC-Complete Blood Count
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