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When to discontinue contact precautions for patients with MRSA
Methicillin-resistant Staphylococcus aureus (MRSA) is a common hospital-acquired infection with significant morbidity and mortality. The CDC currently recommends contact precautions as a mainstay to prevent transmission of MRSA in health care settings. Most hospitals routinely screen patients for MRSA and use contact precautions for those who screen positive. The duration of these precautions vary across hospitals and no standard recommendation exists.
A recent study of members of the Society for Healthcare Epidemiology of America (SHEA) research network indicated that the majority of physicians (94%) and nurses (76%) dislike contact precautions (CP) and most (63%) were in favor of implementing CP in a different way than current practice.1 Patients also report less satisfaction and increased isolation.1
My colleagues and I recently published a study2 in the American Journal of Infection Control to explore the necessary duration of contact precautions for hospitalized patients with MRSA. Our goal was to maintain contact precautions as long as necessary to prevent undesired MRSA infections and colonization but minimize unnecessary days in contact isolation. We also sought to figure out whether patients with positive MRSA surveillance cultures should always remain in isolation and, if not, at what point they could be considered for rescreening and removal of precautions if culture negative.
Our hospital has been performing active surveillance cultures weekly to screen for MRSA among our hospitalized patients for many years; however from 2010 to 2014, we began screening patients who were previously known to be positive for MRSA colonization or infection for at least 1 year. We then assessed medical and demographic factors associated with persistent carriage of MRSA.
In our study, more than 400 patients with known MRSA were rescreened with an active surveillance culture at a subsequent hospital admission. Ultimately 20% of the patients remained MRSA positive on the active surveillance culture. Most patients who were culture positive for MRSA were found on the first active surveillance culture (16.4%) but the remaining positive cultures were found on a second active surveillance culture or a clinical culture.
The amount of time that passed since the patient was culture positive was significantly associated with a lower risk of a positive culture at screening. This continued to drop over time with only 12.5% of patients remaining active surveillance culture positive for MRSA at 5 years after the original positive culture.
Two factors were found to significantly impact the MRSA culture on the multivariate analysis: (1) Female sex reduced the risk of positivity, and (2) Presence of a foreign body increased the risk of positivity.
Most patients who remained positive for an MRSA culture were found with the first active surveillance culture, less than 4% were detected subsequently with a repeat surveillance or clinical culture and this percentage also decreased over time. This indicates that in the absence of a positive active surveillance culture it may be reasonable to discontinue contact precautions, which could result in a substantial cost savings for the hospital and improved patient and provider satisfaction without increasing the risk of MRSA transmission.
We concluded that in the absence of a foreign body and with at least a year from the last known positive culture, patients with known MRSA should be rescreened and, if negative on an active surveillance culture, should be removed from contact precautions.
Lauren Richey, MD, MPH, is assistant professor in the infectious diseases division at the Medical University of South Carolina.
References
1. Morgan DJ, Diekema DJ, Sepkowitz K, Perencevich EN. Adverse outcomes associated with contact precautions: A review of the literature. Am J Infect Control. 2009 Mar;37(2):85-93. doi: 10.1016/j.ajic.2008.04.257.
2. Richey LE, Oh Y, Tchamba DM, Engle M, Formby L, Salgado CD. When should contact precautions be discontinued for patients with Methicillin-resistant Staphylococcus aureus? Am J Infect Control. 2016 Aug 30. doi: 10.1016/j.ajic.2016.05.030.
Methicillin-resistant Staphylococcus aureus (MRSA) is a common hospital-acquired infection with significant morbidity and mortality. The CDC currently recommends contact precautions as a mainstay to prevent transmission of MRSA in health care settings. Most hospitals routinely screen patients for MRSA and use contact precautions for those who screen positive. The duration of these precautions vary across hospitals and no standard recommendation exists.
A recent study of members of the Society for Healthcare Epidemiology of America (SHEA) research network indicated that the majority of physicians (94%) and nurses (76%) dislike contact precautions (CP) and most (63%) were in favor of implementing CP in a different way than current practice.1 Patients also report less satisfaction and increased isolation.1
My colleagues and I recently published a study2 in the American Journal of Infection Control to explore the necessary duration of contact precautions for hospitalized patients with MRSA. Our goal was to maintain contact precautions as long as necessary to prevent undesired MRSA infections and colonization but minimize unnecessary days in contact isolation. We also sought to figure out whether patients with positive MRSA surveillance cultures should always remain in isolation and, if not, at what point they could be considered for rescreening and removal of precautions if culture negative.
Our hospital has been performing active surveillance cultures weekly to screen for MRSA among our hospitalized patients for many years; however from 2010 to 2014, we began screening patients who were previously known to be positive for MRSA colonization or infection for at least 1 year. We then assessed medical and demographic factors associated with persistent carriage of MRSA.
In our study, more than 400 patients with known MRSA were rescreened with an active surveillance culture at a subsequent hospital admission. Ultimately 20% of the patients remained MRSA positive on the active surveillance culture. Most patients who were culture positive for MRSA were found on the first active surveillance culture (16.4%) but the remaining positive cultures were found on a second active surveillance culture or a clinical culture.
The amount of time that passed since the patient was culture positive was significantly associated with a lower risk of a positive culture at screening. This continued to drop over time with only 12.5% of patients remaining active surveillance culture positive for MRSA at 5 years after the original positive culture.
Two factors were found to significantly impact the MRSA culture on the multivariate analysis: (1) Female sex reduced the risk of positivity, and (2) Presence of a foreign body increased the risk of positivity.
Most patients who remained positive for an MRSA culture were found with the first active surveillance culture, less than 4% were detected subsequently with a repeat surveillance or clinical culture and this percentage also decreased over time. This indicates that in the absence of a positive active surveillance culture it may be reasonable to discontinue contact precautions, which could result in a substantial cost savings for the hospital and improved patient and provider satisfaction without increasing the risk of MRSA transmission.
We concluded that in the absence of a foreign body and with at least a year from the last known positive culture, patients with known MRSA should be rescreened and, if negative on an active surveillance culture, should be removed from contact precautions.
Lauren Richey, MD, MPH, is assistant professor in the infectious diseases division at the Medical University of South Carolina.
References
1. Morgan DJ, Diekema DJ, Sepkowitz K, Perencevich EN. Adverse outcomes associated with contact precautions: A review of the literature. Am J Infect Control. 2009 Mar;37(2):85-93. doi: 10.1016/j.ajic.2008.04.257.
2. Richey LE, Oh Y, Tchamba DM, Engle M, Formby L, Salgado CD. When should contact precautions be discontinued for patients with Methicillin-resistant Staphylococcus aureus? Am J Infect Control. 2016 Aug 30. doi: 10.1016/j.ajic.2016.05.030.
Methicillin-resistant Staphylococcus aureus (MRSA) is a common hospital-acquired infection with significant morbidity and mortality. The CDC currently recommends contact precautions as a mainstay to prevent transmission of MRSA in health care settings. Most hospitals routinely screen patients for MRSA and use contact precautions for those who screen positive. The duration of these precautions vary across hospitals and no standard recommendation exists.
A recent study of members of the Society for Healthcare Epidemiology of America (SHEA) research network indicated that the majority of physicians (94%) and nurses (76%) dislike contact precautions (CP) and most (63%) were in favor of implementing CP in a different way than current practice.1 Patients also report less satisfaction and increased isolation.1
My colleagues and I recently published a study2 in the American Journal of Infection Control to explore the necessary duration of contact precautions for hospitalized patients with MRSA. Our goal was to maintain contact precautions as long as necessary to prevent undesired MRSA infections and colonization but minimize unnecessary days in contact isolation. We also sought to figure out whether patients with positive MRSA surveillance cultures should always remain in isolation and, if not, at what point they could be considered for rescreening and removal of precautions if culture negative.
Our hospital has been performing active surveillance cultures weekly to screen for MRSA among our hospitalized patients for many years; however from 2010 to 2014, we began screening patients who were previously known to be positive for MRSA colonization or infection for at least 1 year. We then assessed medical and demographic factors associated with persistent carriage of MRSA.
In our study, more than 400 patients with known MRSA were rescreened with an active surveillance culture at a subsequent hospital admission. Ultimately 20% of the patients remained MRSA positive on the active surveillance culture. Most patients who were culture positive for MRSA were found on the first active surveillance culture (16.4%) but the remaining positive cultures were found on a second active surveillance culture or a clinical culture.
The amount of time that passed since the patient was culture positive was significantly associated with a lower risk of a positive culture at screening. This continued to drop over time with only 12.5% of patients remaining active surveillance culture positive for MRSA at 5 years after the original positive culture.
Two factors were found to significantly impact the MRSA culture on the multivariate analysis: (1) Female sex reduced the risk of positivity, and (2) Presence of a foreign body increased the risk of positivity.
Most patients who remained positive for an MRSA culture were found with the first active surveillance culture, less than 4% were detected subsequently with a repeat surveillance or clinical culture and this percentage also decreased over time. This indicates that in the absence of a positive active surveillance culture it may be reasonable to discontinue contact precautions, which could result in a substantial cost savings for the hospital and improved patient and provider satisfaction without increasing the risk of MRSA transmission.
We concluded that in the absence of a foreign body and with at least a year from the last known positive culture, patients with known MRSA should be rescreened and, if negative on an active surveillance culture, should be removed from contact precautions.
Lauren Richey, MD, MPH, is assistant professor in the infectious diseases division at the Medical University of South Carolina.
References
1. Morgan DJ, Diekema DJ, Sepkowitz K, Perencevich EN. Adverse outcomes associated with contact precautions: A review of the literature. Am J Infect Control. 2009 Mar;37(2):85-93. doi: 10.1016/j.ajic.2008.04.257.
2. Richey LE, Oh Y, Tchamba DM, Engle M, Formby L, Salgado CD. When should contact precautions be discontinued for patients with Methicillin-resistant Staphylococcus aureus? Am J Infect Control. 2016 Aug 30. doi: 10.1016/j.ajic.2016.05.030.
AKT inhibition not superior to everolimus for RCC
The AKT inhibitor MK-2206 was not superior to everolimus (Afinitor) for patients with metastatic renal cell carcinoma refractory to vascular endothelial growth factor inhibitors, according to a phase II trial from the University of Texas MD Anderson Cancer Center, Houston.
Median progression-free survival was 3.68 months in the 29 patients randomized to MK-2206, versus 5.98 months in the 14 randomized to everolimus, leading to closure of the study, reported Eric Jonasch, MD, of the department of genitourinary medical oncology at MD Anderson, and his associates.
However, dichotomous response rate profiles were seen in the MK-2206 arm with one complete response and three partial responses in the MK-2206 arm versus none in the everolimus arm.
“Whereas patients treated with everolimus for the large part had minimal changes in tumor size, MK-2206 induced a fairly dichotomous response dynamic, with [a few] patients demonstrating profound response, [but] a number of patients exhibiting rapid growth,” Dr. Jonasch and associates said (Ann Oncol. 2017 Jan 3. pii: mdw676. doi: 10.1093/annonc/mdw676).
Several studies have shown that upregulation of the PI3K/AKT pathway is associated with poor prognosis in renal cell carcinoma (RCC), making the pathway an attractive target for therapeutic intervention. The trial “results indicate that potential exists for effective blockade of the PI3K pathway in patients with RCC, but considerable work is required to better understand the nuances of this pathway before we can consistently modulate it to benefit patients with RCC,” the investigators said.
Molecular analysis failed to find a biomarker for response, but did demonstrate that deleterious tumor protein 53 or ataxia telangiectasia mutations or deletions were associated with poor prognosis. Among patients who progressed, 57.1% had TP53 or ATM aberrations; TP53 and ATM defects were absent in patients who did not progress.
Malfunction of DNA repair driven by TP53 and ATM gene modifications, the group said, “are associated with early disease progression, indicating that dysregulation of DNA repair is associated with a more aggressive tumor phenotype in RCC ... This subcategory of patients clearly needs new approaches based on our emerging understanding of the significance of TP53 mutations in RCC biology.”
MK-2206 induced significantly more rash and pruritus than did everolimus, with dose reduction in 37.9% of MK-2206 versus 21.4% of everolimus patients.
Subjects were a median of 63.5 years old in the everolimus group and 59 years in the MK-2206 group. The majority of patients were white men. More than 65% of the patients had performance status 1 and around 60% were in the Memorial Sloan Kettering Cancer Center intermediate risk group. The majority of patients in both treatment arms had clear cell histology; 57.1% (8) in the everolimus group and 82.8% (24) in the MK-2206 group had lung metastasis; half of the everolimus and 59% (17) of MK-2206 subjects were previously treated with sunitinib (Sutent).
The National Institutes of Health funded the work. The authors reported no conflicts of interest.
The AKT inhibitor MK-2206 was not superior to everolimus (Afinitor) for patients with metastatic renal cell carcinoma refractory to vascular endothelial growth factor inhibitors, according to a phase II trial from the University of Texas MD Anderson Cancer Center, Houston.
Median progression-free survival was 3.68 months in the 29 patients randomized to MK-2206, versus 5.98 months in the 14 randomized to everolimus, leading to closure of the study, reported Eric Jonasch, MD, of the department of genitourinary medical oncology at MD Anderson, and his associates.
However, dichotomous response rate profiles were seen in the MK-2206 arm with one complete response and three partial responses in the MK-2206 arm versus none in the everolimus arm.
“Whereas patients treated with everolimus for the large part had minimal changes in tumor size, MK-2206 induced a fairly dichotomous response dynamic, with [a few] patients demonstrating profound response, [but] a number of patients exhibiting rapid growth,” Dr. Jonasch and associates said (Ann Oncol. 2017 Jan 3. pii: mdw676. doi: 10.1093/annonc/mdw676).
Several studies have shown that upregulation of the PI3K/AKT pathway is associated with poor prognosis in renal cell carcinoma (RCC), making the pathway an attractive target for therapeutic intervention. The trial “results indicate that potential exists for effective blockade of the PI3K pathway in patients with RCC, but considerable work is required to better understand the nuances of this pathway before we can consistently modulate it to benefit patients with RCC,” the investigators said.
Molecular analysis failed to find a biomarker for response, but did demonstrate that deleterious tumor protein 53 or ataxia telangiectasia mutations or deletions were associated with poor prognosis. Among patients who progressed, 57.1% had TP53 or ATM aberrations; TP53 and ATM defects were absent in patients who did not progress.
Malfunction of DNA repair driven by TP53 and ATM gene modifications, the group said, “are associated with early disease progression, indicating that dysregulation of DNA repair is associated with a more aggressive tumor phenotype in RCC ... This subcategory of patients clearly needs new approaches based on our emerging understanding of the significance of TP53 mutations in RCC biology.”
MK-2206 induced significantly more rash and pruritus than did everolimus, with dose reduction in 37.9% of MK-2206 versus 21.4% of everolimus patients.
Subjects were a median of 63.5 years old in the everolimus group and 59 years in the MK-2206 group. The majority of patients were white men. More than 65% of the patients had performance status 1 and around 60% were in the Memorial Sloan Kettering Cancer Center intermediate risk group. The majority of patients in both treatment arms had clear cell histology; 57.1% (8) in the everolimus group and 82.8% (24) in the MK-2206 group had lung metastasis; half of the everolimus and 59% (17) of MK-2206 subjects were previously treated with sunitinib (Sutent).
The National Institutes of Health funded the work. The authors reported no conflicts of interest.
The AKT inhibitor MK-2206 was not superior to everolimus (Afinitor) for patients with metastatic renal cell carcinoma refractory to vascular endothelial growth factor inhibitors, according to a phase II trial from the University of Texas MD Anderson Cancer Center, Houston.
Median progression-free survival was 3.68 months in the 29 patients randomized to MK-2206, versus 5.98 months in the 14 randomized to everolimus, leading to closure of the study, reported Eric Jonasch, MD, of the department of genitourinary medical oncology at MD Anderson, and his associates.
However, dichotomous response rate profiles were seen in the MK-2206 arm with one complete response and three partial responses in the MK-2206 arm versus none in the everolimus arm.
“Whereas patients treated with everolimus for the large part had minimal changes in tumor size, MK-2206 induced a fairly dichotomous response dynamic, with [a few] patients demonstrating profound response, [but] a number of patients exhibiting rapid growth,” Dr. Jonasch and associates said (Ann Oncol. 2017 Jan 3. pii: mdw676. doi: 10.1093/annonc/mdw676).
Several studies have shown that upregulation of the PI3K/AKT pathway is associated with poor prognosis in renal cell carcinoma (RCC), making the pathway an attractive target for therapeutic intervention. The trial “results indicate that potential exists for effective blockade of the PI3K pathway in patients with RCC, but considerable work is required to better understand the nuances of this pathway before we can consistently modulate it to benefit patients with RCC,” the investigators said.
Molecular analysis failed to find a biomarker for response, but did demonstrate that deleterious tumor protein 53 or ataxia telangiectasia mutations or deletions were associated with poor prognosis. Among patients who progressed, 57.1% had TP53 or ATM aberrations; TP53 and ATM defects were absent in patients who did not progress.
Malfunction of DNA repair driven by TP53 and ATM gene modifications, the group said, “are associated with early disease progression, indicating that dysregulation of DNA repair is associated with a more aggressive tumor phenotype in RCC ... This subcategory of patients clearly needs new approaches based on our emerging understanding of the significance of TP53 mutations in RCC biology.”
MK-2206 induced significantly more rash and pruritus than did everolimus, with dose reduction in 37.9% of MK-2206 versus 21.4% of everolimus patients.
Subjects were a median of 63.5 years old in the everolimus group and 59 years in the MK-2206 group. The majority of patients were white men. More than 65% of the patients had performance status 1 and around 60% were in the Memorial Sloan Kettering Cancer Center intermediate risk group. The majority of patients in both treatment arms had clear cell histology; 57.1% (8) in the everolimus group and 82.8% (24) in the MK-2206 group had lung metastasis; half of the everolimus and 59% (17) of MK-2206 subjects were previously treated with sunitinib (Sutent).
The National Institutes of Health funded the work. The authors reported no conflicts of interest.
FROM SCIENCE TRANSLATIONAL MEDICINE
Key clinical point:
Major finding: Progression-free survival was a median of 3.68 months in the 29 patients randomized to MK-2206, versus 5.98 months in the 14 randomized to everolimus.
Data source: Phase II trial with 43 patients.
Disclosures: The National Institutes of Health funded the work. The authors reported no conflicts of interest.
Inhalers used incorrectly at least one-third of time
Clinical question: What are the most common errors in inhaler use over the past 40 years?
Background: One of the reasons for poor asthma and COPD control is incorrect inhaler use. Problems with technique have been recognized since the launch of the metered-dose inhaler (MDI) in the 1960s. Multiple initiatives have been implemented, including the design of the dry powder inhaler (DPI); however, problems persist despite all corrective measures.
Study design: Meta-analysis.
Synopsis: The most frequent MDI errors were lack of initial full expiration (48%), inadequate coordination (45%), and no postinhalation breath hold (46%). DPI errors were lower, compared with MDI errors: incorrect preparation (29%), no initial full expiration before inhalation (46%), and no postinhalation breath hold (37%).
The overall prevalence of correct technique was the same as poor technique (31%). There was no difference in the rates of incorrect inhaler use between the first and second 20-year periods of investigation.
Bottom line: Incorrect inhaler use in patients with asthma and COPD persists over time despite multiple implemented strategies.
Citation: Sanchis J, Gich I, Pedersen S, Aerosol Drug Management Improvement Team. Systematic review of errors in inhaler use: has the patient technique improved over time? Chest. 2016;150(2):394-406.
Dr. Florindez is an assistant professor at the University of Miami Miller School of Medicine and a hospitalist at University of Miami Hospital and Jackson Memorial Hospital.
Clinical question: What are the most common errors in inhaler use over the past 40 years?
Background: One of the reasons for poor asthma and COPD control is incorrect inhaler use. Problems with technique have been recognized since the launch of the metered-dose inhaler (MDI) in the 1960s. Multiple initiatives have been implemented, including the design of the dry powder inhaler (DPI); however, problems persist despite all corrective measures.
Study design: Meta-analysis.
Synopsis: The most frequent MDI errors were lack of initial full expiration (48%), inadequate coordination (45%), and no postinhalation breath hold (46%). DPI errors were lower, compared with MDI errors: incorrect preparation (29%), no initial full expiration before inhalation (46%), and no postinhalation breath hold (37%).
The overall prevalence of correct technique was the same as poor technique (31%). There was no difference in the rates of incorrect inhaler use between the first and second 20-year periods of investigation.
Bottom line: Incorrect inhaler use in patients with asthma and COPD persists over time despite multiple implemented strategies.
Citation: Sanchis J, Gich I, Pedersen S, Aerosol Drug Management Improvement Team. Systematic review of errors in inhaler use: has the patient technique improved over time? Chest. 2016;150(2):394-406.
Dr. Florindez is an assistant professor at the University of Miami Miller School of Medicine and a hospitalist at University of Miami Hospital and Jackson Memorial Hospital.
Clinical question: What are the most common errors in inhaler use over the past 40 years?
Background: One of the reasons for poor asthma and COPD control is incorrect inhaler use. Problems with technique have been recognized since the launch of the metered-dose inhaler (MDI) in the 1960s. Multiple initiatives have been implemented, including the design of the dry powder inhaler (DPI); however, problems persist despite all corrective measures.
Study design: Meta-analysis.
Synopsis: The most frequent MDI errors were lack of initial full expiration (48%), inadequate coordination (45%), and no postinhalation breath hold (46%). DPI errors were lower, compared with MDI errors: incorrect preparation (29%), no initial full expiration before inhalation (46%), and no postinhalation breath hold (37%).
The overall prevalence of correct technique was the same as poor technique (31%). There was no difference in the rates of incorrect inhaler use between the first and second 20-year periods of investigation.
Bottom line: Incorrect inhaler use in patients with asthma and COPD persists over time despite multiple implemented strategies.
Citation: Sanchis J, Gich I, Pedersen S, Aerosol Drug Management Improvement Team. Systematic review of errors in inhaler use: has the patient technique improved over time? Chest. 2016;150(2):394-406.
Dr. Florindez is an assistant professor at the University of Miami Miller School of Medicine and a hospitalist at University of Miami Hospital and Jackson Memorial Hospital.
Blood thinning with bioprosthetic valves
Clinical question: Does anticoagulation prevent thromboembolic events in patients undergoing bioprosthetic valve implantation?
Background: The main advantage of bioprosthetic valves, compared with mechanical valves, is the avoidance of long-term anticoagulation. Current guidelines recommend the use of vitamin K antagonist (VKA) during the first 3 months after surgery, which remains controversial. Two randomized controlled trials (RCTs) showed no benefit of using VKA in the first 3 months; however, other studies have reported conflicting results.
Study design: Meta-analysis and systematic review.
Setting: Multicenter.
Synopsis: This meta-analysis included two RCTs and 12 observational studies that compared the outcomes in group I (VKA) versus group II (antiplatelet therapy/no treatment). There was no difference in thromboembolic events between group I (1%) and group II (1.5%), but there were more bleeding events in group I (2.6%) versus group II (1.1%). In addition, no differences in all-cause of mortality rate and need for redo surgery were found between the two groups.
Bottom line: The use of VKA in the first 3 months after a bioprosthetic valve implantation does not decrease the rate of thromboembolic events or mortality, but it is associated with increased risk of major bleeding.
Citation: Masri A, Gillinov M, Johnston DM, et al. Anticoagulation versus antiplatelet or no therapy in patients undergoing bioprosthetic valve implantation: a systematic review and meta-analysis [published online ahead of print Aug. 3, 2016]. Heart. doi: 10.1136/heartjnl-2016-309630
Dr. Florindez is an assistant professor at the University of Miami Miller School of Medicine and a hospitalist at University of Miami Hospital and Jackson Memorial Hospital.
Clinical question: Does anticoagulation prevent thromboembolic events in patients undergoing bioprosthetic valve implantation?
Background: The main advantage of bioprosthetic valves, compared with mechanical valves, is the avoidance of long-term anticoagulation. Current guidelines recommend the use of vitamin K antagonist (VKA) during the first 3 months after surgery, which remains controversial. Two randomized controlled trials (RCTs) showed no benefit of using VKA in the first 3 months; however, other studies have reported conflicting results.
Study design: Meta-analysis and systematic review.
Setting: Multicenter.
Synopsis: This meta-analysis included two RCTs and 12 observational studies that compared the outcomes in group I (VKA) versus group II (antiplatelet therapy/no treatment). There was no difference in thromboembolic events between group I (1%) and group II (1.5%), but there were more bleeding events in group I (2.6%) versus group II (1.1%). In addition, no differences in all-cause of mortality rate and need for redo surgery were found between the two groups.
Bottom line: The use of VKA in the first 3 months after a bioprosthetic valve implantation does not decrease the rate of thromboembolic events or mortality, but it is associated with increased risk of major bleeding.
Citation: Masri A, Gillinov M, Johnston DM, et al. Anticoagulation versus antiplatelet or no therapy in patients undergoing bioprosthetic valve implantation: a systematic review and meta-analysis [published online ahead of print Aug. 3, 2016]. Heart. doi: 10.1136/heartjnl-2016-309630
Dr. Florindez is an assistant professor at the University of Miami Miller School of Medicine and a hospitalist at University of Miami Hospital and Jackson Memorial Hospital.
Clinical question: Does anticoagulation prevent thromboembolic events in patients undergoing bioprosthetic valve implantation?
Background: The main advantage of bioprosthetic valves, compared with mechanical valves, is the avoidance of long-term anticoagulation. Current guidelines recommend the use of vitamin K antagonist (VKA) during the first 3 months after surgery, which remains controversial. Two randomized controlled trials (RCTs) showed no benefit of using VKA in the first 3 months; however, other studies have reported conflicting results.
Study design: Meta-analysis and systematic review.
Setting: Multicenter.
Synopsis: This meta-analysis included two RCTs and 12 observational studies that compared the outcomes in group I (VKA) versus group II (antiplatelet therapy/no treatment). There was no difference in thromboembolic events between group I (1%) and group II (1.5%), but there were more bleeding events in group I (2.6%) versus group II (1.1%). In addition, no differences in all-cause of mortality rate and need for redo surgery were found between the two groups.
Bottom line: The use of VKA in the first 3 months after a bioprosthetic valve implantation does not decrease the rate of thromboembolic events or mortality, but it is associated with increased risk of major bleeding.
Citation: Masri A, Gillinov M, Johnston DM, et al. Anticoagulation versus antiplatelet or no therapy in patients undergoing bioprosthetic valve implantation: a systematic review and meta-analysis [published online ahead of print Aug. 3, 2016]. Heart. doi: 10.1136/heartjnl-2016-309630
Dr. Florindez is an assistant professor at the University of Miami Miller School of Medicine and a hospitalist at University of Miami Hospital and Jackson Memorial Hospital.
The Barbershop Study: Hypertension causes nocturia
NEW ORLEANS – Uncontrolled systolic hypertension is a strong independent determinant of nocturia in middle-aged African American men, O’Neil Mason, MD, reported at the American Heart Association scientific sessions.
This finding from the ongoing National Heart, Lung, and Blood Institute–sponsored Barbershop Study challenges the traditional notion of hypertension as an asymptomatic disease. It also provides a novel health promotion message aimed at improving compliance with blood pressure medication.
The Barbershop Study is a hypertension intervention trial that’s being conducted in Los Angeles barbershops frequented by black men. In the initial screening phase for study eligibility, 2,577 African American men aged 35-79 years underwent highly accurate blood pressure measurements using an average of three readings taken via an oscillometric monitor.
The mean age of the men was 53 years. It was an obese group, with a mean body mass index of 30 kg/m2. Fifty percent of the men had hypertension, and among that cohort fully one-third weren’t on antihypertensive medication and another 28% were treated but uncontrolled, with on-treatment blood pressures of 140/90 mm Hg or more. Thus, only 39% of these middle-aged African American men with high blood pressure were treated and controlled at baseline.
Seventy-seven percent of the screened men reported awakening once or more per night to urinate. A progressive increase in nocturia severity was seen with increasing systolic blood pressure. The prevalence of nocturia ranged from 68% among normotensive men to 91% among those with treated but uncontrolled hypertension, Dr. Mason reported.
In a multivariate logistic regression analysis controlling for the standard risk factors for nocturia – including advancing age, an enlarged prostate, and diabetes, which was present in 16% of the men – stage 1 systolic hypertension in the range of 140-159 mm Hg was independently associated with a 1.57-fold increased likelihood of nocturia, compared with normotensive subjects. Stage 2 hypertension, with a systolic blood pressure of 160 mm Hg or more, was associated with a 2.32-fold increased risk; that’s in the same ballpark as having an enlarged prostate, which carried a 2.1-fold increased risk. Prehypertension – that is, a systolic pressure of 120-139 mm Hg – was associated with a nonsignificant 1.18-fold risk.
Diastolic blood pressure wasn’t an independent determinant of nocturia.
In a similar multivariate analysis focused on severe nocturia, defined as three or more episodes per night, stage 1 systolic hypertension was independently associated with a 2.29-fold increased risk, compared with normotension, and stage 2 systolic hypertension carried a 2.77-fold increased risk.
Audience members were clearly intrigued by this novel finding. They were quick to speculate as to potential underlying pathophysiologic mechanisms, including atrial stretch, increased renal blood flow, or perhaps a side effect of diuretic therapy. However, Dr. Mason and his coinvestigators favor another possibility: “African Americans have more salt-sensitive hypertension and they have less nocturnal blood pressure dipping,” he noted. “So if nighttime blood pressure is high it could lead through increased pressure natriuresis to increased urine production. More activity in getting up to go to the bathroom increases the blood pressure and creates a cycle that begets more urine.”
Asked if uncontrolled systolic hypertension is also a determinant of nocturia in African American women, Dr. Mason replied that he would assume so. But that question hasn’t ever been studied. The Barbershop Study is restricted to African American men with hypertension because studies have shown they have a particularly low rate of controlled hypertension. In contrast, the controlled hypertension rate among hypertensive African American women is comparable with their white counterparts.
In the next phase of the Barbershop Study, participants’ use of various classes of antihypertensive medication will be prospectively tracked. Among other things, this will enable investigators to determine whether diuretics contribute to nocturia.
Dr. Mason reported having no conflicts of interest regarding the study.
NEW ORLEANS – Uncontrolled systolic hypertension is a strong independent determinant of nocturia in middle-aged African American men, O’Neil Mason, MD, reported at the American Heart Association scientific sessions.
This finding from the ongoing National Heart, Lung, and Blood Institute–sponsored Barbershop Study challenges the traditional notion of hypertension as an asymptomatic disease. It also provides a novel health promotion message aimed at improving compliance with blood pressure medication.
The Barbershop Study is a hypertension intervention trial that’s being conducted in Los Angeles barbershops frequented by black men. In the initial screening phase for study eligibility, 2,577 African American men aged 35-79 years underwent highly accurate blood pressure measurements using an average of three readings taken via an oscillometric monitor.
The mean age of the men was 53 years. It was an obese group, with a mean body mass index of 30 kg/m2. Fifty percent of the men had hypertension, and among that cohort fully one-third weren’t on antihypertensive medication and another 28% were treated but uncontrolled, with on-treatment blood pressures of 140/90 mm Hg or more. Thus, only 39% of these middle-aged African American men with high blood pressure were treated and controlled at baseline.
Seventy-seven percent of the screened men reported awakening once or more per night to urinate. A progressive increase in nocturia severity was seen with increasing systolic blood pressure. The prevalence of nocturia ranged from 68% among normotensive men to 91% among those with treated but uncontrolled hypertension, Dr. Mason reported.
In a multivariate logistic regression analysis controlling for the standard risk factors for nocturia – including advancing age, an enlarged prostate, and diabetes, which was present in 16% of the men – stage 1 systolic hypertension in the range of 140-159 mm Hg was independently associated with a 1.57-fold increased likelihood of nocturia, compared with normotensive subjects. Stage 2 hypertension, with a systolic blood pressure of 160 mm Hg or more, was associated with a 2.32-fold increased risk; that’s in the same ballpark as having an enlarged prostate, which carried a 2.1-fold increased risk. Prehypertension – that is, a systolic pressure of 120-139 mm Hg – was associated with a nonsignificant 1.18-fold risk.
Diastolic blood pressure wasn’t an independent determinant of nocturia.
In a similar multivariate analysis focused on severe nocturia, defined as three or more episodes per night, stage 1 systolic hypertension was independently associated with a 2.29-fold increased risk, compared with normotension, and stage 2 systolic hypertension carried a 2.77-fold increased risk.
Audience members were clearly intrigued by this novel finding. They were quick to speculate as to potential underlying pathophysiologic mechanisms, including atrial stretch, increased renal blood flow, or perhaps a side effect of diuretic therapy. However, Dr. Mason and his coinvestigators favor another possibility: “African Americans have more salt-sensitive hypertension and they have less nocturnal blood pressure dipping,” he noted. “So if nighttime blood pressure is high it could lead through increased pressure natriuresis to increased urine production. More activity in getting up to go to the bathroom increases the blood pressure and creates a cycle that begets more urine.”
Asked if uncontrolled systolic hypertension is also a determinant of nocturia in African American women, Dr. Mason replied that he would assume so. But that question hasn’t ever been studied. The Barbershop Study is restricted to African American men with hypertension because studies have shown they have a particularly low rate of controlled hypertension. In contrast, the controlled hypertension rate among hypertensive African American women is comparable with their white counterparts.
In the next phase of the Barbershop Study, participants’ use of various classes of antihypertensive medication will be prospectively tracked. Among other things, this will enable investigators to determine whether diuretics contribute to nocturia.
Dr. Mason reported having no conflicts of interest regarding the study.
NEW ORLEANS – Uncontrolled systolic hypertension is a strong independent determinant of nocturia in middle-aged African American men, O’Neil Mason, MD, reported at the American Heart Association scientific sessions.
This finding from the ongoing National Heart, Lung, and Blood Institute–sponsored Barbershop Study challenges the traditional notion of hypertension as an asymptomatic disease. It also provides a novel health promotion message aimed at improving compliance with blood pressure medication.
The Barbershop Study is a hypertension intervention trial that’s being conducted in Los Angeles barbershops frequented by black men. In the initial screening phase for study eligibility, 2,577 African American men aged 35-79 years underwent highly accurate blood pressure measurements using an average of three readings taken via an oscillometric monitor.
The mean age of the men was 53 years. It was an obese group, with a mean body mass index of 30 kg/m2. Fifty percent of the men had hypertension, and among that cohort fully one-third weren’t on antihypertensive medication and another 28% were treated but uncontrolled, with on-treatment blood pressures of 140/90 mm Hg or more. Thus, only 39% of these middle-aged African American men with high blood pressure were treated and controlled at baseline.
Seventy-seven percent of the screened men reported awakening once or more per night to urinate. A progressive increase in nocturia severity was seen with increasing systolic blood pressure. The prevalence of nocturia ranged from 68% among normotensive men to 91% among those with treated but uncontrolled hypertension, Dr. Mason reported.
In a multivariate logistic regression analysis controlling for the standard risk factors for nocturia – including advancing age, an enlarged prostate, and diabetes, which was present in 16% of the men – stage 1 systolic hypertension in the range of 140-159 mm Hg was independently associated with a 1.57-fold increased likelihood of nocturia, compared with normotensive subjects. Stage 2 hypertension, with a systolic blood pressure of 160 mm Hg or more, was associated with a 2.32-fold increased risk; that’s in the same ballpark as having an enlarged prostate, which carried a 2.1-fold increased risk. Prehypertension – that is, a systolic pressure of 120-139 mm Hg – was associated with a nonsignificant 1.18-fold risk.
Diastolic blood pressure wasn’t an independent determinant of nocturia.
In a similar multivariate analysis focused on severe nocturia, defined as three or more episodes per night, stage 1 systolic hypertension was independently associated with a 2.29-fold increased risk, compared with normotension, and stage 2 systolic hypertension carried a 2.77-fold increased risk.
Audience members were clearly intrigued by this novel finding. They were quick to speculate as to potential underlying pathophysiologic mechanisms, including atrial stretch, increased renal blood flow, or perhaps a side effect of diuretic therapy. However, Dr. Mason and his coinvestigators favor another possibility: “African Americans have more salt-sensitive hypertension and they have less nocturnal blood pressure dipping,” he noted. “So if nighttime blood pressure is high it could lead through increased pressure natriuresis to increased urine production. More activity in getting up to go to the bathroom increases the blood pressure and creates a cycle that begets more urine.”
Asked if uncontrolled systolic hypertension is also a determinant of nocturia in African American women, Dr. Mason replied that he would assume so. But that question hasn’t ever been studied. The Barbershop Study is restricted to African American men with hypertension because studies have shown they have a particularly low rate of controlled hypertension. In contrast, the controlled hypertension rate among hypertensive African American women is comparable with their white counterparts.
In the next phase of the Barbershop Study, participants’ use of various classes of antihypertensive medication will be prospectively tracked. Among other things, this will enable investigators to determine whether diuretics contribute to nocturia.
Dr. Mason reported having no conflicts of interest regarding the study.
Key clinical point:
Major finding: A systolic blood pressure of 140-159 mm Hg was independently associated with a 2.29-fold increased risk of severe nocturia, compared with normotension in middle-aged African American men, while a pressure of 160 mm Hg or more conferred a 2.77-fold increased risk.
Data source: A report on the initial cross-sectional screening phase of the Barbershop Study, in which 2,577 middle-aged African American men underwent blood pressure measurements in Los Angeles barbershops.
Disclosures: The Barbershop Study is funded by the National Heart, Lung, and Blood Institute. The presenter reported having no financial conflicts.
Lab values poor surrogate for detecting pediatric Rocky Mountain spotted fever in children
The three fatalities observed in a retrospective analysis of six cases of Rocky Mountain spotted fever (RMSF) in children were associated with either a delayed diagnosis pending laboratory findings or delayed antirickettsia treatment.
“The fact that all fatal cases died before the convalescent period emphasizes that diagnosis should be based on clinical findings instead of RMSF serologic and histologic testing,” wrote the authors of a study published online in Pediatric Dermatology (2016 Dec 19. doi: 10.1111/pde.13053).
Two of the fatal cases involved delayed antirickettsial therapy after the patients were misdiagnosed with group A streptococcus. None of the six children were initially evaluated for R. rickettsii; they averaged three encounters with their clinician before being admitted for acute inpatient care where they received intravenous doxycycline after nearly a week of symptoms.
“All fatal cases were complicated by neurologic manifestations, including seizures, obtundation, and uncal herniation,” a finding that is consistent with the literature, the authors said.
Although the high fatality rate might be the result of the small study size, Ms. Tull and her coinvestigators concluded that the disease should be considered in all differential diagnoses for children who present with a fever and rash during the summer months in endemic areas, particularly since pediatric cases of the disease are associated with poorer outcomes than in adult cases.
Given that RMSF often remains subclinical in its early stages, and typically presents with nonspecific symptoms of fever, rash, headache, and abdominal pain when it does emerge, physicians might be tempted to defer treatment until after serologic and histologic results are in, as is the standard method. Concerns over doxycycline’s tendency to stain teeth and cause enamel hypoplasia are also common. However, empirical administration could mean the difference between life and death, since treatment within the first 5 days following infection is associated with better outcomes – an algorithm complicated by the fact that symptoms caused by R. rickettsii have been known to take as long as 21 days to appear.
In the study, Ms. Tull and her colleagues found that the average time between exposure to the tick and the onset of symptoms was 6.6 days (range, 1-21 days).
Currently, there are no diagnostic tests “that reliably diagnose RMSF during the first 7 days of illness,” and most patients “do not develop detectable antibodies until the second week of illness,” the investigators reported. Even then, sensitivity of indirect fluorescent antibody serum testing after the second week of illness is only between 86% and 94%, they noted. Further, the sensitivity of immunohistochemical (IHC) tissue staining has been reported at 70%, and false-negative IHC results are common in acute disease when antibody response is harder to detect.
Ms. Tull and her colleagues found that five of the six patients in their study had negative IHC testing; two of the six had positive serum antibody titers. For this reason, they concluded that Rocky Mountain spotted fever diagnosis should be based on “clinical history, examination, and laboratory abnormalities” rather than laboratory testing, and urged that “prompt treatment should be instituted empirically.”
The authors did not have any relevant financial disclosures.
The three fatalities observed in a retrospective analysis of six cases of Rocky Mountain spotted fever (RMSF) in children were associated with either a delayed diagnosis pending laboratory findings or delayed antirickettsia treatment.
“The fact that all fatal cases died before the convalescent period emphasizes that diagnosis should be based on clinical findings instead of RMSF serologic and histologic testing,” wrote the authors of a study published online in Pediatric Dermatology (2016 Dec 19. doi: 10.1111/pde.13053).
Two of the fatal cases involved delayed antirickettsial therapy after the patients were misdiagnosed with group A streptococcus. None of the six children were initially evaluated for R. rickettsii; they averaged three encounters with their clinician before being admitted for acute inpatient care where they received intravenous doxycycline after nearly a week of symptoms.
“All fatal cases were complicated by neurologic manifestations, including seizures, obtundation, and uncal herniation,” a finding that is consistent with the literature, the authors said.
Although the high fatality rate might be the result of the small study size, Ms. Tull and her coinvestigators concluded that the disease should be considered in all differential diagnoses for children who present with a fever and rash during the summer months in endemic areas, particularly since pediatric cases of the disease are associated with poorer outcomes than in adult cases.
Given that RMSF often remains subclinical in its early stages, and typically presents with nonspecific symptoms of fever, rash, headache, and abdominal pain when it does emerge, physicians might be tempted to defer treatment until after serologic and histologic results are in, as is the standard method. Concerns over doxycycline’s tendency to stain teeth and cause enamel hypoplasia are also common. However, empirical administration could mean the difference between life and death, since treatment within the first 5 days following infection is associated with better outcomes – an algorithm complicated by the fact that symptoms caused by R. rickettsii have been known to take as long as 21 days to appear.
In the study, Ms. Tull and her colleagues found that the average time between exposure to the tick and the onset of symptoms was 6.6 days (range, 1-21 days).
Currently, there are no diagnostic tests “that reliably diagnose RMSF during the first 7 days of illness,” and most patients “do not develop detectable antibodies until the second week of illness,” the investigators reported. Even then, sensitivity of indirect fluorescent antibody serum testing after the second week of illness is only between 86% and 94%, they noted. Further, the sensitivity of immunohistochemical (IHC) tissue staining has been reported at 70%, and false-negative IHC results are common in acute disease when antibody response is harder to detect.
Ms. Tull and her colleagues found that five of the six patients in their study had negative IHC testing; two of the six had positive serum antibody titers. For this reason, they concluded that Rocky Mountain spotted fever diagnosis should be based on “clinical history, examination, and laboratory abnormalities” rather than laboratory testing, and urged that “prompt treatment should be instituted empirically.”
The authors did not have any relevant financial disclosures.
The three fatalities observed in a retrospective analysis of six cases of Rocky Mountain spotted fever (RMSF) in children were associated with either a delayed diagnosis pending laboratory findings or delayed antirickettsia treatment.
“The fact that all fatal cases died before the convalescent period emphasizes that diagnosis should be based on clinical findings instead of RMSF serologic and histologic testing,” wrote the authors of a study published online in Pediatric Dermatology (2016 Dec 19. doi: 10.1111/pde.13053).
Two of the fatal cases involved delayed antirickettsial therapy after the patients were misdiagnosed with group A streptococcus. None of the six children were initially evaluated for R. rickettsii; they averaged three encounters with their clinician before being admitted for acute inpatient care where they received intravenous doxycycline after nearly a week of symptoms.
“All fatal cases were complicated by neurologic manifestations, including seizures, obtundation, and uncal herniation,” a finding that is consistent with the literature, the authors said.
Although the high fatality rate might be the result of the small study size, Ms. Tull and her coinvestigators concluded that the disease should be considered in all differential diagnoses for children who present with a fever and rash during the summer months in endemic areas, particularly since pediatric cases of the disease are associated with poorer outcomes than in adult cases.
Given that RMSF often remains subclinical in its early stages, and typically presents with nonspecific symptoms of fever, rash, headache, and abdominal pain when it does emerge, physicians might be tempted to defer treatment until after serologic and histologic results are in, as is the standard method. Concerns over doxycycline’s tendency to stain teeth and cause enamel hypoplasia are also common. However, empirical administration could mean the difference between life and death, since treatment within the first 5 days following infection is associated with better outcomes – an algorithm complicated by the fact that symptoms caused by R. rickettsii have been known to take as long as 21 days to appear.
In the study, Ms. Tull and her colleagues found that the average time between exposure to the tick and the onset of symptoms was 6.6 days (range, 1-21 days).
Currently, there are no diagnostic tests “that reliably diagnose RMSF during the first 7 days of illness,” and most patients “do not develop detectable antibodies until the second week of illness,” the investigators reported. Even then, sensitivity of indirect fluorescent antibody serum testing after the second week of illness is only between 86% and 94%, they noted. Further, the sensitivity of immunohistochemical (IHC) tissue staining has been reported at 70%, and false-negative IHC results are common in acute disease when antibody response is harder to detect.
Ms. Tull and her colleagues found that five of the six patients in their study had negative IHC testing; two of the six had positive serum antibody titers. For this reason, they concluded that Rocky Mountain spotted fever diagnosis should be based on “clinical history, examination, and laboratory abnormalities” rather than laboratory testing, and urged that “prompt treatment should be instituted empirically.”
The authors did not have any relevant financial disclosures.
FROM PEDIATRIC DERMATOLOGY
Key clinical point:
Major finding: Half of pediatric patients diagnosed with Rocky Mountain spotted fever died after treatment was delayed.
Data source: A retrospective analysis of 6 pediatric RMSF cases among 3,912 inpatient dermatology consultations over a period of 10 years at a tertiary care center.
Disclosures: The authors did not have any relevant financial disclosures. .
Medicare payments set for infliximab biosimilar Inflectra
Payment for the infliximab biosimilar drug Inflectra will now be covered by Medicare, the drug’s manufacturer, Pfizer, said in an announcement.
The Centers for Medicare & Medicaid Services (CMS) included Inflectra (infliximab-dyyb) in its January 2017 Average Sales Price pricing file, which went into effect Jan. 1, 2017. Pfizer said that Inflectra is priced at a 15% discount to the current wholesale acquisition cost for the infliximab originator Remicade, but this price does not include discounts to payers, providers, distributors, and other purchasing organizations.
For the first quarter of 2017, the payment limit set by the CMS for Inflectra is $100.306 per 10-mg unit and $82.218 for Remicade.
Various national and regional wholesalers across the country began receiving shipments of Inflectra in November 2016, according to Pfizer.
In conjunction with the availability of Inflectra, Pfizer announced its enCompass program, “a comprehensive reimbursement service and patient support program offering coding and reimbursement support for providers, copay assistance to eligible patients who have commercial insurance that covers Inflectra, and financial assistance for eligible uninsured and underinsured patients.”
The FDA approved Inflectra in April 2016 for all of the same indications as Remicade: rheumatoid arthritis, psoriatic arthritis, ankylosing spondylitis, Crohn’s disease, plaque psoriasis, and ulcerative colitis.
Payment for the infliximab biosimilar drug Inflectra will now be covered by Medicare, the drug’s manufacturer, Pfizer, said in an announcement.
The Centers for Medicare & Medicaid Services (CMS) included Inflectra (infliximab-dyyb) in its January 2017 Average Sales Price pricing file, which went into effect Jan. 1, 2017. Pfizer said that Inflectra is priced at a 15% discount to the current wholesale acquisition cost for the infliximab originator Remicade, but this price does not include discounts to payers, providers, distributors, and other purchasing organizations.
For the first quarter of 2017, the payment limit set by the CMS for Inflectra is $100.306 per 10-mg unit and $82.218 for Remicade.
Various national and regional wholesalers across the country began receiving shipments of Inflectra in November 2016, according to Pfizer.
In conjunction with the availability of Inflectra, Pfizer announced its enCompass program, “a comprehensive reimbursement service and patient support program offering coding and reimbursement support for providers, copay assistance to eligible patients who have commercial insurance that covers Inflectra, and financial assistance for eligible uninsured and underinsured patients.”
The FDA approved Inflectra in April 2016 for all of the same indications as Remicade: rheumatoid arthritis, psoriatic arthritis, ankylosing spondylitis, Crohn’s disease, plaque psoriasis, and ulcerative colitis.
Payment for the infliximab biosimilar drug Inflectra will now be covered by Medicare, the drug’s manufacturer, Pfizer, said in an announcement.
The Centers for Medicare & Medicaid Services (CMS) included Inflectra (infliximab-dyyb) in its January 2017 Average Sales Price pricing file, which went into effect Jan. 1, 2017. Pfizer said that Inflectra is priced at a 15% discount to the current wholesale acquisition cost for the infliximab originator Remicade, but this price does not include discounts to payers, providers, distributors, and other purchasing organizations.
For the first quarter of 2017, the payment limit set by the CMS for Inflectra is $100.306 per 10-mg unit and $82.218 for Remicade.
Various national and regional wholesalers across the country began receiving shipments of Inflectra in November 2016, according to Pfizer.
In conjunction with the availability of Inflectra, Pfizer announced its enCompass program, “a comprehensive reimbursement service and patient support program offering coding and reimbursement support for providers, copay assistance to eligible patients who have commercial insurance that covers Inflectra, and financial assistance for eligible uninsured and underinsured patients.”
The FDA approved Inflectra in April 2016 for all of the same indications as Remicade: rheumatoid arthritis, psoriatic arthritis, ankylosing spondylitis, Crohn’s disease, plaque psoriasis, and ulcerative colitis.
High-intensity statins cut amputations and mortality in PAD
NEW ORLEANS – High-intensity statin therapy in patients with peripheral artery disease was associated with significant reductions in amputations as well as mortality during up to 5 years of follow-up in the first large study to examine the relationship, Shipra Arya, MD, reported at the American Heart Association scientific sessions.
Low- or moderate-intensity statin therapy also improved survival compared to no statin, albeit to a significantly lesser magnitude than high-intensity therapy. But high- and low/intermediate-intensity statins were similarly effective in reducing amputation risk, according to Dr. Arya, a vascular surgeon at Emory University in Atlanta.
The 2013 AHA/American College of Cardiology treatment guidelines recommend high-intensity statins for all patients with clinical atherosclerotic disease, including those with PAD (Circulation. 2014 Jun 24;129[25 Suppl 2]:S1-45). (Updated PAD guidelines unveiled at the AHA meeting strongly recommend statin medication for all patients with PAD [Circulation. 2016 Nov 13. doi: 10.1161/CIR.0000000000000470]).However, the bulk of patients in Dr. Arya’s study were captured in the database prior to release of the 2013 guidelines. That may account for the sparse use of high-intensity statin therapy in the study cohort. Indeed, only 11.3% of the PAD patients were on a high-intensity statin. Another 36.2% were on moderate-intensity statin therapy, 3.5% were on low-intensity therapy, and 27.6% weren’t on a statin at all.
The relationship between statin therapy and mortality was strongly dose-dependent.
This study was funded by the AHA and the Atlanta Veterans Affairs Medical Center. Dr. Arya reported having no financial conflicts of interest.
NEW ORLEANS – High-intensity statin therapy in patients with peripheral artery disease was associated with significant reductions in amputations as well as mortality during up to 5 years of follow-up in the first large study to examine the relationship, Shipra Arya, MD, reported at the American Heart Association scientific sessions.
Low- or moderate-intensity statin therapy also improved survival compared to no statin, albeit to a significantly lesser magnitude than high-intensity therapy. But high- and low/intermediate-intensity statins were similarly effective in reducing amputation risk, according to Dr. Arya, a vascular surgeon at Emory University in Atlanta.
The 2013 AHA/American College of Cardiology treatment guidelines recommend high-intensity statins for all patients with clinical atherosclerotic disease, including those with PAD (Circulation. 2014 Jun 24;129[25 Suppl 2]:S1-45). (Updated PAD guidelines unveiled at the AHA meeting strongly recommend statin medication for all patients with PAD [Circulation. 2016 Nov 13. doi: 10.1161/CIR.0000000000000470]).However, the bulk of patients in Dr. Arya’s study were captured in the database prior to release of the 2013 guidelines. That may account for the sparse use of high-intensity statin therapy in the study cohort. Indeed, only 11.3% of the PAD patients were on a high-intensity statin. Another 36.2% were on moderate-intensity statin therapy, 3.5% were on low-intensity therapy, and 27.6% weren’t on a statin at all.
The relationship between statin therapy and mortality was strongly dose-dependent.
This study was funded by the AHA and the Atlanta Veterans Affairs Medical Center. Dr. Arya reported having no financial conflicts of interest.
NEW ORLEANS – High-intensity statin therapy in patients with peripheral artery disease was associated with significant reductions in amputations as well as mortality during up to 5 years of follow-up in the first large study to examine the relationship, Shipra Arya, MD, reported at the American Heart Association scientific sessions.
Low- or moderate-intensity statin therapy also improved survival compared to no statin, albeit to a significantly lesser magnitude than high-intensity therapy. But high- and low/intermediate-intensity statins were similarly effective in reducing amputation risk, according to Dr. Arya, a vascular surgeon at Emory University in Atlanta.
The 2013 AHA/American College of Cardiology treatment guidelines recommend high-intensity statins for all patients with clinical atherosclerotic disease, including those with PAD (Circulation. 2014 Jun 24;129[25 Suppl 2]:S1-45). (Updated PAD guidelines unveiled at the AHA meeting strongly recommend statin medication for all patients with PAD [Circulation. 2016 Nov 13. doi: 10.1161/CIR.0000000000000470]).However, the bulk of patients in Dr. Arya’s study were captured in the database prior to release of the 2013 guidelines. That may account for the sparse use of high-intensity statin therapy in the study cohort. Indeed, only 11.3% of the PAD patients were on a high-intensity statin. Another 36.2% were on moderate-intensity statin therapy, 3.5% were on low-intensity therapy, and 27.6% weren’t on a statin at all.
The relationship between statin therapy and mortality was strongly dose-dependent.
This study was funded by the AHA and the Atlanta Veterans Affairs Medical Center. Dr. Arya reported having no financial conflicts of interest.
AT THE AHA SCIENTIFIC SESSIONS
Key clinical point:
Major finding: The 5-year all-cause mortality rate after diagnosis of peripheral artery disease was 20.4% in patients on high-intensity statin therapy, 28.6% in those on a low- or moderate-intensity statin, and 33.9% in patients not on a statin.
Data source: A retrospective observational study of 208,194 patients with clinical peripheral artery disease in the national Veterans Affairs database for 2003-2014.
Disclosures: The AHA and the Atlanta Veterans Affairs Medical Center funded the study. The presenter reported having no financial conflicts of interest.
USPSTF reaffirms need for folic acid supplements in pregnancy
The U.S. Preventive Services Task Force continues to recommend that all women planning or capable of pregnancy should take a daily supplement of 0.4-0.8 mg of folic acid to prevent neural tube defects in their offspring.
The task force “concludes with high certainty” that the benefits of such supplementation are substantial and the harms are minimal, according to the recommendation statement published online Jan. 10 in JAMA (2017;317[2]:183-9). The group based its updated recommendation on a systematic review of 24 studies performed since 2009 and involving 58,860 women. Although some newer studies have suggested that supplementation is no longer needed in this era of folic acid fortification of foods, “the USPSTF found no new substantial evidence ... that would lead to a change in its recommendation from 2009,” the researchers wrote.
The most recent data estimate that folic acid supplementation prevents neural tube defects in approximately 1,300 births each year.
This updated USPSTF recommendation is in accord with recommendations from the Health and Medicine Division of the National Academies (formerly the Institute of Medicine), the American College of Obstetricians and Gynecologists, the American Academy of Family Physicians, the U.S. Public Health Service, the Centers for Disease Control and Prevention, the American Academy of Pediatrics, the American Academy of Neurology, and the American College of Medical Genetics and Genomics.
This work was supported solely by the USPSTF, an independent voluntary group mandated by Congress to assess preventive care services and funded by the Agency for Healthcare Research and Quality.
The USPSTF recommendation that all women of childbearing age take folic acid supplements is a prudent one. Ideally, it will educate all women who are planning or capable of pregnancy to follow this recommendation and thereby reduce the risk of these severe birth defects in their infants.
Should the USPSTF recommendation be rejected because fortified food is already providing sufficient folic acid to prevent neural tube defects? No. Too little is known about how folic acid prevents neural tube defects. For example, it is not known whether the tissue stores of folate in the developing embryo or the availability of folate in the serum during the all-important few days of neural tube closure is most important. Habitual use of folic acid supplements is a more reliable method of ensuring adequate levels than is diet. In theory, a woman might not consume sufficient enriched cereal grains during the critical period of approximately 1 week when the neural tube is closing. Exactly when folate must be available also is not known. In addition, some popular diets, such as low carbohydrate or gluten free, may reduce exposure to grains, limiting folic acid intake.
James L. Mills, MD, is in the Division of Intramural Population Health Research at the Eunice Kennedy Shriver National Institute of Child Health and Human Development in Bethesda, Md. He reported having no relevant financial disclosures. These comments are adapted from an editorial accompanying the USPSTF report (JAMA. 2017;317 [2]:144-5).
The USPSTF recommendation that all women of childbearing age take folic acid supplements is a prudent one. Ideally, it will educate all women who are planning or capable of pregnancy to follow this recommendation and thereby reduce the risk of these severe birth defects in their infants.
Should the USPSTF recommendation be rejected because fortified food is already providing sufficient folic acid to prevent neural tube defects? No. Too little is known about how folic acid prevents neural tube defects. For example, it is not known whether the tissue stores of folate in the developing embryo or the availability of folate in the serum during the all-important few days of neural tube closure is most important. Habitual use of folic acid supplements is a more reliable method of ensuring adequate levels than is diet. In theory, a woman might not consume sufficient enriched cereal grains during the critical period of approximately 1 week when the neural tube is closing. Exactly when folate must be available also is not known. In addition, some popular diets, such as low carbohydrate or gluten free, may reduce exposure to grains, limiting folic acid intake.
James L. Mills, MD, is in the Division of Intramural Population Health Research at the Eunice Kennedy Shriver National Institute of Child Health and Human Development in Bethesda, Md. He reported having no relevant financial disclosures. These comments are adapted from an editorial accompanying the USPSTF report (JAMA. 2017;317 [2]:144-5).
The USPSTF recommendation that all women of childbearing age take folic acid supplements is a prudent one. Ideally, it will educate all women who are planning or capable of pregnancy to follow this recommendation and thereby reduce the risk of these severe birth defects in their infants.
Should the USPSTF recommendation be rejected because fortified food is already providing sufficient folic acid to prevent neural tube defects? No. Too little is known about how folic acid prevents neural tube defects. For example, it is not known whether the tissue stores of folate in the developing embryo or the availability of folate in the serum during the all-important few days of neural tube closure is most important. Habitual use of folic acid supplements is a more reliable method of ensuring adequate levels than is diet. In theory, a woman might not consume sufficient enriched cereal grains during the critical period of approximately 1 week when the neural tube is closing. Exactly when folate must be available also is not known. In addition, some popular diets, such as low carbohydrate or gluten free, may reduce exposure to grains, limiting folic acid intake.
James L. Mills, MD, is in the Division of Intramural Population Health Research at the Eunice Kennedy Shriver National Institute of Child Health and Human Development in Bethesda, Md. He reported having no relevant financial disclosures. These comments are adapted from an editorial accompanying the USPSTF report (JAMA. 2017;317 [2]:144-5).
The U.S. Preventive Services Task Force continues to recommend that all women planning or capable of pregnancy should take a daily supplement of 0.4-0.8 mg of folic acid to prevent neural tube defects in their offspring.
The task force “concludes with high certainty” that the benefits of such supplementation are substantial and the harms are minimal, according to the recommendation statement published online Jan. 10 in JAMA (2017;317[2]:183-9). The group based its updated recommendation on a systematic review of 24 studies performed since 2009 and involving 58,860 women. Although some newer studies have suggested that supplementation is no longer needed in this era of folic acid fortification of foods, “the USPSTF found no new substantial evidence ... that would lead to a change in its recommendation from 2009,” the researchers wrote.
The most recent data estimate that folic acid supplementation prevents neural tube defects in approximately 1,300 births each year.
This updated USPSTF recommendation is in accord with recommendations from the Health and Medicine Division of the National Academies (formerly the Institute of Medicine), the American College of Obstetricians and Gynecologists, the American Academy of Family Physicians, the U.S. Public Health Service, the Centers for Disease Control and Prevention, the American Academy of Pediatrics, the American Academy of Neurology, and the American College of Medical Genetics and Genomics.
This work was supported solely by the USPSTF, an independent voluntary group mandated by Congress to assess preventive care services and funded by the Agency for Healthcare Research and Quality.
The U.S. Preventive Services Task Force continues to recommend that all women planning or capable of pregnancy should take a daily supplement of 0.4-0.8 mg of folic acid to prevent neural tube defects in their offspring.
The task force “concludes with high certainty” that the benefits of such supplementation are substantial and the harms are minimal, according to the recommendation statement published online Jan. 10 in JAMA (2017;317[2]:183-9). The group based its updated recommendation on a systematic review of 24 studies performed since 2009 and involving 58,860 women. Although some newer studies have suggested that supplementation is no longer needed in this era of folic acid fortification of foods, “the USPSTF found no new substantial evidence ... that would lead to a change in its recommendation from 2009,” the researchers wrote.
The most recent data estimate that folic acid supplementation prevents neural tube defects in approximately 1,300 births each year.
This updated USPSTF recommendation is in accord with recommendations from the Health and Medicine Division of the National Academies (formerly the Institute of Medicine), the American College of Obstetricians and Gynecologists, the American Academy of Family Physicians, the U.S. Public Health Service, the Centers for Disease Control and Prevention, the American Academy of Pediatrics, the American Academy of Neurology, and the American College of Medical Genetics and Genomics.
This work was supported solely by the USPSTF, an independent voluntary group mandated by Congress to assess preventive care services and funded by the Agency for Healthcare Research and Quality.
FROM JAMA
Key clinical point:
Major finding: Folic acid supplementation prevents neural tube defects in an estimated 1,300 births each year in the United States.
Data source: A systematic review of 24 studies (involving 58,860 women) that were performed since 2009 regarding the benefits and harms of folic acid supplementation.
Disclosures: This work was supported solely by the USPSTF, an independent voluntary group mandated by Congress to assess preventive care services and funded by the Agency for Healthcare Research and Quality.
Giant cell arteritis independently raises risk for venous thromboembolism
The risk of venous thromboembolism increases markedly shortly before the diagnosis of giant cell arteritis regardless of glucocorticoid exposure, peaks at the time of diagnosis, and then progressively declines, according to a matched cohort review involving more than 6,000 arteritis patients.
It’s not been clear until now if the recently recognized risk of venous thromboembolism (VTE) in giant cell arteritis (GCA) was due to the disease itself, or the glucocorticoids used to treat it. “Because inflammation in GCA spares the venous circulation, our finding that patients are at greatest risk of VTE in the period surrounding GCA diagnosis (when inflammation is at its highest level), and the demonstration that this risk is not associated with the use of glucocorticoids, suggest that immunothrombosis could play a pathogenic role,” said investigators led by Sebastian Unizony, MD, of Massachusetts General Hospital, Boston (Arthritis Rheumatol. 2017 Jan;69[1]:176-84).
The report was short on advice about what to do to prevent VTE in GCA, but the investigators did recommend “adequate monitoring ... for early recognition of this potentially serious complication.”
The team used a British medical record database covering 1990-2013 to compare 6,441 patients with new-onset GCA to 63,985 controls without GCA matched for age, sex, and date of study entry. VTE was defined as pulmonary embolism and/or deep vein thrombosis.
The incidence of VTE shortly before diagnosis was 4.2 cases per 1,000 person-years in the GCA group, but 2.3 cases per 1,000 person-years among controls. It was about the same when the analysis was limited to GCA patients not exposed to oral glucocorticoids before diagnosis: 4.0 cases versus 2.2 cases in the control group per 1,000 person-years. The finding was key to the conclusion that GCA is an independent VTE risk factor.
During the 12, 9, 6, and 3 months leading up to GCA diagnosis, the relative risks for VTE among patients not treated with glucocorticoids – versus controls – were 1.8, 2.2, 2.4, and 3.6. In the first 3, 6, 12, 24, 48, and 96 months after GCA diagnosis, when virtually all patients were on glucocorticoids at least for the first 6 months, the relative risks for VTE were 9.9, 7.7, 5.9, 4.4, 3.3, 2.4; the last risk score of 2.4 indicated that GCA patients were still slightly more likely than controls to have a VTE even 8 years after diagnosis.
The mean age of patients in the study was 73 years, and 70% of the subjects were women. GCA patients were more likely than were controls to be smokers and to have cardiovascular disease. Also, a greater proportion of GCA patients used aspirin and had recent surgery and hospitalizations. There was no difference in body mass index (mean in both groups 27 kg/m2) or the prevalence of fracture, trauma, or cancer between the groups.
The National Institutes of Health funded the work. There was no disclosure information in the report.
Whether these findings have implications for treatment is unclear. Should a patient with GCA who sustains a VTE early in the course of disease receive anticoagulation short term, with the thought that the VTE was provoked by a risk factor that has been neutralized? Or should treatment be long term, out of concern that the risk factor is still present? Does this finding bear on the controversial question of whether a patient with GCA should receive aspirin?
[A] robust finding of the analysis is that the risk of a first VTE declines steadily over at least the first 2 years after diagnosis of GCA. However, the problem of distinguishing the effects of disease from the effects of treatment has returned. All patients with GCA are now receiving corticosteroids, at least during the period of very high risk in the first 6 months after diagnosis, and one can expect that the average severity of inflammation and average dose of prednisone/prednisolone will decline in parallel. The steadily declining risk of VTE for at least 1 year after diagnosis suggests that both GCA and corticosteroids increase the risk of VTE. It remains impossible to prove or disprove that hypothesis or to estimate the independent risks conferred by the disease and its treatment.
Having GCA probably increases the risk of VTE at least for the first 24 months after diagnosis and the beginning of treatment, but after 24 months, it is unclear. The clinician will still need to make a guess regarding duration of anticoagulation.
Paul Monach, MD, PhD, is a vasculitis specialist at Boston University. He made his comments in an accompanying editorial (Arthritis Rheumatol. 2017 Jan;69[1]:3-5).
Whether these findings have implications for treatment is unclear. Should a patient with GCA who sustains a VTE early in the course of disease receive anticoagulation short term, with the thought that the VTE was provoked by a risk factor that has been neutralized? Or should treatment be long term, out of concern that the risk factor is still present? Does this finding bear on the controversial question of whether a patient with GCA should receive aspirin?
[A] robust finding of the analysis is that the risk of a first VTE declines steadily over at least the first 2 years after diagnosis of GCA. However, the problem of distinguishing the effects of disease from the effects of treatment has returned. All patients with GCA are now receiving corticosteroids, at least during the period of very high risk in the first 6 months after diagnosis, and one can expect that the average severity of inflammation and average dose of prednisone/prednisolone will decline in parallel. The steadily declining risk of VTE for at least 1 year after diagnosis suggests that both GCA and corticosteroids increase the risk of VTE. It remains impossible to prove or disprove that hypothesis or to estimate the independent risks conferred by the disease and its treatment.
Having GCA probably increases the risk of VTE at least for the first 24 months after diagnosis and the beginning of treatment, but after 24 months, it is unclear. The clinician will still need to make a guess regarding duration of anticoagulation.
Paul Monach, MD, PhD, is a vasculitis specialist at Boston University. He made his comments in an accompanying editorial (Arthritis Rheumatol. 2017 Jan;69[1]:3-5).
Whether these findings have implications for treatment is unclear. Should a patient with GCA who sustains a VTE early in the course of disease receive anticoagulation short term, with the thought that the VTE was provoked by a risk factor that has been neutralized? Or should treatment be long term, out of concern that the risk factor is still present? Does this finding bear on the controversial question of whether a patient with GCA should receive aspirin?
[A] robust finding of the analysis is that the risk of a first VTE declines steadily over at least the first 2 years after diagnosis of GCA. However, the problem of distinguishing the effects of disease from the effects of treatment has returned. All patients with GCA are now receiving corticosteroids, at least during the period of very high risk in the first 6 months after diagnosis, and one can expect that the average severity of inflammation and average dose of prednisone/prednisolone will decline in parallel. The steadily declining risk of VTE for at least 1 year after diagnosis suggests that both GCA and corticosteroids increase the risk of VTE. It remains impossible to prove or disprove that hypothesis or to estimate the independent risks conferred by the disease and its treatment.
Having GCA probably increases the risk of VTE at least for the first 24 months after diagnosis and the beginning of treatment, but after 24 months, it is unclear. The clinician will still need to make a guess regarding duration of anticoagulation.
Paul Monach, MD, PhD, is a vasculitis specialist at Boston University. He made his comments in an accompanying editorial (Arthritis Rheumatol. 2017 Jan;69[1]:3-5).
The risk of venous thromboembolism increases markedly shortly before the diagnosis of giant cell arteritis regardless of glucocorticoid exposure, peaks at the time of diagnosis, and then progressively declines, according to a matched cohort review involving more than 6,000 arteritis patients.
It’s not been clear until now if the recently recognized risk of venous thromboembolism (VTE) in giant cell arteritis (GCA) was due to the disease itself, or the glucocorticoids used to treat it. “Because inflammation in GCA spares the venous circulation, our finding that patients are at greatest risk of VTE in the period surrounding GCA diagnosis (when inflammation is at its highest level), and the demonstration that this risk is not associated with the use of glucocorticoids, suggest that immunothrombosis could play a pathogenic role,” said investigators led by Sebastian Unizony, MD, of Massachusetts General Hospital, Boston (Arthritis Rheumatol. 2017 Jan;69[1]:176-84).
The report was short on advice about what to do to prevent VTE in GCA, but the investigators did recommend “adequate monitoring ... for early recognition of this potentially serious complication.”
The team used a British medical record database covering 1990-2013 to compare 6,441 patients with new-onset GCA to 63,985 controls without GCA matched for age, sex, and date of study entry. VTE was defined as pulmonary embolism and/or deep vein thrombosis.
The incidence of VTE shortly before diagnosis was 4.2 cases per 1,000 person-years in the GCA group, but 2.3 cases per 1,000 person-years among controls. It was about the same when the analysis was limited to GCA patients not exposed to oral glucocorticoids before diagnosis: 4.0 cases versus 2.2 cases in the control group per 1,000 person-years. The finding was key to the conclusion that GCA is an independent VTE risk factor.
During the 12, 9, 6, and 3 months leading up to GCA diagnosis, the relative risks for VTE among patients not treated with glucocorticoids – versus controls – were 1.8, 2.2, 2.4, and 3.6. In the first 3, 6, 12, 24, 48, and 96 months after GCA diagnosis, when virtually all patients were on glucocorticoids at least for the first 6 months, the relative risks for VTE were 9.9, 7.7, 5.9, 4.4, 3.3, 2.4; the last risk score of 2.4 indicated that GCA patients were still slightly more likely than controls to have a VTE even 8 years after diagnosis.
The mean age of patients in the study was 73 years, and 70% of the subjects were women. GCA patients were more likely than were controls to be smokers and to have cardiovascular disease. Also, a greater proportion of GCA patients used aspirin and had recent surgery and hospitalizations. There was no difference in body mass index (mean in both groups 27 kg/m2) or the prevalence of fracture, trauma, or cancer between the groups.
The National Institutes of Health funded the work. There was no disclosure information in the report.
The risk of venous thromboembolism increases markedly shortly before the diagnosis of giant cell arteritis regardless of glucocorticoid exposure, peaks at the time of diagnosis, and then progressively declines, according to a matched cohort review involving more than 6,000 arteritis patients.
It’s not been clear until now if the recently recognized risk of venous thromboembolism (VTE) in giant cell arteritis (GCA) was due to the disease itself, or the glucocorticoids used to treat it. “Because inflammation in GCA spares the venous circulation, our finding that patients are at greatest risk of VTE in the period surrounding GCA diagnosis (when inflammation is at its highest level), and the demonstration that this risk is not associated with the use of glucocorticoids, suggest that immunothrombosis could play a pathogenic role,” said investigators led by Sebastian Unizony, MD, of Massachusetts General Hospital, Boston (Arthritis Rheumatol. 2017 Jan;69[1]:176-84).
The report was short on advice about what to do to prevent VTE in GCA, but the investigators did recommend “adequate monitoring ... for early recognition of this potentially serious complication.”
The team used a British medical record database covering 1990-2013 to compare 6,441 patients with new-onset GCA to 63,985 controls without GCA matched for age, sex, and date of study entry. VTE was defined as pulmonary embolism and/or deep vein thrombosis.
The incidence of VTE shortly before diagnosis was 4.2 cases per 1,000 person-years in the GCA group, but 2.3 cases per 1,000 person-years among controls. It was about the same when the analysis was limited to GCA patients not exposed to oral glucocorticoids before diagnosis: 4.0 cases versus 2.2 cases in the control group per 1,000 person-years. The finding was key to the conclusion that GCA is an independent VTE risk factor.
During the 12, 9, 6, and 3 months leading up to GCA diagnosis, the relative risks for VTE among patients not treated with glucocorticoids – versus controls – were 1.8, 2.2, 2.4, and 3.6. In the first 3, 6, 12, 24, 48, and 96 months after GCA diagnosis, when virtually all patients were on glucocorticoids at least for the first 6 months, the relative risks for VTE were 9.9, 7.7, 5.9, 4.4, 3.3, 2.4; the last risk score of 2.4 indicated that GCA patients were still slightly more likely than controls to have a VTE even 8 years after diagnosis.
The mean age of patients in the study was 73 years, and 70% of the subjects were women. GCA patients were more likely than were controls to be smokers and to have cardiovascular disease. Also, a greater proportion of GCA patients used aspirin and had recent surgery and hospitalizations. There was no difference in body mass index (mean in both groups 27 kg/m2) or the prevalence of fracture, trauma, or cancer between the groups.
The National Institutes of Health funded the work. There was no disclosure information in the report.
FROM ARTHRITIS & RHEUMATOLOGY
Key clinical point:
Major finding: In the 12, 9, 6, and 3 months before GCA diagnosis, the relative risks for VTE among patients not treated with glucocorticoids – versus controls without GCA – were 1.8, 2.2, 2.4, and 3.6.
Data source: Matched cohort review involving more than 6,000 arteritis patients.
Disclosures: The National Institutes of Health funded the work. There was no disclosure information in the report.