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Splenic artery embolization increases risk of complications
LAKE BUENA VISTA, FLA. – are at higher risk of infectious complications and readmissions in the long term, according to a study presented at the annual scientific assembly of the Eastern Association for the Surgery of Trauma.
As nonoperative treatments are becoming more common for managing blunt splenic injury (BSI), it is important to understand the risks associated with splenic artery embolization (SAE) and how this treatment may be impacting a larger trend of posttrauma readmissions, according to presenter Rishi Rattan, MD, an acute care surgeon at the University of Miami.
The retrospective study included 37,986 BSI patients admitted into the National Readmissions Database from 2010 to 2014, treated with either nonoperative management (NOM), SAE, or operative management (OM).
Readmission rates for infection after 30 days were significantly higher among SAE (15.4%) and OM (21.9%) patients, compared with NOM patients (6.7%), according to Dr. Rattan. Patients who underwent SAE also had a 17.2% rate of infection after 1 year; significantly higher than the 8.1% of patients who underwent NOM, although less than the 23.2% of those who underwent OM.
For readmission due to organ surgical site infection, patients with SAE had a higher frequency at 30-day (2.9%) and 1-year (3.9%) readmission, compared with both NOM (1.3%, 1.7%) and OM (2.0%, 2.2%).
This can be particularly problematic as these organ surgical site infections, deep in the abdominal cavity around the splenic bed, are usually more complicated to manage, compared with a superficial infection, explained Dr. Rattan. Physiologically, it makes sense that having dead tissue left in the splenic bed could lead to a rise in infection, although more data are necessary to confirm that hypothesis.
SAE was a significant predictive factor for complications after BSI, increasing the odds of 30-day and 1-year readmission by 76% and 99%, respectively, from organ surgical site infection, compared with NOM (P less than .01). Other predictive factors included hospital stays longer than 4 days, not being discharged to home, and a Charlson Comorbidity index score greater than 1.
With an incidence rate of readmission among embolization patients at 30 days and 1 year double that of NOM, Dr. Rattan and fellow investigators suggest surgeons should be conscious of the risks of SAE and OM, especially as infection is a major case of morbidity after trauma in splenectomy patients.
The investigators reported no relevant financial disclosures.
LAKE BUENA VISTA, FLA. – are at higher risk of infectious complications and readmissions in the long term, according to a study presented at the annual scientific assembly of the Eastern Association for the Surgery of Trauma.
As nonoperative treatments are becoming more common for managing blunt splenic injury (BSI), it is important to understand the risks associated with splenic artery embolization (SAE) and how this treatment may be impacting a larger trend of posttrauma readmissions, according to presenter Rishi Rattan, MD, an acute care surgeon at the University of Miami.
The retrospective study included 37,986 BSI patients admitted into the National Readmissions Database from 2010 to 2014, treated with either nonoperative management (NOM), SAE, or operative management (OM).
Readmission rates for infection after 30 days were significantly higher among SAE (15.4%) and OM (21.9%) patients, compared with NOM patients (6.7%), according to Dr. Rattan. Patients who underwent SAE also had a 17.2% rate of infection after 1 year; significantly higher than the 8.1% of patients who underwent NOM, although less than the 23.2% of those who underwent OM.
For readmission due to organ surgical site infection, patients with SAE had a higher frequency at 30-day (2.9%) and 1-year (3.9%) readmission, compared with both NOM (1.3%, 1.7%) and OM (2.0%, 2.2%).
This can be particularly problematic as these organ surgical site infections, deep in the abdominal cavity around the splenic bed, are usually more complicated to manage, compared with a superficial infection, explained Dr. Rattan. Physiologically, it makes sense that having dead tissue left in the splenic bed could lead to a rise in infection, although more data are necessary to confirm that hypothesis.
SAE was a significant predictive factor for complications after BSI, increasing the odds of 30-day and 1-year readmission by 76% and 99%, respectively, from organ surgical site infection, compared with NOM (P less than .01). Other predictive factors included hospital stays longer than 4 days, not being discharged to home, and a Charlson Comorbidity index score greater than 1.
With an incidence rate of readmission among embolization patients at 30 days and 1 year double that of NOM, Dr. Rattan and fellow investigators suggest surgeons should be conscious of the risks of SAE and OM, especially as infection is a major case of morbidity after trauma in splenectomy patients.
The investigators reported no relevant financial disclosures.
LAKE BUENA VISTA, FLA. – are at higher risk of infectious complications and readmissions in the long term, according to a study presented at the annual scientific assembly of the Eastern Association for the Surgery of Trauma.
As nonoperative treatments are becoming more common for managing blunt splenic injury (BSI), it is important to understand the risks associated with splenic artery embolization (SAE) and how this treatment may be impacting a larger trend of posttrauma readmissions, according to presenter Rishi Rattan, MD, an acute care surgeon at the University of Miami.
The retrospective study included 37,986 BSI patients admitted into the National Readmissions Database from 2010 to 2014, treated with either nonoperative management (NOM), SAE, or operative management (OM).
Readmission rates for infection after 30 days were significantly higher among SAE (15.4%) and OM (21.9%) patients, compared with NOM patients (6.7%), according to Dr. Rattan. Patients who underwent SAE also had a 17.2% rate of infection after 1 year; significantly higher than the 8.1% of patients who underwent NOM, although less than the 23.2% of those who underwent OM.
For readmission due to organ surgical site infection, patients with SAE had a higher frequency at 30-day (2.9%) and 1-year (3.9%) readmission, compared with both NOM (1.3%, 1.7%) and OM (2.0%, 2.2%).
This can be particularly problematic as these organ surgical site infections, deep in the abdominal cavity around the splenic bed, are usually more complicated to manage, compared with a superficial infection, explained Dr. Rattan. Physiologically, it makes sense that having dead tissue left in the splenic bed could lead to a rise in infection, although more data are necessary to confirm that hypothesis.
SAE was a significant predictive factor for complications after BSI, increasing the odds of 30-day and 1-year readmission by 76% and 99%, respectively, from organ surgical site infection, compared with NOM (P less than .01). Other predictive factors included hospital stays longer than 4 days, not being discharged to home, and a Charlson Comorbidity index score greater than 1.
With an incidence rate of readmission among embolization patients at 30 days and 1 year double that of NOM, Dr. Rattan and fellow investigators suggest surgeons should be conscious of the risks of SAE and OM, especially as infection is a major case of morbidity after trauma in splenectomy patients.
The investigators reported no relevant financial disclosures.
REPORTING FROM EAST 2018
Key clinical point: Splenic artery embolization can increase risk of infectious complications in patients with blunt splenic injury.
Major finding: Patients who underwent splenic artery embolization had an infectious complication rate of 20% after 1 year.
Data source: Study of 37,986 blunt splenic injury patients gathered from the Nationwide Readmissions Database during 2010-2014.
Disclosures: Investigators reported no relevant financial disclosures.
FDA adds boxed warning to obeticholic acid label
The Food and Drug Administration is requiring a boxed warning on the label for obeticholic acid (Ocaliva) to highlight the correct weekly dosing regimen after incorrect daily dosing caused severe liver injury in patients with moderate to severe primary biliary cholangitis (PBC).
“FDA is adding a new Boxed Warning, FDA’s most prominent warning, to highlight this information in the prescribing information of the drug label,” FDA officials said in a statement Feb. 1. “To ensure correct dosing and reduce the risk of liver problems, FDA is clarifying the current recommendations for screening, dosing, monitoring, and managing PBC patients with moderate to severe liver disease taking Ocaliva.”
FDA recommends that “health care professionals should follow the Ocaliva dosing regimen in the drug label. … Dosing higher than recommended in the drug label can increase the risk for liver decompensation, liver failure, and sometimes death. Routinely monitor all patients for biochemical response, tolerability, and PBC progression, and reevaluate Child-Pugh classification to determine if dosage adjustment is needed.”
Manufacturer Intercept Pharmaceuticals was required to continue studying obeticholic acid in patients with advanced PBC as a condition of its FDA approval. Results from these studies are expected in 2023, FDA noted.
To report adverse medication events and side effects to the FDA, access the MedWatch program.
The Food and Drug Administration is requiring a boxed warning on the label for obeticholic acid (Ocaliva) to highlight the correct weekly dosing regimen after incorrect daily dosing caused severe liver injury in patients with moderate to severe primary biliary cholangitis (PBC).
“FDA is adding a new Boxed Warning, FDA’s most prominent warning, to highlight this information in the prescribing information of the drug label,” FDA officials said in a statement Feb. 1. “To ensure correct dosing and reduce the risk of liver problems, FDA is clarifying the current recommendations for screening, dosing, monitoring, and managing PBC patients with moderate to severe liver disease taking Ocaliva.”
FDA recommends that “health care professionals should follow the Ocaliva dosing regimen in the drug label. … Dosing higher than recommended in the drug label can increase the risk for liver decompensation, liver failure, and sometimes death. Routinely monitor all patients for biochemical response, tolerability, and PBC progression, and reevaluate Child-Pugh classification to determine if dosage adjustment is needed.”
Manufacturer Intercept Pharmaceuticals was required to continue studying obeticholic acid in patients with advanced PBC as a condition of its FDA approval. Results from these studies are expected in 2023, FDA noted.
To report adverse medication events and side effects to the FDA, access the MedWatch program.
The Food and Drug Administration is requiring a boxed warning on the label for obeticholic acid (Ocaliva) to highlight the correct weekly dosing regimen after incorrect daily dosing caused severe liver injury in patients with moderate to severe primary biliary cholangitis (PBC).
“FDA is adding a new Boxed Warning, FDA’s most prominent warning, to highlight this information in the prescribing information of the drug label,” FDA officials said in a statement Feb. 1. “To ensure correct dosing and reduce the risk of liver problems, FDA is clarifying the current recommendations for screening, dosing, monitoring, and managing PBC patients with moderate to severe liver disease taking Ocaliva.”
FDA recommends that “health care professionals should follow the Ocaliva dosing regimen in the drug label. … Dosing higher than recommended in the drug label can increase the risk for liver decompensation, liver failure, and sometimes death. Routinely monitor all patients for biochemical response, tolerability, and PBC progression, and reevaluate Child-Pugh classification to determine if dosage adjustment is needed.”
Manufacturer Intercept Pharmaceuticals was required to continue studying obeticholic acid in patients with advanced PBC as a condition of its FDA approval. Results from these studies are expected in 2023, FDA noted.
To report adverse medication events and side effects to the FDA, access the MedWatch program.
Notable acute care surgery papers from 2017
LAKE BUENA VISTA, FLA. – Every year brings new studies, updates, and trials, and it can be a challenge to keep up.
Christian Jones, MD, FACS, a general surgeon in the division of acute care surgery at Johns Hopkins University, Baltimore, ranked some of the more notable trauma studies published in the past year and presented his perspective on them at the annual scientific assembly of the Eastern Association for the Surgery of Trauma.
Day 2 is the “sweet spot” for cholecystectomy
When it comes to cholecystectomy, acute cholecystitis (AC) patients appear to fare the best when operations are conducted on day 2 after admission, according to a study of patients registered in the Swedish Registry of Gallstone Surgery and Endoscopic Retrograde Cholangiopancreatography (GallRiks).
The retrospective study of 15,760 AC patients found that the rate of 30-day mortality of AC patients was significantly higher for patients who underwent a cholecystectomy on day of (odds ratio = .42) 3 days after (OR = .34), and 4 days after admission (OR = 1.0), compared with those who were operated on between 1 day after (OR = .23), and 2 days after (OR = .29) admission.
Lead author My Blohm, MD, of the department of clinical sciences, intervention, and technology at the Karolinska Institutet, Stockholm, and fellow investigators hypothesized that waiting allows patients to be medically optimized for surgery (J Gastrointest Surg. 2017;21[1]: 33-40).
With 90-day mortality rates showing nearly identical results for day 1 and day 2, holding off on surgery may be the best move for the patient, even if it is not the ideal situation for a provider.
“Sure, as we all know by now, delayed cholecystectomy is seldom necessary, later surgery is more difficult, and more likely to be associated with complications at least with an equal conversion to an open procedure, but even more surprising is the higher mortality on the admissions day,” said Dr. Jones.
Antibiotics for abscess drainage patients
For patients requiring abscess drainage, antibiotics may be the best bet to keep infection at bay, according to a study published in the New England Journal of Medicine in June 2017.
The prospective, randomized, placebo-controlled, double-blind, study of 786 simple skin abscess drainage patients found clindamycin and Bactrim (sulfamethoxazole and trimethoprim) outperformed a placebo in an evaluation of symptoms of true ongoing infection in patients even 30 days after the procedure (N Engl J Med. 2017 Jun 29;376[26]:2545-55).
Patients studied had Staphylococcus aureus (527) or methicillin-resistant S. aureus (388).
After 10 days of therapy, cure rate of infection for the clindamycin and Bactrim groups were 83% and 82% respectively, compared with 70% in the placebo group, according to Robert S. Daum, MD, principal investigator at the MRSA Research Center, University of Chicago. After 30 days, cure rate for both antibiotic groups remained superior to that of the placebo group.
While these treatments were successful, concern of drug resistance is notable and should be taken into consideration when deciding on treatment options.
“This does get to our typical concern with increased antibiotic usage, and that’s the concern of the health of the community versus the health of the individual patient,” said Dr. Jones. “Is the increased rate of [antibiotic] resistance important enough to have a lower cure rate of simple abscess drainage? We don’t know the answer to that.”
Loop ileostomies look good for C. diff patients
This minimally invasive procedure has been the subject of some well-received studies with findings that indicate it is a promising choice for patients with a Clostridium difficile–associated disease (CDAD) over total colectomy, Dr. Jones said.
In a study published in the Journal of Trauma and Acute Care Surgery, a study group of patients with CDAD who had loop ileostomy had no statistical difference in almost any recorded characteristic compared with those who underwent a total colectomy, except mortality rate. The retrospective, multicenter study of 98 CDAD patients found the mortality rate of the loop ileostomy group to be 17.2%, compared with 39.7% in the total colectomy group (J Trauma Acute Care Surg. 2017 Jul;83[1]:36-40).
“The outcomes all favored loop ileostomy in a statistically significant fashion,” said Dr. Jones. “Unsurprisingly, estimated blood loss and need for transfusions were all significantly less in the loop ileostomy patients, and the adjusted overall mortality, even if requiring a reoperation, still favored doing the loop ileostomy first.”
The one difference between LI and colectomy patients was a longer time from initial diagnosis to operation among LI patients, with about 12 hours from diagnosis for the colectomy versus 24 hours for LI patients, according to lead author Paula Ferrada, MD, FACS, director of the surgical and trauma intensive care unit at Virginia Commonwealth University, Richmond, and her fellow investigators,
Contrary to previous findings, the study found that LI can be performed on sick patients as well, according to the researchers, and failure of the procedure is not associated with increased mortality.
While these findings are encouraging, “there are things that the individual patient may reveal to you on your examination that tell you they are not a candidate and that you should go to total colectomy,” said Dr. Jones. “Keep in mind that perhaps we can be a bit more aggressive in this less invasive procedure.”
The skin vac actually works
A study published in Annals of Surgery found prophylactic negative-pressure dressings are associated with a decreased rate of surgical site infections in laparotomy wounds.
“The biggest surprise to me out of all of these studies is that a new piece of technology actually seems to work,” said Dr. Jones.
The randomized study included 50 laparotomy patients with a stapled wound, half of whom received a skin vac over their incision while the other half had a standard OpSite occlusive dressing (Ann Surg. 2017 Jun;265[6]:1082-6).
Patients in both arms had the same type of wound and had their dressings on for 4 days before being switched.
Rate of surgical site infections for the skin vac group was 8.3% over 30 days from operation, compared with 32% in the OpSite group. Average length of stay for patients with the pressure dressing was 6.1 days, while patients with an OpSite dressing had a length of 14.7 days, more than double, according to lead author Donal Peter O’Leary, MD, surgeon at Cork University Hospital, Ireland.
The difference in length of stay does become insignificant if six OpSite patients who stayed longer than 20 days are discounted, only two of whom were delayed because of wound complications as opposed to placement issues or unassociated infections.
“But a surgical site infection difference of 50% or more using a skin vac instead of a standard dressing, whether you’re talking about clean, clean-contaminated, or contaminated cases with a skin closure, seems to be worthy of notice,” explained Dr. Jones.
LAKE BUENA VISTA, FLA. – Every year brings new studies, updates, and trials, and it can be a challenge to keep up.
Christian Jones, MD, FACS, a general surgeon in the division of acute care surgery at Johns Hopkins University, Baltimore, ranked some of the more notable trauma studies published in the past year and presented his perspective on them at the annual scientific assembly of the Eastern Association for the Surgery of Trauma.
Day 2 is the “sweet spot” for cholecystectomy
When it comes to cholecystectomy, acute cholecystitis (AC) patients appear to fare the best when operations are conducted on day 2 after admission, according to a study of patients registered in the Swedish Registry of Gallstone Surgery and Endoscopic Retrograde Cholangiopancreatography (GallRiks).
The retrospective study of 15,760 AC patients found that the rate of 30-day mortality of AC patients was significantly higher for patients who underwent a cholecystectomy on day of (odds ratio = .42) 3 days after (OR = .34), and 4 days after admission (OR = 1.0), compared with those who were operated on between 1 day after (OR = .23), and 2 days after (OR = .29) admission.
Lead author My Blohm, MD, of the department of clinical sciences, intervention, and technology at the Karolinska Institutet, Stockholm, and fellow investigators hypothesized that waiting allows patients to be medically optimized for surgery (J Gastrointest Surg. 2017;21[1]: 33-40).
With 90-day mortality rates showing nearly identical results for day 1 and day 2, holding off on surgery may be the best move for the patient, even if it is not the ideal situation for a provider.
“Sure, as we all know by now, delayed cholecystectomy is seldom necessary, later surgery is more difficult, and more likely to be associated with complications at least with an equal conversion to an open procedure, but even more surprising is the higher mortality on the admissions day,” said Dr. Jones.
Antibiotics for abscess drainage patients
For patients requiring abscess drainage, antibiotics may be the best bet to keep infection at bay, according to a study published in the New England Journal of Medicine in June 2017.
The prospective, randomized, placebo-controlled, double-blind, study of 786 simple skin abscess drainage patients found clindamycin and Bactrim (sulfamethoxazole and trimethoprim) outperformed a placebo in an evaluation of symptoms of true ongoing infection in patients even 30 days after the procedure (N Engl J Med. 2017 Jun 29;376[26]:2545-55).
Patients studied had Staphylococcus aureus (527) or methicillin-resistant S. aureus (388).
After 10 days of therapy, cure rate of infection for the clindamycin and Bactrim groups were 83% and 82% respectively, compared with 70% in the placebo group, according to Robert S. Daum, MD, principal investigator at the MRSA Research Center, University of Chicago. After 30 days, cure rate for both antibiotic groups remained superior to that of the placebo group.
While these treatments were successful, concern of drug resistance is notable and should be taken into consideration when deciding on treatment options.
“This does get to our typical concern with increased antibiotic usage, and that’s the concern of the health of the community versus the health of the individual patient,” said Dr. Jones. “Is the increased rate of [antibiotic] resistance important enough to have a lower cure rate of simple abscess drainage? We don’t know the answer to that.”
Loop ileostomies look good for C. diff patients
This minimally invasive procedure has been the subject of some well-received studies with findings that indicate it is a promising choice for patients with a Clostridium difficile–associated disease (CDAD) over total colectomy, Dr. Jones said.
In a study published in the Journal of Trauma and Acute Care Surgery, a study group of patients with CDAD who had loop ileostomy had no statistical difference in almost any recorded characteristic compared with those who underwent a total colectomy, except mortality rate. The retrospective, multicenter study of 98 CDAD patients found the mortality rate of the loop ileostomy group to be 17.2%, compared with 39.7% in the total colectomy group (J Trauma Acute Care Surg. 2017 Jul;83[1]:36-40).
“The outcomes all favored loop ileostomy in a statistically significant fashion,” said Dr. Jones. “Unsurprisingly, estimated blood loss and need for transfusions were all significantly less in the loop ileostomy patients, and the adjusted overall mortality, even if requiring a reoperation, still favored doing the loop ileostomy first.”
The one difference between LI and colectomy patients was a longer time from initial diagnosis to operation among LI patients, with about 12 hours from diagnosis for the colectomy versus 24 hours for LI patients, according to lead author Paula Ferrada, MD, FACS, director of the surgical and trauma intensive care unit at Virginia Commonwealth University, Richmond, and her fellow investigators,
Contrary to previous findings, the study found that LI can be performed on sick patients as well, according to the researchers, and failure of the procedure is not associated with increased mortality.
While these findings are encouraging, “there are things that the individual patient may reveal to you on your examination that tell you they are not a candidate and that you should go to total colectomy,” said Dr. Jones. “Keep in mind that perhaps we can be a bit more aggressive in this less invasive procedure.”
The skin vac actually works
A study published in Annals of Surgery found prophylactic negative-pressure dressings are associated with a decreased rate of surgical site infections in laparotomy wounds.
“The biggest surprise to me out of all of these studies is that a new piece of technology actually seems to work,” said Dr. Jones.
The randomized study included 50 laparotomy patients with a stapled wound, half of whom received a skin vac over their incision while the other half had a standard OpSite occlusive dressing (Ann Surg. 2017 Jun;265[6]:1082-6).
Patients in both arms had the same type of wound and had their dressings on for 4 days before being switched.
Rate of surgical site infections for the skin vac group was 8.3% over 30 days from operation, compared with 32% in the OpSite group. Average length of stay for patients with the pressure dressing was 6.1 days, while patients with an OpSite dressing had a length of 14.7 days, more than double, according to lead author Donal Peter O’Leary, MD, surgeon at Cork University Hospital, Ireland.
The difference in length of stay does become insignificant if six OpSite patients who stayed longer than 20 days are discounted, only two of whom were delayed because of wound complications as opposed to placement issues or unassociated infections.
“But a surgical site infection difference of 50% or more using a skin vac instead of a standard dressing, whether you’re talking about clean, clean-contaminated, or contaminated cases with a skin closure, seems to be worthy of notice,” explained Dr. Jones.
LAKE BUENA VISTA, FLA. – Every year brings new studies, updates, and trials, and it can be a challenge to keep up.
Christian Jones, MD, FACS, a general surgeon in the division of acute care surgery at Johns Hopkins University, Baltimore, ranked some of the more notable trauma studies published in the past year and presented his perspective on them at the annual scientific assembly of the Eastern Association for the Surgery of Trauma.
Day 2 is the “sweet spot” for cholecystectomy
When it comes to cholecystectomy, acute cholecystitis (AC) patients appear to fare the best when operations are conducted on day 2 after admission, according to a study of patients registered in the Swedish Registry of Gallstone Surgery and Endoscopic Retrograde Cholangiopancreatography (GallRiks).
The retrospective study of 15,760 AC patients found that the rate of 30-day mortality of AC patients was significantly higher for patients who underwent a cholecystectomy on day of (odds ratio = .42) 3 days after (OR = .34), and 4 days after admission (OR = 1.0), compared with those who were operated on between 1 day after (OR = .23), and 2 days after (OR = .29) admission.
Lead author My Blohm, MD, of the department of clinical sciences, intervention, and technology at the Karolinska Institutet, Stockholm, and fellow investigators hypothesized that waiting allows patients to be medically optimized for surgery (J Gastrointest Surg. 2017;21[1]: 33-40).
With 90-day mortality rates showing nearly identical results for day 1 and day 2, holding off on surgery may be the best move for the patient, even if it is not the ideal situation for a provider.
“Sure, as we all know by now, delayed cholecystectomy is seldom necessary, later surgery is more difficult, and more likely to be associated with complications at least with an equal conversion to an open procedure, but even more surprising is the higher mortality on the admissions day,” said Dr. Jones.
Antibiotics for abscess drainage patients
For patients requiring abscess drainage, antibiotics may be the best bet to keep infection at bay, according to a study published in the New England Journal of Medicine in June 2017.
The prospective, randomized, placebo-controlled, double-blind, study of 786 simple skin abscess drainage patients found clindamycin and Bactrim (sulfamethoxazole and trimethoprim) outperformed a placebo in an evaluation of symptoms of true ongoing infection in patients even 30 days after the procedure (N Engl J Med. 2017 Jun 29;376[26]:2545-55).
Patients studied had Staphylococcus aureus (527) or methicillin-resistant S. aureus (388).
After 10 days of therapy, cure rate of infection for the clindamycin and Bactrim groups were 83% and 82% respectively, compared with 70% in the placebo group, according to Robert S. Daum, MD, principal investigator at the MRSA Research Center, University of Chicago. After 30 days, cure rate for both antibiotic groups remained superior to that of the placebo group.
While these treatments were successful, concern of drug resistance is notable and should be taken into consideration when deciding on treatment options.
“This does get to our typical concern with increased antibiotic usage, and that’s the concern of the health of the community versus the health of the individual patient,” said Dr. Jones. “Is the increased rate of [antibiotic] resistance important enough to have a lower cure rate of simple abscess drainage? We don’t know the answer to that.”
Loop ileostomies look good for C. diff patients
This minimally invasive procedure has been the subject of some well-received studies with findings that indicate it is a promising choice for patients with a Clostridium difficile–associated disease (CDAD) over total colectomy, Dr. Jones said.
In a study published in the Journal of Trauma and Acute Care Surgery, a study group of patients with CDAD who had loop ileostomy had no statistical difference in almost any recorded characteristic compared with those who underwent a total colectomy, except mortality rate. The retrospective, multicenter study of 98 CDAD patients found the mortality rate of the loop ileostomy group to be 17.2%, compared with 39.7% in the total colectomy group (J Trauma Acute Care Surg. 2017 Jul;83[1]:36-40).
“The outcomes all favored loop ileostomy in a statistically significant fashion,” said Dr. Jones. “Unsurprisingly, estimated blood loss and need for transfusions were all significantly less in the loop ileostomy patients, and the adjusted overall mortality, even if requiring a reoperation, still favored doing the loop ileostomy first.”
The one difference between LI and colectomy patients was a longer time from initial diagnosis to operation among LI patients, with about 12 hours from diagnosis for the colectomy versus 24 hours for LI patients, according to lead author Paula Ferrada, MD, FACS, director of the surgical and trauma intensive care unit at Virginia Commonwealth University, Richmond, and her fellow investigators,
Contrary to previous findings, the study found that LI can be performed on sick patients as well, according to the researchers, and failure of the procedure is not associated with increased mortality.
While these findings are encouraging, “there are things that the individual patient may reveal to you on your examination that tell you they are not a candidate and that you should go to total colectomy,” said Dr. Jones. “Keep in mind that perhaps we can be a bit more aggressive in this less invasive procedure.”
The skin vac actually works
A study published in Annals of Surgery found prophylactic negative-pressure dressings are associated with a decreased rate of surgical site infections in laparotomy wounds.
“The biggest surprise to me out of all of these studies is that a new piece of technology actually seems to work,” said Dr. Jones.
The randomized study included 50 laparotomy patients with a stapled wound, half of whom received a skin vac over their incision while the other half had a standard OpSite occlusive dressing (Ann Surg. 2017 Jun;265[6]:1082-6).
Patients in both arms had the same type of wound and had their dressings on for 4 days before being switched.
Rate of surgical site infections for the skin vac group was 8.3% over 30 days from operation, compared with 32% in the OpSite group. Average length of stay for patients with the pressure dressing was 6.1 days, while patients with an OpSite dressing had a length of 14.7 days, more than double, according to lead author Donal Peter O’Leary, MD, surgeon at Cork University Hospital, Ireland.
The difference in length of stay does become insignificant if six OpSite patients who stayed longer than 20 days are discounted, only two of whom were delayed because of wound complications as opposed to placement issues or unassociated infections.
“But a surgical site infection difference of 50% or more using a skin vac instead of a standard dressing, whether you’re talking about clean, clean-contaminated, or contaminated cases with a skin closure, seems to be worthy of notice,” explained Dr. Jones.
REPORTING FROM EAST 2018
EEG burst suppression pattern prognosis not always grim post cardiac arrest
WASHINGTON – , according to findings from a retrospective study presented at the annual meeting of the American Epilepsy Society.
Traditionally, burst suppression patterns (BSP) in post–cardiac arrest patients, especially without anesthesia or cooling, has been considered strongly associated with poor network-level recovery, but findings reported by Krithiga Sekar, MD, PhD, and her colleagues in a poster at the meeting show that patients with BSP on EEG recover consciousness with the same frequency as do those who recover without BSP.
In fact, Dr. Sekar, an epilepsy fellow at Columbia University, New York, and her colleagues asserted that prognoses of poor outcomes are more accurately associated with characteristics of the signals themselves, with some cases of BSP acting as a neuroprotective mechanism during metabolic stress.
Dr. Sekar and her coinvestigators retrospectively studied 73 cardiac arrest patients who underwent therapeutic hypothermia with continuous video EEG monitoring at Cornell. Of those studied, 45 (62%) had BSP on EEG, a common occurrence after cardiac arrest, according to Dr. Sekar.
Of those with BSP on EEG, 14 (31%) recovered consciousness within the first 72 hours of arrest, as did 10 (36%) who recovered without BSP.
For those who did not recover, the median number of days hooked up was around 9, much longer than in other studies, which could be why more patients recovered compared with those in older literature, according to Dr. Sekar and her fellow investigators.
“The length of time for withdrawal of care was around 9 or 10 days, while much of the literature I had read had withdrawal of care within the first 4 or 5 days,” Dr. Sekar said. “If people think [BSP] is a poor prognosticator, they will withdraw care more often, and then that accumulates more data that this is a poor prognosticator.”
Of the 49 who did not recover, 12 patients in the BSP group and 10 patients in the non-BSP group had care withdrawn.
During the study, Dr. Sekar and her colleagues found two patients with spontaneous BSP, both of whom were taken off anesthetics and remained in burst suppression: one for 72 hours and one for 4 days. Both patients fully recovered consciousness.
When first induced, the patients with spontaneous BSP started with bursts that had more of a delta feature. However, once spontaneous BSP kicked in, a prominent theta feature emerged and grew increasingly more evident.
The investigators found similar theta features in patients who recovered with only induced and reduced BSP. But those who did not do well either had a flat spectra, similar to type A EEG that is correlated with poor outcomes, or had some signs of theta features within 72 hours and then lost them.
“This suggests this theta frequency activity within the bursts, maybe it signals underlying networks that are potentially recoverable and are necessary for consciousness,” Dr. Sekar explained. “In these cases, maybe they were early on available but as energy dynamics lagged behind recovery of the brain, maybe they just never got those networks to function again.”
Going forward, Dr. Sekar and her colleagues plan to do a prospective study with a longer period of observation to see the effects of these theta frequency features.
The study was supported by individual grants from the National Institutes of Health, a Leon Levy Neuroscience Fellowship Award, and several foundations. The investigators reported no relevant financial disclosures.
ezimmerman@frontlinemedcom.com
SOURCE: Sekar K et al., AES Abstract 1.097
WASHINGTON – , according to findings from a retrospective study presented at the annual meeting of the American Epilepsy Society.
Traditionally, burst suppression patterns (BSP) in post–cardiac arrest patients, especially without anesthesia or cooling, has been considered strongly associated with poor network-level recovery, but findings reported by Krithiga Sekar, MD, PhD, and her colleagues in a poster at the meeting show that patients with BSP on EEG recover consciousness with the same frequency as do those who recover without BSP.
In fact, Dr. Sekar, an epilepsy fellow at Columbia University, New York, and her colleagues asserted that prognoses of poor outcomes are more accurately associated with characteristics of the signals themselves, with some cases of BSP acting as a neuroprotective mechanism during metabolic stress.
Dr. Sekar and her coinvestigators retrospectively studied 73 cardiac arrest patients who underwent therapeutic hypothermia with continuous video EEG monitoring at Cornell. Of those studied, 45 (62%) had BSP on EEG, a common occurrence after cardiac arrest, according to Dr. Sekar.
Of those with BSP on EEG, 14 (31%) recovered consciousness within the first 72 hours of arrest, as did 10 (36%) who recovered without BSP.
For those who did not recover, the median number of days hooked up was around 9, much longer than in other studies, which could be why more patients recovered compared with those in older literature, according to Dr. Sekar and her fellow investigators.
“The length of time for withdrawal of care was around 9 or 10 days, while much of the literature I had read had withdrawal of care within the first 4 or 5 days,” Dr. Sekar said. “If people think [BSP] is a poor prognosticator, they will withdraw care more often, and then that accumulates more data that this is a poor prognosticator.”
Of the 49 who did not recover, 12 patients in the BSP group and 10 patients in the non-BSP group had care withdrawn.
During the study, Dr. Sekar and her colleagues found two patients with spontaneous BSP, both of whom were taken off anesthetics and remained in burst suppression: one for 72 hours and one for 4 days. Both patients fully recovered consciousness.
When first induced, the patients with spontaneous BSP started with bursts that had more of a delta feature. However, once spontaneous BSP kicked in, a prominent theta feature emerged and grew increasingly more evident.
The investigators found similar theta features in patients who recovered with only induced and reduced BSP. But those who did not do well either had a flat spectra, similar to type A EEG that is correlated with poor outcomes, or had some signs of theta features within 72 hours and then lost them.
“This suggests this theta frequency activity within the bursts, maybe it signals underlying networks that are potentially recoverable and are necessary for consciousness,” Dr. Sekar explained. “In these cases, maybe they were early on available but as energy dynamics lagged behind recovery of the brain, maybe they just never got those networks to function again.”
Going forward, Dr. Sekar and her colleagues plan to do a prospective study with a longer period of observation to see the effects of these theta frequency features.
The study was supported by individual grants from the National Institutes of Health, a Leon Levy Neuroscience Fellowship Award, and several foundations. The investigators reported no relevant financial disclosures.
ezimmerman@frontlinemedcom.com
SOURCE: Sekar K et al., AES Abstract 1.097
WASHINGTON – , according to findings from a retrospective study presented at the annual meeting of the American Epilepsy Society.
Traditionally, burst suppression patterns (BSP) in post–cardiac arrest patients, especially without anesthesia or cooling, has been considered strongly associated with poor network-level recovery, but findings reported by Krithiga Sekar, MD, PhD, and her colleagues in a poster at the meeting show that patients with BSP on EEG recover consciousness with the same frequency as do those who recover without BSP.
In fact, Dr. Sekar, an epilepsy fellow at Columbia University, New York, and her colleagues asserted that prognoses of poor outcomes are more accurately associated with characteristics of the signals themselves, with some cases of BSP acting as a neuroprotective mechanism during metabolic stress.
Dr. Sekar and her coinvestigators retrospectively studied 73 cardiac arrest patients who underwent therapeutic hypothermia with continuous video EEG monitoring at Cornell. Of those studied, 45 (62%) had BSP on EEG, a common occurrence after cardiac arrest, according to Dr. Sekar.
Of those with BSP on EEG, 14 (31%) recovered consciousness within the first 72 hours of arrest, as did 10 (36%) who recovered without BSP.
For those who did not recover, the median number of days hooked up was around 9, much longer than in other studies, which could be why more patients recovered compared with those in older literature, according to Dr. Sekar and her fellow investigators.
“The length of time for withdrawal of care was around 9 or 10 days, while much of the literature I had read had withdrawal of care within the first 4 or 5 days,” Dr. Sekar said. “If people think [BSP] is a poor prognosticator, they will withdraw care more often, and then that accumulates more data that this is a poor prognosticator.”
Of the 49 who did not recover, 12 patients in the BSP group and 10 patients in the non-BSP group had care withdrawn.
During the study, Dr. Sekar and her colleagues found two patients with spontaneous BSP, both of whom were taken off anesthetics and remained in burst suppression: one for 72 hours and one for 4 days. Both patients fully recovered consciousness.
When first induced, the patients with spontaneous BSP started with bursts that had more of a delta feature. However, once spontaneous BSP kicked in, a prominent theta feature emerged and grew increasingly more evident.
The investigators found similar theta features in patients who recovered with only induced and reduced BSP. But those who did not do well either had a flat spectra, similar to type A EEG that is correlated with poor outcomes, or had some signs of theta features within 72 hours and then lost them.
“This suggests this theta frequency activity within the bursts, maybe it signals underlying networks that are potentially recoverable and are necessary for consciousness,” Dr. Sekar explained. “In these cases, maybe they were early on available but as energy dynamics lagged behind recovery of the brain, maybe they just never got those networks to function again.”
Going forward, Dr. Sekar and her colleagues plan to do a prospective study with a longer period of observation to see the effects of these theta frequency features.
The study was supported by individual grants from the National Institutes of Health, a Leon Levy Neuroscience Fellowship Award, and several foundations. The investigators reported no relevant financial disclosures.
ezimmerman@frontlinemedcom.com
SOURCE: Sekar K et al., AES Abstract 1.097
REPORTING FROM AES 2017
Key clinical point: A better understanding of BSP in comatose patients will assist improvement for those with potential to recover.
Major finding: Fourteen patients with BSP recovered consciousness, compared with 10 patients without BSP.
Data source: Retrospective study of 73 patients who were comatose after cardiac arrest.
Disclosures: The study was supported by individual grants from the National Institutes of Health, a Leon Levy Neuroscience Fellowship Award, and several foundations. The investigators reported no relevant financial disclosures.
Source: Sekar K et al. AES Abstract 1.097
Elderly trauma patients at high risk for post-discharge mortality
LAKE BUENA VISTA, FLA. – Nearly one-quarter of discharge, according to a study presented at the Eastern Association for the Surgery of Trauma Scientific Assembly.
These findings emphasize a need to know more about geriatric patient outcomes, especially as a tide of elderly trauma patients has begun to sweep through trauma centers, according to presenter Ciara Huntington, MD, a surgical resident at the Carolinas Healthcare System, Charlotte, N.C.
Investigators studied 6,285 geriatric patients in the ACS-verified Level 1 trauma registry between 2009 and 2015, and cross-referenced those files with the Social Security Death Index.
Patients were an average of 78.6 years, and the majority were female (57%) and white (85.7%). Average length of stay of was 6.7 days with an average injury severity score of 11, with a median time to death of 225 days.
While 5,780 patients were alive at discharge, 1,519 (24.2%) were dead within 1 year of hospitalization.
In a comparison of geriatric trauma patients against those of similar age in the general population, geriatric patients within the trauma population had a significantly lower life expectancy across all ages.
For trauma patients aged 65-70 years, life expectancy was estimated at 1.52 years, compared with 18.79 years for those in the general population.
Discharge location may have an impact on mortality, according to Dr. Huntington and her colleagues, who found geriatric patients discharged to their homes had a 1-year mortality rate of 13.5%, compared with 22.6% of those discharged to acute inpatient rehab centers, and 53.7% of those sent to skilled nursing facilities.
Another factor may be mechanism of injury, as the 1-year mortality of trauma patients who had fallen (27%) was nearly double the rate of those in motor vehicle crashes (15%).
Falls also were the most common injury, accounting for around 75% of the hospitalizations in the study.
In a question-and-answer session after the presentation, audience members asked about how these findings will help improve palliative care for geriatric trauma patients.
“The goal of this research is to have better predictive models and also to have better conversations” with families about the potential outcomes of trauma in these elderly patients, Dr. Huntington responded. Knowing the risk of 1-year mortality can change “how families can plan to spend time with their loved ones and how to make more appropriate medical decisions by incorporating quantitative data into the conversation.”
Dr. Huntington and her colleagues reported no relevant financial disclosures.
ezimmerman@frontlinemedcom.com
SOURCE: EAST 2018, Abstract #47.
LAKE BUENA VISTA, FLA. – Nearly one-quarter of discharge, according to a study presented at the Eastern Association for the Surgery of Trauma Scientific Assembly.
These findings emphasize a need to know more about geriatric patient outcomes, especially as a tide of elderly trauma patients has begun to sweep through trauma centers, according to presenter Ciara Huntington, MD, a surgical resident at the Carolinas Healthcare System, Charlotte, N.C.
Investigators studied 6,285 geriatric patients in the ACS-verified Level 1 trauma registry between 2009 and 2015, and cross-referenced those files with the Social Security Death Index.
Patients were an average of 78.6 years, and the majority were female (57%) and white (85.7%). Average length of stay of was 6.7 days with an average injury severity score of 11, with a median time to death of 225 days.
While 5,780 patients were alive at discharge, 1,519 (24.2%) were dead within 1 year of hospitalization.
In a comparison of geriatric trauma patients against those of similar age in the general population, geriatric patients within the trauma population had a significantly lower life expectancy across all ages.
For trauma patients aged 65-70 years, life expectancy was estimated at 1.52 years, compared with 18.79 years for those in the general population.
Discharge location may have an impact on mortality, according to Dr. Huntington and her colleagues, who found geriatric patients discharged to their homes had a 1-year mortality rate of 13.5%, compared with 22.6% of those discharged to acute inpatient rehab centers, and 53.7% of those sent to skilled nursing facilities.
Another factor may be mechanism of injury, as the 1-year mortality of trauma patients who had fallen (27%) was nearly double the rate of those in motor vehicle crashes (15%).
Falls also were the most common injury, accounting for around 75% of the hospitalizations in the study.
In a question-and-answer session after the presentation, audience members asked about how these findings will help improve palliative care for geriatric trauma patients.
“The goal of this research is to have better predictive models and also to have better conversations” with families about the potential outcomes of trauma in these elderly patients, Dr. Huntington responded. Knowing the risk of 1-year mortality can change “how families can plan to spend time with their loved ones and how to make more appropriate medical decisions by incorporating quantitative data into the conversation.”
Dr. Huntington and her colleagues reported no relevant financial disclosures.
ezimmerman@frontlinemedcom.com
SOURCE: EAST 2018, Abstract #47.
LAKE BUENA VISTA, FLA. – Nearly one-quarter of discharge, according to a study presented at the Eastern Association for the Surgery of Trauma Scientific Assembly.
These findings emphasize a need to know more about geriatric patient outcomes, especially as a tide of elderly trauma patients has begun to sweep through trauma centers, according to presenter Ciara Huntington, MD, a surgical resident at the Carolinas Healthcare System, Charlotte, N.C.
Investigators studied 6,285 geriatric patients in the ACS-verified Level 1 trauma registry between 2009 and 2015, and cross-referenced those files with the Social Security Death Index.
Patients were an average of 78.6 years, and the majority were female (57%) and white (85.7%). Average length of stay of was 6.7 days with an average injury severity score of 11, with a median time to death of 225 days.
While 5,780 patients were alive at discharge, 1,519 (24.2%) were dead within 1 year of hospitalization.
In a comparison of geriatric trauma patients against those of similar age in the general population, geriatric patients within the trauma population had a significantly lower life expectancy across all ages.
For trauma patients aged 65-70 years, life expectancy was estimated at 1.52 years, compared with 18.79 years for those in the general population.
Discharge location may have an impact on mortality, according to Dr. Huntington and her colleagues, who found geriatric patients discharged to their homes had a 1-year mortality rate of 13.5%, compared with 22.6% of those discharged to acute inpatient rehab centers, and 53.7% of those sent to skilled nursing facilities.
Another factor may be mechanism of injury, as the 1-year mortality of trauma patients who had fallen (27%) was nearly double the rate of those in motor vehicle crashes (15%).
Falls also were the most common injury, accounting for around 75% of the hospitalizations in the study.
In a question-and-answer session after the presentation, audience members asked about how these findings will help improve palliative care for geriatric trauma patients.
“The goal of this research is to have better predictive models and also to have better conversations” with families about the potential outcomes of trauma in these elderly patients, Dr. Huntington responded. Knowing the risk of 1-year mortality can change “how families can plan to spend time with their loved ones and how to make more appropriate medical decisions by incorporating quantitative data into the conversation.”
Dr. Huntington and her colleagues reported no relevant financial disclosures.
ezimmerman@frontlinemedcom.com
SOURCE: EAST 2018, Abstract #47.
REPORTING FROM EAST 2018
Key clinical point: Short-term mortality rates do not show a full picture of the burden of trauma on elderly patients.
Major finding: While 92% of patients survived to discharge, 24.1% of patients died within 1 year after injury, and 41.9% died within 8 years of injury.
Data source: Study of 6,285 geriatric trauma patients collected from an ACS-verified Level 1 trauma center registry database during 2009-2015.
Disclosures: Presenters reported no relevant financial disclosures.
Source: EAST Scientific Assembly abstract #47.
EHR application doubles hypertension recognition rate
Hypertension discovery in pediatric patients more than doubled for physicians using a clinical decision support (CDS) tool connected to the EHR, results of a study found.
Elyse O. Kharbanda, MD, MPH, a researcher at the HealthPartners Institute, Minneapolis, and her fellow investigators assert that using such a tool will help rectify the trend of underreported hypertension in adolescents, which remains a serious concern despite providers’ routinely taking blood pressure measurements during outpatient visits.
“Among patients with multiple visits, electronic health records should contain sufficient information to diagnose hypertension,” Dr. Kharbanda and her associates reported in their article published in Pediatrics. “However, even when EHRs are configured to display BP percentiles, information on the patterns of BP percentiles over time, previous diagnoses, and medications is not presented in a format that is useful for clinicians.”
With TeenBP, providers are first prompted to take an initial BP reading, as well as height and weight measurements.
If the first measure is above the 95th percentile, the CDS requests an additional reading, which is then averaged with the first. If average of the two is above or within the 95th percentile, the provider is notified and sent a list of recommendations, including a diagnosis of hypertension, lipid screening, and nutrition referral.
The 2-year trial included 522 pediatric patients with incident hypertension; the data were gathered from 20 primary care clinics within one health system between April 2014 and April 2016.
The rate of clinical recognition of patients’ hypertension in the clinics utilizing the CDS tool was more than double the rate seen in the clinics that weren’t (55% and 21%, respectively; P less than .001).
More of the children seen in CDS clinics were referred to dietitians or weight loss programs, compared with those seen in the control clinics (17% and 4%, respectively; P = .001).
Those who used the tool reported high levels of satisfaction, which is likely partly because investigators consulted physicians to help design the application.
“The CDS tool was based on the guidelines for BP management in children and adolescents in effect at the time of the study with local input from clinical and operational leaders within the medical group, and thus it contained the so-called right information,” according to Dr. Kharbanda and her fellow investigators.
Of the 55 physicians who remembered using the tool, 92% thought is was useful in identifying hypertension, 94% considered the CDS a good use of time, and 95% believed is was a useful shared-decision making tool.
When designing TeenBP, investigators tailored the application to the work flow and culture of the health system used for the study, which may limit the generalizability of the findings.
The study was funded by the National Institutes of Health. Dr. Kharbanda and her associates reported no relevant financial disclosures.
ezimmerman@frontlinemedcom.com
Source: Kharbanda EO et al. Pediatrics. 2018. doi: 10.1542/peds.2017- 2954.
The rate of children and adolescents with elevated blood pressure going unrecognized is an increasingly concerning issue – one that is complicated because physicians lack a simple, single BP value system. Some have tried to fill the gap, creating simplified tables of BP values or automated displays of BP values in EHRs, but having a table that only takes age and sex into consideration for screening does not cover the complexities needed to identify hypertension.
Previous studies have looked into utilizing a clinical decision support (CDS) application, which has great potential as a digital multitool to improve quality of care, increase efficiency, and reduce medical errors. However, to be an effective CDS, it must fill the “CDS Five Rights” framework. This guideline states that a CDS tool needs to provide: “the right information, to the right people, through the right channels, in the right intervention formats, at the right points in the work flow.”
The TeenBP CDS developed by Kharbanda et al. fulfills these requirements and goes beyond any CDS previously designed. Even so, 45% of children with elevated BP or hypertension were not recognized, emphasizing the need for additional strategies outside of relying on new technology.
Visit summaries should be given to parents with BP readings so that they can monitor their children’s levels, for example.
Recognition of abnormal BP in teens is the first step toward preventing cardiovascular disease as an adult, and hopefully, the development of new tools, including this CDS, will help physicians find those children who have been overlooked.
Ari H. Pollack, MD, MSIM, is a pediatric nephrologist at the Seattle Children’s Hospital and an assistant professor of pediatrics at the University of Washington, Seattle. Joseph T. Flynn, MD, MS, is the division chief of nephrology in prenatal diagnosis and treatment at the Seattle Children’s Hospital and a professor of pediatrics at the same university. Dr. Pollack and Dr. Flynn reported no relevant financial disclosures in their commentary in Pediatrics (2018. doi: 10.1542/peds.2017-3756).
The rate of children and adolescents with elevated blood pressure going unrecognized is an increasingly concerning issue – one that is complicated because physicians lack a simple, single BP value system. Some have tried to fill the gap, creating simplified tables of BP values or automated displays of BP values in EHRs, but having a table that only takes age and sex into consideration for screening does not cover the complexities needed to identify hypertension.
Previous studies have looked into utilizing a clinical decision support (CDS) application, which has great potential as a digital multitool to improve quality of care, increase efficiency, and reduce medical errors. However, to be an effective CDS, it must fill the “CDS Five Rights” framework. This guideline states that a CDS tool needs to provide: “the right information, to the right people, through the right channels, in the right intervention formats, at the right points in the work flow.”
The TeenBP CDS developed by Kharbanda et al. fulfills these requirements and goes beyond any CDS previously designed. Even so, 45% of children with elevated BP or hypertension were not recognized, emphasizing the need for additional strategies outside of relying on new technology.
Visit summaries should be given to parents with BP readings so that they can monitor their children’s levels, for example.
Recognition of abnormal BP in teens is the first step toward preventing cardiovascular disease as an adult, and hopefully, the development of new tools, including this CDS, will help physicians find those children who have been overlooked.
Ari H. Pollack, MD, MSIM, is a pediatric nephrologist at the Seattle Children’s Hospital and an assistant professor of pediatrics at the University of Washington, Seattle. Joseph T. Flynn, MD, MS, is the division chief of nephrology in prenatal diagnosis and treatment at the Seattle Children’s Hospital and a professor of pediatrics at the same university. Dr. Pollack and Dr. Flynn reported no relevant financial disclosures in their commentary in Pediatrics (2018. doi: 10.1542/peds.2017-3756).
The rate of children and adolescents with elevated blood pressure going unrecognized is an increasingly concerning issue – one that is complicated because physicians lack a simple, single BP value system. Some have tried to fill the gap, creating simplified tables of BP values or automated displays of BP values in EHRs, but having a table that only takes age and sex into consideration for screening does not cover the complexities needed to identify hypertension.
Previous studies have looked into utilizing a clinical decision support (CDS) application, which has great potential as a digital multitool to improve quality of care, increase efficiency, and reduce medical errors. However, to be an effective CDS, it must fill the “CDS Five Rights” framework. This guideline states that a CDS tool needs to provide: “the right information, to the right people, through the right channels, in the right intervention formats, at the right points in the work flow.”
The TeenBP CDS developed by Kharbanda et al. fulfills these requirements and goes beyond any CDS previously designed. Even so, 45% of children with elevated BP or hypertension were not recognized, emphasizing the need for additional strategies outside of relying on new technology.
Visit summaries should be given to parents with BP readings so that they can monitor their children’s levels, for example.
Recognition of abnormal BP in teens is the first step toward preventing cardiovascular disease as an adult, and hopefully, the development of new tools, including this CDS, will help physicians find those children who have been overlooked.
Ari H. Pollack, MD, MSIM, is a pediatric nephrologist at the Seattle Children’s Hospital and an assistant professor of pediatrics at the University of Washington, Seattle. Joseph T. Flynn, MD, MS, is the division chief of nephrology in prenatal diagnosis and treatment at the Seattle Children’s Hospital and a professor of pediatrics at the same university. Dr. Pollack and Dr. Flynn reported no relevant financial disclosures in their commentary in Pediatrics (2018. doi: 10.1542/peds.2017-3756).
Hypertension discovery in pediatric patients more than doubled for physicians using a clinical decision support (CDS) tool connected to the EHR, results of a study found.
Elyse O. Kharbanda, MD, MPH, a researcher at the HealthPartners Institute, Minneapolis, and her fellow investigators assert that using such a tool will help rectify the trend of underreported hypertension in adolescents, which remains a serious concern despite providers’ routinely taking blood pressure measurements during outpatient visits.
“Among patients with multiple visits, electronic health records should contain sufficient information to diagnose hypertension,” Dr. Kharbanda and her associates reported in their article published in Pediatrics. “However, even when EHRs are configured to display BP percentiles, information on the patterns of BP percentiles over time, previous diagnoses, and medications is not presented in a format that is useful for clinicians.”
With TeenBP, providers are first prompted to take an initial BP reading, as well as height and weight measurements.
If the first measure is above the 95th percentile, the CDS requests an additional reading, which is then averaged with the first. If average of the two is above or within the 95th percentile, the provider is notified and sent a list of recommendations, including a diagnosis of hypertension, lipid screening, and nutrition referral.
The 2-year trial included 522 pediatric patients with incident hypertension; the data were gathered from 20 primary care clinics within one health system between April 2014 and April 2016.
The rate of clinical recognition of patients’ hypertension in the clinics utilizing the CDS tool was more than double the rate seen in the clinics that weren’t (55% and 21%, respectively; P less than .001).
More of the children seen in CDS clinics were referred to dietitians or weight loss programs, compared with those seen in the control clinics (17% and 4%, respectively; P = .001).
Those who used the tool reported high levels of satisfaction, which is likely partly because investigators consulted physicians to help design the application.
“The CDS tool was based on the guidelines for BP management in children and adolescents in effect at the time of the study with local input from clinical and operational leaders within the medical group, and thus it contained the so-called right information,” according to Dr. Kharbanda and her fellow investigators.
Of the 55 physicians who remembered using the tool, 92% thought is was useful in identifying hypertension, 94% considered the CDS a good use of time, and 95% believed is was a useful shared-decision making tool.
When designing TeenBP, investigators tailored the application to the work flow and culture of the health system used for the study, which may limit the generalizability of the findings.
The study was funded by the National Institutes of Health. Dr. Kharbanda and her associates reported no relevant financial disclosures.
ezimmerman@frontlinemedcom.com
Source: Kharbanda EO et al. Pediatrics. 2018. doi: 10.1542/peds.2017- 2954.
Hypertension discovery in pediatric patients more than doubled for physicians using a clinical decision support (CDS) tool connected to the EHR, results of a study found.
Elyse O. Kharbanda, MD, MPH, a researcher at the HealthPartners Institute, Minneapolis, and her fellow investigators assert that using such a tool will help rectify the trend of underreported hypertension in adolescents, which remains a serious concern despite providers’ routinely taking blood pressure measurements during outpatient visits.
“Among patients with multiple visits, electronic health records should contain sufficient information to diagnose hypertension,” Dr. Kharbanda and her associates reported in their article published in Pediatrics. “However, even when EHRs are configured to display BP percentiles, information on the patterns of BP percentiles over time, previous diagnoses, and medications is not presented in a format that is useful for clinicians.”
With TeenBP, providers are first prompted to take an initial BP reading, as well as height and weight measurements.
If the first measure is above the 95th percentile, the CDS requests an additional reading, which is then averaged with the first. If average of the two is above or within the 95th percentile, the provider is notified and sent a list of recommendations, including a diagnosis of hypertension, lipid screening, and nutrition referral.
The 2-year trial included 522 pediatric patients with incident hypertension; the data were gathered from 20 primary care clinics within one health system between April 2014 and April 2016.
The rate of clinical recognition of patients’ hypertension in the clinics utilizing the CDS tool was more than double the rate seen in the clinics that weren’t (55% and 21%, respectively; P less than .001).
More of the children seen in CDS clinics were referred to dietitians or weight loss programs, compared with those seen in the control clinics (17% and 4%, respectively; P = .001).
Those who used the tool reported high levels of satisfaction, which is likely partly because investigators consulted physicians to help design the application.
“The CDS tool was based on the guidelines for BP management in children and adolescents in effect at the time of the study with local input from clinical and operational leaders within the medical group, and thus it contained the so-called right information,” according to Dr. Kharbanda and her fellow investigators.
Of the 55 physicians who remembered using the tool, 92% thought is was useful in identifying hypertension, 94% considered the CDS a good use of time, and 95% believed is was a useful shared-decision making tool.
When designing TeenBP, investigators tailored the application to the work flow and culture of the health system used for the study, which may limit the generalizability of the findings.
The study was funded by the National Institutes of Health. Dr. Kharbanda and her associates reported no relevant financial disclosures.
ezimmerman@frontlinemedcom.com
Source: Kharbanda EO et al. Pediatrics. 2018. doi: 10.1542/peds.2017- 2954.
FROM PEDIATRICS
Key clinical point: Using a clinical decision support (CDS) tool doubles the rate of hypertension detection in children.
Major finding: Providers in clinics that used CDS recognized hypertension in 55% of patients, compared with 21% of patients in usual care (P less than .001).
Study details: Cluster-randomized trial of 522 pediatric patients across 20 primary care clinics who received care between April 2014 and April 2016.
Disclosures: The study was funded by the National Institutes of Health. The investigators reported no relevant financial disclosures.
Source: Kharbanda EO et al. Pediatrics. 2018. doi: 10.1542/peds.2017- 2954.
Gastrografin offers an alternative to surgery for SBO
LAKE BUENA VISTA, FLA. – Gastrografin significantly decreased the need for an operation in small bowel obstruction (SBO) patients, even among patients who had never undergone abdominal surgery, according to a study presented at the annual scientific assembly of the Eastern Association for the Surgery of Trauma.
“Small bowel obstruction is a common clinical problem in the United States, with 15 out of 100 admissions for abdominal pain related to SBO,” said Morgan Collom, DO, surgical resident at Medical City Fort Worth (Tex.). “Many studies conclude that [operative exploration] is not needed and it is feasible to perform nonoperative conservative management, yet still argue that small obstruction in a virgin abdomen patient should undergo mandatory exploration to avoid missing a diagnosis of malignancy.”
Investigators studied 601 SBO patients admitted to one of 14 institutions included in an EAST database between February 2015 and December 2016 for this prospective study.
Of those included, 500 had previous abdominal surgery and the others had never had surgery. Gastrografin (Bracco Diagnostics) was used to treat their bowel obstruction.
Those with previous abdominal surgery were more likely to be over age 65 years (48% vs. 36%), be female (50% vs. 25%), have a history of cancer (42.6% vs. 18.8%), and have a prior admission of SBO (41.2% vs 8.9%), according to Dr. Collom.
Among patients who previously had surgery, operative exploration was 50% less likely (odds ratio = .51, P = .04) than among those who had never had surgery. In a comparison of patients with and without previous surgery, introducing Gastrografin evened out the likelihood for an operation (OR = .17 and .21, respectively). Overall, those who received Gastrografin were 86% less likely to undergo bowel exploration(OR = .14, P less than .01).
Of the 36 NAS patients treated with Gastrografin, 33 underwent successful, nonoperative therapy, and 3 underwent a therapeutic laparotomy for a malignancy.
During a question-and-answer session, audience members called to attention the issue of the database used, which does not review complications or recurrences after 30 days or any missed abnormalities, indicating that some malignancies may have developed after the therapy.
Dr. Collom acknowledged the limitation and agreed that the next study would need to address this.
The investigators reported no relevant financial disclosures.
ezimmerman@frontlinemedcom.com
SOURCE: EAST Scientific Assembly abstract No. 24.
LAKE BUENA VISTA, FLA. – Gastrografin significantly decreased the need for an operation in small bowel obstruction (SBO) patients, even among patients who had never undergone abdominal surgery, according to a study presented at the annual scientific assembly of the Eastern Association for the Surgery of Trauma.
“Small bowel obstruction is a common clinical problem in the United States, with 15 out of 100 admissions for abdominal pain related to SBO,” said Morgan Collom, DO, surgical resident at Medical City Fort Worth (Tex.). “Many studies conclude that [operative exploration] is not needed and it is feasible to perform nonoperative conservative management, yet still argue that small obstruction in a virgin abdomen patient should undergo mandatory exploration to avoid missing a diagnosis of malignancy.”
Investigators studied 601 SBO patients admitted to one of 14 institutions included in an EAST database between February 2015 and December 2016 for this prospective study.
Of those included, 500 had previous abdominal surgery and the others had never had surgery. Gastrografin (Bracco Diagnostics) was used to treat their bowel obstruction.
Those with previous abdominal surgery were more likely to be over age 65 years (48% vs. 36%), be female (50% vs. 25%), have a history of cancer (42.6% vs. 18.8%), and have a prior admission of SBO (41.2% vs 8.9%), according to Dr. Collom.
Among patients who previously had surgery, operative exploration was 50% less likely (odds ratio = .51, P = .04) than among those who had never had surgery. In a comparison of patients with and without previous surgery, introducing Gastrografin evened out the likelihood for an operation (OR = .17 and .21, respectively). Overall, those who received Gastrografin were 86% less likely to undergo bowel exploration(OR = .14, P less than .01).
Of the 36 NAS patients treated with Gastrografin, 33 underwent successful, nonoperative therapy, and 3 underwent a therapeutic laparotomy for a malignancy.
During a question-and-answer session, audience members called to attention the issue of the database used, which does not review complications or recurrences after 30 days or any missed abnormalities, indicating that some malignancies may have developed after the therapy.
Dr. Collom acknowledged the limitation and agreed that the next study would need to address this.
The investigators reported no relevant financial disclosures.
ezimmerman@frontlinemedcom.com
SOURCE: EAST Scientific Assembly abstract No. 24.
LAKE BUENA VISTA, FLA. – Gastrografin significantly decreased the need for an operation in small bowel obstruction (SBO) patients, even among patients who had never undergone abdominal surgery, according to a study presented at the annual scientific assembly of the Eastern Association for the Surgery of Trauma.
“Small bowel obstruction is a common clinical problem in the United States, with 15 out of 100 admissions for abdominal pain related to SBO,” said Morgan Collom, DO, surgical resident at Medical City Fort Worth (Tex.). “Many studies conclude that [operative exploration] is not needed and it is feasible to perform nonoperative conservative management, yet still argue that small obstruction in a virgin abdomen patient should undergo mandatory exploration to avoid missing a diagnosis of malignancy.”
Investigators studied 601 SBO patients admitted to one of 14 institutions included in an EAST database between February 2015 and December 2016 for this prospective study.
Of those included, 500 had previous abdominal surgery and the others had never had surgery. Gastrografin (Bracco Diagnostics) was used to treat their bowel obstruction.
Those with previous abdominal surgery were more likely to be over age 65 years (48% vs. 36%), be female (50% vs. 25%), have a history of cancer (42.6% vs. 18.8%), and have a prior admission of SBO (41.2% vs 8.9%), according to Dr. Collom.
Among patients who previously had surgery, operative exploration was 50% less likely (odds ratio = .51, P = .04) than among those who had never had surgery. In a comparison of patients with and without previous surgery, introducing Gastrografin evened out the likelihood for an operation (OR = .17 and .21, respectively). Overall, those who received Gastrografin were 86% less likely to undergo bowel exploration(OR = .14, P less than .01).
Of the 36 NAS patients treated with Gastrografin, 33 underwent successful, nonoperative therapy, and 3 underwent a therapeutic laparotomy for a malignancy.
During a question-and-answer session, audience members called to attention the issue of the database used, which does not review complications or recurrences after 30 days or any missed abnormalities, indicating that some malignancies may have developed after the therapy.
Dr. Collom acknowledged the limitation and agreed that the next study would need to address this.
The investigators reported no relevant financial disclosures.
ezimmerman@frontlinemedcom.com
SOURCE: EAST Scientific Assembly abstract No. 24.
REPORTING FROM EAST 2018
Key clinical point: Gastrografin is an effective alternative to operative exploration in small bowel obstruction patients with or without a history of surgical intervention.
Major finding: Treatment with Gastrografin (Bracco Diagnostics) reduced the risk of operative exploration for patients with small bowel obstruction (OR = .14, P less than .01).
Data source: Prospective, observational study of 601 small bowel obstruction patients seen at 14 institutions between February 2015 and December 2016.
Disclosures: The investigators reported no relevant financial disclosures.
Source: Collom et al. EAST Scientific Assembly, abstract 24.
Atopic dermatitis linked to psychiatric disorders but not hospitalizations
Atopic dermatitis (AD) is associated with anxiety, depression, and suicidal thoughts but does not lead to increased psychiatric hospitalization or suicide, according to a Danish study.
While previous literature has indicated a connection between AD and depressive symptoms, these findings indicated the psychiatric burden is not severe.
A total of 9,656 patients selected from the Danish study of Functional Disorders (DanFunD) during 2011-2015 were asked to fill out a questionnaire concerning clinical diagnoses and psychiatric symptoms.
Investigators also conducted an analysis of 4,259,457 patient records gathered the Danish National Patient Register.
The 1,044 AD patients from the DanFunD were slightly younger on average, at 50 years, compared with an average of 53 years in the 8,612-person control group; there were more women (65%) in the AD group, compared with a relatively even split (53%) in the control group.
Patients with AD were more likely to have clinically diagnosed depression (odds ratio, 1.76) or anxiety (OR, 1.61) than were those in the control group.
The report was published in the journal Allergy.
Among the 568 individuals with symptoms consistent of major depressive disorder, those with AD (112) were almost twice as likely to report these symptoms on the questionnaire (OR, 1.92) and more than twice as likely to report anxiety attacks (OR, 2.32), despite differences in psychiatric hospitalizations remaining insignificant.
The investigators hypothesized the treatment methods for AD patients may be part of the reason that suicide and hospitalization rates were not higher.
“These more severe outcomes of suicide and psychiatric hospitalization could be mitigated in AD patients due to their increased general health care and psychiatric health care utilization leading to, for example, earlier and more aggressive antidepressant therapy,” according to Dr. Thyssen and his fellow investigators.
In an analysis of the general Danish population, medication was most aggressive in patients with moderate-severe AD, who were significantly more likely to use antidepressants (hazard ratio,1.24) and anxiolytic drugs (HR, 1.66), while those with milder symptoms had only a slightly increased likelihood.
Because of the observational nature of the study, investigators could not determine what the specific cause of these psychiatric symptoms were.
The DanFunD Study was supported by TrygFonden and Lundbeck Foundation. Dr. Thyssen is supported by a grant from the Lundbeck Foundation. Some of the investigators received financial support from various pharmaceutical companies or their foundations. The remaining investigators reported no relevant financial disclosures.
ezimmerman@frontlinemedcom.com
SOURCE: Thyssen JP et al. Allergy. 2018 Jan;73(1):214-20.
Atopic dermatitis (AD) is associated with anxiety, depression, and suicidal thoughts but does not lead to increased psychiatric hospitalization or suicide, according to a Danish study.
While previous literature has indicated a connection between AD and depressive symptoms, these findings indicated the psychiatric burden is not severe.
A total of 9,656 patients selected from the Danish study of Functional Disorders (DanFunD) during 2011-2015 were asked to fill out a questionnaire concerning clinical diagnoses and psychiatric symptoms.
Investigators also conducted an analysis of 4,259,457 patient records gathered the Danish National Patient Register.
The 1,044 AD patients from the DanFunD were slightly younger on average, at 50 years, compared with an average of 53 years in the 8,612-person control group; there were more women (65%) in the AD group, compared with a relatively even split (53%) in the control group.
Patients with AD were more likely to have clinically diagnosed depression (odds ratio, 1.76) or anxiety (OR, 1.61) than were those in the control group.
The report was published in the journal Allergy.
Among the 568 individuals with symptoms consistent of major depressive disorder, those with AD (112) were almost twice as likely to report these symptoms on the questionnaire (OR, 1.92) and more than twice as likely to report anxiety attacks (OR, 2.32), despite differences in psychiatric hospitalizations remaining insignificant.
The investigators hypothesized the treatment methods for AD patients may be part of the reason that suicide and hospitalization rates were not higher.
“These more severe outcomes of suicide and psychiatric hospitalization could be mitigated in AD patients due to their increased general health care and psychiatric health care utilization leading to, for example, earlier and more aggressive antidepressant therapy,” according to Dr. Thyssen and his fellow investigators.
In an analysis of the general Danish population, medication was most aggressive in patients with moderate-severe AD, who were significantly more likely to use antidepressants (hazard ratio,1.24) and anxiolytic drugs (HR, 1.66), while those with milder symptoms had only a slightly increased likelihood.
Because of the observational nature of the study, investigators could not determine what the specific cause of these psychiatric symptoms were.
The DanFunD Study was supported by TrygFonden and Lundbeck Foundation. Dr. Thyssen is supported by a grant from the Lundbeck Foundation. Some of the investigators received financial support from various pharmaceutical companies or their foundations. The remaining investigators reported no relevant financial disclosures.
ezimmerman@frontlinemedcom.com
SOURCE: Thyssen JP et al. Allergy. 2018 Jan;73(1):214-20.
Atopic dermatitis (AD) is associated with anxiety, depression, and suicidal thoughts but does not lead to increased psychiatric hospitalization or suicide, according to a Danish study.
While previous literature has indicated a connection between AD and depressive symptoms, these findings indicated the psychiatric burden is not severe.
A total of 9,656 patients selected from the Danish study of Functional Disorders (DanFunD) during 2011-2015 were asked to fill out a questionnaire concerning clinical diagnoses and psychiatric symptoms.
Investigators also conducted an analysis of 4,259,457 patient records gathered the Danish National Patient Register.
The 1,044 AD patients from the DanFunD were slightly younger on average, at 50 years, compared with an average of 53 years in the 8,612-person control group; there were more women (65%) in the AD group, compared with a relatively even split (53%) in the control group.
Patients with AD were more likely to have clinically diagnosed depression (odds ratio, 1.76) or anxiety (OR, 1.61) than were those in the control group.
The report was published in the journal Allergy.
Among the 568 individuals with symptoms consistent of major depressive disorder, those with AD (112) were almost twice as likely to report these symptoms on the questionnaire (OR, 1.92) and more than twice as likely to report anxiety attacks (OR, 2.32), despite differences in psychiatric hospitalizations remaining insignificant.
The investigators hypothesized the treatment methods for AD patients may be part of the reason that suicide and hospitalization rates were not higher.
“These more severe outcomes of suicide and psychiatric hospitalization could be mitigated in AD patients due to their increased general health care and psychiatric health care utilization leading to, for example, earlier and more aggressive antidepressant therapy,” according to Dr. Thyssen and his fellow investigators.
In an analysis of the general Danish population, medication was most aggressive in patients with moderate-severe AD, who were significantly more likely to use antidepressants (hazard ratio,1.24) and anxiolytic drugs (HR, 1.66), while those with milder symptoms had only a slightly increased likelihood.
Because of the observational nature of the study, investigators could not determine what the specific cause of these psychiatric symptoms were.
The DanFunD Study was supported by TrygFonden and Lundbeck Foundation. Dr. Thyssen is supported by a grant from the Lundbeck Foundation. Some of the investigators received financial support from various pharmaceutical companies or their foundations. The remaining investigators reported no relevant financial disclosures.
ezimmerman@frontlinemedcom.com
SOURCE: Thyssen JP et al. Allergy. 2018 Jan;73(1):214-20.
FROM ALLERGY
Key clinical point:
Major finding: Atopic dermatitis patients were at greater risk for depression (OR, 1.76) and anxiety (OR, 1.61).
Study details: Observational, controlled study of 9,656 Danish residents collected from the Danish study of Functional Disorders between 2011 and 2015, and an analysis of 4,259,457 patient records gathered the Danish National Patient Register.
Disclosures: The DanFunD Study was supported by TrygFonden and Lundbeck Foundation. Dr. Thyssen is supported by a grant from the Lundbeck Foundation. Some of the investigators received financial support from various pharmaceutical companies or their foundations. The remaining investigators reported no relevant financial disclosures.
Source: Thyssen JP et al. Allergy. 2018 Jan;73(1):214-20.
Clinical rule decreased pediatric trauma CT scans
ORLANDO – A according to a study presented at the annual scientific assembly of the Eastern Association for the Surgery of Trauma.
With values for five clinical variables, the prediction rule would eliminate the need to subject some patients to unwarranted radiation exposure, which has become a growing health and financial concern for medical institutions.
“CT utilization rates in pediatric blunt trauma are very high, at a rate of 40%-60%, despite a relatively low incidence of intra-abdominal injury after abdominal trauma,” according to presenter Chase A. Arbra, MD, of the department of surgery at the Medical University of South Carolina, Charleston. “With increasing concerns regarding the cost and radiation exposure in children, our group is focusing on research to safely avoid these unnecessary scans.”
The rule, developed by the Pediatric Surgery Research Collaborative (PedSRC), evaluates abdominal wall trauma and tenderness, complaint of abdominal pain, aspartate aminotransferase level greater than 200 U/L, abnormal pancreatic enzymes, and abnormal chest x-rays to determine a patient’s risk of having an intra-abdominal injury (IAI). If none of the five variables in a patient is abnormal, the finding is considered negative and the patient is considered to be at very low risk for having an IAI or an IAI requiring acute intervention (IAI-I).
Investigators studied 2,435 pediatric blunt trauma patients with all five clinical variables documented within 6 hours of arrival, using data gathered from the Pediatric Emergency Care Applied Research Network.
Patients were an average of 9.4 years old, with an IAI rate of 9.7% (n = 235) and an IAI-I rate of 2.5% (n = 60); 61.1% of the patients had a CT scan.
Prediction sensitivity of the method was 97.5% for IAI and 100% for IAI-I, said Dr. Arbra. Negative predictive value for the model was 99.3% for IAI and 100% for IAI-I.
Patients who were found to have aspartate aminotransferase level greater than 200 U/L were at the highest risk of IAI (52.6%) and IAI-I (11.9%), according to investigators. One-third of the test population was found to be at very low risk after using the prediction model, according to Dr. Arbra, with 46.8% of them still undergoing a CT scan. Of those tested, six patients had IAI that was not predicted by the model, three of whom were intubated. Because CT scans were not required and there was no follow-up after discharge, investigators are not able to determine if any minor IAI was missed.
Despite these limitations, the highly sensitive rule shows great promise, according to Dr. Arbra.
“Patients with 0-5 variables, even patients who were involved in a high impact mechanism, could potentially forgo CT scans safely.”
A closer look at the 26 patients who only had abdominal pain showed that only 1 had IAI, suggesting that patients with only abdominal pain could be safely observed with only serial exams, according to Dr. Arbra.
Investigators plan to conduct a prospective study that will include older patients.
Dr. Arbra concluded, “The rule could potentially help centers to determine who could avoid imaging prior to transfer and potentially could one day be used to see who could be discharged.”
Dr. Arbra reported no relevant financial disclosures.
ezimmerman@frontlinemedcom.com
SOURCE: Arbra CA. EAST Scientific Assembly 2018, paper #7.
ORLANDO – A according to a study presented at the annual scientific assembly of the Eastern Association for the Surgery of Trauma.
With values for five clinical variables, the prediction rule would eliminate the need to subject some patients to unwarranted radiation exposure, which has become a growing health and financial concern for medical institutions.
“CT utilization rates in pediatric blunt trauma are very high, at a rate of 40%-60%, despite a relatively low incidence of intra-abdominal injury after abdominal trauma,” according to presenter Chase A. Arbra, MD, of the department of surgery at the Medical University of South Carolina, Charleston. “With increasing concerns regarding the cost and radiation exposure in children, our group is focusing on research to safely avoid these unnecessary scans.”
The rule, developed by the Pediatric Surgery Research Collaborative (PedSRC), evaluates abdominal wall trauma and tenderness, complaint of abdominal pain, aspartate aminotransferase level greater than 200 U/L, abnormal pancreatic enzymes, and abnormal chest x-rays to determine a patient’s risk of having an intra-abdominal injury (IAI). If none of the five variables in a patient is abnormal, the finding is considered negative and the patient is considered to be at very low risk for having an IAI or an IAI requiring acute intervention (IAI-I).
Investigators studied 2,435 pediatric blunt trauma patients with all five clinical variables documented within 6 hours of arrival, using data gathered from the Pediatric Emergency Care Applied Research Network.
Patients were an average of 9.4 years old, with an IAI rate of 9.7% (n = 235) and an IAI-I rate of 2.5% (n = 60); 61.1% of the patients had a CT scan.
Prediction sensitivity of the method was 97.5% for IAI and 100% for IAI-I, said Dr. Arbra. Negative predictive value for the model was 99.3% for IAI and 100% for IAI-I.
Patients who were found to have aspartate aminotransferase level greater than 200 U/L were at the highest risk of IAI (52.6%) and IAI-I (11.9%), according to investigators. One-third of the test population was found to be at very low risk after using the prediction model, according to Dr. Arbra, with 46.8% of them still undergoing a CT scan. Of those tested, six patients had IAI that was not predicted by the model, three of whom were intubated. Because CT scans were not required and there was no follow-up after discharge, investigators are not able to determine if any minor IAI was missed.
Despite these limitations, the highly sensitive rule shows great promise, according to Dr. Arbra.
“Patients with 0-5 variables, even patients who were involved in a high impact mechanism, could potentially forgo CT scans safely.”
A closer look at the 26 patients who only had abdominal pain showed that only 1 had IAI, suggesting that patients with only abdominal pain could be safely observed with only serial exams, according to Dr. Arbra.
Investigators plan to conduct a prospective study that will include older patients.
Dr. Arbra concluded, “The rule could potentially help centers to determine who could avoid imaging prior to transfer and potentially could one day be used to see who could be discharged.”
Dr. Arbra reported no relevant financial disclosures.
ezimmerman@frontlinemedcom.com
SOURCE: Arbra CA. EAST Scientific Assembly 2018, paper #7.
ORLANDO – A according to a study presented at the annual scientific assembly of the Eastern Association for the Surgery of Trauma.
With values for five clinical variables, the prediction rule would eliminate the need to subject some patients to unwarranted radiation exposure, which has become a growing health and financial concern for medical institutions.
“CT utilization rates in pediatric blunt trauma are very high, at a rate of 40%-60%, despite a relatively low incidence of intra-abdominal injury after abdominal trauma,” according to presenter Chase A. Arbra, MD, of the department of surgery at the Medical University of South Carolina, Charleston. “With increasing concerns regarding the cost and radiation exposure in children, our group is focusing on research to safely avoid these unnecessary scans.”
The rule, developed by the Pediatric Surgery Research Collaborative (PedSRC), evaluates abdominal wall trauma and tenderness, complaint of abdominal pain, aspartate aminotransferase level greater than 200 U/L, abnormal pancreatic enzymes, and abnormal chest x-rays to determine a patient’s risk of having an intra-abdominal injury (IAI). If none of the five variables in a patient is abnormal, the finding is considered negative and the patient is considered to be at very low risk for having an IAI or an IAI requiring acute intervention (IAI-I).
Investigators studied 2,435 pediatric blunt trauma patients with all five clinical variables documented within 6 hours of arrival, using data gathered from the Pediatric Emergency Care Applied Research Network.
Patients were an average of 9.4 years old, with an IAI rate of 9.7% (n = 235) and an IAI-I rate of 2.5% (n = 60); 61.1% of the patients had a CT scan.
Prediction sensitivity of the method was 97.5% for IAI and 100% for IAI-I, said Dr. Arbra. Negative predictive value for the model was 99.3% for IAI and 100% for IAI-I.
Patients who were found to have aspartate aminotransferase level greater than 200 U/L were at the highest risk of IAI (52.6%) and IAI-I (11.9%), according to investigators. One-third of the test population was found to be at very low risk after using the prediction model, according to Dr. Arbra, with 46.8% of them still undergoing a CT scan. Of those tested, six patients had IAI that was not predicted by the model, three of whom were intubated. Because CT scans were not required and there was no follow-up after discharge, investigators are not able to determine if any minor IAI was missed.
Despite these limitations, the highly sensitive rule shows great promise, according to Dr. Arbra.
“Patients with 0-5 variables, even patients who were involved in a high impact mechanism, could potentially forgo CT scans safely.”
A closer look at the 26 patients who only had abdominal pain showed that only 1 had IAI, suggesting that patients with only abdominal pain could be safely observed with only serial exams, according to Dr. Arbra.
Investigators plan to conduct a prospective study that will include older patients.
Dr. Arbra concluded, “The rule could potentially help centers to determine who could avoid imaging prior to transfer and potentially could one day be used to see who could be discharged.”
Dr. Arbra reported no relevant financial disclosures.
ezimmerman@frontlinemedcom.com
SOURCE: Arbra CA. EAST Scientific Assembly 2018, paper #7.
REPORTING FROM EAST 2018
Key clinical point: New prediction model successfully identified patients with intra-abdominal injury (IAI) and IAI patients who require acute intervention (IAI-I).
Major finding: The test had a negative predictive value of 99.3% in IAI patients and 100% in IAI-I patients when either had no abnormalities.
Study details: Prospective study of 2,345 pediatric patients with IAI or IAI-I, the data for which was collected from the Pediatric Emergency Care Applied Research Network.
Disclosures: Dr. Arbra reported no relevant financial disclosures.
Source: Arbra CA. EAST Scientific Assembly 2018, paper #7.
Innovative cholecystectomy grading scale could pay off for surgeons
ORLANDO – according to a study presented at the annual scientific assembly of the Eastern Association for the Surgery of Trauma.
As payment models shift toward bundled care, providers will be more closely evaluated on their postoperative outcomes, which can vary based on the difficulty of surgery, even for relatively common procedures.
“Gallbladder disease affects roughly 20 million people annually in the United States, with laparoscopic cholecystectomy being one of the most common operations performed by the typical surgeon,” said presenter Tarik Madni, MD, of the department of surgery, University of Texas Southwestern Medical Center, Dallas. “However not all cholecystectomies are created equal; increased inflammation can lead to increased operative times, increased conversion rates, as well as increased risk of complications.”
Given the increased scrutiny of surgical procedures, the current application of modifier 22, which allows surgeons to receive greater reimbursement for a more difficult surgery, is not enough, according to Dr. Madni.
To address this shortfall, investigators developed the Parkland grading scale, a five-tiered grading system that is designed to be easy to remember, limited in the number of grades, and correlated with clinical outcomes.
To determine the grades of the scale, Dr. Madni and his fellow investigators used 200 gallbladder images collected immediately before dissection and analyzed anatomy and inflammatory characteristics.
Gallbladders with a grade 1 would be relatively normal looking, while a grade 5 gallbladder would show perforation, necrosis, or not be clearly visible because of adhesions, according to Dr. Madni.
Between September 2016 and March 2017, investigators asked 11 acute care surgeons to prospectively grade gallbladders they saw before surgery using the Parkland scale and to fill out a questionnaire describing the difficulty of the procedure afterwards.
Of 667 gallbladders graded, 60 were assessed to be grade 1 (19%), 90 were grade 2 (28%), 102 were grade 3 (32%), 28 were grade 4 (9%), and 37 were grade 5 (12%) on the Parkland scale.
Grade 1 gallbladders had a mean procedure difficulty score of 1.43, while grade 5 gallbladders had a mean difficulty of 4.46. Grade 1 gallbladders also corresponded with the shortest mean surgery time of 63.31 minutes, compared with an average of 108.13 minutes for grade 5.
Acute cholecystitis diagnosis also increased by Parkland grade, from 36.7% in grade 1 gallbladders to 83.8% in grade 5 (P less than .0001), as did open conversion rates, from 0% to 21.6% (P less than .0001).
Mean length of stay rose fivefold between grade 1 and grade 5 procedures, from around 8 hours to 36 hours, respectively (P less than .0001).
Discussant Martin Zielinski, MD, FACS, director of medical trauma clinical research at the Mayo Clinic, Rochester, Minn., recognized the importance of having a grading scale but was curious why investigators did not analyze the American Association for the Surgery of Trauma’s (AAST) Emergency General Surgery anatomic grading scale, which is already in place.
“The AAST is a uniform, anatomic grading scale to measure the severity of diseases from the 16 most common [Emergency General Surgery] diseases,” Dr. Madni responded. “Unlike our operative-only finding scale, the AAST scale gives grades 1 through 5 definitions for four categories in each disease, not just operative, but clinical, imaging, operative, and pathologic categories.”
Comparatively, the Parkland scale is less cumbersome and covers a wider range of difficulty variation, according to Dr. Madni.
In the future, Dr. Madni and his colleagues will work to compare the Parkland scale to the AAST scale and look for ways to bridge the two.
Dr. Madni reported no relevant financial disclosures.
ezimmerman@frontlinemedcom.com
SOURCE: Madni T et al. EAST Scientific Assembly 2018 abstract #11.
ORLANDO – according to a study presented at the annual scientific assembly of the Eastern Association for the Surgery of Trauma.
As payment models shift toward bundled care, providers will be more closely evaluated on their postoperative outcomes, which can vary based on the difficulty of surgery, even for relatively common procedures.
“Gallbladder disease affects roughly 20 million people annually in the United States, with laparoscopic cholecystectomy being one of the most common operations performed by the typical surgeon,” said presenter Tarik Madni, MD, of the department of surgery, University of Texas Southwestern Medical Center, Dallas. “However not all cholecystectomies are created equal; increased inflammation can lead to increased operative times, increased conversion rates, as well as increased risk of complications.”
Given the increased scrutiny of surgical procedures, the current application of modifier 22, which allows surgeons to receive greater reimbursement for a more difficult surgery, is not enough, according to Dr. Madni.
To address this shortfall, investigators developed the Parkland grading scale, a five-tiered grading system that is designed to be easy to remember, limited in the number of grades, and correlated with clinical outcomes.
To determine the grades of the scale, Dr. Madni and his fellow investigators used 200 gallbladder images collected immediately before dissection and analyzed anatomy and inflammatory characteristics.
Gallbladders with a grade 1 would be relatively normal looking, while a grade 5 gallbladder would show perforation, necrosis, or not be clearly visible because of adhesions, according to Dr. Madni.
Between September 2016 and March 2017, investigators asked 11 acute care surgeons to prospectively grade gallbladders they saw before surgery using the Parkland scale and to fill out a questionnaire describing the difficulty of the procedure afterwards.
Of 667 gallbladders graded, 60 were assessed to be grade 1 (19%), 90 were grade 2 (28%), 102 were grade 3 (32%), 28 were grade 4 (9%), and 37 were grade 5 (12%) on the Parkland scale.
Grade 1 gallbladders had a mean procedure difficulty score of 1.43, while grade 5 gallbladders had a mean difficulty of 4.46. Grade 1 gallbladders also corresponded with the shortest mean surgery time of 63.31 minutes, compared with an average of 108.13 minutes for grade 5.
Acute cholecystitis diagnosis also increased by Parkland grade, from 36.7% in grade 1 gallbladders to 83.8% in grade 5 (P less than .0001), as did open conversion rates, from 0% to 21.6% (P less than .0001).
Mean length of stay rose fivefold between grade 1 and grade 5 procedures, from around 8 hours to 36 hours, respectively (P less than .0001).
Discussant Martin Zielinski, MD, FACS, director of medical trauma clinical research at the Mayo Clinic, Rochester, Minn., recognized the importance of having a grading scale but was curious why investigators did not analyze the American Association for the Surgery of Trauma’s (AAST) Emergency General Surgery anatomic grading scale, which is already in place.
“The AAST is a uniform, anatomic grading scale to measure the severity of diseases from the 16 most common [Emergency General Surgery] diseases,” Dr. Madni responded. “Unlike our operative-only finding scale, the AAST scale gives grades 1 through 5 definitions for four categories in each disease, not just operative, but clinical, imaging, operative, and pathologic categories.”
Comparatively, the Parkland scale is less cumbersome and covers a wider range of difficulty variation, according to Dr. Madni.
In the future, Dr. Madni and his colleagues will work to compare the Parkland scale to the AAST scale and look for ways to bridge the two.
Dr. Madni reported no relevant financial disclosures.
ezimmerman@frontlinemedcom.com
SOURCE: Madni T et al. EAST Scientific Assembly 2018 abstract #11.
ORLANDO – according to a study presented at the annual scientific assembly of the Eastern Association for the Surgery of Trauma.
As payment models shift toward bundled care, providers will be more closely evaluated on their postoperative outcomes, which can vary based on the difficulty of surgery, even for relatively common procedures.
“Gallbladder disease affects roughly 20 million people annually in the United States, with laparoscopic cholecystectomy being one of the most common operations performed by the typical surgeon,” said presenter Tarik Madni, MD, of the department of surgery, University of Texas Southwestern Medical Center, Dallas. “However not all cholecystectomies are created equal; increased inflammation can lead to increased operative times, increased conversion rates, as well as increased risk of complications.”
Given the increased scrutiny of surgical procedures, the current application of modifier 22, which allows surgeons to receive greater reimbursement for a more difficult surgery, is not enough, according to Dr. Madni.
To address this shortfall, investigators developed the Parkland grading scale, a five-tiered grading system that is designed to be easy to remember, limited in the number of grades, and correlated with clinical outcomes.
To determine the grades of the scale, Dr. Madni and his fellow investigators used 200 gallbladder images collected immediately before dissection and analyzed anatomy and inflammatory characteristics.
Gallbladders with a grade 1 would be relatively normal looking, while a grade 5 gallbladder would show perforation, necrosis, or not be clearly visible because of adhesions, according to Dr. Madni.
Between September 2016 and March 2017, investigators asked 11 acute care surgeons to prospectively grade gallbladders they saw before surgery using the Parkland scale and to fill out a questionnaire describing the difficulty of the procedure afterwards.
Of 667 gallbladders graded, 60 were assessed to be grade 1 (19%), 90 were grade 2 (28%), 102 were grade 3 (32%), 28 were grade 4 (9%), and 37 were grade 5 (12%) on the Parkland scale.
Grade 1 gallbladders had a mean procedure difficulty score of 1.43, while grade 5 gallbladders had a mean difficulty of 4.46. Grade 1 gallbladders also corresponded with the shortest mean surgery time of 63.31 minutes, compared with an average of 108.13 minutes for grade 5.
Acute cholecystitis diagnosis also increased by Parkland grade, from 36.7% in grade 1 gallbladders to 83.8% in grade 5 (P less than .0001), as did open conversion rates, from 0% to 21.6% (P less than .0001).
Mean length of stay rose fivefold between grade 1 and grade 5 procedures, from around 8 hours to 36 hours, respectively (P less than .0001).
Discussant Martin Zielinski, MD, FACS, director of medical trauma clinical research at the Mayo Clinic, Rochester, Minn., recognized the importance of having a grading scale but was curious why investigators did not analyze the American Association for the Surgery of Trauma’s (AAST) Emergency General Surgery anatomic grading scale, which is already in place.
“The AAST is a uniform, anatomic grading scale to measure the severity of diseases from the 16 most common [Emergency General Surgery] diseases,” Dr. Madni responded. “Unlike our operative-only finding scale, the AAST scale gives grades 1 through 5 definitions for four categories in each disease, not just operative, but clinical, imaging, operative, and pathologic categories.”
Comparatively, the Parkland scale is less cumbersome and covers a wider range of difficulty variation, according to Dr. Madni.
In the future, Dr. Madni and his colleagues will work to compare the Parkland scale to the AAST scale and look for ways to bridge the two.
Dr. Madni reported no relevant financial disclosures.
ezimmerman@frontlinemedcom.com
SOURCE: Madni T et al. EAST Scientific Assembly 2018 abstract #11.
REPORTING FROM EAST SCIENTIFIC ASSEMBLY
Key clinical point: A five-tiered grading system was developed to determine grades of cholecystectomy operative difficulty.
Major finding: Acute cholecystitis diagnosis also increased by Parkland grade, from 36.7% in grade 1 gallbladders to 83.8% in grade 5.
Study details: Eleven acute care surgeons graded gallbladders on initial view and then filled out a postoperative questionnaire.
Disclosures: The investigator reported no relevant financial disclosures.
Source: Madni T et al. EAST Scientifc Assembly 2018 abstract #11.