Thrombosis, prostate cancer and HIV

Too busy to read the journals? Let Dr Lizzie Croton guide you through the latest research.

Prophylactic treatment in AF
Lancet 2008; 371: 315-21

Vitamin K antagonists are the current standard treatment for prophylaxis against systemic embolism and stroke in patients with AF.

A disadvantage is the regular monitoring and dosage adjustment required. Subcutaneous idraparinux is an unmonitored fixed-dose anticoagulant regimen (2.5mg weekly).

Researchers used a randomised open-label method to compare efficacy and safety of the two regimens. The trial was stopped after randomisation of 4,576 patients after a follow-up of 10.7 months due to an of excess clinically relevant bleeding with the idraparinux regimen.

There were 21 instances of intracranial bleeding with idraparinux versus nine with vitamin K antagonists.

Elderly and those with renal impairment were at greater risk of complications.

Both regimens were comparable in efficacy in the prophylaxis of thromboembolism.

Co-morbidity in prostate cancer
JAMA 2008; 299(3): 289-95

Co-morbidity may increase the risks of specific cancer treatment in patients with localised but unfavourable risk prostate cancer.

In the study, 206 men with 'unfavourable risk' tumours were randomised to receive either six months of androgen suppression therapy (AST) and external beam radiotherapy, or radiotherapy alone.

There were several parameters defining 'unfavourable risk' with a high Gleason Score and high PSA >10 being two of them.

The main outcome measure was time to all-cause mortality.

Researchers also incorporated co-morbidity such as pre-existing cardiovascular disease into the analysis to ascertain if this increased the negative effects of the treatment regimens in each group.

After a median follow-up of 7.6 years, the men who received combined AST and radiotherapy had increased overall survival time but the effect was only seen in men with mild or no co-morbidity.

Men with significant co-morbidities fared the same whatever their treatment.

Diagnosis of HIV infection
Sex Transm Infect 2008; 84: 14-6

Current estimates suggest that between 50 and 90 per cent of patients with primary HIV infection develop a seroconversion illness.

Early diagnosis allows for prompt treatment and helps prevent onward transmission of the virus.

This study identified 108 patients diagnosed with primary HIV, of which 103 were male and 93 were homosexual.

A total of 76 patients (70 per cent) reported symptoms of seroconversion. Of these 40 presented to a healthcare provider during this period.

Of these, 21 patients were diagnosed at first presentation. In the remaining 19, where the diagnosis was not made at first presentation, 15 were seen in primary care, three in A&E and one in GUM; 57 per cent of cases picked up at first presentation were diagnosed in GUM clinics.

The most common symptoms reported by patients during seroconversion were fever, rash, sore throat and diarrhoea.

HIV primary infection should be considered in any patient with vague symptoms and lifestyle risk factors.

Wood dust exposure
Occup Environ Med 2008 Online www.oem.bmj.com/cgi/content/abstract/oem.2007.036210v1

This case-control study identified wood dust exposure as a potential risk factor for other upper aero digestive tract and respiratory (UADR) cancers.

Researchers examined the effect of self-reported wood dust exposure on 1,522 male UADR cancer cases.

Controls were matched on age and smoking history. Wood dust exposure was associated with an 82-93 per cent increased risk of squamous cell, small cell and adenocarcinoma of the lung and more than twice the risk of developing squamous cell carcinoma of the nasopharynx and hypopharynx.

A significant increase in the risk of laryngeal and lung cancers was noted for patients who had been exposed to wood dust for more than 20 years.

There was no risk associated with wood dust and gastric or oesophageal cancer.

Unsurprisingly, cancer risk was highest among smokers exposed to wood dust.

Obesity, acid reflux and oesophageal cancers
Gut 2008; 57: 173-80

The incidence of oesophageal and gastro-oesophageal junction adenocarcinomas is increasing, whereas the incidence of oesophageal squamous cell carcinomas has remained static.

Detection and diagnosis of adenocarcinomas remains unchanged, and so a shift in the prevalence of causal factors may be responsible.

Gastro-oesophageal reflux is thought to be the primary causal factor for oesophageal adenocarcinoma.

Obesity increases the risk of reflux and this may explain the higher incidence of cancers in obese patients.

This population-based case-control study showed that the risk of oesophageal adenocarcinoma increased with BMI. The highest risk was found among those with BMI>40.

The risks associated with obesity were higher in men and those aged over 50.

Obese patients with frequent symptoms of reflux were at a higher risk than obese patients with no reflux or individuals with reflux and a normal BMI.

Reflux and obesity may work synergistically in increasing cancer risk.

Similar results, but of a smaller magnitude, were seen for gastro-oesophageal junction carcinomas.

Dr Croton is a salaried GP in Birmingham

The quick study

  • Idraparinux is associated with excess clinically relevant bleeding in the prophylaxis of thromboembolism in patients with AF.
  • Prostate cancer patients' survival is increased when androgen suppression therapy is combined with external beam radiotherapy.
  • HIV seroconversion symptoms are vague and may be missed on first presentation.
  • Wood dust exposure is associated with an increased risk of upper aero digestive tract and respiratory cancers. The risk is even greater in smokers.
  • Increased BMI is linked to a greater risk of oesophageal adenocarcinoma, probably due to a rise in acid reflux.

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