Sharon Worcester

Carotid stenting may be a safe alternative to endarterectomy in patients under age 70 years with symptomatic carotid stenosis, but stenting should be avoided in those aged 70 years or older, according to findings from a meta-analysis of data from three randomized controlled trials.

While current recommendations restrict the use of stenting to symptomatic patients with contraindications to endarterectomy, carotid stenosis at surgically inaccessible sites, recurrent stenosis after previous endarterectomy, and stenosis after irradiation, the findings of this meta-analysis suggest stenting is also a viable alternative in younger patients in whom surgery could otherwise be undertaken without increased risk, said Dr. Leo H. Bonati of University Hospital Basel, Switzerland, and the Institute of Neurology at University College, London, and his colleagues from the Carotid Stenting Trialists' Collaboration.

They advised, however, that some uncertainty remains about whether recurrent stenosis rates are high after stenting vs. endarterectomy and recommended an approach of offering stenting when “technically feasible as an alternative option to endarterectomy to patients younger than 65–70 years with symptomatic carotid stenosis, in centers in which acceptable periprocedural outcomes have been independently verified…as long as patient are made aware of a possible increase in the risk of restenosis.”

Among the 3,433 patients in the trials, overall incidence of any stroke or death in the 120 days after randomization in the three trials was significantly greater in patients who underwent carotid stenting vs. carotid endarterectomy (8.9% vs. 5.8%, respectively; risk ratio 1.53).

However, assessment of multiple subgroup variables showed that age modified the treatment effect; no difference was seen in the estimated 120-day risk of stroke or death in those under age 70 years who underwent stenting vs. endarterectomy, but the risk of stroke or death was doubled in those aged 70 years or older who underwent stenting vs. endarterectomy. (See graph below.)

Similarly, the relative risk estimates for stroke or death at 30 days after treatment were comparable in those under age 70 years who underwent stenting vs. endarterectomy (5.1% and 4.5%, respectively; risk ratio 1.11), but were more than double in those aged 70 years or older for stenting vs. endarterectomy (10.5% and 4.4%, respectively; risk ratio 2.41).

The findings provide “strong evidence that, in the short term, the harm of stenting compared with endarterectomy decreases with younger age,” the investigators wrote.

For the meta-analysis, which was funded by the Stroke Association, the investigators analyzed data from Endarterectomy vs. Angioplasty in Patients With Symptomatic Severe Carotid Stenosis (EVA-3S), Stent-Protected Angioplasty vs. Carotid Endarterectomy (SPACE), and the International Carotid Stenting Study (ICSS).

These and other trials have suggested there is a higher periprocedural risk of stroke with stenting vs. endarterectomy, but none of the trials on their own were sufficiently powered to show whether stenting might be a safe alternative in some patients, the investigators noted (Lancet 2010 [doi:10.1016/S0140-6736(10)61009-4

Indeed, the risk of stenting remained strongly dependent on age even after additional assessment based on sex, type of recent symptoms, degree of treated carotid stenosis, systolic blood pressure at randomization, and a number of other factors, the investigators noted.

The investigators stated that they have no conflicts of interest.

Vitals

Source Elsevier Global Medical News

Carotid stenting may be a safe alternative to endarterectomy in patients under age 70 years with symptomatic carotid stenosis, but stenting should be avoided in those aged 70 years or older, according to findings from a meta-analysis of data from three randomized controlled trials.

While current recommendations restrict the use of stenting to symptomatic patients with contraindications to endarterectomy, carotid stenosis at surgically inaccessible sites, recurrent stenosis after previous endarterectomy, and stenosis after irradiation, the findings of this meta-analysis suggest stenting is also a viable alternative in younger patients in whom surgery could otherwise be undertaken without increased risk, said Dr. Leo H. Bonati of University Hospital Basel, Switzerland, and the Institute of Neurology at University College, London, and his colleagues from the Carotid Stenting Trialists' Collaboration.

They advised, however, that some uncertainty remains about whether recurrent stenosis rates are high after stenting vs. endarterectomy and recommended an approach of offering stenting when “technically feasible as an alternative option to endarterectomy to patients younger than 65–70 years with symptomatic carotid stenosis, in centers in which acceptable periprocedural outcomes have been independently verified…as long as patient are made aware of a possible increase in the risk of restenosis.”

Among the 3,433 patients in the trials, overall incidence of any stroke or death in the 120 days after randomization in the three trials was significantly greater in patients who underwent carotid stenting vs. carotid endarterectomy (8.9% vs. 5.8%, respectively; risk ratio 1.53).

However, assessment of multiple subgroup variables showed that age modified the treatment effect; no difference was seen in the estimated 120-day risk of stroke or death in those under age 70 years who underwent stenting vs. endarterectomy, but the risk of stroke or death was doubled in those aged 70 years or older who underwent stenting vs. endarterectomy. (See graph below.)

Similarly, the relative risk estimates for stroke or death at 30 days after treatment were comparable in those under age 70 years who underwent stenting vs. endarterectomy (5.1% and 4.5%, respectively; risk ratio 1.11), but were more than double in those aged 70 years or older for stenting vs. endarterectomy (10.5% and 4.4%, respectively; risk ratio 2.41).

The findings provide “strong evidence that, in the short term, the harm of stenting compared with endarterectomy decreases with younger age,” the investigators wrote.

For the meta-analysis, which was funded by the Stroke Association, the investigators analyzed data from Endarterectomy vs. Angioplasty in Patients With Symptomatic Severe Carotid Stenosis (EVA-3S), Stent-Protected Angioplasty vs. Carotid Endarterectomy (SPACE), and the International Carotid Stenting Study (ICSS).

These and other trials have suggested there is a higher periprocedural risk of stroke with stenting vs. endarterectomy, but none of the trials on their own were sufficiently powered to show whether stenting might be a safe alternative in some patients, the investigators noted (Lancet 2010 [doi:10.1016/S0140-6736(10)61009-4

Indeed, the risk of stenting remained strongly dependent on age even after additional assessment based on sex, type of recent symptoms, degree of treated carotid stenosis, systolic blood pressure at randomization, and a number of other factors, the investigators noted.

The investigators stated that they have no conflicts of interest.

Vitals

Source Elsevier Global Medical News

Carotid stenting may be a safe alternative to endarterectomy in patients under age 70 years with symptomatic carotid stenosis, but stenting should be avoided in those aged 70 years or older, according to findings from a meta-analysis of data from three randomized controlled trials.

While current recommendations restrict the use of stenting to symptomatic patients with contraindications to endarterectomy, carotid stenosis at surgically inaccessible sites, recurrent stenosis after previous endarterectomy, and stenosis after irradiation, the findings of this meta-analysis suggest stenting is also a viable alternative in younger patients in whom surgery could otherwise be undertaken without increased risk, said Dr. Leo H. Bonati of University Hospital Basel, Switzerland, and the Institute of Neurology at University College, London, and his colleagues from the Carotid Stenting Trialists' Collaboration.

They advised, however, that some uncertainty remains about whether recurrent stenosis rates are high after stenting vs. endarterectomy and recommended an approach of offering stenting when “technically feasible as an alternative option to endarterectomy to patients younger than 65–70 years with symptomatic carotid stenosis, in centers in which acceptable periprocedural outcomes have been independently verified…as long as patient are made aware of a possible increase in the risk of restenosis.”

Among the 3,433 patients in the trials, overall incidence of any stroke or death in the 120 days after randomization in the three trials was significantly greater in patients who underwent carotid stenting vs. carotid endarterectomy (8.9% vs. 5.8%, respectively; risk ratio 1.53).

However, assessment of multiple subgroup variables showed that age modified the treatment effect; no difference was seen in the estimated 120-day risk of stroke or death in those under age 70 years who underwent stenting vs. endarterectomy, but the risk of stroke or death was doubled in those aged 70 years or older who underwent stenting vs. endarterectomy. (See graph below.)

Similarly, the relative risk estimates for stroke or death at 30 days after treatment were comparable in those under age 70 years who underwent stenting vs. endarterectomy (5.1% and 4.5%, respectively; risk ratio 1.11), but were more than double in those aged 70 years or older for stenting vs. endarterectomy (10.5% and 4.4%, respectively; risk ratio 2.41).

The findings provide “strong evidence that, in the short term, the harm of stenting compared with endarterectomy decreases with younger age,” the investigators wrote.

For the meta-analysis, which was funded by the Stroke Association, the investigators analyzed data from Endarterectomy vs. Angioplasty in Patients With Symptomatic Severe Carotid Stenosis (EVA-3S), Stent-Protected Angioplasty vs. Carotid Endarterectomy (SPACE), and the International Carotid Stenting Study (ICSS).

These and other trials have suggested there is a higher periprocedural risk of stroke with stenting vs. endarterectomy, but none of the trials on their own were sufficiently powered to show whether stenting might be a safe alternative in some patients, the investigators noted (Lancet 2010 [doi:10.1016/S0140-6736(10)61009-4

Indeed, the risk of stenting remained strongly dependent on age even after additional assessment based on sex, type of recent symptoms, degree of treated carotid stenosis, systolic blood pressure at randomization, and a number of other factors, the investigators noted.

The investigators stated that they have no conflicts of interest.

Vitals

Source Elsevier Global Medical News

Major Finding: Psoriasis patients were particularly more likely to be diagnosed with depression (3%) or anxiety (1.8%), compared with controls (2.4% and 1.4%, respectively).

Data Source: A large, retrospective, case-control study of 7,404 children with psoriasis under age 18 years and 37,020 controls.

Disclosures: Abbott Laboratories sponsored the study.

MIAMI – Children with psoriasis have a significantly greater risk of developing a psychiatric disorder than do those without psoriasis, according to findings from a large, retrospective, case-control study.

Nationally representative health plan data for 7,404 children with psoriasis aged younger than 18 years found that 5.1% were diagnosed with or treated for a psychiatric disorder after health plan enrollment, compared with 4.1% of 37,020 controls. Psoriasis patients were particularly more likely to be diagnosed with depression (3%) or anxiety (1.8%), compared with controls (2.4% and 1.4%, respectively), Carol Bao, Ph.D., reported during a poster discussion session at the meeting.

For children with psoriasis, the estimated hazard ratio for developing any psychiatric disorder was 1.25, for developing depression was 1.23, and for developing anxiety was 1.32, said Dr. Bao, a senior manager at Abbott Laboratories, Chicago.

The investigators also looked at prescriptions for psychotropic medications in assessing risk for development of psychiatric disorders. Prescriptions can be a marker for a diagnosis in cases where the prescribing physician may be hesitant to refer the patient or make a diagnosis, Dr. Bao explained, noting that this helped correct for possible underestimation of the development of psychiatric disorders and provided a risk estimate range.

When both diagnoses and prescriptions were considered, psoriasis patients had 25%-47% greater risk of developing a psychiatric disorder, 23%-62% greater risk of developing depression, and 32%-250% greater risk of developing anxiety, compared with controls, she said.

Patients included in the study had a mean age of 11.4 years. They were selected from a database of health plan participants who were enrolled in a plan at least 6 months before and after the first psoriasis diagnosis date (the index date), and who were followed from the index date until they were first diagnosed with any psychiatric disorder or were prescribed a drug used for the treatment of a psychiatric disorder. Any plan participant with a preenrollment psychiatric diagnosis or prescription was excluded.

Controls were matched to patients based on age, sex, and index date.

The findings of an increased risk of developing psychiatric disorders in case patients remained significant after controlling for age, sex, health plan, region of residence, and comorbidities, Dr. Bao noted.

The study is limited by the potential for coding and reporting errors in the data used and by lack of information on the severity of the psychiatric disorders. However, the findings do suggest that the psychiatric impact of psoriasis on children must be addressed because of the potential for both short- and long-term adverse effects.

“If we put these data in perspective, the development of psychiatric disorders at a young age can have a great impact in future adult life,” she said.

Major Finding: Psoriasis patients were particularly more likely to be diagnosed with depression (3%) or anxiety (1.8%), compared with controls (2.4% and 1.4%, respectively).

Data Source: A large, retrospective, case-control study of 7,404 children with psoriasis under age 18 years and 37,020 controls.

Disclosures: Abbott Laboratories sponsored the study.

MIAMI – Children with psoriasis have a significantly greater risk of developing a psychiatric disorder than do those without psoriasis, according to findings from a large, retrospective, case-control study.

Nationally representative health plan data for 7,404 children with psoriasis aged younger than 18 years found that 5.1% were diagnosed with or treated for a psychiatric disorder after health plan enrollment, compared with 4.1% of 37,020 controls. Psoriasis patients were particularly more likely to be diagnosed with depression (3%) or anxiety (1.8%), compared with controls (2.4% and 1.4%, respectively), Carol Bao, Ph.D., reported during a poster discussion session at the meeting.

For children with psoriasis, the estimated hazard ratio for developing any psychiatric disorder was 1.25, for developing depression was 1.23, and for developing anxiety was 1.32, said Dr. Bao, a senior manager at Abbott Laboratories, Chicago.

The investigators also looked at prescriptions for psychotropic medications in assessing risk for development of psychiatric disorders. Prescriptions can be a marker for a diagnosis in cases where the prescribing physician may be hesitant to refer the patient or make a diagnosis, Dr. Bao explained, noting that this helped correct for possible underestimation of the development of psychiatric disorders and provided a risk estimate range.

When both diagnoses and prescriptions were considered, psoriasis patients had 25%-47% greater risk of developing a psychiatric disorder, 23%-62% greater risk of developing depression, and 32%-250% greater risk of developing anxiety, compared with controls, she said.

Patients included in the study had a mean age of 11.4 years. They were selected from a database of health plan participants who were enrolled in a plan at least 6 months before and after the first psoriasis diagnosis date (the index date), and who were followed from the index date until they were first diagnosed with any psychiatric disorder or were prescribed a drug used for the treatment of a psychiatric disorder. Any plan participant with a preenrollment psychiatric diagnosis or prescription was excluded.

Controls were matched to patients based on age, sex, and index date.

The findings of an increased risk of developing psychiatric disorders in case patients remained significant after controlling for age, sex, health plan, region of residence, and comorbidities, Dr. Bao noted.

The study is limited by the potential for coding and reporting errors in the data used and by lack of information on the severity of the psychiatric disorders. However, the findings do suggest that the psychiatric impact of psoriasis on children must be addressed because of the potential for both short- and long-term adverse effects.

“If we put these data in perspective, the development of psychiatric disorders at a young age can have a great impact in future adult life,” she said.

Major Finding: Psoriasis patients were particularly more likely to be diagnosed with depression (3%) or anxiety (1.8%), compared with controls (2.4% and 1.4%, respectively).

Data Source: A large, retrospective, case-control study of 7,404 children with psoriasis under age 18 years and 37,020 controls.

Disclosures: Abbott Laboratories sponsored the study.

MIAMI – Children with psoriasis have a significantly greater risk of developing a psychiatric disorder than do those without psoriasis, according to findings from a large, retrospective, case-control study.

Nationally representative health plan data for 7,404 children with psoriasis aged younger than 18 years found that 5.1% were diagnosed with or treated for a psychiatric disorder after health plan enrollment, compared with 4.1% of 37,020 controls. Psoriasis patients were particularly more likely to be diagnosed with depression (3%) or anxiety (1.8%), compared with controls (2.4% and 1.4%, respectively), Carol Bao, Ph.D., reported during a poster discussion session at the meeting.

For children with psoriasis, the estimated hazard ratio for developing any psychiatric disorder was 1.25, for developing depression was 1.23, and for developing anxiety was 1.32, said Dr. Bao, a senior manager at Abbott Laboratories, Chicago.

The investigators also looked at prescriptions for psychotropic medications in assessing risk for development of psychiatric disorders. Prescriptions can be a marker for a diagnosis in cases where the prescribing physician may be hesitant to refer the patient or make a diagnosis, Dr. Bao explained, noting that this helped correct for possible underestimation of the development of psychiatric disorders and provided a risk estimate range.

When both diagnoses and prescriptions were considered, psoriasis patients had 25%-47% greater risk of developing a psychiatric disorder, 23%-62% greater risk of developing depression, and 32%-250% greater risk of developing anxiety, compared with controls, she said.

Patients included in the study had a mean age of 11.4 years. They were selected from a database of health plan participants who were enrolled in a plan at least 6 months before and after the first psoriasis diagnosis date (the index date), and who were followed from the index date until they were first diagnosed with any psychiatric disorder or were prescribed a drug used for the treatment of a psychiatric disorder. Any plan participant with a preenrollment psychiatric diagnosis or prescription was excluded.

Controls were matched to patients based on age, sex, and index date.

The findings of an increased risk of developing psychiatric disorders in case patients remained significant after controlling for age, sex, health plan, region of residence, and comorbidities, Dr. Bao noted.

The study is limited by the potential for coding and reporting errors in the data used and by lack of information on the severity of the psychiatric disorders. However, the findings do suggest that the psychiatric impact of psoriasis on children must be addressed because of the potential for both short- and long-term adverse effects.

“If we put these data in perspective, the development of psychiatric disorders at a young age can have a great impact in future adult life,” she said.

Attention-deficit hyperactivity disorder is a neurodevelopmental disorder, rather than a purely social construct, according to British researchers who have found that a type of genetic variation associated with brain disorders such as schizophrenia and autism also occurs in excess in ADHD patients.

The findings, published online in the Sept. 30 issue of The Lancet, provide the first direct evidence of a genetic basis for ADHD, Dr. Nigel Williams of Cardiff University, Wales, and his colleagues reported.

The investigators performed a genome-wide analysis of large, rare chromosomal deletions and duplications known as copy number variants (CNVs) in 366 children with ADHD and 1,047controls. The genome-wide burden of CNVs was significantly greater in the ADHD patients, compared with that in the controls – rates of 0.156 and 0.075, respectively, they found (Lancet 2010 Sept. 30 [doi:10.1016/S0140-6736(10)61109-9]).

The CNVs identified in this study are similar to those found in patients with schizophrenia and autism, and are significantly enriched for loci that have previously been implicated in those disorders – with particular overlap at a region on chromosome 16 that spans a number of genes, including one that affects brain development.

Furthermore, although the rate of CNVs was significantly higher in children with ADHD with and without intellectual disability, compared with the general population, the rate was particularly high in those with intellectual disability, defined as those with an IQ of less than 70 (rates of 0.424 and 0.075, respectively).

The findings are noteworthy because despite evidence that ADHD might be a genetic condition – for example, it has an estimated heritability of 76% – there has been a great deal of debate over whether it is a result of bad parenting or other external factors, coauthor Dr. Anita Thapar said during a press conference on the findings.

“ADHD can be stigmatizing ... and finding this direct genetic link to ADHD should help clear this misunderstanding and address this issue of stigma,” said Dr. Thapar, professor of child and adolescent psychiatry at Cardiff University.

In addition to providing a window into the biology of the brain, the findings will also influence the way in which ADHD is classified and will improve communication between scientists and clinicians about “what we mean by ADHD,” she said.

“This will be the start of a much more scientific venture because our findings are going to help us unravel the biologic basis of ADHD, and that’s going to be really important in turn in the further future to help us develop new and much more effective treatments for affected individuals.”

The subjects were recruited from community clinics and had met diagnostic criteria for ADHD or hyperkinetic disorder. They were aged 5-17 years (mean, 10.5 years), were of white U.K. origin, and had a mean IQ of 86. Controls were unrelated, ethnically matched children from the 1958 British Birth Cohort.

The findings have important clinical and research implications. “First, our results emphasize that further investigation of CNVs in ADHD is a priority for research into this disorder,” the investigators wrote.

Also, the finding that more than a third of ADHD children with intellectual disability carried a large, rare CNV – and the fact that none of these children had been assessed for this type of mutation by clinical services – suggest that routine referral to clinical geneticists and screening for such mutations could be helpful for children with ADHD who also have intellectual disability, they said.

In an accompanying commentary, Dr. J. Peter H. Burbach said the findings of this study provide “a new chapter to the genetics of neurodevelopmental disorders.”

Not only do they give insight into the neurological basis of ADHD, they also show that ADHD shares specific genes with autism, schizophrenia, and mental retardation. In particular, they highlight the importance of the chromosome 16p13.11 region previously implicated in these and other brain disorders, he said (Lancet 2010 Sept. 30 [doi: 10.1016/S0140-6736(10)61192-0)].

However, although the findings are exciting, it remains unclear how they will be clinically translated, said Dr. Burbach, of the department of neuroscience and pharmacology, Rudolf Magnus Institute of Neuroscience, University Medical Center Utrecht, the Netherlands. He noted that to help clinicians better understand and interpret the diversity of neuropsychiatric phenotypes in light of these findings about overlapping genotypes, future studies should explore in more detail how the genotypes and phenotypes are linked.

“The first gains beyond today’s study might be initial insight into the pathogenesis and neurobiology of brain development as influenced by these genetic variants,” he wrote. “This knowledge will eventually enter the clinic and might affect the way people think about and treat neurodevelopmental disorders by accounting for the biological consequence of the specific patient’s genotype.”

Disclosures: The study was funded primarily by Wellcome Trust. Additional funding was provided by Action Research, Baily Thomas Charitable Trust, U.K. Medical Research Council, and the European Union. The authors stated that they had no conflicts to report. Dr. Burbach reported having no conflicts of interest.

Attention-deficit hyperactivity disorder is a neurodevelopmental disorder, rather than a purely social construct, according to British researchers who have found that a type of genetic variation associated with brain disorders such as schizophrenia and autism also occurs in excess in ADHD patients.

The findings, published online in the Sept. 30 issue of The Lancet, provide the first direct evidence of a genetic basis for ADHD, Dr. Nigel Williams of Cardiff University, Wales, and his colleagues reported.

The investigators performed a genome-wide analysis of large, rare chromosomal deletions and duplications known as copy number variants (CNVs) in 366 children with ADHD and 1,047controls. The genome-wide burden of CNVs was significantly greater in the ADHD patients, compared with that in the controls – rates of 0.156 and 0.075, respectively, they found (Lancet 2010 Sept. 30 [doi:10.1016/S0140-6736(10)61109-9]).

The CNVs identified in this study are similar to those found in patients with schizophrenia and autism, and are significantly enriched for loci that have previously been implicated in those disorders – with particular overlap at a region on chromosome 16 that spans a number of genes, including one that affects brain development.

Furthermore, although the rate of CNVs was significantly higher in children with ADHD with and without intellectual disability, compared with the general population, the rate was particularly high in those with intellectual disability, defined as those with an IQ of less than 70 (rates of 0.424 and 0.075, respectively).

The findings are noteworthy because despite evidence that ADHD might be a genetic condition – for example, it has an estimated heritability of 76% – there has been a great deal of debate over whether it is a result of bad parenting or other external factors, coauthor Dr. Anita Thapar said during a press conference on the findings.

“ADHD can be stigmatizing ... and finding this direct genetic link to ADHD should help clear this misunderstanding and address this issue of stigma,” said Dr. Thapar, professor of child and adolescent psychiatry at Cardiff University.

In addition to providing a window into the biology of the brain, the findings will also influence the way in which ADHD is classified and will improve communication between scientists and clinicians about “what we mean by ADHD,” she said.

“This will be the start of a much more scientific venture because our findings are going to help us unravel the biologic basis of ADHD, and that’s going to be really important in turn in the further future to help us develop new and much more effective treatments for affected individuals.”

The subjects were recruited from community clinics and had met diagnostic criteria for ADHD or hyperkinetic disorder. They were aged 5-17 years (mean, 10.5 years), were of white U.K. origin, and had a mean IQ of 86. Controls were unrelated, ethnically matched children from the 1958 British Birth Cohort.

The findings have important clinical and research implications. “First, our results emphasize that further investigation of CNVs in ADHD is a priority for research into this disorder,” the investigators wrote.

Also, the finding that more than a third of ADHD children with intellectual disability carried a large, rare CNV – and the fact that none of these children had been assessed for this type of mutation by clinical services – suggest that routine referral to clinical geneticists and screening for such mutations could be helpful for children with ADHD who also have intellectual disability, they said.

In an accompanying commentary, Dr. J. Peter H. Burbach said the findings of this study provide “a new chapter to the genetics of neurodevelopmental disorders.”

Not only do they give insight into the neurological basis of ADHD, they also show that ADHD shares specific genes with autism, schizophrenia, and mental retardation. In particular, they highlight the importance of the chromosome 16p13.11 region previously implicated in these and other brain disorders, he said (Lancet 2010 Sept. 30 [doi: 10.1016/S0140-6736(10)61192-0)].

However, although the findings are exciting, it remains unclear how they will be clinically translated, said Dr. Burbach, of the department of neuroscience and pharmacology, Rudolf Magnus Institute of Neuroscience, University Medical Center Utrecht, the Netherlands. He noted that to help clinicians better understand and interpret the diversity of neuropsychiatric phenotypes in light of these findings about overlapping genotypes, future studies should explore in more detail how the genotypes and phenotypes are linked.

“The first gains beyond today’s study might be initial insight into the pathogenesis and neurobiology of brain development as influenced by these genetic variants,” he wrote. “This knowledge will eventually enter the clinic and might affect the way people think about and treat neurodevelopmental disorders by accounting for the biological consequence of the specific patient’s genotype.”

Disclosures: The study was funded primarily by Wellcome Trust. Additional funding was provided by Action Research, Baily Thomas Charitable Trust, U.K. Medical Research Council, and the European Union. The authors stated that they had no conflicts to report. Dr. Burbach reported having no conflicts of interest.

Attention-deficit hyperactivity disorder is a neurodevelopmental disorder, rather than a purely social construct, according to British researchers who have found that a type of genetic variation associated with brain disorders such as schizophrenia and autism also occurs in excess in ADHD patients.

The findings, published online in the Sept. 30 issue of The Lancet, provide the first direct evidence of a genetic basis for ADHD, Dr. Nigel Williams of Cardiff University, Wales, and his colleagues reported.

The investigators performed a genome-wide analysis of large, rare chromosomal deletions and duplications known as copy number variants (CNVs) in 366 children with ADHD and 1,047controls. The genome-wide burden of CNVs was significantly greater in the ADHD patients, compared with that in the controls – rates of 0.156 and 0.075, respectively, they found (Lancet 2010 Sept. 30 [doi:10.1016/S0140-6736(10)61109-9]).

The CNVs identified in this study are similar to those found in patients with schizophrenia and autism, and are significantly enriched for loci that have previously been implicated in those disorders – with particular overlap at a region on chromosome 16 that spans a number of genes, including one that affects brain development.

Furthermore, although the rate of CNVs was significantly higher in children with ADHD with and without intellectual disability, compared with the general population, the rate was particularly high in those with intellectual disability, defined as those with an IQ of less than 70 (rates of 0.424 and 0.075, respectively).

The findings are noteworthy because despite evidence that ADHD might be a genetic condition – for example, it has an estimated heritability of 76% – there has been a great deal of debate over whether it is a result of bad parenting or other external factors, coauthor Dr. Anita Thapar said during a press conference on the findings.

“ADHD can be stigmatizing ... and finding this direct genetic link to ADHD should help clear this misunderstanding and address this issue of stigma,” said Dr. Thapar, professor of child and adolescent psychiatry at Cardiff University.

In addition to providing a window into the biology of the brain, the findings will also influence the way in which ADHD is classified and will improve communication between scientists and clinicians about “what we mean by ADHD,” she said.

“This will be the start of a much more scientific venture because our findings are going to help us unravel the biologic basis of ADHD, and that’s going to be really important in turn in the further future to help us develop new and much more effective treatments for affected individuals.”

The subjects were recruited from community clinics and had met diagnostic criteria for ADHD or hyperkinetic disorder. They were aged 5-17 years (mean, 10.5 years), were of white U.K. origin, and had a mean IQ of 86. Controls were unrelated, ethnically matched children from the 1958 British Birth Cohort.

The findings have important clinical and research implications. “First, our results emphasize that further investigation of CNVs in ADHD is a priority for research into this disorder,” the investigators wrote.

Also, the finding that more than a third of ADHD children with intellectual disability carried a large, rare CNV – and the fact that none of these children had been assessed for this type of mutation by clinical services – suggest that routine referral to clinical geneticists and screening for such mutations could be helpful for children with ADHD who also have intellectual disability, they said.

In an accompanying commentary, Dr. J. Peter H. Burbach said the findings of this study provide “a new chapter to the genetics of neurodevelopmental disorders.”

Not only do they give insight into the neurological basis of ADHD, they also show that ADHD shares specific genes with autism, schizophrenia, and mental retardation. In particular, they highlight the importance of the chromosome 16p13.11 region previously implicated in these and other brain disorders, he said (Lancet 2010 Sept. 30 [doi: 10.1016/S0140-6736(10)61192-0)].

However, although the findings are exciting, it remains unclear how they will be clinically translated, said Dr. Burbach, of the department of neuroscience and pharmacology, Rudolf Magnus Institute of Neuroscience, University Medical Center Utrecht, the Netherlands. He noted that to help clinicians better understand and interpret the diversity of neuropsychiatric phenotypes in light of these findings about overlapping genotypes, future studies should explore in more detail how the genotypes and phenotypes are linked.

“The first gains beyond today’s study might be initial insight into the pathogenesis and neurobiology of brain development as influenced by these genetic variants,” he wrote. “This knowledge will eventually enter the clinic and might affect the way people think about and treat neurodevelopmental disorders by accounting for the biological consequence of the specific patient’s genotype.”

Disclosures: The study was funded primarily by Wellcome Trust. Additional funding was provided by Action Research, Baily Thomas Charitable Trust, U.K. Medical Research Council, and the European Union. The authors stated that they had no conflicts to report. Dr. Burbach reported having no conflicts of interest.

Rheumatic disease patients who are exposed to tumor necrosis factor antagonists have a 10-fold increased risk of hospitalization for varicella zoster virus infections, compared with the general population, according to a secondary analysis of two large databases.

Nonetheless, the absolute incidence of varicella-related hospitalizations remains low at about three cases per 10,000 person-years of exposure, and the risks of using vaccination for prevention likely outweigh the benefits, Dr. Ignacio Garcia-Doval of Complexo Hospitalario de Pontevedra (Spain) and colleagues have reported in the October issue of the Annals of the Rheumatic Diseases.

The estimated incidence rate of hospitalization for shingles in the rheumatic population was 32 cases per 100,000 patient years, compared with an expected rate of 3.4 in the general population, and the estimated incidence of hospitalization for chickenpox in the rheumatic patients was 26 per 100,000, compared with 1.9 in the general population. This finding is based on analysis of data from a national registry of rheumatic disease patients who were treated with TNF agents (BIOBADASER database) and from an administrative database of all hospital admissions in public centers in Spain (Conjunto Mínimo Básico de Datos al Alta Hospitalaria, or CMBD), which together represent more than 114 million patient-years.

The estimated age- and sex-standardized incidence rate per 100,000 person-years, and the estimated standardized incidence difference were 9 and 26, respectively, for shingles, and 19 and 33, respectively, for chickenpox, they said (Ann. Rheum. Dis. 2010;69:1751-5).

TNF antagonists are known to be associated with an increased risk of tuberculosis in particular and of opportunistic infections in general. There is a biological basis for an increased risk of viral infections, the investigators said, noting that although some studies have shown an increased rate of viral infection in TNF antagonist–treated patients, the clinical relevance of the increase is uncertain.

The current study does not allow differentiation of the causes for the increased risk, but it does show that the absolute rate is low.

The investigators said it is unlikely that the cohorts received systematic vaccination against varicella zoster virus, since the general health mandate in Spain was given in 2005 and only for children aged 11-14 years.

"Standard guidelines for chickenpox vaccination probably apply to the population included in our study," they wrote.

However, shingles vaccine, which is an attenuated vaccine with a higher dose of antigen, could potentially lead to more side effects in an immunosuppressed population, they said.

For example, in a randomized trial of adults older than age 60 years, shingles vaccine was associated with 7 cases of severe adverse events and 14 cases of vaccine-related adverse events per 10,000 vaccinations, they noted.

"These vaccination-associated risks are similar in rate and severity to the risks of hospitalized infections in our study. Hence, shingles vaccination before starting a TNF antagonist may not be warranted at present," they wrote, concluding that although vaccination in healthy children is warranted, it is not warranted in adults with "immunosuppression secondary to the baseline inflammatory disease and its complications."

Disclosures: Various study authors reported serving on the advisory board for, and/or receiving lecture fees or honoraria from, Wyeth, Abbott, Schering-Plough, Roche, and/or Bristol-Myers Squibb.

Rheumatic disease patients who are exposed to tumor necrosis factor antagonists have a 10-fold increased risk of hospitalization for varicella zoster virus infections, compared with the general population, according to a secondary analysis of two large databases.

Nonetheless, the absolute incidence of varicella-related hospitalizations remains low at about three cases per 10,000 person-years of exposure, and the risks of using vaccination for prevention likely outweigh the benefits, Dr. Ignacio Garcia-Doval of Complexo Hospitalario de Pontevedra (Spain) and colleagues have reported in the October issue of the Annals of the Rheumatic Diseases.

The estimated incidence rate of hospitalization for shingles in the rheumatic population was 32 cases per 100,000 patient years, compared with an expected rate of 3.4 in the general population, and the estimated incidence of hospitalization for chickenpox in the rheumatic patients was 26 per 100,000, compared with 1.9 in the general population. This finding is based on analysis of data from a national registry of rheumatic disease patients who were treated with TNF agents (BIOBADASER database) and from an administrative database of all hospital admissions in public centers in Spain (Conjunto Mínimo Básico de Datos al Alta Hospitalaria, or CMBD), which together represent more than 114 million patient-years.

The estimated age- and sex-standardized incidence rate per 100,000 person-years, and the estimated standardized incidence difference were 9 and 26, respectively, for shingles, and 19 and 33, respectively, for chickenpox, they said (Ann. Rheum. Dis. 2010;69:1751-5).

TNF antagonists are known to be associated with an increased risk of tuberculosis in particular and of opportunistic infections in general. There is a biological basis for an increased risk of viral infections, the investigators said, noting that although some studies have shown an increased rate of viral infection in TNF antagonist–treated patients, the clinical relevance of the increase is uncertain.

The current study does not allow differentiation of the causes for the increased risk, but it does show that the absolute rate is low.

The investigators said it is unlikely that the cohorts received systematic vaccination against varicella zoster virus, since the general health mandate in Spain was given in 2005 and only for children aged 11-14 years.

"Standard guidelines for chickenpox vaccination probably apply to the population included in our study," they wrote.

However, shingles vaccine, which is an attenuated vaccine with a higher dose of antigen, could potentially lead to more side effects in an immunosuppressed population, they said.

For example, in a randomized trial of adults older than age 60 years, shingles vaccine was associated with 7 cases of severe adverse events and 14 cases of vaccine-related adverse events per 10,000 vaccinations, they noted.

"These vaccination-associated risks are similar in rate and severity to the risks of hospitalized infections in our study. Hence, shingles vaccination before starting a TNF antagonist may not be warranted at present," they wrote, concluding that although vaccination in healthy children is warranted, it is not warranted in adults with "immunosuppression secondary to the baseline inflammatory disease and its complications."

Disclosures: Various study authors reported serving on the advisory board for, and/or receiving lecture fees or honoraria from, Wyeth, Abbott, Schering-Plough, Roche, and/or Bristol-Myers Squibb.

Rheumatic disease patients who are exposed to tumor necrosis factor antagonists have a 10-fold increased risk of hospitalization for varicella zoster virus infections, compared with the general population, according to a secondary analysis of two large databases.

Nonetheless, the absolute incidence of varicella-related hospitalizations remains low at about three cases per 10,000 person-years of exposure, and the risks of using vaccination for prevention likely outweigh the benefits, Dr. Ignacio Garcia-Doval of Complexo Hospitalario de Pontevedra (Spain) and colleagues have reported in the October issue of the Annals of the Rheumatic Diseases.

The estimated incidence rate of hospitalization for shingles in the rheumatic population was 32 cases per 100,000 patient years, compared with an expected rate of 3.4 in the general population, and the estimated incidence of hospitalization for chickenpox in the rheumatic patients was 26 per 100,000, compared with 1.9 in the general population. This finding is based on analysis of data from a national registry of rheumatic disease patients who were treated with TNF agents (BIOBADASER database) and from an administrative database of all hospital admissions in public centers in Spain (Conjunto Mínimo Básico de Datos al Alta Hospitalaria, or CMBD), which together represent more than 114 million patient-years.

The estimated age- and sex-standardized incidence rate per 100,000 person-years, and the estimated standardized incidence difference were 9 and 26, respectively, for shingles, and 19 and 33, respectively, for chickenpox, they said (Ann. Rheum. Dis. 2010;69:1751-5).

TNF antagonists are known to be associated with an increased risk of tuberculosis in particular and of opportunistic infections in general. There is a biological basis for an increased risk of viral infections, the investigators said, noting that although some studies have shown an increased rate of viral infection in TNF antagonist–treated patients, the clinical relevance of the increase is uncertain.

The current study does not allow differentiation of the causes for the increased risk, but it does show that the absolute rate is low.

The investigators said it is unlikely that the cohorts received systematic vaccination against varicella zoster virus, since the general health mandate in Spain was given in 2005 and only for children aged 11-14 years.

"Standard guidelines for chickenpox vaccination probably apply to the population included in our study," they wrote.

However, shingles vaccine, which is an attenuated vaccine with a higher dose of antigen, could potentially lead to more side effects in an immunosuppressed population, they said.

For example, in a randomized trial of adults older than age 60 years, shingles vaccine was associated with 7 cases of severe adverse events and 14 cases of vaccine-related adverse events per 10,000 vaccinations, they noted.

"These vaccination-associated risks are similar in rate and severity to the risks of hospitalized infections in our study. Hence, shingles vaccination before starting a TNF antagonist may not be warranted at present," they wrote, concluding that although vaccination in healthy children is warranted, it is not warranted in adults with "immunosuppression secondary to the baseline inflammatory disease and its complications."

Disclosures: Various study authors reported serving on the advisory board for, and/or receiving lecture fees or honoraria from, Wyeth, Abbott, Schering-Plough, Roche, and/or Bristol-Myers Squibb.

Rheumatic disease patients who are exposed to tumor necrosis factor antagonists have a 10-fold increased risk of hospitalization for varicella zoster virus infections, compared with the general population, according to a secondary analysis of two large databases.

Nonetheless, the absolute incidence of varicella-related hospitalizations remains low at about three cases per 10,000 person-years of exposure, and the risks of using vaccination for prevention likely outweigh the benefits, Dr. Ignacio García-Doval of Complexo Hospitalario de Pontevedra (Spain) and colleagues have reported in the October issue of the Annals of the Rheumatic Diseases.

The estimated incidence rate of hospitalization for shingles in the rheumatic population was 32 cases per 100,000 patient years, compared with an expected rate of 3.4 in the general population, and the estimated incidence of hospitalization for chickenpox in the rheumatic patients was 26 per 100,000, compared with 1.9 in the general population. This finding is based on analysis of data from a national registry of rheumatic disease patients who were treated with TNF agents (BIOBADASER database) and from an administrative database of all hospital admissions in public centers in Spain (Conjunto Mínimo Básico de Datos al Alta Hospitalaria, or CMBD), which together represent more than 114 million patient-years.

The estimated age- and sex-standardized incidence rate per 100,000 person-years, and the estimated standardized incidence difference were 9 and 26, respectively, for shingles, and 19 and 33, respectively, for chickenpox, they said (Ann. Rheum. Dis. 2010;69:1751-5).

TNF antagonists are known to be associated with an increased risk of tuberculosis in particular and of opportunistic infections in general. There is a biological basis for an increased risk of viral infections, the investigators said, noting that although some studies have shown an increased rate of viral infection in TNF antagonist–treated patients, the clinical relevance of the increase is uncertain.

The current study does not allow differentiation of the causes for the increased risk, but it does show that the absolute rate is low.

The investigators said it is unlikely that the cohorts received systematic vaccination against varicella zoster virus, since the general health mandate in Spain was given in 2005 and only for children aged 11-14 years.

“Standard guidelines for chickenpox vaccination probably apply to the population included in our study,” they wrote.

However, shingles vaccine, which is an attenuated vaccine with a higher dose of antigen, could potentially lead to more side effects in an immunosuppressed population, they said.

For example, in a randomized trial of adults older than age 60 years, shingles vaccine was associated with 7 cases of severe adverse events and 14 cases of vaccine-related adverse events per 10,000 vaccinations, they noted.

“These vaccination-associated risks are similar in rate and severity to the risks of hospitalized infections in our study. Hence, shingles vaccination before starting a TNF antagonist may not be warranted at present,” they wrote, concluding that although vaccination in healthy children is warranted, it is not warranted in adults with “immunosuppression secondary to the baseline inflammatory disease and its complications.”

The rationale for zoster vaccination goes beyond the goal of simply preventing hospitalized herpes zoster, noted Dr. Kevin L. Winthrop of the department of infectious diseases at the Oregon Health and Science University, Portland, and Dr. Daniel E. Furst, the Carl M. Pearson Professor of Rheumatology at the University of California, Los Angeles, in an editorial accompanying the study report (Ann. Rheum. Dis. 2010;69:1735-7). Vaccination in rheumatoid arthritis patients who are 60 years of age or older should be the standard of care before initiation of anti-TNF or other long-term immunosuppressive therapy, they wrote.

Prospective data on the efficacy of herpes zoster vaccination, particularly in patients with rheumatoid arthritis, are lacking, they said. But there is strong evidence for the protective effects and importance of vaccination in adults aged 60 years and older. Given that patients with rheumatoid arthritis are at increased risk for herpes zoster and that vaccination with live viruses is contraindicated while biological therapies are used, it would make sense to target this group for vaccination before anti-TNF therapy is initiated.

Dr. Winthrop and Dr. Furst said that the purpose of vaccination is not only to lower the risk of rare, serious manifestations of herpes zoster, but also to lower the risk of uncomplicated herpes zoster, which causes considerable morbidity. Future studies should look at the potential benefits of vaccinating those younger than age 60 and those receiving other types of immunosuppressive

Rheumatic disease patients who are exposed to tumor necrosis factor antagonists have a 10-fold increased risk of hospitalization for varicella zoster virus infections, compared with the general population, according to a secondary analysis of two large databases.

Nonetheless, the absolute incidence of varicella-related hospitalizations remains low at about three cases per 10,000 person-years of exposure, and the risks of using vaccination for prevention likely outweigh the benefits, Dr. Ignacio García-Doval of Complexo Hospitalario de Pontevedra (Spain) and colleagues have reported in the October issue of the Annals of the Rheumatic Diseases.

The estimated incidence rate of hospitalization for shingles in the rheumatic population was 32 cases per 100,000 patient years, compared with an expected rate of 3.4 in the general population, and the estimated incidence of hospitalization for chickenpox in the rheumatic patients was 26 per 100,000, compared with 1.9 in the general population. This finding is based on analysis of data from a national registry of rheumatic disease patients who were treated with TNF agents (BIOBADASER database) and from an administrative database of all hospital admissions in public centers in Spain (Conjunto Mínimo Básico de Datos al Alta Hospitalaria, or CMBD), which together represent more than 114 million patient-years.

The estimated age- and sex-standardized incidence rate per 100,000 person-years, and the estimated standardized incidence difference were 9 and 26, respectively, for shingles, and 19 and 33, respectively, for chickenpox, they said (Ann. Rheum. Dis. 2010;69:1751-5).

TNF antagonists are known to be associated with an increased risk of tuberculosis in particular and of opportunistic infections in general. There is a biological basis for an increased risk of viral infections, the investigators said, noting that although some studies have shown an increased rate of viral infection in TNF antagonist–treated patients, the clinical relevance of the increase is uncertain.

The current study does not allow differentiation of the causes for the increased risk, but it does show that the absolute rate is low.

The investigators said it is unlikely that the cohorts received systematic vaccination against varicella zoster virus, since the general health mandate in Spain was given in 2005 and only for children aged 11-14 years.

“Standard guidelines for chickenpox vaccination probably apply to the population included in our study,” they wrote.

However, shingles vaccine, which is an attenuated vaccine with a higher dose of antigen, could potentially lead to more side effects in an immunosuppressed population, they said.

For example, in a randomized trial of adults older than age 60 years, shingles vaccine was associated with 7 cases of severe adverse events and 14 cases of vaccine-related adverse events per 10,000 vaccinations, they noted.

“These vaccination-associated risks are similar in rate and severity to the risks of hospitalized infections in our study. Hence, shingles vaccination before starting a TNF antagonist may not be warranted at present,” they wrote, concluding that although vaccination in healthy children is warranted, it is not warranted in adults with “immunosuppression secondary to the baseline inflammatory disease and its complications.”

The rationale for zoster vaccination goes beyond the goal of simply preventing hospitalized herpes zoster, noted Dr. Kevin L. Winthrop of the department of infectious diseases at the Oregon Health and Science University, Portland, and Dr. Daniel E. Furst, the Carl M. Pearson Professor of Rheumatology at the University of California, Los Angeles, in an editorial accompanying the study report (Ann. Rheum. Dis. 2010;69:1735-7). Vaccination in rheumatoid arthritis patients who are 60 years of age or older should be the standard of care before initiation of anti-TNF or other long-term immunosuppressive therapy, they wrote.

Prospective data on the efficacy of herpes zoster vaccination, particularly in patients with rheumatoid arthritis, are lacking, they said. But there is strong evidence for the protective effects and importance of vaccination in adults aged 60 years and older. Given that patients with rheumatoid arthritis are at increased risk for herpes zoster and that vaccination with live viruses is contraindicated while biological therapies are used, it would make sense to target this group for vaccination before anti-TNF therapy is initiated.

Dr. Winthrop and Dr. Furst said that the purpose of vaccination is not only to lower the risk of rare, serious manifestations of herpes zoster, but also to lower the risk of uncomplicated herpes zoster, which causes considerable morbidity. Future studies should look at the potential benefits of vaccinating those younger than age 60 and those receiving other types of immunosuppressive

Rheumatic disease patients who are exposed to tumor necrosis factor antagonists have a 10-fold increased risk of hospitalization for varicella zoster virus infections, compared with the general population, according to a secondary analysis of two large databases.

Nonetheless, the absolute incidence of varicella-related hospitalizations remains low at about three cases per 10,000 person-years of exposure, and the risks of using vaccination for prevention likely outweigh the benefits, Dr. Ignacio García-Doval of Complexo Hospitalario de Pontevedra (Spain) and colleagues have reported in the October issue of the Annals of the Rheumatic Diseases.

The estimated incidence rate of hospitalization for shingles in the rheumatic population was 32 cases per 100,000 patient years, compared with an expected rate of 3.4 in the general population, and the estimated incidence of hospitalization for chickenpox in the rheumatic patients was 26 per 100,000, compared with 1.9 in the general population. This finding is based on analysis of data from a national registry of rheumatic disease patients who were treated with TNF agents (BIOBADASER database) and from an administrative database of all hospital admissions in public centers in Spain (Conjunto Mínimo Básico de Datos al Alta Hospitalaria, or CMBD), which together represent more than 114 million patient-years.

The estimated age- and sex-standardized incidence rate per 100,000 person-years, and the estimated standardized incidence difference were 9 and 26, respectively, for shingles, and 19 and 33, respectively, for chickenpox, they said (Ann. Rheum. Dis. 2010;69:1751-5).

TNF antagonists are known to be associated with an increased risk of tuberculosis in particular and of opportunistic infections in general. There is a biological basis for an increased risk of viral infections, the investigators said, noting that although some studies have shown an increased rate of viral infection in TNF antagonist–treated patients, the clinical relevance of the increase is uncertain.

The current study does not allow differentiation of the causes for the increased risk, but it does show that the absolute rate is low.

The investigators said it is unlikely that the cohorts received systematic vaccination against varicella zoster virus, since the general health mandate in Spain was given in 2005 and only for children aged 11-14 years.

“Standard guidelines for chickenpox vaccination probably apply to the population included in our study,” they wrote.

However, shingles vaccine, which is an attenuated vaccine with a higher dose of antigen, could potentially lead to more side effects in an immunosuppressed population, they said.

For example, in a randomized trial of adults older than age 60 years, shingles vaccine was associated with 7 cases of severe adverse events and 14 cases of vaccine-related adverse events per 10,000 vaccinations, they noted.

“These vaccination-associated risks are similar in rate and severity to the risks of hospitalized infections in our study. Hence, shingles vaccination before starting a TNF antagonist may not be warranted at present,” they wrote, concluding that although vaccination in healthy children is warranted, it is not warranted in adults with “immunosuppression secondary to the baseline inflammatory disease and its complications.”

The rationale for zoster vaccination goes beyond the goal of simply preventing hospitalized herpes zoster, noted Dr. Kevin L. Winthrop of the department of infectious diseases at the Oregon Health and Science University, Portland, and Dr. Daniel E. Furst, the Carl M. Pearson Professor of Rheumatology at the University of California, Los Angeles, in an editorial accompanying the study report (Ann. Rheum. Dis. 2010;69:1735-7). Vaccination in rheumatoid arthritis patients who are 60 years of age or older should be the standard of care before initiation of anti-TNF or other long-term immunosuppressive therapy, they wrote.

Prospective data on the efficacy of herpes zoster vaccination, particularly in patients with rheumatoid arthritis, are lacking, they said. But there is strong evidence for the protective effects and importance of vaccination in adults aged 60 years and older. Given that patients with rheumatoid arthritis are at increased risk for herpes zoster and that vaccination with live viruses is contraindicated while biological therapies are used, it would make sense to target this group for vaccination before anti-TNF therapy is initiated.

Dr. Winthrop and Dr. Furst said that the purpose of vaccination is not only to lower the risk of rare, serious manifestations of herpes zoster, but also to lower the risk of uncomplicated herpes zoster, which causes considerable morbidity. Future studies should look at the potential benefits of vaccinating those younger than age 60 and those receiving other types of immunosuppressive

Rheumatic disease patients who are exposed to tumor necrosis factor antagonists have a 10-fold increased risk of hospitalization for varicella zoster virus infections, compared with the general population, according to a secondary analysis of two large databases.

Nonetheless, the absolute incidence of varicella-related hospitalizations remains low at about three cases per 10,000 person-years of exposure, and the risks of using vaccination for prevention likely outweigh the benefits, Dr. Ignacio García-Doval of Complexo Hospitalario de Pontevedra (Spain) and colleagues have reported in the October issue of the Annals of the Rheumatic Diseases.

The estimated incidence rate of hospitalization for shingles in the rheumatic population was 32 cases per 100,000 patient years, compared with an expected rate of 3.4 in the general population, and the estimated incidence of hospitalization for chickenpox in the rheumatic patients was 26 per 100,000, compared with 1.9 in the general population. This finding is based on analysis of data from a national registry of rheumatic disease patients who were treated with TNF agents (BIOBADASER database) and from an administrative database of all hospital admissions in public centers in Spain (Conjunto Mínimo Básico de Datos al Alta Hospitalaria, or CMBD), which together represent more than 114 million patient-years.

The estimated age- and sex-standardized incidence rate per 100,000 person-years, and the estimated standardized incidence difference were 9 and 26, respectively, for shingles, and 19 and 33, respectively, for chickenpox, they said (Ann. Rheum. Dis. 2010;69:1751-5).

TNF antagonists are known to be associated with an increased risk of tuberculosis in particular and of opportunistic infections in general. There is a biological basis for an increased risk of viral infections, the investigators said, noting that although some studies have shown an increased rate of viral infection in TNF antagonist–treated patients, the clinical relevance of the increase is uncertain.

The current study does not allow differentiation of the causes for the increased risk, but it does show that the absolute rate is low.

The investigators said it is unlikely that the cohorts received systematic vaccination against varicella zoster virus, since the general health mandate in Spain was given in 2005 and only for children aged 11-14 years.

“Standard guidelines for chickenpox vaccination probably apply to the population included in our study,” they wrote.

However, shingles vaccine, which is an attenuated vaccine with a higher dose of antigen, could potentially lead to more side effects in an immunosuppressed population, they said.

For example, in a randomized trial of adults older than age 60 years, shingles vaccine was associated with 7 cases of severe adverse events and 14 cases of vaccine-related adverse events per 10,000 vaccinations, they noted.

“These vaccination-associated risks are similar in rate and severity to the risks of hospitalized infections in our study. Hence, shingles vaccination before starting a TNF antagonist may not be warranted at present,” they wrote, concluding that although vaccination in healthy children is warranted, it is not warranted in adults with “immunosuppression secondary to the baseline inflammatory disease and its complications.”

The rationale for zoster vaccination goes beyond the goal of simply preventing hospitalized herpes zoster, noted Dr. Kevin L. Winthrop of the department of infectious diseases at the Oregon Health and Science University, Portland, and Dr. Daniel E. Furst, the Carl M. Pearson Professor of Rheumatology at the University of California, Los Angeles, in an editorial accompanying the study report (Ann. Rheum. Dis. 2010;69:1735-7). Vaccination in rheumatoid arthritis patients who are 60 years of age or older should be the standard of care before initiation of anti-TNF or other long-term immunosuppressive therapy, they wrote.

Prospective data on the efficacy of herpes zoster vaccination, particularly in patients with rheumatoid arthritis, are lacking, they said. But there is strong evidence for the protective effects and importance of vaccination in adults aged 60 years and older. Given that patients with rheumatoid arthritis are at increased risk for herpes zoster and that vaccination with live viruses is contraindicated while biological therapies are used, it would make sense to target this group for vaccination before anti-TNF therapy is initiated.

Dr. Winthrop and Dr. Furst said that the purpose of vaccination is not only to lower the risk of rare, serious manifestations of herpes zoster, but also to lower the risk of uncomplicated herpes zoster, which causes considerable morbidity. Future studies should look at the potential benefits of vaccinating those younger than age 60 and those receiving other types of immunosuppressive therapy, they noted.

Rheumatic disease patients who are exposed to tumor necrosis factor antagonists have a 10-fold increased risk of hospitalization for varicella zoster virus infections, compared with the general population, according to a secondary analysis of two large databases.

Nonetheless, the absolute incidence of varicella-related hospitalizations remains low at about three cases per 10,000 person-years of exposure, and the risks of using vaccination for prevention likely outweigh the benefits, Dr. Ignacio García-Doval of Complexo Hospitalario de Pontevedra (Spain) and colleagues have reported in the October issue of the Annals of the Rheumatic Diseases.

The estimated incidence rate of hospitalization for shingles in the rheumatic population was 32 cases per 100,000 patient years, compared with an expected rate of 3.4 in the general population, and the estimated incidence of hospitalization for chickenpox in the rheumatic patients was 26 per 100,000, compared with 1.9 in the general population. This finding is based on analysis of data from a national registry of rheumatic disease patients who were treated with TNF agents (BIOBADASER database) and from an administrative database of all hospital admissions in public centers in Spain (Conjunto Mínimo Básico de Datos al Alta Hospitalaria, or CMBD), which together represent more than 114 million patient-years.

The estimated age- and sex-standardized incidence rate per 100,000 person-years, and the estimated standardized incidence difference were 9 and 26, respectively, for shingles, and 19 and 33, respectively, for chickenpox, they said (Ann. Rheum. Dis. 2010;69:1751-5).

TNF antagonists are known to be associated with an increased risk of tuberculosis in particular and of opportunistic infections in general. There is a biological basis for an increased risk of viral infections, the investigators said, noting that although some studies have shown an increased rate of viral infection in TNF antagonist–treated patients, the clinical relevance of the increase is uncertain.

The current study does not allow differentiation of the causes for the increased risk, but it does show that the absolute rate is low.

The investigators said it is unlikely that the cohorts received systematic vaccination against varicella zoster virus, since the general health mandate in Spain was given in 2005 and only for children aged 11-14 years.

“Standard guidelines for chickenpox vaccination probably apply to the population included in our study,” they wrote.

However, shingles vaccine, which is an attenuated vaccine with a higher dose of antigen, could potentially lead to more side effects in an immunosuppressed population, they said.

For example, in a randomized trial of adults older than age 60 years, shingles vaccine was associated with 7 cases of severe adverse events and 14 cases of vaccine-related adverse events per 10,000 vaccinations, they noted.

“These vaccination-associated risks are similar in rate and severity to the risks of hospitalized infections in our study. Hence, shingles vaccination before starting a TNF antagonist may not be warranted at present,” they wrote, concluding that although vaccination in healthy children is warranted, it is not warranted in adults with “immunosuppression secondary to the baseline inflammatory disease and its complications.”

The rationale for zoster vaccination goes beyond the goal of simply preventing hospitalized herpes zoster, noted Dr. Kevin L. Winthrop of the department of infectious diseases at the Oregon Health and Science University, Portland, and Dr. Daniel E. Furst, the Carl M. Pearson Professor of Rheumatology at the University of California, Los Angeles, in an editorial accompanying the study report (Ann. Rheum. Dis. 2010;69:1735-7). Vaccination in rheumatoid arthritis patients who are 60 years of age or older should be the standard of care before initiation of anti-TNF or other long-term immunosuppressive therapy, they wrote.

Prospective data on the efficacy of herpes zoster vaccination, particularly in patients with rheumatoid arthritis, are lacking, they said. But there is strong evidence for the protective effects and importance of vaccination in adults aged 60 years and older. Given that patients with rheumatoid arthritis are at increased risk for herpes zoster and that vaccination with live viruses is contraindicated while biological therapies are used, it would make sense to target this group for vaccination before anti-TNF therapy is initiated.

Dr. Winthrop and Dr. Furst said that the purpose of vaccination is not only to lower the risk of rare, serious manifestations of herpes zoster, but also to lower the risk of uncomplicated herpes zoster, which causes considerable morbidity. Future studies should look at the potential benefits of vaccinating those younger than age 60 and those receiving other types of immunosuppressive therapy, they noted.

Rheumatic disease patients who are exposed to tumor necrosis factor antagonists have a 10-fold increased risk of hospitalization for varicella zoster virus infections, compared with the general population, according to a secondary analysis of two large databases.

Nonetheless, the absolute incidence of varicella-related hospitalizations remains low at about three cases per 10,000 person-years of exposure, and the risks of using vaccination for prevention likely outweigh the benefits, Dr. Ignacio García-Doval of Complexo Hospitalario de Pontevedra (Spain) and colleagues have reported in the October issue of the Annals of the Rheumatic Diseases.

The estimated incidence rate of hospitalization for shingles in the rheumatic population was 32 cases per 100,000 patient years, compared with an expected rate of 3.4 in the general population, and the estimated incidence of hospitalization for chickenpox in the rheumatic patients was 26 per 100,000, compared with 1.9 in the general population. This finding is based on analysis of data from a national registry of rheumatic disease patients who were treated with TNF agents (BIOBADASER database) and from an administrative database of all hospital admissions in public centers in Spain (Conjunto Mínimo Básico de Datos al Alta Hospitalaria, or CMBD), which together represent more than 114 million patient-years.

The estimated age- and sex-standardized incidence rate per 100,000 person-years, and the estimated standardized incidence difference were 9 and 26, respectively, for shingles, and 19 and 33, respectively, for chickenpox, they said (Ann. Rheum. Dis. 2010;69:1751-5).

TNF antagonists are known to be associated with an increased risk of tuberculosis in particular and of opportunistic infections in general. There is a biological basis for an increased risk of viral infections, the investigators said, noting that although some studies have shown an increased rate of viral infection in TNF antagonist–treated patients, the clinical relevance of the increase is uncertain.

The current study does not allow differentiation of the causes for the increased risk, but it does show that the absolute rate is low.

The investigators said it is unlikely that the cohorts received systematic vaccination against varicella zoster virus, since the general health mandate in Spain was given in 2005 and only for children aged 11-14 years.

“Standard guidelines for chickenpox vaccination probably apply to the population included in our study,” they wrote.

However, shingles vaccine, which is an attenuated vaccine with a higher dose of antigen, could potentially lead to more side effects in an immunosuppressed population, they said.

For example, in a randomized trial of adults older than age 60 years, shingles vaccine was associated with 7 cases of severe adverse events and 14 cases of vaccine-related adverse events per 10,000 vaccinations, they noted.

“These vaccination-associated risks are similar in rate and severity to the risks of hospitalized infections in our study. Hence, shingles vaccination before starting a TNF antagonist may not be warranted at present,” they wrote, concluding that although vaccination in healthy children is warranted, it is not warranted in adults with “immunosuppression secondary to the baseline inflammatory disease and its complications.”

The rationale for zoster vaccination goes beyond the goal of simply preventing hospitalized herpes zoster, noted Dr. Kevin L. Winthrop of the department of infectious diseases at the Oregon Health and Science University, Portland, and Dr. Daniel E. Furst, the Carl M. Pearson Professor of Rheumatology at the University of California, Los Angeles, in an editorial accompanying the study report (Ann. Rheum. Dis. 2010;69:1735-7). Vaccination in rheumatoid arthritis patients who are 60 years of age or older should be the standard of care before initiation of anti-TNF or other long-term immunosuppressive therapy, they wrote.

Prospective data on the efficacy of herpes zoster vaccination, particularly in patients with rheumatoid arthritis, are lacking, they said. But there is strong evidence for the protective effects and importance of vaccination in adults aged 60 years and older. Given that patients with rheumatoid arthritis are at increased risk for herpes zoster and that vaccination with live viruses is contraindicated while biological therapies are used, it would make sense to target this group for vaccination before anti-TNF therapy is initiated.

Dr. Winthrop and Dr. Furst said that the purpose of vaccination is not only to lower the risk of rare, serious manifestations of herpes zoster, but also to lower the risk of uncomplicated herpes zoster, which causes considerable morbidity. Future studies should look at the potential benefits of vaccinating those younger than age 60 and those receiving other types of immunosuppressive therapy, they noted.

ST. LOUIS – A new surgical approach that addresses the anatomical cause of anterior vaginal wall prolapse has much higher success rates than do standard midline and paravaginal repairs that simply reduce the bulge, preliminary results in more than 500 patients suggest.

Success rates with the new procedure, which involves transverse defect repair, have been 91%-95% based on preliminary reports, compared with 40%-60% with traditional colporrhaphy – and even less when the complications associated with the increasing use of synthetic mesh come into play, Dr. S. Robert Kovac reported at an international pelvic reconstructive and vaginal surgery conference, which was sponsored by the Society of Pelvic Reconstructive Surgeons.

The findings regarding the new technique, which have been submitted for publication, need to be confirmed in additional studies. However, it appears that the approach, which does not require plication, trocars, or synthetic mesh, is quite promising for improving outcomes, Dr. Kovac said, adding that the key to successful treatment is finding the cause of the problem, understanding it, and treating it correctly.

“It’s not the material you use, it’s the technique you use,” he said.

In one study of 276 patients who had undergone multiple surgeries for repair and 122 patients undergoing primary repair, success rates using the new transverse repair technique were 91% at 12 months in 150 patients whose surgery involved sutures only, and 92% at 12 months in the remaining patients who were treated with Surgisis Biodesign (Cook Medical Inc.), said Dr. Kovac, the John D. Thompson Distinguished Professor of Gynecologic Surgery and director of the center for pelvic reconstructive surgery and urogynecology at Emory University, Atlanta.

The success rate was greater than 95% in a separate study of 122 patients with stage III or IV prolapse who underwent primary repair using Surgisis Biodesign and were followed for 12 months, he said.

The new transverse defect repair technique involves reattaching the pubocervical fascia to the pericervical ring to correct the transverse defect. This is followed by providing apical support to the iliococcygeal fascia and then to the retroperitoneal uterosacral ligaments at the level of their insertion at S2-S3.

The theory behind this approach to anterior vaginal wall prolapse is based on anatomical childbirth studies that provide “very, very strong evidence” demonstrating that transverse defects, and not midline or paravaginal defects, are the cause of cystocele, he explained.

The reason failure rates are so high with traditional colporrhaphy is because the source of the problem is not treated, he said, noting that despite consistently poor results, 80% of gynecologists are still using “this 100-year-old technique,” Dr. Kovac said.

Dr. Kovac teaches the use of Surgisis Biodesign for cystocele repair to visiting surgeons. Payment is made by Cook Medical to the department of gynecology and obstetrics at Emory University.

ST. LOUIS – A new surgical approach that addresses the anatomical cause of anterior vaginal wall prolapse has much higher success rates than do standard midline and paravaginal repairs that simply reduce the bulge, preliminary results in more than 500 patients suggest.

Success rates with the new procedure, which involves transverse defect repair, have been 91%-95% based on preliminary reports, compared with 40%-60% with traditional colporrhaphy – and even less when the complications associated with the increasing use of synthetic mesh come into play, Dr. S. Robert Kovac reported at an international pelvic reconstructive and vaginal surgery conference, which was sponsored by the Society of Pelvic Reconstructive Surgeons.

The findings regarding the new technique, which have been submitted for publication, need to be confirmed in additional studies. However, it appears that the approach, which does not require plication, trocars, or synthetic mesh, is quite promising for improving outcomes, Dr. Kovac said, adding that the key to successful treatment is finding the cause of the problem, understanding it, and treating it correctly.

“It’s not the material you use, it’s the technique you use,” he said.

In one study of 276 patients who had undergone multiple surgeries for repair and 122 patients undergoing primary repair, success rates using the new transverse repair technique were 91% at 12 months in 150 patients whose surgery involved sutures only, and 92% at 12 months in the remaining patients who were treated with Surgisis Biodesign (Cook Medical Inc.), said Dr. Kovac, the John D. Thompson Distinguished Professor of Gynecologic Surgery and director of the center for pelvic reconstructive surgery and urogynecology at Emory University, Atlanta.

The success rate was greater than 95% in a separate study of 122 patients with stage III or IV prolapse who underwent primary repair using Surgisis Biodesign and were followed for 12 months, he said.

The new transverse defect repair technique involves reattaching the pubocervical fascia to the pericervical ring to correct the transverse defect. This is followed by providing apical support to the iliococcygeal fascia and then to the retroperitoneal uterosacral ligaments at the level of their insertion at S2-S3.

The theory behind this approach to anterior vaginal wall prolapse is based on anatomical childbirth studies that provide “very, very strong evidence” demonstrating that transverse defects, and not midline or paravaginal defects, are the cause of cystocele, he explained.

The reason failure rates are so high with traditional colporrhaphy is because the source of the problem is not treated, he said, noting that despite consistently poor results, 80% of gynecologists are still using “this 100-year-old technique,” Dr. Kovac said.

Dr. Kovac teaches the use of Surgisis Biodesign for cystocele repair to visiting surgeons. Payment is made by Cook Medical to the department of gynecology and obstetrics at Emory University.

ST. LOUIS – A new surgical approach that addresses the anatomical cause of anterior vaginal wall prolapse has much higher success rates than do standard midline and paravaginal repairs that simply reduce the bulge, preliminary results in more than 500 patients suggest.

Success rates with the new procedure, which involves transverse defect repair, have been 91%-95% based on preliminary reports, compared with 40%-60% with traditional colporrhaphy – and even less when the complications associated with the increasing use of synthetic mesh come into play, Dr. S. Robert Kovac reported at an international pelvic reconstructive and vaginal surgery conference, which was sponsored by the Society of Pelvic Reconstructive Surgeons.

The findings regarding the new technique, which have been submitted for publication, need to be confirmed in additional studies. However, it appears that the approach, which does not require plication, trocars, or synthetic mesh, is quite promising for improving outcomes, Dr. Kovac said, adding that the key to successful treatment is finding the cause of the problem, understanding it, and treating it correctly.

“It’s not the material you use, it’s the technique you use,” he said.

In one study of 276 patients who had undergone multiple surgeries for repair and 122 patients undergoing primary repair, success rates using the new transverse repair technique were 91% at 12 months in 150 patients whose surgery involved sutures only, and 92% at 12 months in the remaining patients who were treated with Surgisis Biodesign (Cook Medical Inc.), said Dr. Kovac, the John D. Thompson Distinguished Professor of Gynecologic Surgery and director of the center for pelvic reconstructive surgery and urogynecology at Emory University, Atlanta.

The success rate was greater than 95% in a separate study of 122 patients with stage III or IV prolapse who underwent primary repair using Surgisis Biodesign and were followed for 12 months, he said.

The new transverse defect repair technique involves reattaching the pubocervical fascia to the pericervical ring to correct the transverse defect. This is followed by providing apical support to the iliococcygeal fascia and then to the retroperitoneal uterosacral ligaments at the level of their insertion at S2-S3.

The theory behind this approach to anterior vaginal wall prolapse is based on anatomical childbirth studies that provide “very, very strong evidence” demonstrating that transverse defects, and not midline or paravaginal defects, are the cause of cystocele, he explained.

The reason failure rates are so high with traditional colporrhaphy is because the source of the problem is not treated, he said, noting that despite consistently poor results, 80% of gynecologists are still using “this 100-year-old technique,” Dr. Kovac said.

Dr. Kovac teaches the use of Surgisis Biodesign for cystocele repair to visiting surgeons. Payment is made by Cook Medical to the department of gynecology and obstetrics at Emory University.

ST. LOUIS – A new surgical approach that addresses the anatomical cause of anterior vaginal wall prolapse has much higher success rates than do standard midline and paravaginal repairs that simply reduce the bulge, preliminary results in more than 500 patients suggest.

Success rates with the new procedure, which involves transverse defect repair, have been 91%-95% based on preliminary reports, compared with 40%-60% with traditional colporrhaphy – and even less when the complications associated with the increasing use of synthetic mesh come into play, Dr. S. Robert Kovac reported at an international pelvic reconstructive and vaginal surgery conference, which was sponsored by the Society of Pelvic Reconstructive Surgeons.

The findings regarding the new technique, which have been submitted for publication, need to be confirmed in additional studies. However, it appears that the approach, which does not require plication, trocars, or synthetic mesh, is quite promising for improving outcomes, Dr. Kovac said, adding that the key to successful treatment is finding the cause of the problem, understanding it, and treating it correctly.

“It’s not the material you use, it’s the technique you use,” he said.

In one study of 276 patients who had undergone multiple surgeries for repair and 122 patients undergoing primary repair, success rates using the new transverse repair technique were 91% at 12 months in 150 patients whose surgery involved sutures only, and 92% at 12 months in the remaining patients who were treated with Surgisis Biodesign (Cook Medical Inc.), said Dr. Kovac, the John D. Thompson Distinguished Professor of Gynecologic Surgery and director of the center for pelvic reconstructive surgery and urogynecology at Emory University, Atlanta.

The success rate was greater than 95% in a separate study of 122 patients with stage III or IV prolapse who underwent primary repair using Surgisis Biodesign and were followed for 12 months, he said.

The new transverse defect repair technique involves reattaching the pubocervical fascia to the pericervical ring to correct the transverse defect. This is followed by providing apical support to the iliococcygeal fascia and then to the retroperitoneal uterosacral ligaments at the level of their insertion at S2-S3.

The theory behind this approach to anterior vaginal wall prolapse is based on anatomical childbirth studies that provide “very, very strong evidence” demonstrating that transverse defects, and not midline or paravaginal defects, are the cause of cystocele, he explained.

The reason failure rates are so high with traditional colporrhaphy is because the source of the problem is not treated, he said, noting that despite consistently poor results, 80% of gynecologists are still using “this 100-year-old technique,” Dr. Kovac said.

Dr. Kovac teaches the use of Surgisis Biodesign for cystocele repair to visiting surgeons. Payment is made by Cook Medical to the department of gynecology and obstetrics at Emory University.

ST. LOUIS – A new surgical approach that addresses the anatomical cause of anterior vaginal wall prolapse has much higher success rates than do standard midline and paravaginal repairs that simply reduce the bulge, preliminary results in more than 500 patients suggest.

Success rates with the new procedure, which involves transverse defect repair, have been 91%-95% based on preliminary reports, compared with 40%-60% with traditional colporrhaphy – and even less when the complications associated with the increasing use of synthetic mesh come into play, Dr. S. Robert Kovac reported at an international pelvic reconstructive and vaginal surgery conference, which was sponsored by the Society of Pelvic Reconstructive Surgeons.

The findings regarding the new technique, which have been submitted for publication, need to be confirmed in additional studies. However, it appears that the approach, which does not require plication, trocars, or synthetic mesh, is quite promising for improving outcomes, Dr. Kovac said, adding that the key to successful treatment is finding the cause of the problem, understanding it, and treating it correctly.

“It’s not the material you use, it’s the technique you use,” he said.

In one study of 276 patients who had undergone multiple surgeries for repair and 122 patients undergoing primary repair, success rates using the new transverse repair technique were 91% at 12 months in 150 patients whose surgery involved sutures only, and 92% at 12 months in the remaining patients who were treated with Surgisis Biodesign (Cook Medical Inc.), said Dr. Kovac, the John D. Thompson Distinguished Professor of Gynecologic Surgery and director of the center for pelvic reconstructive surgery and urogynecology at Emory University, Atlanta.

The success rate was greater than 95% in a separate study of 122 patients with stage III or IV prolapse who underwent primary repair using Surgisis Biodesign and were followed for 12 months, he said.

The new transverse defect repair technique involves reattaching the pubocervical fascia to the pericervical ring to correct the transverse defect. This is followed by providing apical support to the iliococcygeal fascia and then to the retroperitoneal uterosacral ligaments at the level of their insertion at S2-S3.

The theory behind this approach to anterior vaginal wall prolapse is based on anatomical childbirth studies that provide “very, very strong evidence” demonstrating that transverse defects, and not midline or paravaginal defects, are the cause of cystocele, he explained.

The reason failure rates are so high with traditional colporrhaphy is because the source of the problem is not treated, he said, noting that despite consistently poor results, 80% of gynecologists are still using “this 100-year-old technique,” Dr. Kovac said.

Dr. Kovac teaches the use of Surgisis Biodesign for cystocele repair to visiting surgeons. Payment is made by Cook Medical to the department of gynecology and obstetrics at Emory University.

ST. LOUIS – A new surgical approach that addresses the anatomical cause of anterior vaginal wall prolapse has much higher success rates than do standard midline and paravaginal repairs that simply reduce the bulge, preliminary results in more than 500 patients suggest.

Success rates with the new procedure, which involves transverse defect repair, have been 91%-95% based on preliminary reports, compared with 40%-60% with traditional colporrhaphy – and even less when the complications associated with the increasing use of synthetic mesh come into play, Dr. S. Robert Kovac reported at an international pelvic reconstructive and vaginal surgery conference, which was sponsored by the Society of Pelvic Reconstructive Surgeons.

The findings regarding the new technique, which have been submitted for publication, need to be confirmed in additional studies. However, it appears that the approach, which does not require plication, trocars, or synthetic mesh, is quite promising for improving outcomes, Dr. Kovac said, adding that the key to successful treatment is finding the cause of the problem, understanding it, and treating it correctly.

“It’s not the material you use, it’s the technique you use,” he said.

In one study of 276 patients who had undergone multiple surgeries for repair and 122 patients undergoing primary repair, success rates using the new transverse repair technique were 91% at 12 months in 150 patients whose surgery involved sutures only, and 92% at 12 months in the remaining patients who were treated with Surgisis Biodesign (Cook Medical Inc.), said Dr. Kovac, the John D. Thompson Distinguished Professor of Gynecologic Surgery and director of the center for pelvic reconstructive surgery and urogynecology at Emory University, Atlanta.

The success rate was greater than 95% in a separate study of 122 patients with stage III or IV prolapse who underwent primary repair using Surgisis Biodesign and were followed for 12 months, he said.

The new transverse defect repair technique involves reattaching the pubocervical fascia to the pericervical ring to correct the transverse defect. This is followed by providing apical support to the iliococcygeal fascia and then to the retroperitoneal uterosacral ligaments at the level of their insertion at S2-S3.

The theory behind this approach to anterior vaginal wall prolapse is based on anatomical childbirth studies that provide “very, very strong evidence” demonstrating that transverse defects, and not midline or paravaginal defects, are the cause of cystocele, he explained.

The reason failure rates are so high with traditional colporrhaphy is because the source of the problem is not treated, he said, noting that despite consistently poor results, 80% of gynecologists are still using “this 100-year-old technique,” Dr. Kovac said.

Dr. Kovac teaches the use of Surgisis Biodesign for cystocele repair to visiting surgeons. Payment is made by Cook Medical to the department of gynecology and obstetrics at Emory University.

ST. LOUIS – Complaints of vaginal discharge, bleeding, and/or general vaginal discomfort in a patient who has undergone sling placement may signal vaginal mesh erosion.

Patients with vaginal mesh erosion might also note that their partner “feels something” in the vagina during intercourse, Dr. Ginger Cathey said at an international pelvic reconstructive and vaginal surgery conference, which was sponsored by the Society of Pelvic Reconstructive Surgeons.

Vaginal mesh erosion occurs in about 0.5% of synthetic sling patients, according to the most recent reports in the literature, and in most cases, the mesh erosion will be quite apparent although, in some cases, the mesh fibers can be felt, but not visualized, said Dr. Cathey, a practicing urogynecologist at Baylor College of Medicine, Houston.

Bladder and urethral mesh erosions are far less common, with only case reports appearing in the literature.

Patients with bladder or urethral erosions might present with complaints of recurrent urinary tract infections, irritative voiding symptoms such as frequency and urgency, and hematuria. Consider these types of erosions if you have a sling-placement patient who complains of greater frequency and urgency than before the procedure and who has normal post void residuals, Dr. Cathey advised.

Management of vaginal mesh erosion – which usually occurs in the midurethral area, can include local estrogen, especially in cases where a few fibers can be palpated, but not seen, or when the patient is hesitant about excision. However, Dr. Cathey has doubts about the ability of local estrogen to promote re-epithelialization. Excision, she said, is her preferred approach to management of vaginal mesh erosion, and it can generally be performed in the office.

“It’s very rare that I would take a sling erosion back to the operating room to excise it,” she said.

Even if a patient has undergone excision and comes back saying they still feel something, you may be able to remove the remaining fibers in the office by using a colposcope and a suture removal kit to tweeze out the fibers and snip them at that time.

Treatment of larger areas involving exposed tissues or recurrent erosion is best treated by advancing the vaginal epithelium to cover the defect, Dr. Cathey said, noting that use of a Martius graft in such cases would be overkill, but that such a graft would be reasonable in cases of urethral erosion in which the patient has developed a urethral-vaginal fistula.

For bladder or urethral erosion, avoid urethral dilation, which can loosen the sling, but which also places the sling closer to the urethra thereby increasing the potential for more erosion, Dr. Cathey explained.

Try to manage these patients “as minimally invasively as possible,” she said.

Separation of the mesh from the bladder can be challenging, but it can be accomplished using laparoscopic or cystoscopic equipment, or by mini-laparotomy, she noted.

“If you want to resect all the mesh fibers, it’s really important that you put counter-traction on the mesh before cutting it,” she said, noting that the simplest approach is to distend the bladder and to place a 5-mm suprapubic trocar through the bladder, using it to apply traction while you take the endoscopic endoshears and trim the mesh as closely as possible.

If a patient treated for bladder or urethral erosion presents with recurrent irritating voiding symptoms, be sure to evaluate the contralateral side for a second erosion, she said.

Dr. Cathey disclosed that she is a consultant for Bard Medical.

ST. LOUIS – Complaints of vaginal discharge, bleeding, and/or general vaginal discomfort in a patient who has undergone sling placement may signal vaginal mesh erosion.

Patients with vaginal mesh erosion might also note that their partner “feels something” in the vagina during intercourse, Dr. Ginger Cathey said at an international pelvic reconstructive and vaginal surgery conference, which was sponsored by the Society of Pelvic Reconstructive Surgeons.

Vaginal mesh erosion occurs in about 0.5% of synthetic sling patients, according to the most recent reports in the literature, and in most cases, the mesh erosion will be quite apparent although, in some cases, the mesh fibers can be felt, but not visualized, said Dr. Cathey, a practicing urogynecologist at Baylor College of Medicine, Houston.

Bladder and urethral mesh erosions are far less common, with only case reports appearing in the literature.

Patients with bladder or urethral erosions might present with complaints of recurrent urinary tract infections, irritative voiding symptoms such as frequency and urgency, and hematuria. Consider these types of erosions if you have a sling-placement patient who complains of greater frequency and urgency than before the procedure and who has normal post void residuals, Dr. Cathey advised.

Management of vaginal mesh erosion – which usually occurs in the midurethral area, can include local estrogen, especially in cases where a few fibers can be palpated, but not seen, or when the patient is hesitant about excision. However, Dr. Cathey has doubts about the ability of local estrogen to promote re-epithelialization. Excision, she said, is her preferred approach to management of vaginal mesh erosion, and it can generally be performed in the office.

“It’s very rare that I would take a sling erosion back to the operating room to excise it,” she said.

Even if a patient has undergone excision and comes back saying they still feel something, you may be able to remove the remaining fibers in the office by using a colposcope and a suture removal kit to tweeze out the fibers and snip them at that time.

Treatment of larger areas involving exposed tissues or recurrent erosion is best treated by advancing the vaginal epithelium to cover the defect, Dr. Cathey said, noting that use of a Martius graft in such cases would be overkill, but that such a graft would be reasonable in cases of urethral erosion in which the patient has developed a urethral-vaginal fistula.

For bladder or urethral erosion, avoid urethral dilation, which can loosen the sling, but which also places the sling closer to the urethra thereby increasing the potential for more erosion, Dr. Cathey explained.

Try to manage these patients “as minimally invasively as possible,” she said.

Separation of the mesh from the bladder can be challenging, but it can be accomplished using laparoscopic or cystoscopic equipment, or by mini-laparotomy, she noted.

“If you want to resect all the mesh fibers, it’s really important that you put counter-traction on the mesh before cutting it,” she said, noting that the simplest approach is to distend the bladder and to place a 5-mm suprapubic trocar through the bladder, using it to apply traction while you take the endoscopic endoshears and trim the mesh as closely as possible.

If a patient treated for bladder or urethral erosion presents with recurrent irritating voiding symptoms, be sure to evaluate the contralateral side for a second erosion, she said.

Dr. Cathey disclosed that she is a consultant for Bard Medical.

ST. LOUIS – Complaints of vaginal discharge, bleeding, and/or general vaginal discomfort in a patient who has undergone sling placement may signal vaginal mesh erosion.

Patients with vaginal mesh erosion might also note that their partner “feels something” in the vagina during intercourse, Dr. Ginger Cathey said at an international pelvic reconstructive and vaginal surgery conference, which was sponsored by the Society of Pelvic Reconstructive Surgeons.

Vaginal mesh erosion occurs in about 0.5% of synthetic sling patients, according to the most recent reports in the literature, and in most cases, the mesh erosion will be quite apparent although, in some cases, the mesh fibers can be felt, but not visualized, said Dr. Cathey, a practicing urogynecologist at Baylor College of Medicine, Houston.

Bladder and urethral mesh erosions are far less common, with only case reports appearing in the literature.

Patients with bladder or urethral erosions might present with complaints of recurrent urinary tract infections, irritative voiding symptoms such as frequency and urgency, and hematuria. Consider these types of erosions if you have a sling-placement patient who complains of greater frequency and urgency than before the procedure and who has normal post void residuals, Dr. Cathey advised.

Management of vaginal mesh erosion – which usually occurs in the midurethral area, can include local estrogen, especially in cases where a few fibers can be palpated, but not seen, or when the patient is hesitant about excision. However, Dr. Cathey has doubts about the ability of local estrogen to promote re-epithelialization. Excision, she said, is her preferred approach to management of vaginal mesh erosion, and it can generally be performed in the office.

“It’s very rare that I would take a sling erosion back to the operating room to excise it,” she said.

Even if a patient has undergone excision and comes back saying they still feel something, you may be able to remove the remaining fibers in the office by using a colposcope and a suture removal kit to tweeze out the fibers and snip them at that time.

Treatment of larger areas involving exposed tissues or recurrent erosion is best treated by advancing the vaginal epithelium to cover the defect, Dr. Cathey said, noting that use of a Martius graft in such cases would be overkill, but that such a graft would be reasonable in cases of urethral erosion in which the patient has developed a urethral-vaginal fistula.

For bladder or urethral erosion, avoid urethral dilation, which can loosen the sling, but which also places the sling closer to the urethra thereby increasing the potential for more erosion, Dr. Cathey explained.

Try to manage these patients “as minimally invasively as possible,” she said.

Separation of the mesh from the bladder can be challenging, but it can be accomplished using laparoscopic or cystoscopic equipment, or by mini-laparotomy, she noted.

“If you want to resect all the mesh fibers, it’s really important that you put counter-traction on the mesh before cutting it,” she said, noting that the simplest approach is to distend the bladder and to place a 5-mm suprapubic trocar through the bladder, using it to apply traction while you take the endoscopic endoshears and trim the mesh as closely as possible.

If a patient treated for bladder or urethral erosion presents with recurrent irritating voiding symptoms, be sure to evaluate the contralateral side for a second erosion, she said.

Dr. Cathey disclosed that she is a consultant for Bard Medical.

ST. LOUIS – Coring is an excellent technique for facilitating vaginal hysterectomy in patients with large adenomyotic uteri, according to Dr. Carl W. Zimmerman.

Adenomyosis creates a very dense, unforgiving myometrium that is very symptomatic for the patient, and affected uteri can reach at least 20 weeks in size without a well-defined mass that can be enucleated, he said at the conference, which was sponsored by the Society of Pelvic Reconstructive Surgeons.

Debulking is a challenge in cases like this, but a coring technique that changes the shape of the uterus can ease removal.

An incision is made around the cervix, the paracolpium is divided, and the blood supply is divided, creating a bloodless organ, he said.

“What you do then is take a knife and make an encircling cut concentrically around the cervix and into the fundus of the uterus, but parallel to the long access of the uterus and endometrial cavity, going around and around and around,” explained Dr. Zimmerman, professor of obstetrics and gynecology at Vanderbilt University, Nashville, Tenn.

If you do this long enough, and make incisions parallel to the endometrial cavity and away from the serosal surface of the uterus, the globular structure is converted to a tubular structure that can be a foot long or longer, and which “literally comes down to meet you,” he said.

Dr. Zimmerman is a speaker/proctor for Cook Medical, is a proctor for Boston Scientific Corp. and Covidien, and receives royalties from Lumitex Inc. and Marina Medical Instruments Inc.

ST. LOUIS – Coring is an excellent technique for facilitating vaginal hysterectomy in patients with large adenomyotic uteri, according to Dr. Carl W. Zimmerman.

Adenomyosis creates a very dense, unforgiving myometrium that is very symptomatic for the patient, and affected uteri can reach at least 20 weeks in size without a well-defined mass that can be enucleated, he said at the conference, which was sponsored by the Society of Pelvic Reconstructive Surgeons.

Debulking is a challenge in cases like this, but a coring technique that changes the shape of the uterus can ease removal.

An incision is made around the cervix, the paracolpium is divided, and the blood supply is divided, creating a bloodless organ, he said.

“What you do then is take a knife and make an encircling cut concentrically around the cervix and into the fundus of the uterus, but parallel to the long access of the uterus and endometrial cavity, going around and around and around,” explained Dr. Zimmerman, professor of obstetrics and gynecology at Vanderbilt University, Nashville, Tenn.

If you do this long enough, and make incisions parallel to the endometrial cavity and away from the serosal surface of the uterus, the globular structure is converted to a tubular structure that can be a foot long or longer, and which “literally comes down to meet you,” he said.

Dr. Zimmerman is a speaker/proctor for Cook Medical, is a proctor for Boston Scientific Corp. and Covidien, and receives royalties from Lumitex Inc. and Marina Medical Instruments Inc.

ST. LOUIS – Coring is an excellent technique for facilitating vaginal hysterectomy in patients with large adenomyotic uteri, according to Dr. Carl W. Zimmerman.

Adenomyosis creates a very dense, unforgiving myometrium that is very symptomatic for the patient, and affected uteri can reach at least 20 weeks in size without a well-defined mass that can be enucleated, he said at the conference, which was sponsored by the Society of Pelvic Reconstructive Surgeons.

Debulking is a challenge in cases like this, but a coring technique that changes the shape of the uterus can ease removal.

An incision is made around the cervix, the paracolpium is divided, and the blood supply is divided, creating a bloodless organ, he said.

“What you do then is take a knife and make an encircling cut concentrically around the cervix and into the fundus of the uterus, but parallel to the long access of the uterus and endometrial cavity, going around and around and around,” explained Dr. Zimmerman, professor of obstetrics and gynecology at Vanderbilt University, Nashville, Tenn.

If you do this long enough, and make incisions parallel to the endometrial cavity and away from the serosal surface of the uterus, the globular structure is converted to a tubular structure that can be a foot long or longer, and which “literally comes down to meet you,” he said.

Dr. Zimmerman is a speaker/proctor for Cook Medical, is a proctor for Boston Scientific Corp. and Covidien, and receives royalties from Lumitex Inc. and Marina Medical Instruments Inc.