M. Alexander Otto

BERNALILLO, N.M. – Women with HIV probably need a booster shot of HPV vaccine within 2 years to maintain efficacy, according to a Canadian study of quadrivalent HPV vaccine (Gardasil) in 136 HIV-positive women.

Antibody response to the vaccine is strong enough at 2 years to protect about 90% of HIV-negative women against HPV [human papillomavirus]. "But in our population, with approximately a year and a half of follow-up, that number decreased to about 63%. There’s a much more rapid decline in antibody levels" among HIV-positive women, "which suggests this population might in fact benefit from a booster," said lead investigator Erin Moses, R.N., a researcher at the Women’s Health Research Institute in Vancouver, B.C.

Cervical specimens from the women were negative for HPV DNA – and their blood was negative for HPV antibodies– both at screening and 3 months later when they received the vaccine. They were then assessed at 6, 12, and 18 months for cervical HPV DNA.

The initial seroconversion rate was high at about 99%, but "we saw nine breakthrough infections" to HPV types targeted by the vaccine "in a short period of follow up. Although we’ve only been monitoring these women for approximately a year and a half, we have already seen five [new] infections of HPV type 18. Of those five, we saw two persistent infections, which means these women had two positive tests 6 months apart for HPV 18," Ms. Moses said at the Infectious Diseases Society for Obstetrics and Gynecology annual meeting.

Women who picked up a new infection had a mean CD4 nadir of 69 cells/mm³; women who did not had a mean nadir of 228 cells/mm³, a significant difference. Women who became infected also were more likely to have a new sexual partner.

"We didn’t see a correlation between viral load" and new infections, "which was odd because typically you would think that if they have an unsuppressed viral load, they would be more at risk, but there was no correlation with that," Ms. Moses said.

The median age in the study was 40 years; about half the women were black, most of the rest were white. The median time since HIV diagnosis was 8 years, and 11% were coinfected with hepatitis C; 92% of the women were on highly active antiretroviral medications, and 69% had undetectable viral loads.

Ms. Moses said she had no relevant financial disclosures. The study was funded by Merck, the maker of Gardasil, and the Canadian Institutes of Health Research.

aotto@frontlinemedcom.com

BERNALILLO, N.M. – Women with HIV probably need a booster shot of HPV vaccine within 2 years to maintain efficacy, according to a Canadian study of quadrivalent HPV vaccine (Gardasil) in 136 HIV-positive women.

Antibody response to the vaccine is strong enough at 2 years to protect about 90% of HIV-negative women against HPV [human papillomavirus]. "But in our population, with approximately a year and a half of follow-up, that number decreased to about 63%. There’s a much more rapid decline in antibody levels" among HIV-positive women, "which suggests this population might in fact benefit from a booster," said lead investigator Erin Moses, R.N., a researcher at the Women’s Health Research Institute in Vancouver, B.C.

Cervical specimens from the women were negative for HPV DNA – and their blood was negative for HPV antibodies– both at screening and 3 months later when they received the vaccine. They were then assessed at 6, 12, and 18 months for cervical HPV DNA.

The initial seroconversion rate was high at about 99%, but "we saw nine breakthrough infections" to HPV types targeted by the vaccine "in a short period of follow up. Although we’ve only been monitoring these women for approximately a year and a half, we have already seen five [new] infections of HPV type 18. Of those five, we saw two persistent infections, which means these women had two positive tests 6 months apart for HPV 18," Ms. Moses said at the Infectious Diseases Society for Obstetrics and Gynecology annual meeting.

Women who picked up a new infection had a mean CD4 nadir of 69 cells/mm³; women who did not had a mean nadir of 228 cells/mm³, a significant difference. Women who became infected also were more likely to have a new sexual partner.

"We didn’t see a correlation between viral load" and new infections, "which was odd because typically you would think that if they have an unsuppressed viral load, they would be more at risk, but there was no correlation with that," Ms. Moses said.

The median age in the study was 40 years; about half the women were black, most of the rest were white. The median time since HIV diagnosis was 8 years, and 11% were coinfected with hepatitis C; 92% of the women were on highly active antiretroviral medications, and 69% had undetectable viral loads.

Ms. Moses said she had no relevant financial disclosures. The study was funded by Merck, the maker of Gardasil, and the Canadian Institutes of Health Research.

aotto@frontlinemedcom.com

BERNALILLO, N.M. – Women with HIV probably need a booster shot of HPV vaccine within 2 years to maintain efficacy, according to a Canadian study of quadrivalent HPV vaccine (Gardasil) in 136 HIV-positive women.

Antibody response to the vaccine is strong enough at 2 years to protect about 90% of HIV-negative women against HPV [human papillomavirus]. "But in our population, with approximately a year and a half of follow-up, that number decreased to about 63%. There’s a much more rapid decline in antibody levels" among HIV-positive women, "which suggests this population might in fact benefit from a booster," said lead investigator Erin Moses, R.N., a researcher at the Women’s Health Research Institute in Vancouver, B.C.

Cervical specimens from the women were negative for HPV DNA – and their blood was negative for HPV antibodies– both at screening and 3 months later when they received the vaccine. They were then assessed at 6, 12, and 18 months for cervical HPV DNA.

The initial seroconversion rate was high at about 99%, but "we saw nine breakthrough infections" to HPV types targeted by the vaccine "in a short period of follow up. Although we’ve only been monitoring these women for approximately a year and a half, we have already seen five [new] infections of HPV type 18. Of those five, we saw two persistent infections, which means these women had two positive tests 6 months apart for HPV 18," Ms. Moses said at the Infectious Diseases Society for Obstetrics and Gynecology annual meeting.

Women who picked up a new infection had a mean CD4 nadir of 69 cells/mm³; women who did not had a mean nadir of 228 cells/mm³, a significant difference. Women who became infected also were more likely to have a new sexual partner.

"We didn’t see a correlation between viral load" and new infections, "which was odd because typically you would think that if they have an unsuppressed viral load, they would be more at risk, but there was no correlation with that," Ms. Moses said.

The median age in the study was 40 years; about half the women were black, most of the rest were white. The median time since HIV diagnosis was 8 years, and 11% were coinfected with hepatitis C; 92% of the women were on highly active antiretroviral medications, and 69% had undetectable viral loads.

Ms. Moses said she had no relevant financial disclosures. The study was funded by Merck, the maker of Gardasil, and the Canadian Institutes of Health Research.

aotto@frontlinemedcom.com

Earn 0.25 hours AMA PRA Category 1 credit: Read this article, and click the link at the end to take the post-test.

SANTA ANA PUEBLO, N.M. – Only certain classes of antibiotics increased the risk of yeast infections in a study of 650 women followed for 18 months to see what factors were associated with new-onset vulvovaginal candidiasis.

Penicillins increased the risk the most (adjusted hazard ratio, 4.1), followed by cephalosporins (aHR, 3.3) and metronidazole (aHR, 2.8), compared with women who did not report antibiotic use. Other classes of antibiotics were not associated with yeast infections.

"Many women and physicians believe that if you take an antibiotic, you’re just bound to get yeast. The message is that not all antibiotics are associated with yeast vaginitis; it’s certain classes of antibiotics that carry the highest risk," said senior investigator Sharon L. Hillier, Ph.D., a professor of obstetrics and gynecology and reproductive sciences at the University of Pittsburgh.

"When women are given antibiotics, I think it’s useful to help them understand they have some likelihood of getting a yeast infection with these three, and less so with quinolones or tetracyclines or something else," she said at the annual scientific meeting of the Infectious Diseases Society for Obstetrics and Gynecology.

The 650 subjects – 18-40 years old, not pregnant, and with no signs or symptoms of yeast at baseline – were followed at 2-month intervals during the investigation, and had a total of 4,934 follow-up office visits. Each time, they were asked what antibiotics they had been on, if any, among other questions.

There were 82 clinical yeast vaginitis diagnoses and 58 self-diagnosed infections with documented antifungal use. The results were largely similar when the team limited analysis to just clinically diagnosed cases.

A total of 312 women used an antibiotic at least once. Macrolides, metronidazole, and penicillins were used most often among the nine classes of reported antibiotics. The most common indications were upper respiratory tract infections, bacterial vaginosis, urinary tract infections, and sexually transmitted infections.

Having two or more male sexual partners was also a strong predictor of yeast vaginitis (aHR, 5.0), "and that was something that was a little bit surprising because it’s not a sexually transmitted infection. It’s useful maybe to tell women that limiting their numbers of sex partners will also decrease their risk," Dr. Hillier said.

Using depot medroxyprogesterone acetate (Depo-Provera), meanwhile, had a protective effect (aHR, 0.3), compared with women not using hormonal contraceptives. "Depo-Provera has a very strong progestin; some women who get the shot actually have estrogen depletion in the vaginal epithelium. The finding suggests that when you remove the estrogen from the [vaginal] epithelium, it can reduce your risk for yeast vaginitis," Dr. Hillier said.

Other forms of hormonal contraception were not associated with yeast vaginitis. Although "many women believe oral contraceptives and other hormonal methods increase the risk, there was no evidence of increased risk in this study," she said.

Dr. Hillier said she had no disclosures. The work was funded by the National Institutes of Health.

To earn 0.25 hours AMA PRA Category 1 credit after reading this article, take the post-test here.

aotto@frontlinemedcom.com

Earn 0.25 hours AMA PRA Category 1 credit: Read this article, and click the link at the end to take the post-test.

SANTA ANA PUEBLO, N.M. – Only certain classes of antibiotics increased the risk of yeast infections in a study of 650 women followed for 18 months to see what factors were associated with new-onset vulvovaginal candidiasis.

Penicillins increased the risk the most (adjusted hazard ratio, 4.1), followed by cephalosporins (aHR, 3.3) and metronidazole (aHR, 2.8), compared with women who did not report antibiotic use. Other classes of antibiotics were not associated with yeast infections.

"Many women and physicians believe that if you take an antibiotic, you’re just bound to get yeast. The message is that not all antibiotics are associated with yeast vaginitis; it’s certain classes of antibiotics that carry the highest risk," said senior investigator Sharon L. Hillier, Ph.D., a professor of obstetrics and gynecology and reproductive sciences at the University of Pittsburgh.

"When women are given antibiotics, I think it’s useful to help them understand they have some likelihood of getting a yeast infection with these three, and less so with quinolones or tetracyclines or something else," she said at the annual scientific meeting of the Infectious Diseases Society for Obstetrics and Gynecology.

The 650 subjects – 18-40 years old, not pregnant, and with no signs or symptoms of yeast at baseline – were followed at 2-month intervals during the investigation, and had a total of 4,934 follow-up office visits. Each time, they were asked what antibiotics they had been on, if any, among other questions.

There were 82 clinical yeast vaginitis diagnoses and 58 self-diagnosed infections with documented antifungal use. The results were largely similar when the team limited analysis to just clinically diagnosed cases.

A total of 312 women used an antibiotic at least once. Macrolides, metronidazole, and penicillins were used most often among the nine classes of reported antibiotics. The most common indications were upper respiratory tract infections, bacterial vaginosis, urinary tract infections, and sexually transmitted infections.

Having two or more male sexual partners was also a strong predictor of yeast vaginitis (aHR, 5.0), "and that was something that was a little bit surprising because it’s not a sexually transmitted infection. It’s useful maybe to tell women that limiting their numbers of sex partners will also decrease their risk," Dr. Hillier said.

Using depot medroxyprogesterone acetate (Depo-Provera), meanwhile, had a protective effect (aHR, 0.3), compared with women not using hormonal contraceptives. "Depo-Provera has a very strong progestin; some women who get the shot actually have estrogen depletion in the vaginal epithelium. The finding suggests that when you remove the estrogen from the [vaginal] epithelium, it can reduce your risk for yeast vaginitis," Dr. Hillier said.

Other forms of hormonal contraception were not associated with yeast vaginitis. Although "many women believe oral contraceptives and other hormonal methods increase the risk, there was no evidence of increased risk in this study," she said.

Dr. Hillier said she had no disclosures. The work was funded by the National Institutes of Health.

To earn 0.25 hours AMA PRA Category 1 credit after reading this article, take the post-test here.

aotto@frontlinemedcom.com

Earn 0.25 hours AMA PRA Category 1 credit: Read this article, and click the link at the end to take the post-test.

SANTA ANA PUEBLO, N.M. – Only certain classes of antibiotics increased the risk of yeast infections in a study of 650 women followed for 18 months to see what factors were associated with new-onset vulvovaginal candidiasis.

Penicillins increased the risk the most (adjusted hazard ratio, 4.1), followed by cephalosporins (aHR, 3.3) and metronidazole (aHR, 2.8), compared with women who did not report antibiotic use. Other classes of antibiotics were not associated with yeast infections.

"Many women and physicians believe that if you take an antibiotic, you’re just bound to get yeast. The message is that not all antibiotics are associated with yeast vaginitis; it’s certain classes of antibiotics that carry the highest risk," said senior investigator Sharon L. Hillier, Ph.D., a professor of obstetrics and gynecology and reproductive sciences at the University of Pittsburgh.

"When women are given antibiotics, I think it’s useful to help them understand they have some likelihood of getting a yeast infection with these three, and less so with quinolones or tetracyclines or something else," she said at the annual scientific meeting of the Infectious Diseases Society for Obstetrics and Gynecology.

The 650 subjects – 18-40 years old, not pregnant, and with no signs or symptoms of yeast at baseline – were followed at 2-month intervals during the investigation, and had a total of 4,934 follow-up office visits. Each time, they were asked what antibiotics they had been on, if any, among other questions.

There were 82 clinical yeast vaginitis diagnoses and 58 self-diagnosed infections with documented antifungal use. The results were largely similar when the team limited analysis to just clinically diagnosed cases.

A total of 312 women used an antibiotic at least once. Macrolides, metronidazole, and penicillins were used most often among the nine classes of reported antibiotics. The most common indications were upper respiratory tract infections, bacterial vaginosis, urinary tract infections, and sexually transmitted infections.

Having two or more male sexual partners was also a strong predictor of yeast vaginitis (aHR, 5.0), "and that was something that was a little bit surprising because it’s not a sexually transmitted infection. It’s useful maybe to tell women that limiting their numbers of sex partners will also decrease their risk," Dr. Hillier said.

Using depot medroxyprogesterone acetate (Depo-Provera), meanwhile, had a protective effect (aHR, 0.3), compared with women not using hormonal contraceptives. "Depo-Provera has a very strong progestin; some women who get the shot actually have estrogen depletion in the vaginal epithelium. The finding suggests that when you remove the estrogen from the [vaginal] epithelium, it can reduce your risk for yeast vaginitis," Dr. Hillier said.

Other forms of hormonal contraception were not associated with yeast vaginitis. Although "many women believe oral contraceptives and other hormonal methods increase the risk, there was no evidence of increased risk in this study," she said.

Dr. Hillier said she had no disclosures. The work was funded by the National Institutes of Health.

To earn 0.25 hours AMA PRA Category 1 credit after reading this article, take the post-test here.

aotto@frontlinemedcom.com

SANTA ANA PUEBLO, N.M. – Only certain classes of antibiotics increased the risk of yeast infections in a study of 650 women followed for 18 months to see what factors were associated with new-onset vulvovaginal candidiasis.

Penicillins increased the risk the most (adjusted hazard ratio, 4.1), followed by cephalosporins (aHR, 3.3) and metronidazole (aHR, 2.8), compared with women who did not report antibiotic use. Other classes of antibiotics were not associated with yeast infections.

"Many women and physicians believe that if you take an antibiotic, you’re just bound to get yeast. The message is that not all antibiotics are associated with yeast vaginitis; it’s certain classes of antibiotics that carry the highest risk," said senior investigator Sharon L. Hillier, Ph.D., a professor of obstetrics and gynecology and reproductive sciences at the University of Pittsburgh.

"When women are given antibiotics, I think it’s useful to help them understand they have some likelihood of getting a yeast infection with these three, and less so with quinolones or tetracyclines or something else," she said at the annual scientific meeting of the Infectious Diseases Society for Obstetrics and Gynecology.

The 650 subjects – 18-40 years old, not pregnant, and with no signs or symptoms of yeast at baseline – were followed at 2-month intervals during the investigation, and had a total of 4,934 follow-up office visits. Each time, they were asked what antibiotics they had been on, if any, among other questions.

There were 82 clinical yeast vaginitis diagnoses and 58 self-diagnosed infections with documented antifungal use. The results were largely similar when the team limited analysis to just clinically diagnosed cases.

A total of 312 women used an antibiotic at least once. Macrolides, metronidazole, and penicillins were used most often among the nine classes of reported antibiotics. The most common indications were upper respiratory tract infections, bacterial vaginosis, urinary tract infections, and sexually transmitted infections.

Having two or more male sexual partners was also a strong predictor of yeast vaginitis (aHR, 5.0), "and that was something that was a little bit surprising because it’s not a sexually transmitted infection. It’s useful maybe to tell women that limiting their numbers of sex partners will also decrease their risk," Dr. Hillier said.

Using depot medroxyprogesterone acetate (Depo-Provera), meanwhile, had a protective effect (aHR, 0.3), compared with women not using hormonal contraceptives. "Depo-Provera has a very strong progestin; some women who get the shot actually have estrogen depletion in the vaginal epithelium. The finding suggests that when you remove the estrogen from the [vaginal] epithelium, it can reduce your risk for yeast vaginitis," Dr. Hillier said.

Other forms of hormonal contraception were not associated with yeast vaginitis. Although "many women believe oral contraceptives and other hormonal methods increase the risk, there was no evidence of increased risk in this study," she said.

Dr. Hillier said she had no disclosures. The work was funded by the National Institutes of Health.

aotto@frontlinemedcom.com

SANTA ANA PUEBLO, N.M. – Only certain classes of antibiotics increased the risk of yeast infections in a study of 650 women followed for 18 months to see what factors were associated with new-onset vulvovaginal candidiasis.

Penicillins increased the risk the most (adjusted hazard ratio, 4.1), followed by cephalosporins (aHR, 3.3) and metronidazole (aHR, 2.8), compared with women who did not report antibiotic use. Other classes of antibiotics were not associated with yeast infections.

"Many women and physicians believe that if you take an antibiotic, you’re just bound to get yeast. The message is that not all antibiotics are associated with yeast vaginitis; it’s certain classes of antibiotics that carry the highest risk," said senior investigator Sharon L. Hillier, Ph.D., a professor of obstetrics and gynecology and reproductive sciences at the University of Pittsburgh.

"When women are given antibiotics, I think it’s useful to help them understand they have some likelihood of getting a yeast infection with these three, and less so with quinolones or tetracyclines or something else," she said at the annual scientific meeting of the Infectious Diseases Society for Obstetrics and Gynecology.

The 650 subjects – 18-40 years old, not pregnant, and with no signs or symptoms of yeast at baseline – were followed at 2-month intervals during the investigation, and had a total of 4,934 follow-up office visits. Each time, they were asked what antibiotics they had been on, if any, among other questions.

There were 82 clinical yeast vaginitis diagnoses and 58 self-diagnosed infections with documented antifungal use. The results were largely similar when the team limited analysis to just clinically diagnosed cases.

A total of 312 women used an antibiotic at least once. Macrolides, metronidazole, and penicillins were used most often among the nine classes of reported antibiotics. The most common indications were upper respiratory tract infections, bacterial vaginosis, urinary tract infections, and sexually transmitted infections.

Having two or more male sexual partners was also a strong predictor of yeast vaginitis (aHR, 5.0), "and that was something that was a little bit surprising because it’s not a sexually transmitted infection. It’s useful maybe to tell women that limiting their numbers of sex partners will also decrease their risk," Dr. Hillier said.

Using depot medroxyprogesterone acetate (Depo-Provera), meanwhile, had a protective effect (aHR, 0.3), compared with women not using hormonal contraceptives. "Depo-Provera has a very strong progestin; some women who get the shot actually have estrogen depletion in the vaginal epithelium. The finding suggests that when you remove the estrogen from the [vaginal] epithelium, it can reduce your risk for yeast vaginitis," Dr. Hillier said.

Other forms of hormonal contraception were not associated with yeast vaginitis. Although "many women believe oral contraceptives and other hormonal methods increase the risk, there was no evidence of increased risk in this study," she said.

Dr. Hillier said she had no disclosures. The work was funded by the National Institutes of Health.

aotto@frontlinemedcom.com

SANTA ANA PUEBLO, N.M. – Only certain classes of antibiotics increased the risk of yeast infections in a study of 650 women followed for 18 months to see what factors were associated with new-onset vulvovaginal candidiasis.

Penicillins increased the risk the most (adjusted hazard ratio, 4.1), followed by cephalosporins (aHR, 3.3) and metronidazole (aHR, 2.8), compared with women who did not report antibiotic use. Other classes of antibiotics were not associated with yeast infections.

"Many women and physicians believe that if you take an antibiotic, you’re just bound to get yeast. The message is that not all antibiotics are associated with yeast vaginitis; it’s certain classes of antibiotics that carry the highest risk," said senior investigator Sharon L. Hillier, Ph.D., a professor of obstetrics and gynecology and reproductive sciences at the University of Pittsburgh.

"When women are given antibiotics, I think it’s useful to help them understand they have some likelihood of getting a yeast infection with these three, and less so with quinolones or tetracyclines or something else," she said at the annual scientific meeting of the Infectious Diseases Society for Obstetrics and Gynecology.

The 650 subjects – 18-40 years old, not pregnant, and with no signs or symptoms of yeast at baseline – were followed at 2-month intervals during the investigation, and had a total of 4,934 follow-up office visits. Each time, they were asked what antibiotics they had been on, if any, among other questions.

There were 82 clinical yeast vaginitis diagnoses and 58 self-diagnosed infections with documented antifungal use. The results were largely similar when the team limited analysis to just clinically diagnosed cases.

A total of 312 women used an antibiotic at least once. Macrolides, metronidazole, and penicillins were used most often among the nine classes of reported antibiotics. The most common indications were upper respiratory tract infections, bacterial vaginosis, urinary tract infections, and sexually transmitted infections.

Having two or more male sexual partners was also a strong predictor of yeast vaginitis (aHR, 5.0), "and that was something that was a little bit surprising because it’s not a sexually transmitted infection. It’s useful maybe to tell women that limiting their numbers of sex partners will also decrease their risk," Dr. Hillier said.

Using depot medroxyprogesterone acetate (Depo-Provera), meanwhile, had a protective effect (aHR, 0.3), compared with women not using hormonal contraceptives. "Depo-Provera has a very strong progestin; some women who get the shot actually have estrogen depletion in the vaginal epithelium. The finding suggests that when you remove the estrogen from the [vaginal] epithelium, it can reduce your risk for yeast vaginitis," Dr. Hillier said.

Other forms of hormonal contraception were not associated with yeast vaginitis. Although "many women believe oral contraceptives and other hormonal methods increase the risk, there was no evidence of increased risk in this study," she said.

Dr. Hillier said she had no disclosures. The work was funded by the National Institutes of Health.

aotto@frontlinemedcom.com

BERNALILLO, N.M. – A personal one-on-one recommendation from a woman’s obstetrician is what’s most likely to convince a woman to get flu and Tdap shots during pregnancy, according to an e-mail survey of 274 women from nine private obstetrics practices in Colorado.

Women were almost four times more likely to get Tdap during pregnancy and have at least one close contact get the shot – a practice known as cocooning – if their obstetricians recommended it (adjusted odds ratio [aOR], 3.67), and almost twice as likely to cocoon with the flu shot (aOR, 1.89). Recommendations from office staff, written material, and other sources didn’t work.

And yet only about half of the respondents said that their obstetrician recommended the flu vaccine, and that about two-thirds recommended Tdap vaccine; the survey was done after Tdap was recommended for all pregnant women in the fall of 2012. "The practice may have provided written material or the nurse may have said [something], but their [obstetrician] didn’t sit down with them and recommend it. We are not doing a great job of recommending cocooning for our patients," said Dr. Meghan Donnelly, an ob.gyn. specializing in maternal and fetal medicine at the University of Colorado Hospital in Aurora.

"You can’t just be lazy and put the ACOG [American College of Obstetricians and Gynecologists] pamphlet in your office," she said.

Just 61% of women reported cocooning for Tdap or flu vaccines. Perceived benefit – gauged by questions such as "getting myself vaccinated will help keep my baby from getting pertussis" – and perceived susceptibility to infection also made cocooning more likely; negative beliefs about vaccines made it less likely. Hispanic women also were less likely to get the shots than white women (aOR, 0.26).

In addition to patient education, the solution is "to educate providers" that they need "to mention [the shots] specifically in the office visit" and that it’s possible to give the shots without slowing down their practices or losing money, Dr. Donnelly said at the Infectious Diseases Society for Obstetrics and Gynecology annual meeting.

She and her colleagues are working to get the word out; the survey was part of an ongoing, randomized Centers for Disease Control and Prevention–funded trial to compare vaccine uptake rates between practices that are taught those things and those that are not.

Vaccine supply specialists are meeting with offices in the intervention group to teach them how to predict the needs of their patients, and effectively order, properly store, and bill for vaccines so they don’t lose money.

"We are [also] helping them create a vaccine champion program so that there’s one person who takes ownership of the [issue]. We are providing education to every level of staff about the importance of this, how to record a vaccination history, and how you identify who you need to talk to about vaccination, because it’s not every person and you don’t need to ask every time. We are [also] creating flow maps of practices to come up with the most efficient way to increase vaccine uptake [without] taking more time per patient," she said.

"In some practices, we created a standing order set where a nurse could identify who needs the flu vaccine and administer it without a doctor seeing the patient or writing a separate order. In some clinics, nurses did not feel comfortable with that approach, whereas other clinics thought it was a really great idea and embraced it enthusiastically," Dr. Donnelly said.

"It is harder to do interventions in some practices than others, mainly if their medical record system isn’t electronic. We’ve had to adjust interventions differently for each practice," she said.

Dr. Donnelly said she had no relevant financial disclosures.

aotto@frontlinemedcom.com

BERNALILLO, N.M. – A personal one-on-one recommendation from a woman’s obstetrician is what’s most likely to convince a woman to get flu and Tdap shots during pregnancy, according to an e-mail survey of 274 women from nine private obstetrics practices in Colorado.

Women were almost four times more likely to get Tdap during pregnancy and have at least one close contact get the shot – a practice known as cocooning – if their obstetricians recommended it (adjusted odds ratio [aOR], 3.67), and almost twice as likely to cocoon with the flu shot (aOR, 1.89). Recommendations from office staff, written material, and other sources didn’t work.

And yet only about half of the respondents said that their obstetrician recommended the flu vaccine, and that about two-thirds recommended Tdap vaccine; the survey was done after Tdap was recommended for all pregnant women in the fall of 2012. "The practice may have provided written material or the nurse may have said [something], but their [obstetrician] didn’t sit down with them and recommend it. We are not doing a great job of recommending cocooning for our patients," said Dr. Meghan Donnelly, an ob.gyn. specializing in maternal and fetal medicine at the University of Colorado Hospital in Aurora.

"You can’t just be lazy and put the ACOG [American College of Obstetricians and Gynecologists] pamphlet in your office," she said.

Just 61% of women reported cocooning for Tdap or flu vaccines. Perceived benefit – gauged by questions such as "getting myself vaccinated will help keep my baby from getting pertussis" – and perceived susceptibility to infection also made cocooning more likely; negative beliefs about vaccines made it less likely. Hispanic women also were less likely to get the shots than white women (aOR, 0.26).

In addition to patient education, the solution is "to educate providers" that they need "to mention [the shots] specifically in the office visit" and that it’s possible to give the shots without slowing down their practices or losing money, Dr. Donnelly said at the Infectious Diseases Society for Obstetrics and Gynecology annual meeting.

She and her colleagues are working to get the word out; the survey was part of an ongoing, randomized Centers for Disease Control and Prevention–funded trial to compare vaccine uptake rates between practices that are taught those things and those that are not.

Vaccine supply specialists are meeting with offices in the intervention group to teach them how to predict the needs of their patients, and effectively order, properly store, and bill for vaccines so they don’t lose money.

"We are [also] helping them create a vaccine champion program so that there’s one person who takes ownership of the [issue]. We are providing education to every level of staff about the importance of this, how to record a vaccination history, and how you identify who you need to talk to about vaccination, because it’s not every person and you don’t need to ask every time. We are [also] creating flow maps of practices to come up with the most efficient way to increase vaccine uptake [without] taking more time per patient," she said.

"In some practices, we created a standing order set where a nurse could identify who needs the flu vaccine and administer it without a doctor seeing the patient or writing a separate order. In some clinics, nurses did not feel comfortable with that approach, whereas other clinics thought it was a really great idea and embraced it enthusiastically," Dr. Donnelly said.

"It is harder to do interventions in some practices than others, mainly if their medical record system isn’t electronic. We’ve had to adjust interventions differently for each practice," she said.

Dr. Donnelly said she had no relevant financial disclosures.

aotto@frontlinemedcom.com

BERNALILLO, N.M. – A personal one-on-one recommendation from a woman’s obstetrician is what’s most likely to convince a woman to get flu and Tdap shots during pregnancy, according to an e-mail survey of 274 women from nine private obstetrics practices in Colorado.

Women were almost four times more likely to get Tdap during pregnancy and have at least one close contact get the shot – a practice known as cocooning – if their obstetricians recommended it (adjusted odds ratio [aOR], 3.67), and almost twice as likely to cocoon with the flu shot (aOR, 1.89). Recommendations from office staff, written material, and other sources didn’t work.

And yet only about half of the respondents said that their obstetrician recommended the flu vaccine, and that about two-thirds recommended Tdap vaccine; the survey was done after Tdap was recommended for all pregnant women in the fall of 2012. "The practice may have provided written material or the nurse may have said [something], but their [obstetrician] didn’t sit down with them and recommend it. We are not doing a great job of recommending cocooning for our patients," said Dr. Meghan Donnelly, an ob.gyn. specializing in maternal and fetal medicine at the University of Colorado Hospital in Aurora.

"You can’t just be lazy and put the ACOG [American College of Obstetricians and Gynecologists] pamphlet in your office," she said.

Just 61% of women reported cocooning for Tdap or flu vaccines. Perceived benefit – gauged by questions such as "getting myself vaccinated will help keep my baby from getting pertussis" – and perceived susceptibility to infection also made cocooning more likely; negative beliefs about vaccines made it less likely. Hispanic women also were less likely to get the shots than white women (aOR, 0.26).

In addition to patient education, the solution is "to educate providers" that they need "to mention [the shots] specifically in the office visit" and that it’s possible to give the shots without slowing down their practices or losing money, Dr. Donnelly said at the Infectious Diseases Society for Obstetrics and Gynecology annual meeting.

She and her colleagues are working to get the word out; the survey was part of an ongoing, randomized Centers for Disease Control and Prevention–funded trial to compare vaccine uptake rates between practices that are taught those things and those that are not.

Vaccine supply specialists are meeting with offices in the intervention group to teach them how to predict the needs of their patients, and effectively order, properly store, and bill for vaccines so they don’t lose money.

"We are [also] helping them create a vaccine champion program so that there’s one person who takes ownership of the [issue]. We are providing education to every level of staff about the importance of this, how to record a vaccination history, and how you identify who you need to talk to about vaccination, because it’s not every person and you don’t need to ask every time. We are [also] creating flow maps of practices to come up with the most efficient way to increase vaccine uptake [without] taking more time per patient," she said.

"In some practices, we created a standing order set where a nurse could identify who needs the flu vaccine and administer it without a doctor seeing the patient or writing a separate order. In some clinics, nurses did not feel comfortable with that approach, whereas other clinics thought it was a really great idea and embraced it enthusiastically," Dr. Donnelly said.

"It is harder to do interventions in some practices than others, mainly if their medical record system isn’t electronic. We’ve had to adjust interventions differently for each practice," she said.

Dr. Donnelly said she had no relevant financial disclosures.

aotto@frontlinemedcom.com

VANCOUVER, B.C. – The volume of denervated myocardium after a heart attack predicts the likelihood of sudden cardiac death and the need for an implantable defibrillator, according to results from a prospective, 4-year observational study.

"In this study, we found that in patients with ischemic cardiomyopathy who are eligible for an ICD [implantable cardioverter defibrillator], the volume of denervated myocardium predicts sudden death. It’s independent of more traditional endpoints that have been used," such as B-type natriuretic peptide, left ventricular ejection fraction, and New York Heart Association (NYHA) class. "Thus, molecular imaging may improve risk stratification for current ICD candidates," said investigator and cardiologist Dr. Michael E. Cain, dean of the School of Medicine and Biomedical Sciences, University at Buffalo (N.Y.).

The goal of the study is to better predict who will benefit from a defibrillator, he said at the 18th World Congress on Heart Disease.

He and his fellow investigators at the university found that about 30% of post-MI patients with more than 33% of their left ventricle denervated experienced arrhythmic death or – in those who had them – a defibrillator discharge for ventricular tachycardia or fibrillation greater than 240 beats per minute within 4 years of their heart attack; on average, about 6.7% met those endpoints each year.

In contrast, only about 5% of patients with less than 22% left ventricular sympathetic denervation met those endpoints, as did about 10% of those with 22%-33% left ventricular denervation, as assessed by myocardial response to a norepinephrine analogue on positron emission tomography. Denervated myocardium had a hazard ratio of 3.5 for sudden cardiac arrest or equivalent in the trial (P = .001).

Thirty-three of 204 post-MI patients experienced arrhythmic death or defibrillator discharge during the project. Most of the patients had undergone initial revascularization, and all were eligible for defibrillators at baseline. Overall, they were in their mid-60s, with left ventricular ejection fractions of about 26% and greater than NYHA class II heart failure. There were no significant demographic differences between patients who did and did not meet the study’s endpoints.

Prediction of sudden cardiac death events was even better when denervation was used in conjunction with three other factors: increase in the left ventricular end-diastolic volume index, creatinine greater than 1.5 mg/dL, and lack of angiotensin-converting enzyme inhibitor or angiotensin II receptor antagonist therapy.

Four-year event-free survival was about 98% in patients with none of those risk factors, about 85% in patients with one, and 50% in patients with two or more. The volume of infarcted or hibernating myocardium did not predict sudden cardiac arrest.

"The proven metric is left ventricle ejection fraction," but it and the many other methods that have been tried "have good negative predictive accuracy but not that good positive predictive accuracy, and so you are putting in defibrillators for people who don’t need them," he said.

For now, however, it would be "a leap of faith from a study that was prospective and observational" to actually use denervation "to determine therapies," he said.

Dr. Cain reported having no disclosures.

aotto@frontlinemedcom.com

VANCOUVER, B.C. – The volume of denervated myocardium after a heart attack predicts the likelihood of sudden cardiac death and the need for an implantable defibrillator, according to results from a prospective, 4-year observational study.

"In this study, we found that in patients with ischemic cardiomyopathy who are eligible for an ICD [implantable cardioverter defibrillator], the volume of denervated myocardium predicts sudden death. It’s independent of more traditional endpoints that have been used," such as B-type natriuretic peptide, left ventricular ejection fraction, and New York Heart Association (NYHA) class. "Thus, molecular imaging may improve risk stratification for current ICD candidates," said investigator and cardiologist Dr. Michael E. Cain, dean of the School of Medicine and Biomedical Sciences, University at Buffalo (N.Y.).

The goal of the study is to better predict who will benefit from a defibrillator, he said at the 18th World Congress on Heart Disease.

He and his fellow investigators at the university found that about 30% of post-MI patients with more than 33% of their left ventricle denervated experienced arrhythmic death or – in those who had them – a defibrillator discharge for ventricular tachycardia or fibrillation greater than 240 beats per minute within 4 years of their heart attack; on average, about 6.7% met those endpoints each year.

In contrast, only about 5% of patients with less than 22% left ventricular sympathetic denervation met those endpoints, as did about 10% of those with 22%-33% left ventricular denervation, as assessed by myocardial response to a norepinephrine analogue on positron emission tomography. Denervated myocardium had a hazard ratio of 3.5 for sudden cardiac arrest or equivalent in the trial (P = .001).

Thirty-three of 204 post-MI patients experienced arrhythmic death or defibrillator discharge during the project. Most of the patients had undergone initial revascularization, and all were eligible for defibrillators at baseline. Overall, they were in their mid-60s, with left ventricular ejection fractions of about 26% and greater than NYHA class II heart failure. There were no significant demographic differences between patients who did and did not meet the study’s endpoints.

Prediction of sudden cardiac death events was even better when denervation was used in conjunction with three other factors: increase in the left ventricular end-diastolic volume index, creatinine greater than 1.5 mg/dL, and lack of angiotensin-converting enzyme inhibitor or angiotensin II receptor antagonist therapy.

Four-year event-free survival was about 98% in patients with none of those risk factors, about 85% in patients with one, and 50% in patients with two or more. The volume of infarcted or hibernating myocardium did not predict sudden cardiac arrest.

"The proven metric is left ventricle ejection fraction," but it and the many other methods that have been tried "have good negative predictive accuracy but not that good positive predictive accuracy, and so you are putting in defibrillators for people who don’t need them," he said.

For now, however, it would be "a leap of faith from a study that was prospective and observational" to actually use denervation "to determine therapies," he said.

Dr. Cain reported having no disclosures.

aotto@frontlinemedcom.com

VANCOUVER, B.C. – The volume of denervated myocardium after a heart attack predicts the likelihood of sudden cardiac death and the need for an implantable defibrillator, according to results from a prospective, 4-year observational study.

"In this study, we found that in patients with ischemic cardiomyopathy who are eligible for an ICD [implantable cardioverter defibrillator], the volume of denervated myocardium predicts sudden death. It’s independent of more traditional endpoints that have been used," such as B-type natriuretic peptide, left ventricular ejection fraction, and New York Heart Association (NYHA) class. "Thus, molecular imaging may improve risk stratification for current ICD candidates," said investigator and cardiologist Dr. Michael E. Cain, dean of the School of Medicine and Biomedical Sciences, University at Buffalo (N.Y.).

The goal of the study is to better predict who will benefit from a defibrillator, he said at the 18th World Congress on Heart Disease.

He and his fellow investigators at the university found that about 30% of post-MI patients with more than 33% of their left ventricle denervated experienced arrhythmic death or – in those who had them – a defibrillator discharge for ventricular tachycardia or fibrillation greater than 240 beats per minute within 4 years of their heart attack; on average, about 6.7% met those endpoints each year.

In contrast, only about 5% of patients with less than 22% left ventricular sympathetic denervation met those endpoints, as did about 10% of those with 22%-33% left ventricular denervation, as assessed by myocardial response to a norepinephrine analogue on positron emission tomography. Denervated myocardium had a hazard ratio of 3.5 for sudden cardiac arrest or equivalent in the trial (P = .001).

Thirty-three of 204 post-MI patients experienced arrhythmic death or defibrillator discharge during the project. Most of the patients had undergone initial revascularization, and all were eligible for defibrillators at baseline. Overall, they were in their mid-60s, with left ventricular ejection fractions of about 26% and greater than NYHA class II heart failure. There were no significant demographic differences between patients who did and did not meet the study’s endpoints.

Prediction of sudden cardiac death events was even better when denervation was used in conjunction with three other factors: increase in the left ventricular end-diastolic volume index, creatinine greater than 1.5 mg/dL, and lack of angiotensin-converting enzyme inhibitor or angiotensin II receptor antagonist therapy.

Four-year event-free survival was about 98% in patients with none of those risk factors, about 85% in patients with one, and 50% in patients with two or more. The volume of infarcted or hibernating myocardium did not predict sudden cardiac arrest.

"The proven metric is left ventricle ejection fraction," but it and the many other methods that have been tried "have good negative predictive accuracy but not that good positive predictive accuracy, and so you are putting in defibrillators for people who don’t need them," he said.

For now, however, it would be "a leap of faith from a study that was prospective and observational" to actually use denervation "to determine therapies," he said.

Dr. Cain reported having no disclosures.

aotto@frontlinemedcom.com

VANCOUVER, B.C. – Patients with baseline PR intervals less than 200 ms have a better response to biventricular cardiac resynchronization therapy than do those with longer baseline intervals, a finding that may help predict who will respond to pacing, judging from recent data.

Investigators compared biventricular CRT [cardiac resynchronization therapy] outcomes in 66 patients with baseline PR intervals less than 200 ms to outcomes in 37 patients with intervals of 200 ms or greater.

Overall, left ventricular ejection fractions improved from 23.7% to 32.2%, but patients with baseline intervals below 200 ms had greater improvement (+11.8% vs. +4.9%) and had greater reductions in left ventricular end-systolic diameters (–0.37 mm vs. –0.06 mm) and mitral regurgitation grade (–0.16 vs. –0.03). Left ventricular end-diastolic diameters deteriorated in both groups, but less so among patients with shorter baseline PR intervals (+0.05 mm vs. +0.1 mm), according to the lead investigator Preya Simlote, a medical student at Thomas Jefferson University Hospital in Philadelphia.

Men accounted for two-thirds of the patients, and the average age in the study was 68 years. Patients had either coronary artery disease or nonischemic cardiomyopathy and were followed for a mean of about 282 days.

At baseline, patients in the longer–PR interval group had slower heart rates (68.7 bpm vs. 75.3 bpm), shorter QRS intervals (144.4 ms vs. 154.8 ms), worse mitral regurgitation (grade 2.29 vs. 1.95), and larger left atriums.

The findings suggest that the severity of "preexisting conduction system disease ... may be a more powerful marker of poor outcomes [than] the effects of short [atrioventricular] delay and truncated transmitral flow," the investigators concluded.

"We were kind of expecting that maybe people who had the longer PR interval would show more improvement. What we actually found was the opposite," Ms. Simlote said.

"Patients are given CRT based on their QRS interval and their symptoms, and their left ventricular ejection fraction. This suggests perhaps we should also be checking patients’ PR interval to predict how they will respond to CRT," she said at the 18th World Congress on Heart Disease.

Ms. Simlote had no disclosures.

aotto@frontlinemedcom.com

VANCOUVER, B.C. – Patients with baseline PR intervals less than 200 ms have a better response to biventricular cardiac resynchronization therapy than do those with longer baseline intervals, a finding that may help predict who will respond to pacing, judging from recent data.

Investigators compared biventricular CRT [cardiac resynchronization therapy] outcomes in 66 patients with baseline PR intervals less than 200 ms to outcomes in 37 patients with intervals of 200 ms or greater.

Overall, left ventricular ejection fractions improved from 23.7% to 32.2%, but patients with baseline intervals below 200 ms had greater improvement (+11.8% vs. +4.9%) and had greater reductions in left ventricular end-systolic diameters (–0.37 mm vs. –0.06 mm) and mitral regurgitation grade (–0.16 vs. –0.03). Left ventricular end-diastolic diameters deteriorated in both groups, but less so among patients with shorter baseline PR intervals (+0.05 mm vs. +0.1 mm), according to the lead investigator Preya Simlote, a medical student at Thomas Jefferson University Hospital in Philadelphia.

Men accounted for two-thirds of the patients, and the average age in the study was 68 years. Patients had either coronary artery disease or nonischemic cardiomyopathy and were followed for a mean of about 282 days.

At baseline, patients in the longer–PR interval group had slower heart rates (68.7 bpm vs. 75.3 bpm), shorter QRS intervals (144.4 ms vs. 154.8 ms), worse mitral regurgitation (grade 2.29 vs. 1.95), and larger left atriums.

The findings suggest that the severity of "preexisting conduction system disease ... may be a more powerful marker of poor outcomes [than] the effects of short [atrioventricular] delay and truncated transmitral flow," the investigators concluded.

"We were kind of expecting that maybe people who had the longer PR interval would show more improvement. What we actually found was the opposite," Ms. Simlote said.

"Patients are given CRT based on their QRS interval and their symptoms, and their left ventricular ejection fraction. This suggests perhaps we should also be checking patients’ PR interval to predict how they will respond to CRT," she said at the 18th World Congress on Heart Disease.

Ms. Simlote had no disclosures.

aotto@frontlinemedcom.com

VANCOUVER, B.C. – Patients with baseline PR intervals less than 200 ms have a better response to biventricular cardiac resynchronization therapy than do those with longer baseline intervals, a finding that may help predict who will respond to pacing, judging from recent data.

Investigators compared biventricular CRT [cardiac resynchronization therapy] outcomes in 66 patients with baseline PR intervals less than 200 ms to outcomes in 37 patients with intervals of 200 ms or greater.

Overall, left ventricular ejection fractions improved from 23.7% to 32.2%, but patients with baseline intervals below 200 ms had greater improvement (+11.8% vs. +4.9%) and had greater reductions in left ventricular end-systolic diameters (–0.37 mm vs. –0.06 mm) and mitral regurgitation grade (–0.16 vs. –0.03). Left ventricular end-diastolic diameters deteriorated in both groups, but less so among patients with shorter baseline PR intervals (+0.05 mm vs. +0.1 mm), according to the lead investigator Preya Simlote, a medical student at Thomas Jefferson University Hospital in Philadelphia.

Men accounted for two-thirds of the patients, and the average age in the study was 68 years. Patients had either coronary artery disease or nonischemic cardiomyopathy and were followed for a mean of about 282 days.

At baseline, patients in the longer–PR interval group had slower heart rates (68.7 bpm vs. 75.3 bpm), shorter QRS intervals (144.4 ms vs. 154.8 ms), worse mitral regurgitation (grade 2.29 vs. 1.95), and larger left atriums.

The findings suggest that the severity of "preexisting conduction system disease ... may be a more powerful marker of poor outcomes [than] the effects of short [atrioventricular] delay and truncated transmitral flow," the investigators concluded.

"We were kind of expecting that maybe people who had the longer PR interval would show more improvement. What we actually found was the opposite," Ms. Simlote said.

"Patients are given CRT based on their QRS interval and their symptoms, and their left ventricular ejection fraction. This suggests perhaps we should also be checking patients’ PR interval to predict how they will respond to CRT," she said at the 18th World Congress on Heart Disease.

Ms. Simlote had no disclosures.

aotto@frontlinemedcom.com

VANCOUVER, B.C. – Laser lead extraction can damage nearby adjacent leads, and the damage isn’t always apparent at the time of removal, according to findings from a recent small study presented by Dr. Jeffrey Snow.

Sixteen patients underwent laser lead extraction at Winthrop University Hospital on Long Island (N.Y.) during defibrillator upgrades or replacement of recalled leads; 24 adjacent leads were left in place and reused. After a mean follow-up of 24 months, a reused lead failed in 4 of the 16 patients. Two patients had a loss of capture, one a fractured lead, and another a sensing noise artifact; the leads appeared to be working fine at the time of extraction.

Meanwhile, 40 control patients had new leads placed without laser extraction; 60 adjacent leads were left in place and reused. Not one failed during a mean follow-up of 25 months (P = .0099).

"In this study," leads remaining after laser extraction "were shown to have a decreased lifespan. If the finding is proved in a larger population, it would have a significant impact on our treatment strategy for recalled defibrillator leads," the authors concluded.

"This comes up most often in patients with a recalled lead. We have to figure out what to do about those leads; there isn’t a good answer out there in the literature," said lead investigator Dr. Snow, an electrophysiologist at Winthrop.

"You have the choice of trying to slip a new lead in alongside it, but that doesn’t always work. There may not be venous access. You could try to remove the lead that you worry may become defective and put a new lead in, which is what we were doing. It took us by surprise that by doing that, we were having a higher than expected failure rate in adjacent leads," he said at the 18th World Congress on Heart Disease.

"We act more quickly now to take out adjacent leads and just start fresh," especially if "it was a difficult extraction that took a lot of time and a lot of force or traction. We don’t want to find out in 6 months that [an adjacent] lead went bad and we have to operate for a third time," Dr. Snow said.

Dr. Snow said he has no relevant disclosures.

aotto@frontlinemedcom.com

VANCOUVER, B.C. – Laser lead extraction can damage nearby adjacent leads, and the damage isn’t always apparent at the time of removal, according to findings from a recent small study presented by Dr. Jeffrey Snow.

Sixteen patients underwent laser lead extraction at Winthrop University Hospital on Long Island (N.Y.) during defibrillator upgrades or replacement of recalled leads; 24 adjacent leads were left in place and reused. After a mean follow-up of 24 months, a reused lead failed in 4 of the 16 patients. Two patients had a loss of capture, one a fractured lead, and another a sensing noise artifact; the leads appeared to be working fine at the time of extraction.

Meanwhile, 40 control patients had new leads placed without laser extraction; 60 adjacent leads were left in place and reused. Not one failed during a mean follow-up of 25 months (P = .0099).

"In this study," leads remaining after laser extraction "were shown to have a decreased lifespan. If the finding is proved in a larger population, it would have a significant impact on our treatment strategy for recalled defibrillator leads," the authors concluded.

"This comes up most often in patients with a recalled lead. We have to figure out what to do about those leads; there isn’t a good answer out there in the literature," said lead investigator Dr. Snow, an electrophysiologist at Winthrop.

"You have the choice of trying to slip a new lead in alongside it, but that doesn’t always work. There may not be venous access. You could try to remove the lead that you worry may become defective and put a new lead in, which is what we were doing. It took us by surprise that by doing that, we were having a higher than expected failure rate in adjacent leads," he said at the 18th World Congress on Heart Disease.

"We act more quickly now to take out adjacent leads and just start fresh," especially if "it was a difficult extraction that took a lot of time and a lot of force or traction. We don’t want to find out in 6 months that [an adjacent] lead went bad and we have to operate for a third time," Dr. Snow said.

Dr. Snow said he has no relevant disclosures.

aotto@frontlinemedcom.com

VANCOUVER, B.C. – Laser lead extraction can damage nearby adjacent leads, and the damage isn’t always apparent at the time of removal, according to findings from a recent small study presented by Dr. Jeffrey Snow.

Sixteen patients underwent laser lead extraction at Winthrop University Hospital on Long Island (N.Y.) during defibrillator upgrades or replacement of recalled leads; 24 adjacent leads were left in place and reused. After a mean follow-up of 24 months, a reused lead failed in 4 of the 16 patients. Two patients had a loss of capture, one a fractured lead, and another a sensing noise artifact; the leads appeared to be working fine at the time of extraction.

Meanwhile, 40 control patients had new leads placed without laser extraction; 60 adjacent leads were left in place and reused. Not one failed during a mean follow-up of 25 months (P = .0099).

"In this study," leads remaining after laser extraction "were shown to have a decreased lifespan. If the finding is proved in a larger population, it would have a significant impact on our treatment strategy for recalled defibrillator leads," the authors concluded.

"This comes up most often in patients with a recalled lead. We have to figure out what to do about those leads; there isn’t a good answer out there in the literature," said lead investigator Dr. Snow, an electrophysiologist at Winthrop.

"You have the choice of trying to slip a new lead in alongside it, but that doesn’t always work. There may not be venous access. You could try to remove the lead that you worry may become defective and put a new lead in, which is what we were doing. It took us by surprise that by doing that, we were having a higher than expected failure rate in adjacent leads," he said at the 18th World Congress on Heart Disease.

"We act more quickly now to take out adjacent leads and just start fresh," especially if "it was a difficult extraction that took a lot of time and a lot of force or traction. We don’t want to find out in 6 months that [an adjacent] lead went bad and we have to operate for a third time," Dr. Snow said.

Dr. Snow said he has no relevant disclosures.

aotto@frontlinemedcom.com

Among patients with community-associated Clostridium difficile infection, more than a third had not used antibiotics in the 12 weeks prior to diagnosis and more than half reported limited or no health care contact over the same period.

To assess possible sources of infection, Dr. Amit S. Chitnis and his colleagues at the Centers for Disease Control and Prevention reviewed the medical records of, and interviewed, 984 patients with new-onset community-associated Clostridium difficile infection (CDI) in eight states as identified through CDC surveillance efforts.

The patients’ median age was 51 years and median Charlson comorbidity index 0. Almost 90% of were white and two-thirds were women; 41% had preceding high-level outpatient care, such as surgery or dialysis.

In assessing risk factors for CDI, investigators found that 400 patients (41%) reported low-level health care exposure, such as a visit to a physician or dentist, while 177 (18%) reported no exposure (JAMA Intern. Med. 2013;173:1359-67).

Regarding medication use, 64% (631) reported antibiotic use within 12 weeks of diagnosis, while 28% (273) reported using a PPI, and 9% (90) reported using an H₂-reception antagonist.

Just under a third (31%) of patients with no antibiotic history had used a PPI in the previous 12 weeks. "Based on our data, if the effect of reducing unnecessary PPI use on community-associated CDI is limited to those patients who have not received recent antibiotics, such an intervention would prevent only 11.2% of community-associated CDI," the investigators noted.

Among 177 patients with no health care contact, 44% had used antibiotics, 24% used a PPI, and 12% had used H₂-receptor antagonists.

Patients with no – or limited – health care contact were significantly more likely to live with an active CDI case, or have contact with infants under a year old, who are often asymptomatic carriers of C. difficile. There were no associations between CDI and food or animal exposure.

Among the 64% of patients who had received antibiotics, "it is likely that a substantial proportion ... received antibiotics inappropriately," the investigators said. Ear, sinus, and upper respiratory tract infections were the most common indications.

"Prevention of community-associated CDI should primarily focus on reducing inappropriate antibiotic use and better infection control practices in outpatient settings. Our data support evaluation of additional strategies, including further examination of C. difficile transmission in outpatient and household settings and reduction of PPI use," the investigators concluded.

The CDC funded the work. The authors reported no conflicts of interest.

aotto@frontlinemedcom.com

Among patients with community-associated Clostridium difficile infection, more than a third had not used antibiotics in the 12 weeks prior to diagnosis and more than half reported limited or no health care contact over the same period.

To assess possible sources of infection, Dr. Amit S. Chitnis and his colleagues at the Centers for Disease Control and Prevention reviewed the medical records of, and interviewed, 984 patients with new-onset community-associated Clostridium difficile infection (CDI) in eight states as identified through CDC surveillance efforts.

The patients’ median age was 51 years and median Charlson comorbidity index 0. Almost 90% of were white and two-thirds were women; 41% had preceding high-level outpatient care, such as surgery or dialysis.

In assessing risk factors for CDI, investigators found that 400 patients (41%) reported low-level health care exposure, such as a visit to a physician or dentist, while 177 (18%) reported no exposure (JAMA Intern. Med. 2013;173:1359-67).

Regarding medication use, 64% (631) reported antibiotic use within 12 weeks of diagnosis, while 28% (273) reported using a PPI, and 9% (90) reported using an H₂-reception antagonist.

Just under a third (31%) of patients with no antibiotic history had used a PPI in the previous 12 weeks. "Based on our data, if the effect of reducing unnecessary PPI use on community-associated CDI is limited to those patients who have not received recent antibiotics, such an intervention would prevent only 11.2% of community-associated CDI," the investigators noted.

Among 177 patients with no health care contact, 44% had used antibiotics, 24% used a PPI, and 12% had used H₂-receptor antagonists.

Patients with no – or limited – health care contact were significantly more likely to live with an active CDI case, or have contact with infants under a year old, who are often asymptomatic carriers of C. difficile. There were no associations between CDI and food or animal exposure.

Among the 64% of patients who had received antibiotics, "it is likely that a substantial proportion ... received antibiotics inappropriately," the investigators said. Ear, sinus, and upper respiratory tract infections were the most common indications.

"Prevention of community-associated CDI should primarily focus on reducing inappropriate antibiotic use and better infection control practices in outpatient settings. Our data support evaluation of additional strategies, including further examination of C. difficile transmission in outpatient and household settings and reduction of PPI use," the investigators concluded.

The CDC funded the work. The authors reported no conflicts of interest.

aotto@frontlinemedcom.com

Among patients with community-associated Clostridium difficile infection, more than a third had not used antibiotics in the 12 weeks prior to diagnosis and more than half reported limited or no health care contact over the same period.

To assess possible sources of infection, Dr. Amit S. Chitnis and his colleagues at the Centers for Disease Control and Prevention reviewed the medical records of, and interviewed, 984 patients with new-onset community-associated Clostridium difficile infection (CDI) in eight states as identified through CDC surveillance efforts.

The patients’ median age was 51 years and median Charlson comorbidity index 0. Almost 90% of were white and two-thirds were women; 41% had preceding high-level outpatient care, such as surgery or dialysis.

In assessing risk factors for CDI, investigators found that 400 patients (41%) reported low-level health care exposure, such as a visit to a physician or dentist, while 177 (18%) reported no exposure (JAMA Intern. Med. 2013;173:1359-67).

Regarding medication use, 64% (631) reported antibiotic use within 12 weeks of diagnosis, while 28% (273) reported using a PPI, and 9% (90) reported using an H₂-reception antagonist.

Just under a third (31%) of patients with no antibiotic history had used a PPI in the previous 12 weeks. "Based on our data, if the effect of reducing unnecessary PPI use on community-associated CDI is limited to those patients who have not received recent antibiotics, such an intervention would prevent only 11.2% of community-associated CDI," the investigators noted.

Among 177 patients with no health care contact, 44% had used antibiotics, 24% used a PPI, and 12% had used H₂-receptor antagonists.

Patients with no – or limited – health care contact were significantly more likely to live with an active CDI case, or have contact with infants under a year old, who are often asymptomatic carriers of C. difficile. There were no associations between CDI and food or animal exposure.

Among the 64% of patients who had received antibiotics, "it is likely that a substantial proportion ... received antibiotics inappropriately," the investigators said. Ear, sinus, and upper respiratory tract infections were the most common indications.

"Prevention of community-associated CDI should primarily focus on reducing inappropriate antibiotic use and better infection control practices in outpatient settings. Our data support evaluation of additional strategies, including further examination of C. difficile transmission in outpatient and household settings and reduction of PPI use," the investigators concluded.

The CDC funded the work. The authors reported no conflicts of interest.

aotto@frontlinemedcom.com

Being less than 40 years old does not significantly impact survival in women with HER2-positive breast cancer, according to a retrospective analysis of a large, randomized breast cancer study.

"Our finding that age is neither a clear prognostic factor for early recurrence nor a predictive factor for benefit of trastuzumab in women with HER2-positive breast cancer may have important implications for care and future research. Most prior research suggesting that age is an independent prognostic factor has not taken HER2 status into account," noted Dr. Ann H. Partridge and her colleagues.

Younger women are more likely to present with aggressive breast tumors and advanced disease; young age at diagnosis is an independent risk factor for recurrence and death. Few studies have been conducted to evaluate if the finding remains the same among women with HER2-positive (human epidermal growth factor receptor 2–positive) tumors, according to Dr. Partridge, an oncologist at the Dana-Farber Cancer Institute in Boston, and her colleagues.

They performed a retrospective analysis of data from the HERA [Herceptin Adjuvant] study, an open-label, phase III randomized trial that found significantly improved disease-free survival in HER2-positive breast cancer patients who received a year of trastuzumab following adjuvant chemotherapy (N. Engl. J. Med. 2005;353:1659-72).

Among 1,698 women randomly assigned to observation in the trial, there was no significant difference in disease-free survival (HR 1.18; 95% CI, 0.90-1.54) or overall survival (HR 1.01; 95% CI, 0.60-1.69) in women aged 40 years or younger, compared with women over age 40 years (J. Clin. Oncol. 2013;31:2692-8).

This was also true among the 1,703 women randomly assigned to trastuzumab. Disease-free survival (HR 1.11; 95% CI, 0.81-1.51) and overall survival (HR 1.18; 95% CI, 0.66-2.09) were comparable in younger women, compared with those over 40 years of age. Interaction between age group and treatment effect was not statistically significant for either parameter (DFS P = 0.89; OS P = 0.55).

Overall, 722 women (21%) were 40 years of age or younger at study entry.

"Our findings suggest that as breast cancer continues to be better characterized molecularly, and therapies such as trastuzumab are developed to target molecular subtypes, the importance of age with regard to prognosis will continue to diminish, if not disappear," they wrote.

The short follow-up was a limitation of the study. "Future research should investigate whether age is a predictor of later recurrence and evaluate the impact of age within groups with other tumor subtypes," they noted.

Dr. Partridge is a consultant for Genentech, maker of trastuzumab. Another author is an employee of, and holds stock in, Roche, the parent company of Genentech. All but one of the six other investigators have ties to the two companies

aotto@frontlinemedcom.com

Being less than 40 years old does not significantly impact survival in women with HER2-positive breast cancer, according to a retrospective analysis of a large, randomized breast cancer study.

"Our finding that age is neither a clear prognostic factor for early recurrence nor a predictive factor for benefit of trastuzumab in women with HER2-positive breast cancer may have important implications for care and future research. Most prior research suggesting that age is an independent prognostic factor has not taken HER2 status into account," noted Dr. Ann H. Partridge and her colleagues.

Younger women are more likely to present with aggressive breast tumors and advanced disease; young age at diagnosis is an independent risk factor for recurrence and death. Few studies have been conducted to evaluate if the finding remains the same among women with HER2-positive (human epidermal growth factor receptor 2–positive) tumors, according to Dr. Partridge, an oncologist at the Dana-Farber Cancer Institute in Boston, and her colleagues.

They performed a retrospective analysis of data from the HERA [Herceptin Adjuvant] study, an open-label, phase III randomized trial that found significantly improved disease-free survival in HER2-positive breast cancer patients who received a year of trastuzumab following adjuvant chemotherapy (N. Engl. J. Med. 2005;353:1659-72).

Among 1,698 women randomly assigned to observation in the trial, there was no significant difference in disease-free survival (HR 1.18; 95% CI, 0.90-1.54) or overall survival (HR 1.01; 95% CI, 0.60-1.69) in women aged 40 years or younger, compared with women over age 40 years (J. Clin. Oncol. 2013;31:2692-8).

This was also true among the 1,703 women randomly assigned to trastuzumab. Disease-free survival (HR 1.11; 95% CI, 0.81-1.51) and overall survival (HR 1.18; 95% CI, 0.66-2.09) were comparable in younger women, compared with those over 40 years of age. Interaction between age group and treatment effect was not statistically significant for either parameter (DFS P = 0.89; OS P = 0.55).

Overall, 722 women (21%) were 40 years of age or younger at study entry.

"Our findings suggest that as breast cancer continues to be better characterized molecularly, and therapies such as trastuzumab are developed to target molecular subtypes, the importance of age with regard to prognosis will continue to diminish, if not disappear," they wrote.

The short follow-up was a limitation of the study. "Future research should investigate whether age is a predictor of later recurrence and evaluate the impact of age within groups with other tumor subtypes," they noted.

Dr. Partridge is a consultant for Genentech, maker of trastuzumab. Another author is an employee of, and holds stock in, Roche, the parent company of Genentech. All but one of the six other investigators have ties to the two companies

aotto@frontlinemedcom.com

Being less than 40 years old does not significantly impact survival in women with HER2-positive breast cancer, according to a retrospective analysis of a large, randomized breast cancer study.

"Our finding that age is neither a clear prognostic factor for early recurrence nor a predictive factor for benefit of trastuzumab in women with HER2-positive breast cancer may have important implications for care and future research. Most prior research suggesting that age is an independent prognostic factor has not taken HER2 status into account," noted Dr. Ann H. Partridge and her colleagues.

Younger women are more likely to present with aggressive breast tumors and advanced disease; young age at diagnosis is an independent risk factor for recurrence and death. Few studies have been conducted to evaluate if the finding remains the same among women with HER2-positive (human epidermal growth factor receptor 2–positive) tumors, according to Dr. Partridge, an oncologist at the Dana-Farber Cancer Institute in Boston, and her colleagues.

They performed a retrospective analysis of data from the HERA [Herceptin Adjuvant] study, an open-label, phase III randomized trial that found significantly improved disease-free survival in HER2-positive breast cancer patients who received a year of trastuzumab following adjuvant chemotherapy (N. Engl. J. Med. 2005;353:1659-72).

Among 1,698 women randomly assigned to observation in the trial, there was no significant difference in disease-free survival (HR 1.18; 95% CI, 0.90-1.54) or overall survival (HR 1.01; 95% CI, 0.60-1.69) in women aged 40 years or younger, compared with women over age 40 years (J. Clin. Oncol. 2013;31:2692-8).

This was also true among the 1,703 women randomly assigned to trastuzumab. Disease-free survival (HR 1.11; 95% CI, 0.81-1.51) and overall survival (HR 1.18; 95% CI, 0.66-2.09) were comparable in younger women, compared with those over 40 years of age. Interaction between age group and treatment effect was not statistically significant for either parameter (DFS P = 0.89; OS P = 0.55).

Overall, 722 women (21%) were 40 years of age or younger at study entry.

"Our findings suggest that as breast cancer continues to be better characterized molecularly, and therapies such as trastuzumab are developed to target molecular subtypes, the importance of age with regard to prognosis will continue to diminish, if not disappear," they wrote.

The short follow-up was a limitation of the study. "Future research should investigate whether age is a predictor of later recurrence and evaluate the impact of age within groups with other tumor subtypes," they noted.

Dr. Partridge is a consultant for Genentech, maker of trastuzumab. Another author is an employee of, and holds stock in, Roche, the parent company of Genentech. All but one of the six other investigators have ties to the two companies

aotto@frontlinemedcom.com