Sharon Worcester

ORLANDO – Antibiotic prophylaxis was shown in the recently published RIVUR trial to halve the risk of recurrent febrile urinary tract infection in infants and young children with vesicoureteral reflux. Conversely, a meta-analysis of six controlled trials concluded there is little to no benefit of antibiotic prophylaxis in this population.

The conflicting data highlight the ongoing debate regarding the best approach for preventing and managing febrile urinary tract infections (UTIs) in children with vesicoureteral reflux (VUR).

The RIVUR (Randomized Intervention for Children with Vesicoureteral Reflux) trial findings, which were published in May in the New England Journal of Medicine, showed that among children with VUR who were aged 2-71 months, 2 years of treatment with trimethoprim-sulfamethoxazole halved the risk of febrile or symptomatic UTI recurrence (N. Eng. J. Med. 2014;370:2367-76). The difference between those who received prophylaxis and those who did not emerged early and increased over the 2-year study period, Dr. Saul Greenfield said during an update on the trial results at the annual meeting of the American Urological Association.

"The magnitude of treatment effect warrants serious consideration of prophylaxis in these children. We also feel that these results warrant reconsideration of the recent guideline recommendations by the American Academy of Pediatrics in 2011 ... advising against evaluation of children with a VCUG [voiding cystourethrogram] after their first UTI," said Dr. Greenfield, director of pediatric urology at Women and Children’s Hospital of Buffalo, N.Y. and one of the RIVUR investigators.

That AAP recommendation was based on a number of studies that showed no benefit from antibiotic prophylaxis in children with VUR, which suggests there is little value in diagnosing VUR (Pediatrics 2011;28:595-610).

In fact, a meta-analysis of six controlled trials, which also was presented at the AUA meeting, suggested that the benefit of antibiotic prophylaxis for preventing febrile UTIs in children with VUR is small at best, and evidence to support its use is lacking.

Pooled data for 986 patients included in the trials showed that in 417 with dilating VUR, the risk of recurrent febrile UTI was 22.46% in those who received antibiotics, and 29.79% in controls. The relative risk of treatment failure with antibiotic prophylaxis was 0.75, and the absolute risk reduction was 7.33%, Dr. José Netto reported.

The number needed to treat to prevent one UTI was 13.64, according to Dr. Netto of State University of Feira de Santana in Brazil.

In 515 patients with nondilating VUR, the risk of febrile UTI was 5.31% in patients who received prophylactic antibiotics, and 6.09% in those who did not. The relative risk of treatment failure was 0.87, and the absolute risk reduction was 0.78%. The number needed to treat was 129, Dr. Netto said.

The studies included in the meta-analysis were published prior to August 2013. Only one was placebo-controlled. Patients included in the study included 663 girls (67.2%), and the median age of all patients was 21 months.

The studies all used co-trimoxazole in standard doses, and three of the six also used co-amoxiclav or nitrofurantoin as alternative treatments.

Antibiotic prophylaxis is often used in children with VUR, but several recent studies have failed to demonstrate the usefulness of this approach with respect to reducing the risk of febrile UTI, Dr. Netto said, noting that the studies included heterogeneous populations with distinct grades of VUR and varying rates of recurrent UTI.

Based on the current findings, it remains uncertain whether antibiotic prophylaxis reduces the risk of febrile UTI in children with VUR, although it is possible – given the differences seen between those with dilating VUR and those with nondilating VUR – that specific subgroups of children with dilating VUR may benefit from prophylaxis, he concluded.

The conflicting findings between this meta-analysis, and the RIVUR trial underscore the importance of ongoing evaluation of antibiotic prophylaxis.

"The best ways to prevent and treat febrile urinary tract infections in children with VUR are still very much up for discussion," Dr. Anthony Atala, W.H. Boyce Professor and chair of the urology department at Wake Forest Baptist Medical Center in Winston-Salem, N.C., said in an AUA press statement.

"Examining and reexamining the AAP guidelines and practices that guide our work are critical to better understand the condition and improve the lives of those children who are living with the condition each day," said Dr. Atala, who is also director of the Wake Forest Institute for Regenerative Medicine.

Dr. Atala reported serving in a leadership position at Plureon Corp. Dr. Greenfield and Dr. Netto reported having no disclosures.

ORLANDO – Antibiotic prophylaxis was shown in the recently published RIVUR trial to halve the risk of recurrent febrile urinary tract infection in infants and young children with vesicoureteral reflux. Conversely, a meta-analysis of six controlled trials concluded there is little to no benefit of antibiotic prophylaxis in this population.

The conflicting data highlight the ongoing debate regarding the best approach for preventing and managing febrile urinary tract infections (UTIs) in children with vesicoureteral reflux (VUR).

The RIVUR (Randomized Intervention for Children with Vesicoureteral Reflux) trial findings, which were published in May in the New England Journal of Medicine, showed that among children with VUR who were aged 2-71 months, 2 years of treatment with trimethoprim-sulfamethoxazole halved the risk of febrile or symptomatic UTI recurrence (N. Eng. J. Med. 2014;370:2367-76). The difference between those who received prophylaxis and those who did not emerged early and increased over the 2-year study period, Dr. Saul Greenfield said during an update on the trial results at the annual meeting of the American Urological Association.

"The magnitude of treatment effect warrants serious consideration of prophylaxis in these children. We also feel that these results warrant reconsideration of the recent guideline recommendations by the American Academy of Pediatrics in 2011 ... advising against evaluation of children with a VCUG [voiding cystourethrogram] after their first UTI," said Dr. Greenfield, director of pediatric urology at Women and Children’s Hospital of Buffalo, N.Y. and one of the RIVUR investigators.

That AAP recommendation was based on a number of studies that showed no benefit from antibiotic prophylaxis in children with VUR, which suggests there is little value in diagnosing VUR (Pediatrics 2011;28:595-610).

In fact, a meta-analysis of six controlled trials, which also was presented at the AUA meeting, suggested that the benefit of antibiotic prophylaxis for preventing febrile UTIs in children with VUR is small at best, and evidence to support its use is lacking.

Pooled data for 986 patients included in the trials showed that in 417 with dilating VUR, the risk of recurrent febrile UTI was 22.46% in those who received antibiotics, and 29.79% in controls. The relative risk of treatment failure with antibiotic prophylaxis was 0.75, and the absolute risk reduction was 7.33%, Dr. José Netto reported.

The number needed to treat to prevent one UTI was 13.64, according to Dr. Netto of State University of Feira de Santana in Brazil.

In 515 patients with nondilating VUR, the risk of febrile UTI was 5.31% in patients who received prophylactic antibiotics, and 6.09% in those who did not. The relative risk of treatment failure was 0.87, and the absolute risk reduction was 0.78%. The number needed to treat was 129, Dr. Netto said.

The studies included in the meta-analysis were published prior to August 2013. Only one was placebo-controlled. Patients included in the study included 663 girls (67.2%), and the median age of all patients was 21 months.

The studies all used co-trimoxazole in standard doses, and three of the six also used co-amoxiclav or nitrofurantoin as alternative treatments.

Antibiotic prophylaxis is often used in children with VUR, but several recent studies have failed to demonstrate the usefulness of this approach with respect to reducing the risk of febrile UTI, Dr. Netto said, noting that the studies included heterogeneous populations with distinct grades of VUR and varying rates of recurrent UTI.

Based on the current findings, it remains uncertain whether antibiotic prophylaxis reduces the risk of febrile UTI in children with VUR, although it is possible – given the differences seen between those with dilating VUR and those with nondilating VUR – that specific subgroups of children with dilating VUR may benefit from prophylaxis, he concluded.

The conflicting findings between this meta-analysis, and the RIVUR trial underscore the importance of ongoing evaluation of antibiotic prophylaxis.

"The best ways to prevent and treat febrile urinary tract infections in children with VUR are still very much up for discussion," Dr. Anthony Atala, W.H. Boyce Professor and chair of the urology department at Wake Forest Baptist Medical Center in Winston-Salem, N.C., said in an AUA press statement.

"Examining and reexamining the AAP guidelines and practices that guide our work are critical to better understand the condition and improve the lives of those children who are living with the condition each day," said Dr. Atala, who is also director of the Wake Forest Institute for Regenerative Medicine.

Dr. Atala reported serving in a leadership position at Plureon Corp. Dr. Greenfield and Dr. Netto reported having no disclosures.

ORLANDO – Antibiotic prophylaxis was shown in the recently published RIVUR trial to halve the risk of recurrent febrile urinary tract infection in infants and young children with vesicoureteral reflux. Conversely, a meta-analysis of six controlled trials concluded there is little to no benefit of antibiotic prophylaxis in this population.

The conflicting data highlight the ongoing debate regarding the best approach for preventing and managing febrile urinary tract infections (UTIs) in children with vesicoureteral reflux (VUR).

The RIVUR (Randomized Intervention for Children with Vesicoureteral Reflux) trial findings, which were published in May in the New England Journal of Medicine, showed that among children with VUR who were aged 2-71 months, 2 years of treatment with trimethoprim-sulfamethoxazole halved the risk of febrile or symptomatic UTI recurrence (N. Eng. J. Med. 2014;370:2367-76). The difference between those who received prophylaxis and those who did not emerged early and increased over the 2-year study period, Dr. Saul Greenfield said during an update on the trial results at the annual meeting of the American Urological Association.

"The magnitude of treatment effect warrants serious consideration of prophylaxis in these children. We also feel that these results warrant reconsideration of the recent guideline recommendations by the American Academy of Pediatrics in 2011 ... advising against evaluation of children with a VCUG [voiding cystourethrogram] after their first UTI," said Dr. Greenfield, director of pediatric urology at Women and Children’s Hospital of Buffalo, N.Y. and one of the RIVUR investigators.

That AAP recommendation was based on a number of studies that showed no benefit from antibiotic prophylaxis in children with VUR, which suggests there is little value in diagnosing VUR (Pediatrics 2011;28:595-610).

In fact, a meta-analysis of six controlled trials, which also was presented at the AUA meeting, suggested that the benefit of antibiotic prophylaxis for preventing febrile UTIs in children with VUR is small at best, and evidence to support its use is lacking.

Pooled data for 986 patients included in the trials showed that in 417 with dilating VUR, the risk of recurrent febrile UTI was 22.46% in those who received antibiotics, and 29.79% in controls. The relative risk of treatment failure with antibiotic prophylaxis was 0.75, and the absolute risk reduction was 7.33%, Dr. José Netto reported.

The number needed to treat to prevent one UTI was 13.64, according to Dr. Netto of State University of Feira de Santana in Brazil.

In 515 patients with nondilating VUR, the risk of febrile UTI was 5.31% in patients who received prophylactic antibiotics, and 6.09% in those who did not. The relative risk of treatment failure was 0.87, and the absolute risk reduction was 0.78%. The number needed to treat was 129, Dr. Netto said.

The studies included in the meta-analysis were published prior to August 2013. Only one was placebo-controlled. Patients included in the study included 663 girls (67.2%), and the median age of all patients was 21 months.

The studies all used co-trimoxazole in standard doses, and three of the six also used co-amoxiclav or nitrofurantoin as alternative treatments.

Antibiotic prophylaxis is often used in children with VUR, but several recent studies have failed to demonstrate the usefulness of this approach with respect to reducing the risk of febrile UTI, Dr. Netto said, noting that the studies included heterogeneous populations with distinct grades of VUR and varying rates of recurrent UTI.

Based on the current findings, it remains uncertain whether antibiotic prophylaxis reduces the risk of febrile UTI in children with VUR, although it is possible – given the differences seen between those with dilating VUR and those with nondilating VUR – that specific subgroups of children with dilating VUR may benefit from prophylaxis, he concluded.

The conflicting findings between this meta-analysis, and the RIVUR trial underscore the importance of ongoing evaluation of antibiotic prophylaxis.

"The best ways to prevent and treat febrile urinary tract infections in children with VUR are still very much up for discussion," Dr. Anthony Atala, W.H. Boyce Professor and chair of the urology department at Wake Forest Baptist Medical Center in Winston-Salem, N.C., said in an AUA press statement.

"Examining and reexamining the AAP guidelines and practices that guide our work are critical to better understand the condition and improve the lives of those children who are living with the condition each day," said Dr. Atala, who is also director of the Wake Forest Institute for Regenerative Medicine.

Dr. Atala reported serving in a leadership position at Plureon Corp. Dr. Greenfield and Dr. Netto reported having no disclosures.

Cognitive behavioral therapy–informed psychotherapy was associated with significant seizure reduction and improved comorbid symptoms and global functioning in patients with psychogenic nonepileptic seizures in a multicenter, pilot, randomized clinical trial.

In 38 patients with psychogenic nonepileptic seizures (PNES) who were randomized to receive treatment with flexible-dose sertraline hydrochloride only, cognitive behavioral therapy–informed psychotherapy (CBT-IP) only, CBT-IP along with sertraline, or treatment as usual, CBT-IP-only was associated with a 51.4% reduction in total monthly seizures and significant improvement in depression, anxiety, quality of life, and global functioning measures. Combined CBT-IP and sertraline was associated with a 59.3% reduction in total monthly seizures and with significant improvement in global functioning, Dr. W. Curt LaFrance Jr. of Brown University, Providence, R.I., and his colleagues reported July 2 in JAMA Psychiatry on behalf of the NES Treatment Trial Consortium.

The patients were treated at three academic medical centers with mental health clinicians specially trained to treat outpatients with PNES, which is the most common type of conversion disorder, and which is as disabling as epilepsy. They were followed for 16 weeks. No significant seizure reduction was seen in those treated with sertraline only or with usual care, the investigators reported (JAMA Psychiatry 2014 July 2 [doi: 10.1001/jamapsychiatry.2014.817]).

The findings of this study, which address only the effect of treatment in the phase of gaining control of seizures, support the use of this type of manualized psychotherapy for patients with PNES, they concluded, noting that the durability of treatment will be assessed in future studies.

This study was supported by the American Epilepsy Society and the Research Infrastructure Award from the Epilepsy Foundation. Dr. LaFrance reported receiving research support from government institutes and epilepsy organizations and foundations, serving on the editorial boards of Epilepsia and Epilepsy & Behavior, and providing medicolegal expert testimony. Several coauthors reported receiving research support from, serving on an advisory board of, or receiving honoraria from several pharmaceutical companies.

Cognitive behavioral therapy–informed psychotherapy was associated with significant seizure reduction and improved comorbid symptoms and global functioning in patients with psychogenic nonepileptic seizures in a multicenter, pilot, randomized clinical trial.

In 38 patients with psychogenic nonepileptic seizures (PNES) who were randomized to receive treatment with flexible-dose sertraline hydrochloride only, cognitive behavioral therapy–informed psychotherapy (CBT-IP) only, CBT-IP along with sertraline, or treatment as usual, CBT-IP-only was associated with a 51.4% reduction in total monthly seizures and significant improvement in depression, anxiety, quality of life, and global functioning measures. Combined CBT-IP and sertraline was associated with a 59.3% reduction in total monthly seizures and with significant improvement in global functioning, Dr. W. Curt LaFrance Jr. of Brown University, Providence, R.I., and his colleagues reported July 2 in JAMA Psychiatry on behalf of the NES Treatment Trial Consortium.

The patients were treated at three academic medical centers with mental health clinicians specially trained to treat outpatients with PNES, which is the most common type of conversion disorder, and which is as disabling as epilepsy. They were followed for 16 weeks. No significant seizure reduction was seen in those treated with sertraline only or with usual care, the investigators reported (JAMA Psychiatry 2014 July 2 [doi: 10.1001/jamapsychiatry.2014.817]).

The findings of this study, which address only the effect of treatment in the phase of gaining control of seizures, support the use of this type of manualized psychotherapy for patients with PNES, they concluded, noting that the durability of treatment will be assessed in future studies.

This study was supported by the American Epilepsy Society and the Research Infrastructure Award from the Epilepsy Foundation. Dr. LaFrance reported receiving research support from government institutes and epilepsy organizations and foundations, serving on the editorial boards of Epilepsia and Epilepsy & Behavior, and providing medicolegal expert testimony. Several coauthors reported receiving research support from, serving on an advisory board of, or receiving honoraria from several pharmaceutical companies.

Cognitive behavioral therapy–informed psychotherapy was associated with significant seizure reduction and improved comorbid symptoms and global functioning in patients with psychogenic nonepileptic seizures in a multicenter, pilot, randomized clinical trial.

In 38 patients with psychogenic nonepileptic seizures (PNES) who were randomized to receive treatment with flexible-dose sertraline hydrochloride only, cognitive behavioral therapy–informed psychotherapy (CBT-IP) only, CBT-IP along with sertraline, or treatment as usual, CBT-IP-only was associated with a 51.4% reduction in total monthly seizures and significant improvement in depression, anxiety, quality of life, and global functioning measures. Combined CBT-IP and sertraline was associated with a 59.3% reduction in total monthly seizures and with significant improvement in global functioning, Dr. W. Curt LaFrance Jr. of Brown University, Providence, R.I., and his colleagues reported July 2 in JAMA Psychiatry on behalf of the NES Treatment Trial Consortium.

The patients were treated at three academic medical centers with mental health clinicians specially trained to treat outpatients with PNES, which is the most common type of conversion disorder, and which is as disabling as epilepsy. They were followed for 16 weeks. No significant seizure reduction was seen in those treated with sertraline only or with usual care, the investigators reported (JAMA Psychiatry 2014 July 2 [doi: 10.1001/jamapsychiatry.2014.817]).

The findings of this study, which address only the effect of treatment in the phase of gaining control of seizures, support the use of this type of manualized psychotherapy for patients with PNES, they concluded, noting that the durability of treatment will be assessed in future studies.

This study was supported by the American Epilepsy Society and the Research Infrastructure Award from the Epilepsy Foundation. Dr. LaFrance reported receiving research support from government institutes and epilepsy organizations and foundations, serving on the editorial boards of Epilepsia and Epilepsy & Behavior, and providing medicolegal expert testimony. Several coauthors reported receiving research support from, serving on an advisory board of, or receiving honoraria from several pharmaceutical companies.

Median starting doses of infliximab in psoriatic arthritis patients in two nationwide registries were below the recommended dose of 5 mg/kg every 8 weeks, but outcomes suggest that a low starting dose with subsequent step-up is an effective treatment strategy, according to an observational cohort study based on the registries.

In 376 Danish patients in the Danish Rheumatologic Database (DANBIO) registry and 86 Icelandic patients in the Center for Rheumatology Research (ICEBIO) registry, starting infliximab doses were less than 3 mg/kg in 29% and 74%, respectively, 3-5 mg/kg in 42% and 27%, respectively, and greater than 5 mg/kg in 10% and 0%, respectively (starting doses in the remaining patients were not registered). In those cohorts, median starting doses were 3.1 mg/kg and 2.3 mg/kg, respectively, Dr. Bente Glintborg of the Copenhagen Center for Arthritis Research and Glostrup (Denmark) Hospital and her colleagues reported (Rheumatology 2014 June 17 [doi:10.1093/rheumatology/keu252]).

Treatment was maintained after 12 months in 58% and 66% of the Danish and Icelandic patients, respectively (and was highest in those taking concomitant methotrexate). At 12 months, the median doses were 3.3 and 2.9 mg/kg, respectively, and time until dose escalation, response rates, drug survival, and disease activity at 12 months did not differ based on starting dose. Dosing was sustained at below the recommended level in more than 70% of the patients, the investigators found.

Recommended starting doses of infliximab are higher for psoriatic arthritis than for rheumatoid arthritis (5 mg/kg vs. 3 mg/kg) based on randomized trial data, but data on the effectiveness of lower doses are lacking. The current findings suggest that the approach often used in RA – a lower starting dose with gradual escalation – is also effective in psoriatic arthritis, they concluded.

Dr. Glintborg reported having no disclosures. Other study authors reported receiving research grants, serving on a speakers’ bureau, providing consultancy, or serving as an adviser or investigator to a variety of manufacturers of biologic drugs.

Median starting doses of infliximab in psoriatic arthritis patients in two nationwide registries were below the recommended dose of 5 mg/kg every 8 weeks, but outcomes suggest that a low starting dose with subsequent step-up is an effective treatment strategy, according to an observational cohort study based on the registries.

In 376 Danish patients in the Danish Rheumatologic Database (DANBIO) registry and 86 Icelandic patients in the Center for Rheumatology Research (ICEBIO) registry, starting infliximab doses were less than 3 mg/kg in 29% and 74%, respectively, 3-5 mg/kg in 42% and 27%, respectively, and greater than 5 mg/kg in 10% and 0%, respectively (starting doses in the remaining patients were not registered). In those cohorts, median starting doses were 3.1 mg/kg and 2.3 mg/kg, respectively, Dr. Bente Glintborg of the Copenhagen Center for Arthritis Research and Glostrup (Denmark) Hospital and her colleagues reported (Rheumatology 2014 June 17 [doi:10.1093/rheumatology/keu252]).

Treatment was maintained after 12 months in 58% and 66% of the Danish and Icelandic patients, respectively (and was highest in those taking concomitant methotrexate). At 12 months, the median doses were 3.3 and 2.9 mg/kg, respectively, and time until dose escalation, response rates, drug survival, and disease activity at 12 months did not differ based on starting dose. Dosing was sustained at below the recommended level in more than 70% of the patients, the investigators found.

Recommended starting doses of infliximab are higher for psoriatic arthritis than for rheumatoid arthritis (5 mg/kg vs. 3 mg/kg) based on randomized trial data, but data on the effectiveness of lower doses are lacking. The current findings suggest that the approach often used in RA – a lower starting dose with gradual escalation – is also effective in psoriatic arthritis, they concluded.

Dr. Glintborg reported having no disclosures. Other study authors reported receiving research grants, serving on a speakers’ bureau, providing consultancy, or serving as an adviser or investigator to a variety of manufacturers of biologic drugs.

Median starting doses of infliximab in psoriatic arthritis patients in two nationwide registries were below the recommended dose of 5 mg/kg every 8 weeks, but outcomes suggest that a low starting dose with subsequent step-up is an effective treatment strategy, according to an observational cohort study based on the registries.

In 376 Danish patients in the Danish Rheumatologic Database (DANBIO) registry and 86 Icelandic patients in the Center for Rheumatology Research (ICEBIO) registry, starting infliximab doses were less than 3 mg/kg in 29% and 74%, respectively, 3-5 mg/kg in 42% and 27%, respectively, and greater than 5 mg/kg in 10% and 0%, respectively (starting doses in the remaining patients were not registered). In those cohorts, median starting doses were 3.1 mg/kg and 2.3 mg/kg, respectively, Dr. Bente Glintborg of the Copenhagen Center for Arthritis Research and Glostrup (Denmark) Hospital and her colleagues reported (Rheumatology 2014 June 17 [doi:10.1093/rheumatology/keu252]).

Treatment was maintained after 12 months in 58% and 66% of the Danish and Icelandic patients, respectively (and was highest in those taking concomitant methotrexate). At 12 months, the median doses were 3.3 and 2.9 mg/kg, respectively, and time until dose escalation, response rates, drug survival, and disease activity at 12 months did not differ based on starting dose. Dosing was sustained at below the recommended level in more than 70% of the patients, the investigators found.

Recommended starting doses of infliximab are higher for psoriatic arthritis than for rheumatoid arthritis (5 mg/kg vs. 3 mg/kg) based on randomized trial data, but data on the effectiveness of lower doses are lacking. The current findings suggest that the approach often used in RA – a lower starting dose with gradual escalation – is also effective in psoriatic arthritis, they concluded.

Dr. Glintborg reported having no disclosures. Other study authors reported receiving research grants, serving on a speakers’ bureau, providing consultancy, or serving as an adviser or investigator to a variety of manufacturers of biologic drugs.

ATLANTA – Gonorrhea reinfection rates are high among women in Florida, with more than 1 in 4 becoming reinfected after treatment, according to a review of surveillance data.

Of 9,923 female Florida residents with a reported gonorrhea infection in 2000, 27% had an additional infection reported within 10 years, and of 9,617 women with a gonorrhea infection reported in 2011, 23% had an earlier infection reported in the previous 10 years, Daniel R. Newman of the Centers for Disease Control and Prevention, Atlanta, reported in a poster at a conference on STD prevention sponsored by the CDC.

Centers for Disease Control and Prevention

During 2000-2011, there were 127,081 gonorrhea infections reported among 103,156 women and girls aged 13 years and older, and the number of infections per year ranged from 9,345 to 11,970. Repeat infections occurred in 17,500 individuals.

The mean time to reported reinfection was 2.1 years; the median time was 1.28 years, Mr. Newman noted.

Most reinfections (74%) occurred in African Americans at a median age of 19 years at first diagnosis; 22% of African American women and girls and 14% of white women and girls with an infection in 2000 were reinfected at least once over the next decade, highlighting a 57% racial disparity in reinfection rates.

Additionally, 16% of 1,059 women who were HIV positive at the time of their first reported gonococcal infection were reinfected, indicating possible risk of HIV transmission to partners.

Since gonorrhea is often asymptomatic, and since a history of infections prior to 2000 was unavailable, it is likely that these findings underestimate the incidence of gonorrhea infection and reinfection, Mr. Newman reported.

Also, some women with an initial gonorrhea infection may have left the state after their initial infection; thus reinfection in those women would not have been captured, and some women may have moved to the state after an initial infection and thus would not be listed as a repeater.

The findings underscore the need to follow recommendations regarding rescreening of patients with gonorrhea after their initial diagnosis, Mr. Newman concluded, noting that partner services, including expedited partner therapy, and high-intensity behavioral counseling have been shown to reduce reinfection rates.

Mr. Newman reported having no disclosures.

ATLANTA – Gonorrhea reinfection rates are high among women in Florida, with more than 1 in 4 becoming reinfected after treatment, according to a review of surveillance data.

Of 9,923 female Florida residents with a reported gonorrhea infection in 2000, 27% had an additional infection reported within 10 years, and of 9,617 women with a gonorrhea infection reported in 2011, 23% had an earlier infection reported in the previous 10 years, Daniel R. Newman of the Centers for Disease Control and Prevention, Atlanta, reported in a poster at a conference on STD prevention sponsored by the CDC.

Centers for Disease Control and Prevention

During 2000-2011, there were 127,081 gonorrhea infections reported among 103,156 women and girls aged 13 years and older, and the number of infections per year ranged from 9,345 to 11,970. Repeat infections occurred in 17,500 individuals.

The mean time to reported reinfection was 2.1 years; the median time was 1.28 years, Mr. Newman noted.

Most reinfections (74%) occurred in African Americans at a median age of 19 years at first diagnosis; 22% of African American women and girls and 14% of white women and girls with an infection in 2000 were reinfected at least once over the next decade, highlighting a 57% racial disparity in reinfection rates.

Additionally, 16% of 1,059 women who were HIV positive at the time of their first reported gonococcal infection were reinfected, indicating possible risk of HIV transmission to partners.

Since gonorrhea is often asymptomatic, and since a history of infections prior to 2000 was unavailable, it is likely that these findings underestimate the incidence of gonorrhea infection and reinfection, Mr. Newman reported.

Also, some women with an initial gonorrhea infection may have left the state after their initial infection; thus reinfection in those women would not have been captured, and some women may have moved to the state after an initial infection and thus would not be listed as a repeater.

The findings underscore the need to follow recommendations regarding rescreening of patients with gonorrhea after their initial diagnosis, Mr. Newman concluded, noting that partner services, including expedited partner therapy, and high-intensity behavioral counseling have been shown to reduce reinfection rates.

Mr. Newman reported having no disclosures.

ATLANTA – Gonorrhea reinfection rates are high among women in Florida, with more than 1 in 4 becoming reinfected after treatment, according to a review of surveillance data.

Of 9,923 female Florida residents with a reported gonorrhea infection in 2000, 27% had an additional infection reported within 10 years, and of 9,617 women with a gonorrhea infection reported in 2011, 23% had an earlier infection reported in the previous 10 years, Daniel R. Newman of the Centers for Disease Control and Prevention, Atlanta, reported in a poster at a conference on STD prevention sponsored by the CDC.

Centers for Disease Control and Prevention

During 2000-2011, there were 127,081 gonorrhea infections reported among 103,156 women and girls aged 13 years and older, and the number of infections per year ranged from 9,345 to 11,970. Repeat infections occurred in 17,500 individuals.

The mean time to reported reinfection was 2.1 years; the median time was 1.28 years, Mr. Newman noted.

Most reinfections (74%) occurred in African Americans at a median age of 19 years at first diagnosis; 22% of African American women and girls and 14% of white women and girls with an infection in 2000 were reinfected at least once over the next decade, highlighting a 57% racial disparity in reinfection rates.

Additionally, 16% of 1,059 women who were HIV positive at the time of their first reported gonococcal infection were reinfected, indicating possible risk of HIV transmission to partners.

Since gonorrhea is often asymptomatic, and since a history of infections prior to 2000 was unavailable, it is likely that these findings underestimate the incidence of gonorrhea infection and reinfection, Mr. Newman reported.

Also, some women with an initial gonorrhea infection may have left the state after their initial infection; thus reinfection in those women would not have been captured, and some women may have moved to the state after an initial infection and thus would not be listed as a repeater.

The findings underscore the need to follow recommendations regarding rescreening of patients with gonorrhea after their initial diagnosis, Mr. Newman concluded, noting that partner services, including expedited partner therapy, and high-intensity behavioral counseling have been shown to reduce reinfection rates.

Mr. Newman reported having no disclosures.

ATLANTA – Gonorrhea reinfection rates are high among women in Florida, with more than 1 in 4 becoming reinfected after treatment, according to a review of surveillance data.

Of 9,923 female Florida residents with a reported gonorrhea infection in 2000, 27% had an additional infection reported within 10 years, and of 9,617 women with a gonorrhea infection reported in 2011, 23% had an earlier infection reported in the previous 10 years, Daniel R. Newman of the Centers for Disease Control and Prevention, Atlanta, reported in a poster at a conference on STD prevention sponsored by the CDC.

Centers for Disease Control and Prevention

During 2000-2011, there were 127,081 gonorrhea infections reported among 103,156 women and girls aged 13 years and older, and the number of infections per year ranged from 9,345 to 11,970. Repeat infections occurred in 17,500 individuals.

The mean time to reported reinfection was 2.1 years; the median time was 1.28 years, Mr. Newman noted.

Most reinfections (74%) occurred in African Americans at a median age of 19 years at first diagnosis; 22% of African American women and girls and 14% of white women and girls with an infection in 2000 were reinfected at least once over the next decade, highlighting a 57% racial disparity in reinfection rates.

Additionally, 16% of 1,059 women who were HIV positive at the time of their first reported gonococcal infection were reinfected, indicating possible risk of HIV transmission to partners.

Since gonorrhea is often asymptomatic, and since a history of infections prior to 2000 was unavailable, it is likely that these findings underestimate the incidence of gonorrhea infection and reinfection, Mr. Newman reported.

Also, some women with an initial gonorrhea infection may have left the state after their initial infection; thus reinfection in those women would not have been captured, and some women may have moved to the state after an initial infection and thus would not be listed as a repeater.

The findings underscore the need to follow recommendations regarding rescreening of patients with gonorrhea after their initial diagnosis, Mr. Newman concluded, noting that partner services, including expedited partner therapy, and high-intensity behavioral counseling have been shown to reduce reinfection rates.

Mr. Newman reported having no disclosures.

ATLANTA – Gonorrhea reinfection rates are high among women in Florida, with more than 1 in 4 becoming reinfected after treatment, according to a review of surveillance data.

Of 9,923 female Florida residents with a reported gonorrhea infection in 2000, 27% had an additional infection reported within 10 years, and of 9,617 women with a gonorrhea infection reported in 2011, 23% had an earlier infection reported in the previous 10 years, Daniel R. Newman of the Centers for Disease Control and Prevention, Atlanta, reported in a poster at a conference on STD prevention sponsored by the CDC.

Centers for Disease Control and Prevention

During 2000-2011, there were 127,081 gonorrhea infections reported among 103,156 women and girls aged 13 years and older, and the number of infections per year ranged from 9,345 to 11,970. Repeat infections occurred in 17,500 individuals.

The mean time to reported reinfection was 2.1 years; the median time was 1.28 years, Mr. Newman noted.

Most reinfections (74%) occurred in African Americans at a median age of 19 years at first diagnosis; 22% of African American women and girls and 14% of white women and girls with an infection in 2000 were reinfected at least once over the next decade, highlighting a 57% racial disparity in reinfection rates.

Additionally, 16% of 1,059 women who were HIV positive at the time of their first reported gonococcal infection were reinfected, indicating possible risk of HIV transmission to partners.

Since gonorrhea is often asymptomatic, and since a history of infections prior to 2000 was unavailable, it is likely that these findings underestimate the incidence of gonorrhea infection and reinfection, Mr. Newman reported.

Also, some women with an initial gonorrhea infection may have left the state after their initial infection; thus reinfection in those women would not have been captured, and some women may have moved to the state after an initial infection and thus would not be listed as a repeater.

The findings underscore the need to follow recommendations regarding rescreening of patients with gonorrhea after their initial diagnosis, Mr. Newman concluded, noting that partner services, including expedited partner therapy, and high-intensity behavioral counseling have been shown to reduce reinfection rates.

Mr. Newman reported having no disclosures.

ATLANTA – Gonorrhea reinfection rates are high among women in Florida, with more than 1 in 4 becoming reinfected after treatment, according to a review of surveillance data.

Of 9,923 female Florida residents with a reported gonorrhea infection in 2000, 27% had an additional infection reported within 10 years, and of 9,617 women with a gonorrhea infection reported in 2011, 23% had an earlier infection reported in the previous 10 years, Daniel R. Newman of the Centers for Disease Control and Prevention, Atlanta, reported in a poster at a conference on STD prevention sponsored by the CDC.

Centers for Disease Control and Prevention

During 2000-2011, there were 127,081 gonorrhea infections reported among 103,156 women and girls aged 13 years and older, and the number of infections per year ranged from 9,345 to 11,970. Repeat infections occurred in 17,500 individuals.

The mean time to reported reinfection was 2.1 years; the median time was 1.28 years, Mr. Newman noted.

Most reinfections (74%) occurred in African Americans at a median age of 19 years at first diagnosis; 22% of African American women and girls and 14% of white women and girls with an infection in 2000 were reinfected at least once over the next decade, highlighting a 57% racial disparity in reinfection rates.

Additionally, 16% of 1,059 women who were HIV positive at the time of their first reported gonococcal infection were reinfected, indicating possible risk of HIV transmission to partners.

Since gonorrhea is often asymptomatic, and since a history of infections prior to 2000 was unavailable, it is likely that these findings underestimate the incidence of gonorrhea infection and reinfection, Mr. Newman reported.

Also, some women with an initial gonorrhea infection may have left the state after their initial infection; thus reinfection in those women would not have been captured, and some women may have moved to the state after an initial infection and thus would not be listed as a repeater.

The findings underscore the need to follow recommendations regarding rescreening of patients with gonorrhea after their initial diagnosis, Mr. Newman concluded, noting that partner services, including expedited partner therapy, and high-intensity behavioral counseling have been shown to reduce reinfection rates.

Mr. Newman reported having no disclosures.

Median starting doses of infliximab in psoriatic arthritis patients in two nationwide registries were below the recommended dose of 5 mg/kg every 8 weeks, but outcomes suggest that a low starting dose with subsequent step-up is an effective treatment strategy, according to an observational cohort study based on the registries.

In 376 Danish patients in the Danish Rheumatologic Database (DANBIO) registry and 86 Icelandic patients in the Center for Rheumatology Research (ICEBIO) registry, starting infliximab doses were less than 3 mg/kg in 29% and 74%, respectively, 3-5 mg/kg in 42% and 27%, respectively, and greater than 5 mg/kg in 10% and 0%, respectively (starting doses in the remaining patients were not registered). In those cohorts, median starting doses were 3.1 mg/kg and 2.3 mg/kg, respectively, Dr. Bente Glintborg of the Copenhagen Center for Arthritis Research and Glostrup (Denmark) Hospital and her colleagues reported (Rheumatology 2014 June 17 [doi:10.1093/rheumatology/keu252]).

Treatment was maintained after 12 months in 58% and 66% of the Danish and Icelandic patients, respectively (and was highest in those taking concomitant methotrexate). At 12 months, the median doses were 3.3 and 2.9 mg/kg, respectively, and time until dose escalation, response rates, drug survival, and disease activity at 12 months did not differ based on starting dose. Dosing was sustained at below the recommended level in more than 70% of the patients, the investigators found.

Recommended starting doses of infliximab are higher for psoriatic arthritis than for rheumatoid arthritis (5 mg/kg vs. 3 mg/kg) based on randomized trial data, but data on the effectiveness of lower doses are lacking. The current findings suggest that the approach often used in RA – a lower starting dose with gradual escalation – is also effective in psoriatic arthritis, they concluded.

Dr. Glintborg reported having no disclosures. Other study authors reported receiving research grants, serving on a speakers’ bureau, providing consultancy, or serving as an adviser or investigator to a variety of manufacturers of biologic drugs.

Median starting doses of infliximab in psoriatic arthritis patients in two nationwide registries were below the recommended dose of 5 mg/kg every 8 weeks, but outcomes suggest that a low starting dose with subsequent step-up is an effective treatment strategy, according to an observational cohort study based on the registries.

In 376 Danish patients in the Danish Rheumatologic Database (DANBIO) registry and 86 Icelandic patients in the Center for Rheumatology Research (ICEBIO) registry, starting infliximab doses were less than 3 mg/kg in 29% and 74%, respectively, 3-5 mg/kg in 42% and 27%, respectively, and greater than 5 mg/kg in 10% and 0%, respectively (starting doses in the remaining patients were not registered). In those cohorts, median starting doses were 3.1 mg/kg and 2.3 mg/kg, respectively, Dr. Bente Glintborg of the Copenhagen Center for Arthritis Research and Glostrup (Denmark) Hospital and her colleagues reported (Rheumatology 2014 June 17 [doi:10.1093/rheumatology/keu252]).

Treatment was maintained after 12 months in 58% and 66% of the Danish and Icelandic patients, respectively (and was highest in those taking concomitant methotrexate). At 12 months, the median doses were 3.3 and 2.9 mg/kg, respectively, and time until dose escalation, response rates, drug survival, and disease activity at 12 months did not differ based on starting dose. Dosing was sustained at below the recommended level in more than 70% of the patients, the investigators found.

Recommended starting doses of infliximab are higher for psoriatic arthritis than for rheumatoid arthritis (5 mg/kg vs. 3 mg/kg) based on randomized trial data, but data on the effectiveness of lower doses are lacking. The current findings suggest that the approach often used in RA – a lower starting dose with gradual escalation – is also effective in psoriatic arthritis, they concluded.

Dr. Glintborg reported having no disclosures. Other study authors reported receiving research grants, serving on a speakers’ bureau, providing consultancy, or serving as an adviser or investigator to a variety of manufacturers of biologic drugs.

Median starting doses of infliximab in psoriatic arthritis patients in two nationwide registries were below the recommended dose of 5 mg/kg every 8 weeks, but outcomes suggest that a low starting dose with subsequent step-up is an effective treatment strategy, according to an observational cohort study based on the registries.

In 376 Danish patients in the Danish Rheumatologic Database (DANBIO) registry and 86 Icelandic patients in the Center for Rheumatology Research (ICEBIO) registry, starting infliximab doses were less than 3 mg/kg in 29% and 74%, respectively, 3-5 mg/kg in 42% and 27%, respectively, and greater than 5 mg/kg in 10% and 0%, respectively (starting doses in the remaining patients were not registered). In those cohorts, median starting doses were 3.1 mg/kg and 2.3 mg/kg, respectively, Dr. Bente Glintborg of the Copenhagen Center for Arthritis Research and Glostrup (Denmark) Hospital and her colleagues reported (Rheumatology 2014 June 17 [doi:10.1093/rheumatology/keu252]).

Treatment was maintained after 12 months in 58% and 66% of the Danish and Icelandic patients, respectively (and was highest in those taking concomitant methotrexate). At 12 months, the median doses were 3.3 and 2.9 mg/kg, respectively, and time until dose escalation, response rates, drug survival, and disease activity at 12 months did not differ based on starting dose. Dosing was sustained at below the recommended level in more than 70% of the patients, the investigators found.

Recommended starting doses of infliximab are higher for psoriatic arthritis than for rheumatoid arthritis (5 mg/kg vs. 3 mg/kg) based on randomized trial data, but data on the effectiveness of lower doses are lacking. The current findings suggest that the approach often used in RA – a lower starting dose with gradual escalation – is also effective in psoriatic arthritis, they concluded.

Dr. Glintborg reported having no disclosures. Other study authors reported receiving research grants, serving on a speakers’ bureau, providing consultancy, or serving as an adviser or investigator to a variety of manufacturers of biologic drugs.

Severe QTc prolongation and early repolarization pattern on electrocardiogram were more prevalent in people with refractory epilepsy than in controls in a cross-sectional, retrospective analysis of electrocardiogram recordings.

Severe QTc prolongation was present in 5% of recordings from 185 patients with drug-refractory epilepsy, compared with none of those from 178 controls without epilepsy, and early repolarization pattern (ERP) was present in 34% vs. 13% of recordings from the patients and controls, respectively. After adjustment for epilepsy, gender, age, and heart rate, epilepsy remained associated with severe QTc prolongation (odds ratio, 9.9), and ERP (OR, 2.4), reported Dr. Robert J. Lamberts of Stichting Epilepsie Instellingen Nederland, Heemstede, the Netherlands (J. Neurol. Neurosurg. Psychiatry 2014 June 19 [doi:10.1136/jnnp-2014-307772]).

Recent data show that patients with epilepsy are at a two- to threefold increased risk of sudden cardiac arrest (SCA), and severe QTc prolongation and ERP are known markers for SCA risk in the general population. The current findings might explain why patients with epilepsy carry an increased risk of SCA, noted Dr. Lamberts and his colleagues.

"Routine ECG evaluation in people with epilepsy may be of importance in guiding clinicians in their choice of antiepilepsy drug therapy, for example, avoidance of QT-prolonging or depolarization-blocking drugs in people with ECG markers of increased SCA risk," they concluded.

The Dutch Epilepsy Foundation, Christelijke Vereniging voor de Verpleging van Lijders aan Epilepsie, and the Netherlands Organisation for Scientific Research funded the study. Dr. Lamberts had no disclosures. Coauthors disclosed ties with the Epilepsy Society, the Dr. Marvin Weil Epilepsy Research Fund, Eisai, GSK, UCB Pharma, the World Health Organization, the National Institutes of Health, NUTS Ohra Fund, Medtronic, the AC Thomson Foundation, the Swiss National Science Foundation, and the SICPA Foundation.

Severe QTc prolongation and early repolarization pattern on electrocardiogram were more prevalent in people with refractory epilepsy than in controls in a cross-sectional, retrospective analysis of electrocardiogram recordings.

Severe QTc prolongation was present in 5% of recordings from 185 patients with drug-refractory epilepsy, compared with none of those from 178 controls without epilepsy, and early repolarization pattern (ERP) was present in 34% vs. 13% of recordings from the patients and controls, respectively. After adjustment for epilepsy, gender, age, and heart rate, epilepsy remained associated with severe QTc prolongation (odds ratio, 9.9), and ERP (OR, 2.4), reported Dr. Robert J. Lamberts of Stichting Epilepsie Instellingen Nederland, Heemstede, the Netherlands (J. Neurol. Neurosurg. Psychiatry 2014 June 19 [doi:10.1136/jnnp-2014-307772]).

Recent data show that patients with epilepsy are at a two- to threefold increased risk of sudden cardiac arrest (SCA), and severe QTc prolongation and ERP are known markers for SCA risk in the general population. The current findings might explain why patients with epilepsy carry an increased risk of SCA, noted Dr. Lamberts and his colleagues.

"Routine ECG evaluation in people with epilepsy may be of importance in guiding clinicians in their choice of antiepilepsy drug therapy, for example, avoidance of QT-prolonging or depolarization-blocking drugs in people with ECG markers of increased SCA risk," they concluded.

The Dutch Epilepsy Foundation, Christelijke Vereniging voor de Verpleging van Lijders aan Epilepsie, and the Netherlands Organisation for Scientific Research funded the study. Dr. Lamberts had no disclosures. Coauthors disclosed ties with the Epilepsy Society, the Dr. Marvin Weil Epilepsy Research Fund, Eisai, GSK, UCB Pharma, the World Health Organization, the National Institutes of Health, NUTS Ohra Fund, Medtronic, the AC Thomson Foundation, the Swiss National Science Foundation, and the SICPA Foundation.

Severe QTc prolongation and early repolarization pattern on electrocardiogram were more prevalent in people with refractory epilepsy than in controls in a cross-sectional, retrospective analysis of electrocardiogram recordings.

Severe QTc prolongation was present in 5% of recordings from 185 patients with drug-refractory epilepsy, compared with none of those from 178 controls without epilepsy, and early repolarization pattern (ERP) was present in 34% vs. 13% of recordings from the patients and controls, respectively. After adjustment for epilepsy, gender, age, and heart rate, epilepsy remained associated with severe QTc prolongation (odds ratio, 9.9), and ERP (OR, 2.4), reported Dr. Robert J. Lamberts of Stichting Epilepsie Instellingen Nederland, Heemstede, the Netherlands (J. Neurol. Neurosurg. Psychiatry 2014 June 19 [doi:10.1136/jnnp-2014-307772]).

Recent data show that patients with epilepsy are at a two- to threefold increased risk of sudden cardiac arrest (SCA), and severe QTc prolongation and ERP are known markers for SCA risk in the general population. The current findings might explain why patients with epilepsy carry an increased risk of SCA, noted Dr. Lamberts and his colleagues.

"Routine ECG evaluation in people with epilepsy may be of importance in guiding clinicians in their choice of antiepilepsy drug therapy, for example, avoidance of QT-prolonging or depolarization-blocking drugs in people with ECG markers of increased SCA risk," they concluded.

The Dutch Epilepsy Foundation, Christelijke Vereniging voor de Verpleging van Lijders aan Epilepsie, and the Netherlands Organisation for Scientific Research funded the study. Dr. Lamberts had no disclosures. Coauthors disclosed ties with the Epilepsy Society, the Dr. Marvin Weil Epilepsy Research Fund, Eisai, GSK, UCB Pharma, the World Health Organization, the National Institutes of Health, NUTS Ohra Fund, Medtronic, the AC Thomson Foundation, the Swiss National Science Foundation, and the SICPA Foundation.

BOSTON – Medical therapy for acute uncomplicated type B aortic dissections was effective in the short term, but was associated with low 6-year intervention-free survival in a review of 298 cases.

Furthermore, patients who received medical therapy without operative intervention had increased mortality at 6 years, compared with those who received intervention, Dr. Christopher A. Durham reported at a meeting hosted by the Society for Vascular Surgery.

During a mean follow-up of nearly 4.3 years, medical therapy failed in almost 60% of the patients; 114 died after an average of 2.7 years, and 87 required aortic intervention.

Aneurysmal degeneration was the indication for intervention in 65% of patients requiring intervention, and six of these patients experienced a ruptured aneurysm.

"Only six of these patients underwent stent placement, with the remainder receiving open aortic replacement," said Dr. Durham of Massachusetts General Hospital, Boston.

The average time to operation in this subset of patients was 2.3 years. Visceral malperfusion was the indication for intervention in 18 patients (21%), and most underwent an endovascular intervention including either stenting or endovascular fenestration. A less common indication for intervention was retrograde type A dissection development in two patients. These patients underwent open replacement.

The average time to intervention in the subset of patients whose indication was not aneurysmal degeneration was 24 days.

Early treatment failure – within 15 days of presentation – occurred in 37 patients (12%) and included 12 deaths and 25 interventions.

"In this group of patients who ultimately required an intervention within the acute period, aneurysmal degeneration was the indication in 25% of patients, all of whom were treated with an open approach," Dr. Durham said.

Visceral malperfusion was the indication in half of the early interventions.

The 30-day mortality rate among patients with early intervention after initial medical therapy was 12%.

Freedom from intervention was 74% at 6 years, with most interventions occurring within the first 12 months. Intervention-free survival was 55% at 3 years and 41% at 6 years. Only end-stage renal disease was found to be predictive of failure, and age over 70 years was protective against failure (hazard ratio, 0.97), Dr. Durham said, adding that no variables associated with progression to intervention were identified.

Notably, although survival was similar during the first 3 years in those who remained on medical management and those who required intervention (73% and 78%, respectively), survival at 6 years was 58% and 76% in the groups, respectively.

"These data join emerging data demonstrating a survival benefit in patients undergoing intervention when compared to those who are treated with medical therapy alone," he said.

Study subjects were all patients who were initially managed medically for acute uncomplicated type B aortic dissection between March 1999 and March 2011 in a health care system. The patients had a mean age of 66 years at presentation, about 62% were men, and most were white. Nearly 75% had hypertension, and most of those were on therapy. About 5% had end-stage renal disease.

Failure of medical therapy was defined as any death or aortic-related intervention. Early failure was defined as failure within 15 days of presentation.

"Aortic dissection is the most common catastrophic event affecting the aorta, with an incidence exceeding that of ruptured abdominal aortic aneurysm. The majority of patients with type B aortic dissections, where the entry tear originates distal to the left subclavian artery, are treated with medical therapy," he said.

In fact, medical management aimed at lowering the systolic blood pressure and pulse remains the standard of care, and a number of studies have demonstrated a favorable 1-year survival – ranging from 70% to 90% – with medical therapy alone in this population.

"However, at what cost?" Dr. Durham asked. "The principal late complication of aortic dissection is aneurysmal degeneration of the outer wall of the false lumen, which has been reported to occur in up to 40% of medically treated patients," he said, adding that, because of a paucity of contemporary data regarding the natural history of medically treated patients, it has been unclear whether the natural history has been altered with current medical therapy.

The current findings suggest that operative intervention is associated with a survival benefit.

As Food and Drug Administration "approval has just been granted for thoracic stent grafts to be used in aortic dissection, it is clear that endovascular coverage of proximal aortic entry tears will become more common in the acute phase. As such, further study is needed to determine which patients presenting with type B dissections will benefit from early intervention," he concluded.

Dr. Durham reported having no disclosures.

BOSTON – Medical therapy for acute uncomplicated type B aortic dissections was effective in the short term, but was associated with low 6-year intervention-free survival in a review of 298 cases.

Furthermore, patients who received medical therapy without operative intervention had increased mortality at 6 years, compared with those who received intervention, Dr. Christopher A. Durham reported at a meeting hosted by the Society for Vascular Surgery.

During a mean follow-up of nearly 4.3 years, medical therapy failed in almost 60% of the patients; 114 died after an average of 2.7 years, and 87 required aortic intervention.

Aneurysmal degeneration was the indication for intervention in 65% of patients requiring intervention, and six of these patients experienced a ruptured aneurysm.

"Only six of these patients underwent stent placement, with the remainder receiving open aortic replacement," said Dr. Durham of Massachusetts General Hospital, Boston.

The average time to operation in this subset of patients was 2.3 years. Visceral malperfusion was the indication for intervention in 18 patients (21%), and most underwent an endovascular intervention including either stenting or endovascular fenestration. A less common indication for intervention was retrograde type A dissection development in two patients. These patients underwent open replacement.

The average time to intervention in the subset of patients whose indication was not aneurysmal degeneration was 24 days.

Early treatment failure – within 15 days of presentation – occurred in 37 patients (12%) and included 12 deaths and 25 interventions.

"In this group of patients who ultimately required an intervention within the acute period, aneurysmal degeneration was the indication in 25% of patients, all of whom were treated with an open approach," Dr. Durham said.

Visceral malperfusion was the indication in half of the early interventions.

The 30-day mortality rate among patients with early intervention after initial medical therapy was 12%.

Freedom from intervention was 74% at 6 years, with most interventions occurring within the first 12 months. Intervention-free survival was 55% at 3 years and 41% at 6 years. Only end-stage renal disease was found to be predictive of failure, and age over 70 years was protective against failure (hazard ratio, 0.97), Dr. Durham said, adding that no variables associated with progression to intervention were identified.

Notably, although survival was similar during the first 3 years in those who remained on medical management and those who required intervention (73% and 78%, respectively), survival at 6 years was 58% and 76% in the groups, respectively.

"These data join emerging data demonstrating a survival benefit in patients undergoing intervention when compared to those who are treated with medical therapy alone," he said.

Study subjects were all patients who were initially managed medically for acute uncomplicated type B aortic dissection between March 1999 and March 2011 in a health care system. The patients had a mean age of 66 years at presentation, about 62% were men, and most were white. Nearly 75% had hypertension, and most of those were on therapy. About 5% had end-stage renal disease.

Failure of medical therapy was defined as any death or aortic-related intervention. Early failure was defined as failure within 15 days of presentation.

"Aortic dissection is the most common catastrophic event affecting the aorta, with an incidence exceeding that of ruptured abdominal aortic aneurysm. The majority of patients with type B aortic dissections, where the entry tear originates distal to the left subclavian artery, are treated with medical therapy," he said.

In fact, medical management aimed at lowering the systolic blood pressure and pulse remains the standard of care, and a number of studies have demonstrated a favorable 1-year survival – ranging from 70% to 90% – with medical therapy alone in this population.

"However, at what cost?" Dr. Durham asked. "The principal late complication of aortic dissection is aneurysmal degeneration of the outer wall of the false lumen, which has been reported to occur in up to 40% of medically treated patients," he said, adding that, because of a paucity of contemporary data regarding the natural history of medically treated patients, it has been unclear whether the natural history has been altered with current medical therapy.

The current findings suggest that operative intervention is associated with a survival benefit.

As Food and Drug Administration "approval has just been granted for thoracic stent grafts to be used in aortic dissection, it is clear that endovascular coverage of proximal aortic entry tears will become more common in the acute phase. As such, further study is needed to determine which patients presenting with type B dissections will benefit from early intervention," he concluded.

Dr. Durham reported having no disclosures.

BOSTON – Medical therapy for acute uncomplicated type B aortic dissections was effective in the short term, but was associated with low 6-year intervention-free survival in a review of 298 cases.

Furthermore, patients who received medical therapy without operative intervention had increased mortality at 6 years, compared with those who received intervention, Dr. Christopher A. Durham reported at a meeting hosted by the Society for Vascular Surgery.

During a mean follow-up of nearly 4.3 years, medical therapy failed in almost 60% of the patients; 114 died after an average of 2.7 years, and 87 required aortic intervention.

Aneurysmal degeneration was the indication for intervention in 65% of patients requiring intervention, and six of these patients experienced a ruptured aneurysm.

"Only six of these patients underwent stent placement, with the remainder receiving open aortic replacement," said Dr. Durham of Massachusetts General Hospital, Boston.

The average time to operation in this subset of patients was 2.3 years. Visceral malperfusion was the indication for intervention in 18 patients (21%), and most underwent an endovascular intervention including either stenting or endovascular fenestration. A less common indication for intervention was retrograde type A dissection development in two patients. These patients underwent open replacement.

The average time to intervention in the subset of patients whose indication was not aneurysmal degeneration was 24 days.

Early treatment failure – within 15 days of presentation – occurred in 37 patients (12%) and included 12 deaths and 25 interventions.

"In this group of patients who ultimately required an intervention within the acute period, aneurysmal degeneration was the indication in 25% of patients, all of whom were treated with an open approach," Dr. Durham said.

Visceral malperfusion was the indication in half of the early interventions.

The 30-day mortality rate among patients with early intervention after initial medical therapy was 12%.

Freedom from intervention was 74% at 6 years, with most interventions occurring within the first 12 months. Intervention-free survival was 55% at 3 years and 41% at 6 years. Only end-stage renal disease was found to be predictive of failure, and age over 70 years was protective against failure (hazard ratio, 0.97), Dr. Durham said, adding that no variables associated with progression to intervention were identified.

Notably, although survival was similar during the first 3 years in those who remained on medical management and those who required intervention (73% and 78%, respectively), survival at 6 years was 58% and 76% in the groups, respectively.

"These data join emerging data demonstrating a survival benefit in patients undergoing intervention when compared to those who are treated with medical therapy alone," he said.

Study subjects were all patients who were initially managed medically for acute uncomplicated type B aortic dissection between March 1999 and March 2011 in a health care system. The patients had a mean age of 66 years at presentation, about 62% were men, and most were white. Nearly 75% had hypertension, and most of those were on therapy. About 5% had end-stage renal disease.

Failure of medical therapy was defined as any death or aortic-related intervention. Early failure was defined as failure within 15 days of presentation.

"Aortic dissection is the most common catastrophic event affecting the aorta, with an incidence exceeding that of ruptured abdominal aortic aneurysm. The majority of patients with type B aortic dissections, where the entry tear originates distal to the left subclavian artery, are treated with medical therapy," he said.

In fact, medical management aimed at lowering the systolic blood pressure and pulse remains the standard of care, and a number of studies have demonstrated a favorable 1-year survival – ranging from 70% to 90% – with medical therapy alone in this population.

"However, at what cost?" Dr. Durham asked. "The principal late complication of aortic dissection is aneurysmal degeneration of the outer wall of the false lumen, which has been reported to occur in up to 40% of medically treated patients," he said, adding that, because of a paucity of contemporary data regarding the natural history of medically treated patients, it has been unclear whether the natural history has been altered with current medical therapy.

The current findings suggest that operative intervention is associated with a survival benefit.

As Food and Drug Administration "approval has just been granted for thoracic stent grafts to be used in aortic dissection, it is clear that endovascular coverage of proximal aortic entry tears will become more common in the acute phase. As such, further study is needed to determine which patients presenting with type B dissections will benefit from early intervention," he concluded.

Dr. Durham reported having no disclosures.

ATLANTA – A substantial proportion of patients who tested positive for HIV infection in urban emergency departments had not been tested elsewhere, according to a retrospective study of patient records.

The findings suggest that EDs are an ideal venue for identifying new infections and linking patients to appropriate care, Hilda Ndirangu of the Baltimore City Health Department reported in a poster at a conference on STD prevention sponsored by the Centers for Disease Control and Prevention.

© Dr. A. Harrison; Dr. P. Feorino / CDC

HIV testing in EDs not only helps identify new infections and link patients to care, but also helps re-link previously diagnosed patients to care for better HIV continuum of care outcomes, and can reduce HIV-related disparities, Ms. Ndirangu noted.

Of 27,816 patients tested in Baltimore area EDs between July 2012 and December 2013, 118 had a confirmed positive HIV test, and 68 of the tests were "new positives," while 50 were in patients who had previously tested HIV positive. Of the patients with new positives, 44 (65%) had not been tested at any other publicly funded testing site in the department’s database, Ms. Ndirangu said.

"These findings give merit to the utility of ED testing programs in finding acute HIV positive cases and those who are vulnerable to being infected with HIV," Ms. Ndirangu said.

The Baltimore City Health Department initiated routine HIV testing in EDs in 2008. Since then, more than 93,000 patients have been tested. Of those tests, 493 were positive, and 355 were new positives. Of the new positives, 241 (68%) were linked to care.

The study involved a review of the records of all HIV-positive cases during the study period, and a search of electronic databases to determine whether the patients had ever been tested at any of the publicly funded programs that report HIV testing activities to the Baltimore City Health Department.

HIV remains a major public health problem that disproportionately affects the urban poor, who often use EDs for primary care. The findings, though limited by small sample size, incomplete reporting of negative tests, and the likelihood that some patients with positive tests had been tested somewhere other than at publicly funded test sites in the study area, suggest that HIV testing in EDs reaches patients who do not perceive themselves to be at risk and who thus do not seek testing elsewhere, Ms. Ndirangu said.

"Despite the declining new positivity rates (1.05% in 2008, 0.5% in 2009, 0.5% in 2010, 0.3% in 2011, 0.25% in 2012) Baltimore EDs still surpass the cost-effectiveness threshold of 0.1% for undiagnosed rate that warrants routine testing," she wrote. In Baltimore, the HIV incidence remains high at 81.4/100,000.

Ms. Ndirangu reported having no disclosures.

ATLANTA – A substantial proportion of patients who tested positive for HIV infection in urban emergency departments had not been tested elsewhere, according to a retrospective study of patient records.

The findings suggest that EDs are an ideal venue for identifying new infections and linking patients to appropriate care, Hilda Ndirangu of the Baltimore City Health Department reported in a poster at a conference on STD prevention sponsored by the Centers for Disease Control and Prevention.

© Dr. A. Harrison; Dr. P. Feorino / CDC

HIV testing in EDs not only helps identify new infections and link patients to care, but also helps re-link previously diagnosed patients to care for better HIV continuum of care outcomes, and can reduce HIV-related disparities, Ms. Ndirangu noted.

Of 27,816 patients tested in Baltimore area EDs between July 2012 and December 2013, 118 had a confirmed positive HIV test, and 68 of the tests were "new positives," while 50 were in patients who had previously tested HIV positive. Of the patients with new positives, 44 (65%) had not been tested at any other publicly funded testing site in the department’s database, Ms. Ndirangu said.

"These findings give merit to the utility of ED testing programs in finding acute HIV positive cases and those who are vulnerable to being infected with HIV," Ms. Ndirangu said.

The Baltimore City Health Department initiated routine HIV testing in EDs in 2008. Since then, more than 93,000 patients have been tested. Of those tests, 493 were positive, and 355 were new positives. Of the new positives, 241 (68%) were linked to care.

The study involved a review of the records of all HIV-positive cases during the study period, and a search of electronic databases to determine whether the patients had ever been tested at any of the publicly funded programs that report HIV testing activities to the Baltimore City Health Department.

HIV remains a major public health problem that disproportionately affects the urban poor, who often use EDs for primary care. The findings, though limited by small sample size, incomplete reporting of negative tests, and the likelihood that some patients with positive tests had been tested somewhere other than at publicly funded test sites in the study area, suggest that HIV testing in EDs reaches patients who do not perceive themselves to be at risk and who thus do not seek testing elsewhere, Ms. Ndirangu said.

"Despite the declining new positivity rates (1.05% in 2008, 0.5% in 2009, 0.5% in 2010, 0.3% in 2011, 0.25% in 2012) Baltimore EDs still surpass the cost-effectiveness threshold of 0.1% for undiagnosed rate that warrants routine testing," she wrote. In Baltimore, the HIV incidence remains high at 81.4/100,000.

Ms. Ndirangu reported having no disclosures.

ATLANTA – A substantial proportion of patients who tested positive for HIV infection in urban emergency departments had not been tested elsewhere, according to a retrospective study of patient records.

The findings suggest that EDs are an ideal venue for identifying new infections and linking patients to appropriate care, Hilda Ndirangu of the Baltimore City Health Department reported in a poster at a conference on STD prevention sponsored by the Centers for Disease Control and Prevention.

© Dr. A. Harrison; Dr. P. Feorino / CDC

HIV testing in EDs not only helps identify new infections and link patients to care, but also helps re-link previously diagnosed patients to care for better HIV continuum of care outcomes, and can reduce HIV-related disparities, Ms. Ndirangu noted.

Of 27,816 patients tested in Baltimore area EDs between July 2012 and December 2013, 118 had a confirmed positive HIV test, and 68 of the tests were "new positives," while 50 were in patients who had previously tested HIV positive. Of the patients with new positives, 44 (65%) had not been tested at any other publicly funded testing site in the department’s database, Ms. Ndirangu said.

"These findings give merit to the utility of ED testing programs in finding acute HIV positive cases and those who are vulnerable to being infected with HIV," Ms. Ndirangu said.

The Baltimore City Health Department initiated routine HIV testing in EDs in 2008. Since then, more than 93,000 patients have been tested. Of those tests, 493 were positive, and 355 were new positives. Of the new positives, 241 (68%) were linked to care.

The study involved a review of the records of all HIV-positive cases during the study period, and a search of electronic databases to determine whether the patients had ever been tested at any of the publicly funded programs that report HIV testing activities to the Baltimore City Health Department.

HIV remains a major public health problem that disproportionately affects the urban poor, who often use EDs for primary care. The findings, though limited by small sample size, incomplete reporting of negative tests, and the likelihood that some patients with positive tests had been tested somewhere other than at publicly funded test sites in the study area, suggest that HIV testing in EDs reaches patients who do not perceive themselves to be at risk and who thus do not seek testing elsewhere, Ms. Ndirangu said.

"Despite the declining new positivity rates (1.05% in 2008, 0.5% in 2009, 0.5% in 2010, 0.3% in 2011, 0.25% in 2012) Baltimore EDs still surpass the cost-effectiveness threshold of 0.1% for undiagnosed rate that warrants routine testing," she wrote. In Baltimore, the HIV incidence remains high at 81.4/100,000.

Ms. Ndirangu reported having no disclosures.

A proposed scoring system based in part on the extent of carotid intima-media thickness and carotid atherosclerotic plaque on carotid ultrasonography may help predict significant renal artery stenosis in patients undergoing coronary angiography, a study suggests.

Of 641 consecutive coronary angiography (CAG) patients, 60 had significant renal artery stenosis (RAS). A number of factors were found to be independent predictors of RAS, including significant coronary artery disease (odds ratio, 5.6), unilateral carotid atherosclerotic plaque (OR, 2.6), bilateral carotid atherosclerotic plaque (OR, 4.9), stage 3 or greater chronic kidney disease (OR, 4.8), use of four or more antihypertensive medications (OR, 4.8), carotid intima-media thickness (OR, 2.3), age of 67 years or older (OR, 2.3), and body mass index less than 22 kg/m² (OR, 2.4), reported Dr. Yonggu Lee of Hanyang University Guri Hospital, Republic of Korea.

The report was published online in BMC Nephrology.

A scoring system developed based on these predictors had 83.3% sensitivity and 81.6% specificity for predicting significant renal artery stenosis, the investigators said (BMC Nephrology 2014 April 14 [doi:10.1186/1471-2369-15-60].

"The proposed model for predicting significant RAS ... may be a useful tool for deciding whether a definite diagnostic procedure is needed at the time of CAG," the investigators concluded.

The investigators reported having no disclosures.

A proposed scoring system based in part on the extent of carotid intima-media thickness and carotid atherosclerotic plaque on carotid ultrasonography may help predict significant renal artery stenosis in patients undergoing coronary angiography, a study suggests.

Of 641 consecutive coronary angiography (CAG) patients, 60 had significant renal artery stenosis (RAS). A number of factors were found to be independent predictors of RAS, including significant coronary artery disease (odds ratio, 5.6), unilateral carotid atherosclerotic plaque (OR, 2.6), bilateral carotid atherosclerotic plaque (OR, 4.9), stage 3 or greater chronic kidney disease (OR, 4.8), use of four or more antihypertensive medications (OR, 4.8), carotid intima-media thickness (OR, 2.3), age of 67 years or older (OR, 2.3), and body mass index less than 22 kg/m² (OR, 2.4), reported Dr. Yonggu Lee of Hanyang University Guri Hospital, Republic of Korea.

The report was published online in BMC Nephrology.

A scoring system developed based on these predictors had 83.3% sensitivity and 81.6% specificity for predicting significant renal artery stenosis, the investigators said (BMC Nephrology 2014 April 14 [doi:10.1186/1471-2369-15-60].

"The proposed model for predicting significant RAS ... may be a useful tool for deciding whether a definite diagnostic procedure is needed at the time of CAG," the investigators concluded.

The investigators reported having no disclosures.

A proposed scoring system based in part on the extent of carotid intima-media thickness and carotid atherosclerotic plaque on carotid ultrasonography may help predict significant renal artery stenosis in patients undergoing coronary angiography, a study suggests.

Of 641 consecutive coronary angiography (CAG) patients, 60 had significant renal artery stenosis (RAS). A number of factors were found to be independent predictors of RAS, including significant coronary artery disease (odds ratio, 5.6), unilateral carotid atherosclerotic plaque (OR, 2.6), bilateral carotid atherosclerotic plaque (OR, 4.9), stage 3 or greater chronic kidney disease (OR, 4.8), use of four or more antihypertensive medications (OR, 4.8), carotid intima-media thickness (OR, 2.3), age of 67 years or older (OR, 2.3), and body mass index less than 22 kg/m² (OR, 2.4), reported Dr. Yonggu Lee of Hanyang University Guri Hospital, Republic of Korea.

The report was published online in BMC Nephrology.

A scoring system developed based on these predictors had 83.3% sensitivity and 81.6% specificity for predicting significant renal artery stenosis, the investigators said (BMC Nephrology 2014 April 14 [doi:10.1186/1471-2369-15-60].

"The proposed model for predicting significant RAS ... may be a useful tool for deciding whether a definite diagnostic procedure is needed at the time of CAG," the investigators concluded.

The investigators reported having no disclosures.