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AMA HOD: Preconception care, reducing opioid abuse are top issues
CHIGAGO – Primary care physicians need better training on preconception counseling, according to the American Medical Association House of Delegates.
At its annual meeting, the HOD passed without debate on June 9 a resolution that calls for the AMA to “support the training of all primary care physicians and relevant allied health professionals in the area of preconception counseling, including the recognition of long-acting reversible contraceptives as efficacious and economical forms of contraception.”
According to the reference committee report, the committee noted that “tremendously supportive testimony was heard for efforts to prevent teen pregnancy and for the use of long-acting reversible contraceptives (sic) methods to achieve such prevention and minimize barriers for the use of effective contraception.”
Delegates also called upon the AMA to work with federal stakeholders and pharmaceutical manufacturers to “intensify collaborative efforts involving a public health approach” to reduce harm from inappropriate use, misuse, and diversion of prescription controlled substances, increase awareness that substance use disorders are chronic diseases in need of treatment, and reduce the stigma associated with patients suffering from persistent pain and/or substance use disorders.
According to the report, limited testimony noted that it was “incumbent upon our AMA to continue to address these issues, and further intensify collaborative efforts in order to promote solutions to what are difficult and complex public health issues facing the American public, patients, and their families, and the health care professionals who are entrusted with their treatment.”
The reference committee tackled a number of other issues. Among them was a resolution targeting advocacy for hepatitis C virus education, prevention, screening and treatment. The resolution adopted without debate called for birth year–based HCV screening in alignment with recommendations of the Centers for Disease Control and Prevention; working with the CDC and others on education and prevention efforts; supporting screening, prevention, and treatment programs “targeted toward maximum health benefit”; supporting adequate funding and negotiation for affordable pricing for HCV treatments; and recognizing correctional physicians and other physicians in the public health sector as key stakeholders in the development of HCV treatment guidelines.
Also addressed were issues related to drug labeling, with calls to the AMA to work with the Food and Drug Administration to ensure that drug labels are updated quicker as new evidence comes to market.
Delegates called on the AMA to support federal efforts to stimulate early research and development of rapid infectious disease diagnostic technologies through increased funding for the appropriate agencies, and to work with payers to overcome reimbursement barriers.
CHIGAGO – Primary care physicians need better training on preconception counseling, according to the American Medical Association House of Delegates.
At its annual meeting, the HOD passed without debate on June 9 a resolution that calls for the AMA to “support the training of all primary care physicians and relevant allied health professionals in the area of preconception counseling, including the recognition of long-acting reversible contraceptives as efficacious and economical forms of contraception.”
According to the reference committee report, the committee noted that “tremendously supportive testimony was heard for efforts to prevent teen pregnancy and for the use of long-acting reversible contraceptives (sic) methods to achieve such prevention and minimize barriers for the use of effective contraception.”
Delegates also called upon the AMA to work with federal stakeholders and pharmaceutical manufacturers to “intensify collaborative efforts involving a public health approach” to reduce harm from inappropriate use, misuse, and diversion of prescription controlled substances, increase awareness that substance use disorders are chronic diseases in need of treatment, and reduce the stigma associated with patients suffering from persistent pain and/or substance use disorders.
According to the report, limited testimony noted that it was “incumbent upon our AMA to continue to address these issues, and further intensify collaborative efforts in order to promote solutions to what are difficult and complex public health issues facing the American public, patients, and their families, and the health care professionals who are entrusted with their treatment.”
The reference committee tackled a number of other issues. Among them was a resolution targeting advocacy for hepatitis C virus education, prevention, screening and treatment. The resolution adopted without debate called for birth year–based HCV screening in alignment with recommendations of the Centers for Disease Control and Prevention; working with the CDC and others on education and prevention efforts; supporting screening, prevention, and treatment programs “targeted toward maximum health benefit”; supporting adequate funding and negotiation for affordable pricing for HCV treatments; and recognizing correctional physicians and other physicians in the public health sector as key stakeholders in the development of HCV treatment guidelines.
Also addressed were issues related to drug labeling, with calls to the AMA to work with the Food and Drug Administration to ensure that drug labels are updated quicker as new evidence comes to market.
Delegates called on the AMA to support federal efforts to stimulate early research and development of rapid infectious disease diagnostic technologies through increased funding for the appropriate agencies, and to work with payers to overcome reimbursement barriers.
CHIGAGO – Primary care physicians need better training on preconception counseling, according to the American Medical Association House of Delegates.
At its annual meeting, the HOD passed without debate on June 9 a resolution that calls for the AMA to “support the training of all primary care physicians and relevant allied health professionals in the area of preconception counseling, including the recognition of long-acting reversible contraceptives as efficacious and economical forms of contraception.”
According to the reference committee report, the committee noted that “tremendously supportive testimony was heard for efforts to prevent teen pregnancy and for the use of long-acting reversible contraceptives (sic) methods to achieve such prevention and minimize barriers for the use of effective contraception.”
Delegates also called upon the AMA to work with federal stakeholders and pharmaceutical manufacturers to “intensify collaborative efforts involving a public health approach” to reduce harm from inappropriate use, misuse, and diversion of prescription controlled substances, increase awareness that substance use disorders are chronic diseases in need of treatment, and reduce the stigma associated with patients suffering from persistent pain and/or substance use disorders.
According to the report, limited testimony noted that it was “incumbent upon our AMA to continue to address these issues, and further intensify collaborative efforts in order to promote solutions to what are difficult and complex public health issues facing the American public, patients, and their families, and the health care professionals who are entrusted with their treatment.”
The reference committee tackled a number of other issues. Among them was a resolution targeting advocacy for hepatitis C virus education, prevention, screening and treatment. The resolution adopted without debate called for birth year–based HCV screening in alignment with recommendations of the Centers for Disease Control and Prevention; working with the CDC and others on education and prevention efforts; supporting screening, prevention, and treatment programs “targeted toward maximum health benefit”; supporting adequate funding and negotiation for affordable pricing for HCV treatments; and recognizing correctional physicians and other physicians in the public health sector as key stakeholders in the development of HCV treatment guidelines.
Also addressed were issues related to drug labeling, with calls to the AMA to work with the Food and Drug Administration to ensure that drug labels are updated quicker as new evidence comes to market.
Delegates called on the AMA to support federal efforts to stimulate early research and development of rapid infectious disease diagnostic technologies through increased funding for the appropriate agencies, and to work with payers to overcome reimbursement barriers.
AT THE AMA HOD MEETING
ICOO: Massachusetts governor takes on opioid epidemic
BOSTON – A campaign promise to create viable strategies aimed at reducing the overuse of prescription opioids will be fulfilled, the governor of Massachusetts said during a keynote address at the International Conference on Opioids.
Without providing many specifics, Gov. Charles D. Baker (R) reported that the task force he created will soon release recommendations around three major components: 1. prevention and education; 2. addiction and intervention; and 3. the treatment of pain. He emphasized the importance of a comprehensive strategy.
“I am smart enough to know or humble enough to know that any one initiative in regard to this type of thing is unlikely to get us to where we need to go,” Gov. Baker said. Decriminalizing addiction will be part of the strategy aimed at reducing roadblocks to treatment, he said.
The opioid epidemic was not an initial part of Gov. Baker’s 2014 platform in his campaign for governor. Rather, he added a promise to address this problem in his inaugural address after voters expressed their concern repeatedly. He reported being “astonished” by how often he heard stories of addiction to prescription opioids.
“It didn’t matter where I was. It didn’t matter what part of the commonwealth I was in. It did not matter what kind of neighborhood I was in. It didn’t matter what the socioeconomic demographic makeup was of the group I was talking to,” Gov. Baker said. “It was literally everywhere.”
He said hard numbers tell the same story. In addition to the often repeated national statistics regarding the rapid increase in opioid prescriptions and its close correlation with opioid-related deaths, he said no area of Massachusetts has been left untouched. According to Gov. Baker, the largest hospital in the town of Plymouth, Mass., which has a population just under 60,000, is now averaging one opioid overdose per day.
“I am one of those people who thinks that you cannot solve this problem if you do not engage the health care community,” Gov. Baker said. One reason to focus on health care providers, the governor said, is that data from the Substance Abuse and Mental Health Services Administration show that a large percentage of patients addicted to heroin started on prescription pain medication.
The thrust of the coming initiatives is therefore likely to advocate pain medicine practice that reduces inappropriate prescriptions, Gov. Baker said. He noted that an initiative started 2 years ago by Blue Cross Blue Shield of Massachusetts resulted in a 25% reduction in opioid prescribing without restricting pain medications for those who need them.
In general, the address, which was heavily covered by the local news media, was well-received by those who attended the International Conference on Opioids. There was one area of disagreement. Many did not believe that most heroin addictions start with a prescription pain medication. Of those who challenged that assertion, Dr. Carol A. Warfield, the Lowenstein Distinguished Professor of Anesthesia at Harvard Medical School, Boston, clarified that those opioids might have been prescription drugs but were not prescribed to the user. Rather, the drugs were diverted, and this is a much more important focus of efforts to halt the epidemic than new restrictions on their use for pain control.
Similarly, Pamela J. Madej, a registered nurse affiliated with the Albany Center for Pain Management, New York, cautioned against overemphasizing the value of regulating opioids. She said plenty of regulations exist in New York but the problem persists. Many people are self-medicating for mental health disorders, she said, including the chronic brain disorder of addiction, for which coverage continues to be limited.
“Patients switch from hydrocodone to heroin, because heroin is cheaper,” Ms. Madej said. “We need expanded coverage for mental health to address the underlying problem.”
BOSTON – A campaign promise to create viable strategies aimed at reducing the overuse of prescription opioids will be fulfilled, the governor of Massachusetts said during a keynote address at the International Conference on Opioids.
Without providing many specifics, Gov. Charles D. Baker (R) reported that the task force he created will soon release recommendations around three major components: 1. prevention and education; 2. addiction and intervention; and 3. the treatment of pain. He emphasized the importance of a comprehensive strategy.
“I am smart enough to know or humble enough to know that any one initiative in regard to this type of thing is unlikely to get us to where we need to go,” Gov. Baker said. Decriminalizing addiction will be part of the strategy aimed at reducing roadblocks to treatment, he said.
The opioid epidemic was not an initial part of Gov. Baker’s 2014 platform in his campaign for governor. Rather, he added a promise to address this problem in his inaugural address after voters expressed their concern repeatedly. He reported being “astonished” by how often he heard stories of addiction to prescription opioids.
“It didn’t matter where I was. It didn’t matter what part of the commonwealth I was in. It did not matter what kind of neighborhood I was in. It didn’t matter what the socioeconomic demographic makeup was of the group I was talking to,” Gov. Baker said. “It was literally everywhere.”
He said hard numbers tell the same story. In addition to the often repeated national statistics regarding the rapid increase in opioid prescriptions and its close correlation with opioid-related deaths, he said no area of Massachusetts has been left untouched. According to Gov. Baker, the largest hospital in the town of Plymouth, Mass., which has a population just under 60,000, is now averaging one opioid overdose per day.
“I am one of those people who thinks that you cannot solve this problem if you do not engage the health care community,” Gov. Baker said. One reason to focus on health care providers, the governor said, is that data from the Substance Abuse and Mental Health Services Administration show that a large percentage of patients addicted to heroin started on prescription pain medication.
The thrust of the coming initiatives is therefore likely to advocate pain medicine practice that reduces inappropriate prescriptions, Gov. Baker said. He noted that an initiative started 2 years ago by Blue Cross Blue Shield of Massachusetts resulted in a 25% reduction in opioid prescribing without restricting pain medications for those who need them.
In general, the address, which was heavily covered by the local news media, was well-received by those who attended the International Conference on Opioids. There was one area of disagreement. Many did not believe that most heroin addictions start with a prescription pain medication. Of those who challenged that assertion, Dr. Carol A. Warfield, the Lowenstein Distinguished Professor of Anesthesia at Harvard Medical School, Boston, clarified that those opioids might have been prescription drugs but were not prescribed to the user. Rather, the drugs were diverted, and this is a much more important focus of efforts to halt the epidemic than new restrictions on their use for pain control.
Similarly, Pamela J. Madej, a registered nurse affiliated with the Albany Center for Pain Management, New York, cautioned against overemphasizing the value of regulating opioids. She said plenty of regulations exist in New York but the problem persists. Many people are self-medicating for mental health disorders, she said, including the chronic brain disorder of addiction, for which coverage continues to be limited.
“Patients switch from hydrocodone to heroin, because heroin is cheaper,” Ms. Madej said. “We need expanded coverage for mental health to address the underlying problem.”
BOSTON – A campaign promise to create viable strategies aimed at reducing the overuse of prescription opioids will be fulfilled, the governor of Massachusetts said during a keynote address at the International Conference on Opioids.
Without providing many specifics, Gov. Charles D. Baker (R) reported that the task force he created will soon release recommendations around three major components: 1. prevention and education; 2. addiction and intervention; and 3. the treatment of pain. He emphasized the importance of a comprehensive strategy.
“I am smart enough to know or humble enough to know that any one initiative in regard to this type of thing is unlikely to get us to where we need to go,” Gov. Baker said. Decriminalizing addiction will be part of the strategy aimed at reducing roadblocks to treatment, he said.
The opioid epidemic was not an initial part of Gov. Baker’s 2014 platform in his campaign for governor. Rather, he added a promise to address this problem in his inaugural address after voters expressed their concern repeatedly. He reported being “astonished” by how often he heard stories of addiction to prescription opioids.
“It didn’t matter where I was. It didn’t matter what part of the commonwealth I was in. It did not matter what kind of neighborhood I was in. It didn’t matter what the socioeconomic demographic makeup was of the group I was talking to,” Gov. Baker said. “It was literally everywhere.”
He said hard numbers tell the same story. In addition to the often repeated national statistics regarding the rapid increase in opioid prescriptions and its close correlation with opioid-related deaths, he said no area of Massachusetts has been left untouched. According to Gov. Baker, the largest hospital in the town of Plymouth, Mass., which has a population just under 60,000, is now averaging one opioid overdose per day.
“I am one of those people who thinks that you cannot solve this problem if you do not engage the health care community,” Gov. Baker said. One reason to focus on health care providers, the governor said, is that data from the Substance Abuse and Mental Health Services Administration show that a large percentage of patients addicted to heroin started on prescription pain medication.
The thrust of the coming initiatives is therefore likely to advocate pain medicine practice that reduces inappropriate prescriptions, Gov. Baker said. He noted that an initiative started 2 years ago by Blue Cross Blue Shield of Massachusetts resulted in a 25% reduction in opioid prescribing without restricting pain medications for those who need them.
In general, the address, which was heavily covered by the local news media, was well-received by those who attended the International Conference on Opioids. There was one area of disagreement. Many did not believe that most heroin addictions start with a prescription pain medication. Of those who challenged that assertion, Dr. Carol A. Warfield, the Lowenstein Distinguished Professor of Anesthesia at Harvard Medical School, Boston, clarified that those opioids might have been prescription drugs but were not prescribed to the user. Rather, the drugs were diverted, and this is a much more important focus of efforts to halt the epidemic than new restrictions on their use for pain control.
Similarly, Pamela J. Madej, a registered nurse affiliated with the Albany Center for Pain Management, New York, cautioned against overemphasizing the value of regulating opioids. She said plenty of regulations exist in New York but the problem persists. Many people are self-medicating for mental health disorders, she said, including the chronic brain disorder of addiction, for which coverage continues to be limited.
“Patients switch from hydrocodone to heroin, because heroin is cheaper,” Ms. Madej said. “We need expanded coverage for mental health to address the underlying problem.”
Stent-retriever thrombectomy reduces poststroke disability
For patients with proximal large-vessel anterior stroke, neurovascular thrombectomy with a stent retriever plus medical therapy in the REVASCAT trial reduced the severity of poststroke disability and raised the rate of functional independence, compared with medical therapy alone, according to a report in the New England Journal of Medicine.
To assess the efficacy and safety of thrombectomy with a stent retriever, investigators performed a prospective, open-label, phase III clinical trial involving 206 adults up to 85 years of age treated at four designated comprehensive stroke centers in Catalonia, Spain.
All the participants in the Randomized Trial of Revascularization With Solitaire FR Device Versus Best Medical Therapy in the Treatment of Acute Stroke Due to Anterior Circulation Large Vessel Occlusion Presenting Within Eight Hours of Symptom Onset (REVASCAT) had either not responded to intravenous alteplase administered within 4.5 hours of symptom onset or had contraindications to alteplase therapy. They were randomly assigned in equal numbers to undergo endovascular treatment with a stent retriever or medical therapy alone, said Dr. Tudor G. Jovin, director of the Stroke Institute, University of Pittsburgh Medical Center, and his associates.
The trial was halted early when the first interim analysis showed “lack of equipoise” between the two study groups, and because emerging results from three other studies demonstrated the superior efficacy of thrombectomy. The primary efficacy outcome measure – severity of disability at 90 days, as measured by expert assessors blinded to treatment assignment – significantly favored thrombectomy over medical therapy. The proportion of patients who achieved functional independence by day 90 on the modified Rankin scale also demonstrated the clear superiority of thrombectomy (43.7%) over medical therapy (28.2%).
Only 6.5 patients would need to be treated with thrombectomy to prevent 1 case of functional dependency or death. In addition, “thrombectomy was associated with a shift toward better outcomes across the entire spectrum of disability,” Dr. Jovin and his associates said (N. Engl. J. Med. 2015 [doi:10.1056/NEJMoa1503780]).
Regarding safety, the rate of death at 90 days did not differ significantly between patients who underwent thrombectomy (18.4%) and control subjects (15.5%). Rates of intracranial hemorrhage were the same, 1.9%, in both groups, and rates of other serious adverse events also were similar.
These findings are consistent with those of several other recently reported clinical trials and show that “in patients with acute stroke caused by a proximal large-vessel occlusion and an absence of a large infarct on baseline imaging, mechanical thrombectomy with [a] stent retriever was safe and led to improved clinical outcomes, as compared with medical therapy alone,” the investigators said.
REVASCAT was funded by an unrestricted grant from Covidien, maker of the stent retriever, and by grants from several Spanish research institutes. Dr. Jovin reported ties to Covidien, Silk Road Medical, Air Liquide, Medtronic, and Stryker Neurovascular.
For patients with proximal large-vessel anterior stroke, neurovascular thrombectomy with a stent retriever plus medical therapy in the REVASCAT trial reduced the severity of poststroke disability and raised the rate of functional independence, compared with medical therapy alone, according to a report in the New England Journal of Medicine.
To assess the efficacy and safety of thrombectomy with a stent retriever, investigators performed a prospective, open-label, phase III clinical trial involving 206 adults up to 85 years of age treated at four designated comprehensive stroke centers in Catalonia, Spain.
All the participants in the Randomized Trial of Revascularization With Solitaire FR Device Versus Best Medical Therapy in the Treatment of Acute Stroke Due to Anterior Circulation Large Vessel Occlusion Presenting Within Eight Hours of Symptom Onset (REVASCAT) had either not responded to intravenous alteplase administered within 4.5 hours of symptom onset or had contraindications to alteplase therapy. They were randomly assigned in equal numbers to undergo endovascular treatment with a stent retriever or medical therapy alone, said Dr. Tudor G. Jovin, director of the Stroke Institute, University of Pittsburgh Medical Center, and his associates.
The trial was halted early when the first interim analysis showed “lack of equipoise” between the two study groups, and because emerging results from three other studies demonstrated the superior efficacy of thrombectomy. The primary efficacy outcome measure – severity of disability at 90 days, as measured by expert assessors blinded to treatment assignment – significantly favored thrombectomy over medical therapy. The proportion of patients who achieved functional independence by day 90 on the modified Rankin scale also demonstrated the clear superiority of thrombectomy (43.7%) over medical therapy (28.2%).
Only 6.5 patients would need to be treated with thrombectomy to prevent 1 case of functional dependency or death. In addition, “thrombectomy was associated with a shift toward better outcomes across the entire spectrum of disability,” Dr. Jovin and his associates said (N. Engl. J. Med. 2015 [doi:10.1056/NEJMoa1503780]).
Regarding safety, the rate of death at 90 days did not differ significantly between patients who underwent thrombectomy (18.4%) and control subjects (15.5%). Rates of intracranial hemorrhage were the same, 1.9%, in both groups, and rates of other serious adverse events also were similar.
These findings are consistent with those of several other recently reported clinical trials and show that “in patients with acute stroke caused by a proximal large-vessel occlusion and an absence of a large infarct on baseline imaging, mechanical thrombectomy with [a] stent retriever was safe and led to improved clinical outcomes, as compared with medical therapy alone,” the investigators said.
REVASCAT was funded by an unrestricted grant from Covidien, maker of the stent retriever, and by grants from several Spanish research institutes. Dr. Jovin reported ties to Covidien, Silk Road Medical, Air Liquide, Medtronic, and Stryker Neurovascular.
For patients with proximal large-vessel anterior stroke, neurovascular thrombectomy with a stent retriever plus medical therapy in the REVASCAT trial reduced the severity of poststroke disability and raised the rate of functional independence, compared with medical therapy alone, according to a report in the New England Journal of Medicine.
To assess the efficacy and safety of thrombectomy with a stent retriever, investigators performed a prospective, open-label, phase III clinical trial involving 206 adults up to 85 years of age treated at four designated comprehensive stroke centers in Catalonia, Spain.
All the participants in the Randomized Trial of Revascularization With Solitaire FR Device Versus Best Medical Therapy in the Treatment of Acute Stroke Due to Anterior Circulation Large Vessel Occlusion Presenting Within Eight Hours of Symptom Onset (REVASCAT) had either not responded to intravenous alteplase administered within 4.5 hours of symptom onset or had contraindications to alteplase therapy. They were randomly assigned in equal numbers to undergo endovascular treatment with a stent retriever or medical therapy alone, said Dr. Tudor G. Jovin, director of the Stroke Institute, University of Pittsburgh Medical Center, and his associates.
The trial was halted early when the first interim analysis showed “lack of equipoise” between the two study groups, and because emerging results from three other studies demonstrated the superior efficacy of thrombectomy. The primary efficacy outcome measure – severity of disability at 90 days, as measured by expert assessors blinded to treatment assignment – significantly favored thrombectomy over medical therapy. The proportion of patients who achieved functional independence by day 90 on the modified Rankin scale also demonstrated the clear superiority of thrombectomy (43.7%) over medical therapy (28.2%).
Only 6.5 patients would need to be treated with thrombectomy to prevent 1 case of functional dependency or death. In addition, “thrombectomy was associated with a shift toward better outcomes across the entire spectrum of disability,” Dr. Jovin and his associates said (N. Engl. J. Med. 2015 [doi:10.1056/NEJMoa1503780]).
Regarding safety, the rate of death at 90 days did not differ significantly between patients who underwent thrombectomy (18.4%) and control subjects (15.5%). Rates of intracranial hemorrhage were the same, 1.9%, in both groups, and rates of other serious adverse events also were similar.
These findings are consistent with those of several other recently reported clinical trials and show that “in patients with acute stroke caused by a proximal large-vessel occlusion and an absence of a large infarct on baseline imaging, mechanical thrombectomy with [a] stent retriever was safe and led to improved clinical outcomes, as compared with medical therapy alone,” the investigators said.
REVASCAT was funded by an unrestricted grant from Covidien, maker of the stent retriever, and by grants from several Spanish research institutes. Dr. Jovin reported ties to Covidien, Silk Road Medical, Air Liquide, Medtronic, and Stryker Neurovascular.
FROM THE NEW ENGLAND JOURNAL OF MEDICINE
Key clinical point: Thrombectomy with a stent retriever reduced poststroke disability in patients with occlusion of the proximal anterior circulation.
Major finding: The proportion of patients who achieved functional independence by day 90 showed the clear superiority of thrombectomy (43.7%) over medical therapy (28.2%); only 6.5 patients would need to be treated with thrombectomy to prevent 1 case of functional dependency or death.
Data source: REVASCAT, a prospective, open-label, randomized phase III trial involving 206 adults treated during a 4-year period at four stroke centers in Spain.
Disclosures: REVASCAT was funded by an unrestricted grant from Covidien, maker of the stent retriever, and by grants from several Spanish research institutes. Dr. Jovin reported ties to Covidien, Silk Road Medical, Air Liquide, Medtronic, and Stryker Neurovascular.
ICOO: Opioid self-dosing falls short of pain control
BOSTON – Many cancer patients do not pursue or at least do not achieve complete freedom from pain when permitted control over their opioid dose, according to a comprehensive analysis of published studies that evaluated patient-controlled analgesia.
“We do not know why. Patients were encouraged in these studies to titrate opioids until they were pain free or until they had side effects. Although this could be an issue of side effects, another interpretation is that complete pain control is not the goal for many individuals,” reported Dr. Brian H. Wetherington of the University of Kentucky, Lexington.
The data from this analysis were presented at the International Conference on Opioids from a comprehensive literature search that included 905 potentially relevant articles. Of these, 62 met inclusion criteria, particularly an assessment of patient-controlled opioids in patients with cancer pain. The studies also had to assess pain control with a visual analog scale (VAS) or the Neuropathy Pain Scale (NPS) using a 10-point system with 10 being the greatest level of pain imaginable.
“We were interested in evaluating whether patients, when given complete control over their opioids, would take sufficient doses to provide complete pain relief, which is often stated as the goal in pain management,” explained Dr. Wetherington, who was coauthor of a study led by his colleague at University of Kentucky, Dr. Michael Harned.
The answer was no. When the data from the 62 studies, which included 5,251 patients with cancer pain were collated, the average pain score at baseline was 5.4. At the time of assessment of pain control, the mean pain score was 2.7.
“The mean pain score for patients managing their own cancer pain on opioids was reduced from study entry but remained at the moderate to severe pain level or higher than what many health care providers would recommend,” Dr. Wetherington reported.
This review of published studies does not explain why lower pain scores are not reached, but the Dr. Wetherington and his coauthors hypothesized that patients are demonstrating their own benefit-to-risk ratio assessment.
This is thought to be the first systematic review to find that patients do not seek complete control of pain when given access to unrestricted analgesia, but several individual studies have made the same point. In one study cited by the authors, patients on a fentanyl patch only reduced their pain scores to 3.0 on average when given unlimited access to oral morphine for breakthroughs (J. Pain Symptom Manage. 1998;16:102-11).
“We think this deserves further study, because there may be lessons regarding how we think of optimal pain control. While the therapeutic target is often described as complete pain relief, these data suggest that this may not be the goal for patients when they are left to select their own level of pain control,” Dr. Wetherington explained.
The same observation regarding the failure of patients to eliminate all pain on patient-controlled analgesia has been made anecdotally by Dr. William G. Brose of Stanford (Calif.) University. However, he suggested in an interview that patients might be reluctant to rate themselves completely pain free on a subjective scale. He also believes that level of analgesia may not be the most relevant endpoint.
“We are increasingly evaluating change in patient function, which may be a more useful tool for evaluating the efficacy of pain control,” Dr. Brose said.
BOSTON – Many cancer patients do not pursue or at least do not achieve complete freedom from pain when permitted control over their opioid dose, according to a comprehensive analysis of published studies that evaluated patient-controlled analgesia.
“We do not know why. Patients were encouraged in these studies to titrate opioids until they were pain free or until they had side effects. Although this could be an issue of side effects, another interpretation is that complete pain control is not the goal for many individuals,” reported Dr. Brian H. Wetherington of the University of Kentucky, Lexington.
The data from this analysis were presented at the International Conference on Opioids from a comprehensive literature search that included 905 potentially relevant articles. Of these, 62 met inclusion criteria, particularly an assessment of patient-controlled opioids in patients with cancer pain. The studies also had to assess pain control with a visual analog scale (VAS) or the Neuropathy Pain Scale (NPS) using a 10-point system with 10 being the greatest level of pain imaginable.
“We were interested in evaluating whether patients, when given complete control over their opioids, would take sufficient doses to provide complete pain relief, which is often stated as the goal in pain management,” explained Dr. Wetherington, who was coauthor of a study led by his colleague at University of Kentucky, Dr. Michael Harned.
The answer was no. When the data from the 62 studies, which included 5,251 patients with cancer pain were collated, the average pain score at baseline was 5.4. At the time of assessment of pain control, the mean pain score was 2.7.
“The mean pain score for patients managing their own cancer pain on opioids was reduced from study entry but remained at the moderate to severe pain level or higher than what many health care providers would recommend,” Dr. Wetherington reported.
This review of published studies does not explain why lower pain scores are not reached, but the Dr. Wetherington and his coauthors hypothesized that patients are demonstrating their own benefit-to-risk ratio assessment.
This is thought to be the first systematic review to find that patients do not seek complete control of pain when given access to unrestricted analgesia, but several individual studies have made the same point. In one study cited by the authors, patients on a fentanyl patch only reduced their pain scores to 3.0 on average when given unlimited access to oral morphine for breakthroughs (J. Pain Symptom Manage. 1998;16:102-11).
“We think this deserves further study, because there may be lessons regarding how we think of optimal pain control. While the therapeutic target is often described as complete pain relief, these data suggest that this may not be the goal for patients when they are left to select their own level of pain control,” Dr. Wetherington explained.
The same observation regarding the failure of patients to eliminate all pain on patient-controlled analgesia has been made anecdotally by Dr. William G. Brose of Stanford (Calif.) University. However, he suggested in an interview that patients might be reluctant to rate themselves completely pain free on a subjective scale. He also believes that level of analgesia may not be the most relevant endpoint.
“We are increasingly evaluating change in patient function, which may be a more useful tool for evaluating the efficacy of pain control,” Dr. Brose said.
BOSTON – Many cancer patients do not pursue or at least do not achieve complete freedom from pain when permitted control over their opioid dose, according to a comprehensive analysis of published studies that evaluated patient-controlled analgesia.
“We do not know why. Patients were encouraged in these studies to titrate opioids until they were pain free or until they had side effects. Although this could be an issue of side effects, another interpretation is that complete pain control is not the goal for many individuals,” reported Dr. Brian H. Wetherington of the University of Kentucky, Lexington.
The data from this analysis were presented at the International Conference on Opioids from a comprehensive literature search that included 905 potentially relevant articles. Of these, 62 met inclusion criteria, particularly an assessment of patient-controlled opioids in patients with cancer pain. The studies also had to assess pain control with a visual analog scale (VAS) or the Neuropathy Pain Scale (NPS) using a 10-point system with 10 being the greatest level of pain imaginable.
“We were interested in evaluating whether patients, when given complete control over their opioids, would take sufficient doses to provide complete pain relief, which is often stated as the goal in pain management,” explained Dr. Wetherington, who was coauthor of a study led by his colleague at University of Kentucky, Dr. Michael Harned.
The answer was no. When the data from the 62 studies, which included 5,251 patients with cancer pain were collated, the average pain score at baseline was 5.4. At the time of assessment of pain control, the mean pain score was 2.7.
“The mean pain score for patients managing their own cancer pain on opioids was reduced from study entry but remained at the moderate to severe pain level or higher than what many health care providers would recommend,” Dr. Wetherington reported.
This review of published studies does not explain why lower pain scores are not reached, but the Dr. Wetherington and his coauthors hypothesized that patients are demonstrating their own benefit-to-risk ratio assessment.
This is thought to be the first systematic review to find that patients do not seek complete control of pain when given access to unrestricted analgesia, but several individual studies have made the same point. In one study cited by the authors, patients on a fentanyl patch only reduced their pain scores to 3.0 on average when given unlimited access to oral morphine for breakthroughs (J. Pain Symptom Manage. 1998;16:102-11).
“We think this deserves further study, because there may be lessons regarding how we think of optimal pain control. While the therapeutic target is often described as complete pain relief, these data suggest that this may not be the goal for patients when they are left to select their own level of pain control,” Dr. Wetherington explained.
The same observation regarding the failure of patients to eliminate all pain on patient-controlled analgesia has been made anecdotally by Dr. William G. Brose of Stanford (Calif.) University. However, he suggested in an interview that patients might be reluctant to rate themselves completely pain free on a subjective scale. He also believes that level of analgesia may not be the most relevant endpoint.
“We are increasingly evaluating change in patient function, which may be a more useful tool for evaluating the efficacy of pain control,” Dr. Brose said.
AT ICOO 2015
Key clinical point: Given the opportunity, patients do not titrate opioid therapy to a point of complete pain control, according to a comprehensive survey of published studies.
Major finding: In a survey of 62 published studies of cancer patients who were provided unlimited access to opioids for pain control, the average pain control was 2.7 on a scale of 10, indicating that most patients do not seek or are unable to achieve complete control with an acceptable benefit-to-risk ratio.
Data source: Retrospective data review.
Disclosures: The study was investigator initiated. Dr. Wetherington reported having no financial disclosures.
AMA HOD: Delegates advocate medical service, health system reforms resolutions with little debate
CHICAGO – Other than a brief amendment related to the 3-day rule, the American Medical Association House of Delegates adopted via voice vote a series of reference committee recommendations related to medical service and health system reform.
The lone item that came up for discussion during the June 9 vote at the AMA HOD annual meeting was related to the 3-day rule. The reference committee had substituted language of two separate resolutions and combined it into one, with two provisions: that the AMA “continue to advocate that Congress eliminate the 3-day hospital inpatient requirement for Medicare coverage of posthospital skilled nursing facility services, and educate Congress on the impact of this requirement on patients,” and that the association continue to advocate for the start of the timing clock toward meeting the 3-day rule being when the person enters the hospital or the emergency department or when under an observational status.
During the full-house session, a third resolution was added that the AMA work with the Centers for Medicare & Medicaid Services to eliminate any regulations requiring inpatient hospitalization as a prerequisite for a Medicare patient’s being eligible for skilled nursing facility or long-term care placement, language resurrected from one of the two earlier resolutions.
Other adopted resolutions cover a wide range of topics, including the high price of generic drugs, vasectomy coverage, end-of-life counseling, and understanding the effects of Medicaid expansion.
Various separate resolutions related to the high cost of generic drugs were rolled into one final resolution that calls for a number of actions.
First, it calls on the AMA to work collaboratively with Food and Drug Administration, the Federal Trade Commission, the Generic Pharmaceutical Association, and other relevant stakeholders to promote policies that address the rising cost of generic drugs. The resolution calls on the AMA to seek a legislative solution to ensure fair generic drug pricing and to educate Congress on the adverse effects of high generic drug pricing.
On Medicaid expansion, the house instructed the AMA to understand the level of health care access due to expansion, the quality of health care delivered, the adequacy of provider payments, and the effects of Medicaid expansion as a whole.
Delegates also adopted a resolution asking the AMA to encourage all private and public payers to reimburse for advanced care planning.
On contraception, the AMA was directed to work with national state and medical specialty societies “to advocate for patient access to the full continuum of evidence-based contraceptive methods and sterilization procedures, including vasectomy and male contraceptive counseling, to promote gender equality in contraceptive services under the ACA.”
With the move to alternate payment models that pay for value and outcomes, the AMA received direction to help practicing physicians with guidance and other assistance to help in the transition.
CHICAGO – Other than a brief amendment related to the 3-day rule, the American Medical Association House of Delegates adopted via voice vote a series of reference committee recommendations related to medical service and health system reform.
The lone item that came up for discussion during the June 9 vote at the AMA HOD annual meeting was related to the 3-day rule. The reference committee had substituted language of two separate resolutions and combined it into one, with two provisions: that the AMA “continue to advocate that Congress eliminate the 3-day hospital inpatient requirement for Medicare coverage of posthospital skilled nursing facility services, and educate Congress on the impact of this requirement on patients,” and that the association continue to advocate for the start of the timing clock toward meeting the 3-day rule being when the person enters the hospital or the emergency department or when under an observational status.
During the full-house session, a third resolution was added that the AMA work with the Centers for Medicare & Medicaid Services to eliminate any regulations requiring inpatient hospitalization as a prerequisite for a Medicare patient’s being eligible for skilled nursing facility or long-term care placement, language resurrected from one of the two earlier resolutions.
Other adopted resolutions cover a wide range of topics, including the high price of generic drugs, vasectomy coverage, end-of-life counseling, and understanding the effects of Medicaid expansion.
Various separate resolutions related to the high cost of generic drugs were rolled into one final resolution that calls for a number of actions.
First, it calls on the AMA to work collaboratively with Food and Drug Administration, the Federal Trade Commission, the Generic Pharmaceutical Association, and other relevant stakeholders to promote policies that address the rising cost of generic drugs. The resolution calls on the AMA to seek a legislative solution to ensure fair generic drug pricing and to educate Congress on the adverse effects of high generic drug pricing.
On Medicaid expansion, the house instructed the AMA to understand the level of health care access due to expansion, the quality of health care delivered, the adequacy of provider payments, and the effects of Medicaid expansion as a whole.
Delegates also adopted a resolution asking the AMA to encourage all private and public payers to reimburse for advanced care planning.
On contraception, the AMA was directed to work with national state and medical specialty societies “to advocate for patient access to the full continuum of evidence-based contraceptive methods and sterilization procedures, including vasectomy and male contraceptive counseling, to promote gender equality in contraceptive services under the ACA.”
With the move to alternate payment models that pay for value and outcomes, the AMA received direction to help practicing physicians with guidance and other assistance to help in the transition.
CHICAGO – Other than a brief amendment related to the 3-day rule, the American Medical Association House of Delegates adopted via voice vote a series of reference committee recommendations related to medical service and health system reform.
The lone item that came up for discussion during the June 9 vote at the AMA HOD annual meeting was related to the 3-day rule. The reference committee had substituted language of two separate resolutions and combined it into one, with two provisions: that the AMA “continue to advocate that Congress eliminate the 3-day hospital inpatient requirement for Medicare coverage of posthospital skilled nursing facility services, and educate Congress on the impact of this requirement on patients,” and that the association continue to advocate for the start of the timing clock toward meeting the 3-day rule being when the person enters the hospital or the emergency department or when under an observational status.
During the full-house session, a third resolution was added that the AMA work with the Centers for Medicare & Medicaid Services to eliminate any regulations requiring inpatient hospitalization as a prerequisite for a Medicare patient’s being eligible for skilled nursing facility or long-term care placement, language resurrected from one of the two earlier resolutions.
Other adopted resolutions cover a wide range of topics, including the high price of generic drugs, vasectomy coverage, end-of-life counseling, and understanding the effects of Medicaid expansion.
Various separate resolutions related to the high cost of generic drugs were rolled into one final resolution that calls for a number of actions.
First, it calls on the AMA to work collaboratively with Food and Drug Administration, the Federal Trade Commission, the Generic Pharmaceutical Association, and other relevant stakeholders to promote policies that address the rising cost of generic drugs. The resolution calls on the AMA to seek a legislative solution to ensure fair generic drug pricing and to educate Congress on the adverse effects of high generic drug pricing.
On Medicaid expansion, the house instructed the AMA to understand the level of health care access due to expansion, the quality of health care delivered, the adequacy of provider payments, and the effects of Medicaid expansion as a whole.
Delegates also adopted a resolution asking the AMA to encourage all private and public payers to reimburse for advanced care planning.
On contraception, the AMA was directed to work with national state and medical specialty societies “to advocate for patient access to the full continuum of evidence-based contraceptive methods and sterilization procedures, including vasectomy and male contraceptive counseling, to promote gender equality in contraceptive services under the ACA.”
With the move to alternate payment models that pay for value and outcomes, the AMA received direction to help practicing physicians with guidance and other assistance to help in the transition.
AT THE AMA HOD MEETING
Communication failures behind many surgical ‘never events’
Poor communication remains at the heart of most surgical “never events” (i.e., preventable events), say the authors of a systematic review that estimates around 500 wrong-site surgeries and 5,000 retained surgical items incidents still happen each year in the United States.
The review of 138 empirical studies of wrong-site surgery, retained surgical items, and surgical fires, published between 2004 and 2014, found wrong-site surgery occurred roughly once per 100,000 surgical procedures, and retained surgical items incidents at a rate of 1.32 events per 10,000 procedures, with unknown data on the per-procedure incidence of surgical fire, according to data published online June 10 in JAMA Surgery.
“A frequently reported cause of wrong-site surgery across 28 identified analyses was communication problems, including miscommunications among staff, missing information that should have been available to the operating room staff, surgical team members not speaking up when they noticed that a procedure targeted the wrong side, and a surgeon ignoring surgical team members who questioned laterality,” wrote Susanne Hempel, PhD, of the Southern California Evidence-Based Practice Center, Santa Monica, and her coauthors.
They found that very few evaluations of interventions designed specifically to reduce the incidence of never events were conclusive, although they pointed out that given the rarity of these events, it was methodologically challenging to assess the effectiveness of these interventions (JAMA Surg. 2015 June 10 [doi:10.1001/jamasurg.2015.0301]).
The Department of Veterans Affairs supported the study. There were no conflicts of interest declared.
Poor communication remains at the heart of most surgical “never events” (i.e., preventable events), say the authors of a systematic review that estimates around 500 wrong-site surgeries and 5,000 retained surgical items incidents still happen each year in the United States.
The review of 138 empirical studies of wrong-site surgery, retained surgical items, and surgical fires, published between 2004 and 2014, found wrong-site surgery occurred roughly once per 100,000 surgical procedures, and retained surgical items incidents at a rate of 1.32 events per 10,000 procedures, with unknown data on the per-procedure incidence of surgical fire, according to data published online June 10 in JAMA Surgery.
“A frequently reported cause of wrong-site surgery across 28 identified analyses was communication problems, including miscommunications among staff, missing information that should have been available to the operating room staff, surgical team members not speaking up when they noticed that a procedure targeted the wrong side, and a surgeon ignoring surgical team members who questioned laterality,” wrote Susanne Hempel, PhD, of the Southern California Evidence-Based Practice Center, Santa Monica, and her coauthors.
They found that very few evaluations of interventions designed specifically to reduce the incidence of never events were conclusive, although they pointed out that given the rarity of these events, it was methodologically challenging to assess the effectiveness of these interventions (JAMA Surg. 2015 June 10 [doi:10.1001/jamasurg.2015.0301]).
The Department of Veterans Affairs supported the study. There were no conflicts of interest declared.
Poor communication remains at the heart of most surgical “never events” (i.e., preventable events), say the authors of a systematic review that estimates around 500 wrong-site surgeries and 5,000 retained surgical items incidents still happen each year in the United States.
The review of 138 empirical studies of wrong-site surgery, retained surgical items, and surgical fires, published between 2004 and 2014, found wrong-site surgery occurred roughly once per 100,000 surgical procedures, and retained surgical items incidents at a rate of 1.32 events per 10,000 procedures, with unknown data on the per-procedure incidence of surgical fire, according to data published online June 10 in JAMA Surgery.
“A frequently reported cause of wrong-site surgery across 28 identified analyses was communication problems, including miscommunications among staff, missing information that should have been available to the operating room staff, surgical team members not speaking up when they noticed that a procedure targeted the wrong side, and a surgeon ignoring surgical team members who questioned laterality,” wrote Susanne Hempel, PhD, of the Southern California Evidence-Based Practice Center, Santa Monica, and her coauthors.
They found that very few evaluations of interventions designed specifically to reduce the incidence of never events were conclusive, although they pointed out that given the rarity of these events, it was methodologically challenging to assess the effectiveness of these interventions (JAMA Surg. 2015 June 10 [doi:10.1001/jamasurg.2015.0301]).
The Department of Veterans Affairs supported the study. There were no conflicts of interest declared.
FROM JAMA SURGERY
Key clinical point: Around 500 wrong-site surgeries and 5,000 retained surgical items incidents still happen each year, many caused by inadequate communication.
Major finding: Wrong-site surgery occurs roughly once per 100,000 surgical procedures, and retained surgical items incidents occur at a rate of 1.32 events per 10,000 procedures.
Data source: Systematic review of 138 empirical studies.
Disclosures: The Department of Veterans Affairs supported the study. There were no conflicts of interest declared.
Obama calls opposition to ACA subsidies ‘cynical’
As the country awaits a U.S. Supreme Court ruling on the constitutionality of federal health insurance subsidies to millions of Americans, President Obama praised the impact of the Affordable Care Act and called attempts to roll back the law “cynical.”
“We need more governors and state legislators to expand Medicaid, which was a central part of the architecture of the overall plan,” the president said, addressing the Catholic Health Association’s annual meeting in Washington. “It’s not perfect, but it’s serving so many people so much better, and we’re not going to go backwards.”
The Supreme Court is expected to rule sometime in June on King v. Burwell, a controversial case that affects health care coverage for millions of Americans who are receiving subsidies to purchase insurance through the federally run ACA marketplace.
President Obama’s remarks came on the heels of similar signs he is frustrated with the Supreme Court for its handling of the King v. Burwell case. “This should be an easy case. Frankly, it probably shouldn’t even have been taken up,” he told reporters after the G-7 Summit in Krun, Germany.
If the Supreme Court sides with the plaintiff in this case, federally funded health insurance subsidies paid to beneficiaries in states that did not establish their own insurance marketplaces would become unconstitutional, leaving as many as 7.5 million people without subsidies, according to an estimate from the Kaiser Family Foundation.
The White House has not announced a contingency plan if King wins. While there are some plans circulating in Congress to maintain subsidies, the GOP majority has not coalesced around a specific option.
“Instead of bullying the Supreme Court, the president should spend his time preparing for the reality that the court may soon rule against his decision to illegally issue tax penalties and subsidies on Americans in two-thirds of the country,” Sen. John Barrasso (R-Wyo.) said in a statement. “Let’s be clear: If the Supreme Court rules against the administration, Congress will not pass a so called ‘one-sentence’ fake fix.”
On Twitter @whitneymcknight
As the country awaits a U.S. Supreme Court ruling on the constitutionality of federal health insurance subsidies to millions of Americans, President Obama praised the impact of the Affordable Care Act and called attempts to roll back the law “cynical.”
“We need more governors and state legislators to expand Medicaid, which was a central part of the architecture of the overall plan,” the president said, addressing the Catholic Health Association’s annual meeting in Washington. “It’s not perfect, but it’s serving so many people so much better, and we’re not going to go backwards.”
The Supreme Court is expected to rule sometime in June on King v. Burwell, a controversial case that affects health care coverage for millions of Americans who are receiving subsidies to purchase insurance through the federally run ACA marketplace.
President Obama’s remarks came on the heels of similar signs he is frustrated with the Supreme Court for its handling of the King v. Burwell case. “This should be an easy case. Frankly, it probably shouldn’t even have been taken up,” he told reporters after the G-7 Summit in Krun, Germany.
If the Supreme Court sides with the plaintiff in this case, federally funded health insurance subsidies paid to beneficiaries in states that did not establish their own insurance marketplaces would become unconstitutional, leaving as many as 7.5 million people without subsidies, according to an estimate from the Kaiser Family Foundation.
The White House has not announced a contingency plan if King wins. While there are some plans circulating in Congress to maintain subsidies, the GOP majority has not coalesced around a specific option.
“Instead of bullying the Supreme Court, the president should spend his time preparing for the reality that the court may soon rule against his decision to illegally issue tax penalties and subsidies on Americans in two-thirds of the country,” Sen. John Barrasso (R-Wyo.) said in a statement. “Let’s be clear: If the Supreme Court rules against the administration, Congress will not pass a so called ‘one-sentence’ fake fix.”
On Twitter @whitneymcknight
As the country awaits a U.S. Supreme Court ruling on the constitutionality of federal health insurance subsidies to millions of Americans, President Obama praised the impact of the Affordable Care Act and called attempts to roll back the law “cynical.”
“We need more governors and state legislators to expand Medicaid, which was a central part of the architecture of the overall plan,” the president said, addressing the Catholic Health Association’s annual meeting in Washington. “It’s not perfect, but it’s serving so many people so much better, and we’re not going to go backwards.”
The Supreme Court is expected to rule sometime in June on King v. Burwell, a controversial case that affects health care coverage for millions of Americans who are receiving subsidies to purchase insurance through the federally run ACA marketplace.
President Obama’s remarks came on the heels of similar signs he is frustrated with the Supreme Court for its handling of the King v. Burwell case. “This should be an easy case. Frankly, it probably shouldn’t even have been taken up,” he told reporters after the G-7 Summit in Krun, Germany.
If the Supreme Court sides with the plaintiff in this case, federally funded health insurance subsidies paid to beneficiaries in states that did not establish their own insurance marketplaces would become unconstitutional, leaving as many as 7.5 million people without subsidies, according to an estimate from the Kaiser Family Foundation.
The White House has not announced a contingency plan if King wins. While there are some plans circulating in Congress to maintain subsidies, the GOP majority has not coalesced around a specific option.
“Instead of bullying the Supreme Court, the president should spend his time preparing for the reality that the court may soon rule against his decision to illegally issue tax penalties and subsidies on Americans in two-thirds of the country,” Sen. John Barrasso (R-Wyo.) said in a statement. “Let’s be clear: If the Supreme Court rules against the administration, Congress will not pass a so called ‘one-sentence’ fake fix.”
On Twitter @whitneymcknight
AMA HOD: Delegates back ICD-10 reprieve, but gun proposals draw fire
CHICAGO – Physicians would have a 2-year reprieve from penalties while using the new ICD-10 coding set, under a resolution easily passed June 8 by the American Medical Association’s House of Delegates.
However, two proposals related to gun violence generated more heat than consensus among the AMA delegates at their annual meeting.
The ICD-10 resolution calls for the AMA to push the Centers for Medicare & Medicaid Services and other payers for a 2-year grace period from penalties physicians would otherwise face due to coding errors, mistakes, or other issues that might arise after the Oct. 1, 2015, transition to the new coding set.
The resolution passed without any discussion, other than a request that its reference committee report be considered at the top of the voting agenda so the AMA could begin working on it immediately.
The rest of the ICD-10 resolution calls for the AMA to educate physicians on how to meet obligations to Medicare and private payers if they choose to become a cash-only practice that no longer accepts insurance. The resolution also calls for the AMA to collect data on how ICD-10 implementation affects patients and changes practice patterns.
In contrast, two resolutions on gun-related violence produced far less agreement among the delegates.
The first resolution addressed prevention of firearm-related injuries and deaths among youth by calling on the AMA to work with other organizations to identify materials that could be handed out as educational material in clinical practice.
Some delegates were concerned that the resolution could open the door to partnerships with organizations such as the National Rifle Association. However, others saw that as a good thing, because it could open the door to the organizations working together and finding common ground. Some delegates also noted that the NRA has the ability to reach people to promote gun safety whom the AMA might not be able to reach.
After discussion, delegates passed the resolution with a voice vote.
Delegates also considered a resolution in favor of background checks for gun purchases. An earlier AMA Board of Trustees report recommended support for background checks for anyone buying firearms.
A number of delegates rose in support of this proposal. Speaking on behalf of the American Academy of Family Physicians, AAFP President Dr. Robert L. Wergin noted the recent statement of support signed by a number of medical societies and the American Bar Association.
However, the background-check provision met resistance. Some delegates said it would not do anything to stop criminals who are obtaining guns illegally, while others said it was too far-reaching to require all sales to be accompanied with a criminal background check.
The proposal does not address those who can legally own guns, such as law enforcement officials and those who recently purchased a gun and already underwent a check, cautioned Dr. Michael Greene, of Macon, Ga. Others mentioned the potential impact on situations such as nonoperative weapons that are transferred as heirlooms, as well as guns given as gifts.
In the end, delegates sent the resolution back to committee for further consideration.
Delegates did approve an electronic health records resolution that called for holding vendors accountable for system downtime and other technology disruptions, and working with the CMS to earn physicians partial credit if some meaningful use objectives are met, rather than the current all-or-none situation.
Delegates also approved provisions to increase the use of prescription drug monitoring programs (PDMP). Under those provisions, the AMA would support voluntary use of state PDMP programs, encourage states to modernize their programs, and support allowing access to PDMPs by a delegate appointed by a physician.
CHICAGO – Physicians would have a 2-year reprieve from penalties while using the new ICD-10 coding set, under a resolution easily passed June 8 by the American Medical Association’s House of Delegates.
However, two proposals related to gun violence generated more heat than consensus among the AMA delegates at their annual meeting.
The ICD-10 resolution calls for the AMA to push the Centers for Medicare & Medicaid Services and other payers for a 2-year grace period from penalties physicians would otherwise face due to coding errors, mistakes, or other issues that might arise after the Oct. 1, 2015, transition to the new coding set.
The resolution passed without any discussion, other than a request that its reference committee report be considered at the top of the voting agenda so the AMA could begin working on it immediately.
The rest of the ICD-10 resolution calls for the AMA to educate physicians on how to meet obligations to Medicare and private payers if they choose to become a cash-only practice that no longer accepts insurance. The resolution also calls for the AMA to collect data on how ICD-10 implementation affects patients and changes practice patterns.
In contrast, two resolutions on gun-related violence produced far less agreement among the delegates.
The first resolution addressed prevention of firearm-related injuries and deaths among youth by calling on the AMA to work with other organizations to identify materials that could be handed out as educational material in clinical practice.
Some delegates were concerned that the resolution could open the door to partnerships with organizations such as the National Rifle Association. However, others saw that as a good thing, because it could open the door to the organizations working together and finding common ground. Some delegates also noted that the NRA has the ability to reach people to promote gun safety whom the AMA might not be able to reach.
After discussion, delegates passed the resolution with a voice vote.
Delegates also considered a resolution in favor of background checks for gun purchases. An earlier AMA Board of Trustees report recommended support for background checks for anyone buying firearms.
A number of delegates rose in support of this proposal. Speaking on behalf of the American Academy of Family Physicians, AAFP President Dr. Robert L. Wergin noted the recent statement of support signed by a number of medical societies and the American Bar Association.
However, the background-check provision met resistance. Some delegates said it would not do anything to stop criminals who are obtaining guns illegally, while others said it was too far-reaching to require all sales to be accompanied with a criminal background check.
The proposal does not address those who can legally own guns, such as law enforcement officials and those who recently purchased a gun and already underwent a check, cautioned Dr. Michael Greene, of Macon, Ga. Others mentioned the potential impact on situations such as nonoperative weapons that are transferred as heirlooms, as well as guns given as gifts.
In the end, delegates sent the resolution back to committee for further consideration.
Delegates did approve an electronic health records resolution that called for holding vendors accountable for system downtime and other technology disruptions, and working with the CMS to earn physicians partial credit if some meaningful use objectives are met, rather than the current all-or-none situation.
Delegates also approved provisions to increase the use of prescription drug monitoring programs (PDMP). Under those provisions, the AMA would support voluntary use of state PDMP programs, encourage states to modernize their programs, and support allowing access to PDMPs by a delegate appointed by a physician.
CHICAGO – Physicians would have a 2-year reprieve from penalties while using the new ICD-10 coding set, under a resolution easily passed June 8 by the American Medical Association’s House of Delegates.
However, two proposals related to gun violence generated more heat than consensus among the AMA delegates at their annual meeting.
The ICD-10 resolution calls for the AMA to push the Centers for Medicare & Medicaid Services and other payers for a 2-year grace period from penalties physicians would otherwise face due to coding errors, mistakes, or other issues that might arise after the Oct. 1, 2015, transition to the new coding set.
The resolution passed without any discussion, other than a request that its reference committee report be considered at the top of the voting agenda so the AMA could begin working on it immediately.
The rest of the ICD-10 resolution calls for the AMA to educate physicians on how to meet obligations to Medicare and private payers if they choose to become a cash-only practice that no longer accepts insurance. The resolution also calls for the AMA to collect data on how ICD-10 implementation affects patients and changes practice patterns.
In contrast, two resolutions on gun-related violence produced far less agreement among the delegates.
The first resolution addressed prevention of firearm-related injuries and deaths among youth by calling on the AMA to work with other organizations to identify materials that could be handed out as educational material in clinical practice.
Some delegates were concerned that the resolution could open the door to partnerships with organizations such as the National Rifle Association. However, others saw that as a good thing, because it could open the door to the organizations working together and finding common ground. Some delegates also noted that the NRA has the ability to reach people to promote gun safety whom the AMA might not be able to reach.
After discussion, delegates passed the resolution with a voice vote.
Delegates also considered a resolution in favor of background checks for gun purchases. An earlier AMA Board of Trustees report recommended support for background checks for anyone buying firearms.
A number of delegates rose in support of this proposal. Speaking on behalf of the American Academy of Family Physicians, AAFP President Dr. Robert L. Wergin noted the recent statement of support signed by a number of medical societies and the American Bar Association.
However, the background-check provision met resistance. Some delegates said it would not do anything to stop criminals who are obtaining guns illegally, while others said it was too far-reaching to require all sales to be accompanied with a criminal background check.
The proposal does not address those who can legally own guns, such as law enforcement officials and those who recently purchased a gun and already underwent a check, cautioned Dr. Michael Greene, of Macon, Ga. Others mentioned the potential impact on situations such as nonoperative weapons that are transferred as heirlooms, as well as guns given as gifts.
In the end, delegates sent the resolution back to committee for further consideration.
Delegates did approve an electronic health records resolution that called for holding vendors accountable for system downtime and other technology disruptions, and working with the CMS to earn physicians partial credit if some meaningful use objectives are met, rather than the current all-or-none situation.
Delegates also approved provisions to increase the use of prescription drug monitoring programs (PDMP). Under those provisions, the AMA would support voluntary use of state PDMP programs, encourage states to modernize their programs, and support allowing access to PDMPs by a delegate appointed by a physician.
AT THE AMA HOD MEETING
ASCO: Omitting adjuvant radiation after pCR ups locoregional recurrence risk
CHICAGO – Women with breast cancer treated with neoadjuvant chemotherapy and surgery are more likely to have a recurrence in the breast, chest wall, or axilla or to die if they don’t receive adjuvant radiation therapy, even if they had a pathologic complete response to the chemotherapy, new data show.
In a meta-analysis of three Gepar trials conducted by the German Breast Group, radiation therapy was associated with a 38% lower multivariate risk of locoregional recurrence or death, investigators reported at the annual meeting of the American Society of Clinical Oncology. Significant benefit was seen regardless of pathologic complete response, although findings across other subgroups were not consistent, possibly due to selection bias or underlying confounders.
“Radiotherapy is an independent prognostic factor for locoregional recurrence–free survival after neoadjuvant chemotherapy in breast cancer. However, the optimal selection criteria remain unclear,” commented first author Dr. David Krug of University Hospital Heidelberg (Germany).
“We are eagerly awaiting the results of prospective studies that are currently recruiting patients,” he added, referring to the National Surgical Adjuvant Breast and Bowel Project (NSABP) B-51 trial and the Radiotherapy After Primary Chemotherapy for Breast Cancer (RAPCHEM) trial.
Findings of this meta-analysis are not practice changing, according to invited discussant Dr. Monica Morrow, chief of the breast service, department of surgery, and the Anne Burnett Windfohr Chair of Clinical Oncology at the Memorial Sloan Kettering Cancer Center in New York. “The Gepar data is not consistent enough across subsets to draw any different conclusions other than we need more data,” she said.
Focusing on the women who underwent mastectomy, she noted that only a small number who had a pathologic complete response did not receive radiation therapy, “so this study unfortunately lacks the power to tell us anything about the ability to eliminate radiation in this group.”
“What we’d really like to know about local control after neoadjuvant therapy is what’s the relative contribution of pretreatment stage and posttreatment stage to the risk of locoregional recurrence, especially in patients who achieve pathologic complete response? And if we try to address that question with this study, the results were a little murky,” Dr. Morrow further noted. For example, patients with higher–T stage primary tumors benefited from postmastectomy radiation, but patients who were clinically node positive did not.
“I think right now, what we have to say is we need to continue to do what we have been doing up until the present time, namely, patients whose presenting stage clearly indicates the need for radiotherapy should receive it, and patients who have lower-stage disease perhaps not,” she concluded, agreeing that the NSABP B-51 trial should help put this issue to rest.
Dr. Krug and his colleagues performed a pooled meta-analysis of data from the GeparTrio, GeparQuattro, and GeparQuinto trials of neoadjuvant chemotherapy, in which guidelines specified when adjuvant radiation therapy should be used. Those guidelines called for whole-breast radiation therapy with a boost after breast-conserving surgery (with omission of the boost in low-risk patients); radiation therapy after mastectomy for patients having more extensive disease before neoadjuvant chemotherapy; and radiation therapy for those with greater involvement of the regional lymphatics.
The meta-analysis was based on a total of 3,370 women. Overall, 94% received radiation therapy (99% of those who had undergone breast-conserving surgery and 85% of those who had undergone mastectomy).
With a median follow-up of 4.2 years, the 5-year rate of locoregional recurrence–free survival was 89.2% in the entire study population, according to Dr. Krug.
Women who did not receive radiation therapy had a significantly elevated risk of such recurrence or death compared with peers who received it. In subgroups analyses, benefit was significant whether women had had a pathologic complete response to neoadjuvant chemotherapy or not. Greatest absolute benefit was seen in those with a pathologic complete response, clinically positive nodes, or pathologically negative nodes.
The 5-year rate of disease-free survival was 74.0% in the entire study population. Here, there was only a trend toward a higher risk of events for women who did not receive radiation therapy.
In multivariate analyses, radiation therapy independently predicted better locoregional recurrence–free survival (hazard ratio, 0.62; P = .038) but not disease-free survival.
When analyses were restricted to women who had undergone mastectomy, radiation therapy was associated with significantly better locoregional recurrence–free survival among those with clinical stage T3/4 disease, pathologically negative nodes, a conversion from clinically positive to pathologically negative nodes, or hormone receptor–negative, HER2-positive disease.
It was associated with poorer disease-free survival for patients who did not achieve a pathologic complete response, had clinical stage T1/2 disease, or were clinically node negative.
Multivariate analysis here again showed that radiation therapy independently predicted better locoregional recurrence–free survival (HR, 0.56; P = .029) but not disease-free survival.
CHICAGO – Women with breast cancer treated with neoadjuvant chemotherapy and surgery are more likely to have a recurrence in the breast, chest wall, or axilla or to die if they don’t receive adjuvant radiation therapy, even if they had a pathologic complete response to the chemotherapy, new data show.
In a meta-analysis of three Gepar trials conducted by the German Breast Group, radiation therapy was associated with a 38% lower multivariate risk of locoregional recurrence or death, investigators reported at the annual meeting of the American Society of Clinical Oncology. Significant benefit was seen regardless of pathologic complete response, although findings across other subgroups were not consistent, possibly due to selection bias or underlying confounders.
“Radiotherapy is an independent prognostic factor for locoregional recurrence–free survival after neoadjuvant chemotherapy in breast cancer. However, the optimal selection criteria remain unclear,” commented first author Dr. David Krug of University Hospital Heidelberg (Germany).
“We are eagerly awaiting the results of prospective studies that are currently recruiting patients,” he added, referring to the National Surgical Adjuvant Breast and Bowel Project (NSABP) B-51 trial and the Radiotherapy After Primary Chemotherapy for Breast Cancer (RAPCHEM) trial.
Findings of this meta-analysis are not practice changing, according to invited discussant Dr. Monica Morrow, chief of the breast service, department of surgery, and the Anne Burnett Windfohr Chair of Clinical Oncology at the Memorial Sloan Kettering Cancer Center in New York. “The Gepar data is not consistent enough across subsets to draw any different conclusions other than we need more data,” she said.
Focusing on the women who underwent mastectomy, she noted that only a small number who had a pathologic complete response did not receive radiation therapy, “so this study unfortunately lacks the power to tell us anything about the ability to eliminate radiation in this group.”
“What we’d really like to know about local control after neoadjuvant therapy is what’s the relative contribution of pretreatment stage and posttreatment stage to the risk of locoregional recurrence, especially in patients who achieve pathologic complete response? And if we try to address that question with this study, the results were a little murky,” Dr. Morrow further noted. For example, patients with higher–T stage primary tumors benefited from postmastectomy radiation, but patients who were clinically node positive did not.
“I think right now, what we have to say is we need to continue to do what we have been doing up until the present time, namely, patients whose presenting stage clearly indicates the need for radiotherapy should receive it, and patients who have lower-stage disease perhaps not,” she concluded, agreeing that the NSABP B-51 trial should help put this issue to rest.
Dr. Krug and his colleagues performed a pooled meta-analysis of data from the GeparTrio, GeparQuattro, and GeparQuinto trials of neoadjuvant chemotherapy, in which guidelines specified when adjuvant radiation therapy should be used. Those guidelines called for whole-breast radiation therapy with a boost after breast-conserving surgery (with omission of the boost in low-risk patients); radiation therapy after mastectomy for patients having more extensive disease before neoadjuvant chemotherapy; and radiation therapy for those with greater involvement of the regional lymphatics.
The meta-analysis was based on a total of 3,370 women. Overall, 94% received radiation therapy (99% of those who had undergone breast-conserving surgery and 85% of those who had undergone mastectomy).
With a median follow-up of 4.2 years, the 5-year rate of locoregional recurrence–free survival was 89.2% in the entire study population, according to Dr. Krug.
Women who did not receive radiation therapy had a significantly elevated risk of such recurrence or death compared with peers who received it. In subgroups analyses, benefit was significant whether women had had a pathologic complete response to neoadjuvant chemotherapy or not. Greatest absolute benefit was seen in those with a pathologic complete response, clinically positive nodes, or pathologically negative nodes.
The 5-year rate of disease-free survival was 74.0% in the entire study population. Here, there was only a trend toward a higher risk of events for women who did not receive radiation therapy.
In multivariate analyses, radiation therapy independently predicted better locoregional recurrence–free survival (hazard ratio, 0.62; P = .038) but not disease-free survival.
When analyses were restricted to women who had undergone mastectomy, radiation therapy was associated with significantly better locoregional recurrence–free survival among those with clinical stage T3/4 disease, pathologically negative nodes, a conversion from clinically positive to pathologically negative nodes, or hormone receptor–negative, HER2-positive disease.
It was associated with poorer disease-free survival for patients who did not achieve a pathologic complete response, had clinical stage T1/2 disease, or were clinically node negative.
Multivariate analysis here again showed that radiation therapy independently predicted better locoregional recurrence–free survival (HR, 0.56; P = .029) but not disease-free survival.
CHICAGO – Women with breast cancer treated with neoadjuvant chemotherapy and surgery are more likely to have a recurrence in the breast, chest wall, or axilla or to die if they don’t receive adjuvant radiation therapy, even if they had a pathologic complete response to the chemotherapy, new data show.
In a meta-analysis of three Gepar trials conducted by the German Breast Group, radiation therapy was associated with a 38% lower multivariate risk of locoregional recurrence or death, investigators reported at the annual meeting of the American Society of Clinical Oncology. Significant benefit was seen regardless of pathologic complete response, although findings across other subgroups were not consistent, possibly due to selection bias or underlying confounders.
“Radiotherapy is an independent prognostic factor for locoregional recurrence–free survival after neoadjuvant chemotherapy in breast cancer. However, the optimal selection criteria remain unclear,” commented first author Dr. David Krug of University Hospital Heidelberg (Germany).
“We are eagerly awaiting the results of prospective studies that are currently recruiting patients,” he added, referring to the National Surgical Adjuvant Breast and Bowel Project (NSABP) B-51 trial and the Radiotherapy After Primary Chemotherapy for Breast Cancer (RAPCHEM) trial.
Findings of this meta-analysis are not practice changing, according to invited discussant Dr. Monica Morrow, chief of the breast service, department of surgery, and the Anne Burnett Windfohr Chair of Clinical Oncology at the Memorial Sloan Kettering Cancer Center in New York. “The Gepar data is not consistent enough across subsets to draw any different conclusions other than we need more data,” she said.
Focusing on the women who underwent mastectomy, she noted that only a small number who had a pathologic complete response did not receive radiation therapy, “so this study unfortunately lacks the power to tell us anything about the ability to eliminate radiation in this group.”
“What we’d really like to know about local control after neoadjuvant therapy is what’s the relative contribution of pretreatment stage and posttreatment stage to the risk of locoregional recurrence, especially in patients who achieve pathologic complete response? And if we try to address that question with this study, the results were a little murky,” Dr. Morrow further noted. For example, patients with higher–T stage primary tumors benefited from postmastectomy radiation, but patients who were clinically node positive did not.
“I think right now, what we have to say is we need to continue to do what we have been doing up until the present time, namely, patients whose presenting stage clearly indicates the need for radiotherapy should receive it, and patients who have lower-stage disease perhaps not,” she concluded, agreeing that the NSABP B-51 trial should help put this issue to rest.
Dr. Krug and his colleagues performed a pooled meta-analysis of data from the GeparTrio, GeparQuattro, and GeparQuinto trials of neoadjuvant chemotherapy, in which guidelines specified when adjuvant radiation therapy should be used. Those guidelines called for whole-breast radiation therapy with a boost after breast-conserving surgery (with omission of the boost in low-risk patients); radiation therapy after mastectomy for patients having more extensive disease before neoadjuvant chemotherapy; and radiation therapy for those with greater involvement of the regional lymphatics.
The meta-analysis was based on a total of 3,370 women. Overall, 94% received radiation therapy (99% of those who had undergone breast-conserving surgery and 85% of those who had undergone mastectomy).
With a median follow-up of 4.2 years, the 5-year rate of locoregional recurrence–free survival was 89.2% in the entire study population, according to Dr. Krug.
Women who did not receive radiation therapy had a significantly elevated risk of such recurrence or death compared with peers who received it. In subgroups analyses, benefit was significant whether women had had a pathologic complete response to neoadjuvant chemotherapy or not. Greatest absolute benefit was seen in those with a pathologic complete response, clinically positive nodes, or pathologically negative nodes.
The 5-year rate of disease-free survival was 74.0% in the entire study population. Here, there was only a trend toward a higher risk of events for women who did not receive radiation therapy.
In multivariate analyses, radiation therapy independently predicted better locoregional recurrence–free survival (hazard ratio, 0.62; P = .038) but not disease-free survival.
When analyses were restricted to women who had undergone mastectomy, radiation therapy was associated with significantly better locoregional recurrence–free survival among those with clinical stage T3/4 disease, pathologically negative nodes, a conversion from clinically positive to pathologically negative nodes, or hormone receptor–negative, HER2-positive disease.
It was associated with poorer disease-free survival for patients who did not achieve a pathologic complete response, had clinical stage T1/2 disease, or were clinically node negative.
Multivariate analysis here again showed that radiation therapy independently predicted better locoregional recurrence–free survival (HR, 0.56; P = .029) but not disease-free survival.
AT THE 2015 ASCO ANNUAL MEETING
Key clinical point: Adjuvant radiation therapy improves locoregional recurrence–free survival after neoadjuvant chemo and surgery for breast cancer.
Major finding: Women who received adjuvant radiation therapy had a 38% lower risk of locoregional recurrence or death.
Data source: A meta-analysis of three randomized trials among 3,370 women who underwent neoadjuvant chemotherapy and surgery for breast cancer.
Disclosures: Dr. Krug disclosed that he receives travel expenses from Accuray.
SAEM: Pelvic CT may not be needed to diagnose intra-abdominal injury in children
SAN DIEGO – Children who have suffered blunt trauma are routinely screened in emergency departments for intra-abdominal injury via computed tomography of the abdomen and pelvis.
But concerns about excess exposure to CT radiation, particularly to the gonads, led one group of researchers to question whether it’s necessary to scan the entire abdominopelvic region in all of these patients to identify intra-abdominal injury (IAI).
Dr. Stacy Reynolds and her colleagues at the Carolinas Medical Center in Charlotte, N.C., hypothesized that CT limited to the radiographic abdomen – the region between the dome of the diaphragm to the top of the iliac crest – can capture the vast majority of IAIs in this population.
At the Society for Academic Emergency Medicine annual meeting, Dr. Reynolds presented results from a retrospective cohort study enrolling 313 hemodynamically stable pediatric patients (median age 14 years, 64% male) presenting to 12 EDs after blunt trauma. Patients with known pelvic fractures or hip dislocation were excluded, as they would have had a clear indication for a full abdominopelvic CT.
All subjects underwent axial abdominopelvic CT imaging. Researchers created matched pairs of images comprising the original scans and those that had been altered with software that truncated the pelvic portion of the study to create CT abdomen-only studies. Study radiologists were blinded to the results of the original scans.
Twenty-six IAI’s were diagnosed in 24 patients: 8 hepatic injuries, 12 splenic injuries, 5 renal injuries, and 1 retroperitoneal hemorrhage. Abdominal CT alone was 85% sensitive (95% confidence interval, 65%-96%) and 99% specific (95% CI, 97%-100%) in identifying IAIs. The four missed injuries were solid organ injuries within the radiographic abdomen. False positives occurred in two of the complete scans, both involving free fluid prompting suspicion of small bowel injury later ruled out by clinical observation.
Dr. Reynolds said in an interview said that the findings, while promising, were limited by the study’s small numbers, and its use of axial images alone, when sagittal images also would be required for the most accurate diagnoses. Also, physician suspicion of IAI prior to imaging was not captured because of the study’s retrospective design, she said. “The real key to whether or not this hypothesis is valuable is if physicians are able to target the right population of patients for application.”
Dr. Reynolds cautioned that the findings would need to be validated in a larger trial before any changes could be made to clinical practice. “Some of the outcomes that we need to make sure whether we’re missing are still rare,” she said. “You couldn’t feel confident that this is the right way to go with a study this small, but it establishes that we can safely and ethically pursue a multicenter trial that would examine the issue with bigger numbers.”
Other groups of investigators, including members of the Pediatric Emergency Care Applied Research Network (PECARN), also have taken up the question of identifying children at low risk of IAI who may not need CT screening after blunt trauma. In 2013, PECARN published a prediction rule using only patient history and physical examination findings intended to obviate use of CT in the lowest-risk patients (Ann. Emerg. Med. 2013;62:107-16.e2).
Dr. Reynolds said that while overuse of CT was a worrisome trend that could have long-term implications for patients, and that it was important to identify ways it might be limited, there is a reason it remains the go-to technology in the ED for detecting IAI. “It’s got very high sensitivity and specificity. If you’re a busy trauma surgeon who’s admitting 20 injured patients in a night, there’s no faster or more efficient way to determine whether the patient in front of you is injured.”
The study was funded by the Carolinas Trauma Network Research Center of Excellence. None of the investigators disclosed conflicts of interest.
SAN DIEGO – Children who have suffered blunt trauma are routinely screened in emergency departments for intra-abdominal injury via computed tomography of the abdomen and pelvis.
But concerns about excess exposure to CT radiation, particularly to the gonads, led one group of researchers to question whether it’s necessary to scan the entire abdominopelvic region in all of these patients to identify intra-abdominal injury (IAI).
Dr. Stacy Reynolds and her colleagues at the Carolinas Medical Center in Charlotte, N.C., hypothesized that CT limited to the radiographic abdomen – the region between the dome of the diaphragm to the top of the iliac crest – can capture the vast majority of IAIs in this population.
At the Society for Academic Emergency Medicine annual meeting, Dr. Reynolds presented results from a retrospective cohort study enrolling 313 hemodynamically stable pediatric patients (median age 14 years, 64% male) presenting to 12 EDs after blunt trauma. Patients with known pelvic fractures or hip dislocation were excluded, as they would have had a clear indication for a full abdominopelvic CT.
All subjects underwent axial abdominopelvic CT imaging. Researchers created matched pairs of images comprising the original scans and those that had been altered with software that truncated the pelvic portion of the study to create CT abdomen-only studies. Study radiologists were blinded to the results of the original scans.
Twenty-six IAI’s were diagnosed in 24 patients: 8 hepatic injuries, 12 splenic injuries, 5 renal injuries, and 1 retroperitoneal hemorrhage. Abdominal CT alone was 85% sensitive (95% confidence interval, 65%-96%) and 99% specific (95% CI, 97%-100%) in identifying IAIs. The four missed injuries were solid organ injuries within the radiographic abdomen. False positives occurred in two of the complete scans, both involving free fluid prompting suspicion of small bowel injury later ruled out by clinical observation.
Dr. Reynolds said in an interview said that the findings, while promising, were limited by the study’s small numbers, and its use of axial images alone, when sagittal images also would be required for the most accurate diagnoses. Also, physician suspicion of IAI prior to imaging was not captured because of the study’s retrospective design, she said. “The real key to whether or not this hypothesis is valuable is if physicians are able to target the right population of patients for application.”
Dr. Reynolds cautioned that the findings would need to be validated in a larger trial before any changes could be made to clinical practice. “Some of the outcomes that we need to make sure whether we’re missing are still rare,” she said. “You couldn’t feel confident that this is the right way to go with a study this small, but it establishes that we can safely and ethically pursue a multicenter trial that would examine the issue with bigger numbers.”
Other groups of investigators, including members of the Pediatric Emergency Care Applied Research Network (PECARN), also have taken up the question of identifying children at low risk of IAI who may not need CT screening after blunt trauma. In 2013, PECARN published a prediction rule using only patient history and physical examination findings intended to obviate use of CT in the lowest-risk patients (Ann. Emerg. Med. 2013;62:107-16.e2).
Dr. Reynolds said that while overuse of CT was a worrisome trend that could have long-term implications for patients, and that it was important to identify ways it might be limited, there is a reason it remains the go-to technology in the ED for detecting IAI. “It’s got very high sensitivity and specificity. If you’re a busy trauma surgeon who’s admitting 20 injured patients in a night, there’s no faster or more efficient way to determine whether the patient in front of you is injured.”
The study was funded by the Carolinas Trauma Network Research Center of Excellence. None of the investigators disclosed conflicts of interest.
SAN DIEGO – Children who have suffered blunt trauma are routinely screened in emergency departments for intra-abdominal injury via computed tomography of the abdomen and pelvis.
But concerns about excess exposure to CT radiation, particularly to the gonads, led one group of researchers to question whether it’s necessary to scan the entire abdominopelvic region in all of these patients to identify intra-abdominal injury (IAI).
Dr. Stacy Reynolds and her colleagues at the Carolinas Medical Center in Charlotte, N.C., hypothesized that CT limited to the radiographic abdomen – the region between the dome of the diaphragm to the top of the iliac crest – can capture the vast majority of IAIs in this population.
At the Society for Academic Emergency Medicine annual meeting, Dr. Reynolds presented results from a retrospective cohort study enrolling 313 hemodynamically stable pediatric patients (median age 14 years, 64% male) presenting to 12 EDs after blunt trauma. Patients with known pelvic fractures or hip dislocation were excluded, as they would have had a clear indication for a full abdominopelvic CT.
All subjects underwent axial abdominopelvic CT imaging. Researchers created matched pairs of images comprising the original scans and those that had been altered with software that truncated the pelvic portion of the study to create CT abdomen-only studies. Study radiologists were blinded to the results of the original scans.
Twenty-six IAI’s were diagnosed in 24 patients: 8 hepatic injuries, 12 splenic injuries, 5 renal injuries, and 1 retroperitoneal hemorrhage. Abdominal CT alone was 85% sensitive (95% confidence interval, 65%-96%) and 99% specific (95% CI, 97%-100%) in identifying IAIs. The four missed injuries were solid organ injuries within the radiographic abdomen. False positives occurred in two of the complete scans, both involving free fluid prompting suspicion of small bowel injury later ruled out by clinical observation.
Dr. Reynolds said in an interview said that the findings, while promising, were limited by the study’s small numbers, and its use of axial images alone, when sagittal images also would be required for the most accurate diagnoses. Also, physician suspicion of IAI prior to imaging was not captured because of the study’s retrospective design, she said. “The real key to whether or not this hypothesis is valuable is if physicians are able to target the right population of patients for application.”
Dr. Reynolds cautioned that the findings would need to be validated in a larger trial before any changes could be made to clinical practice. “Some of the outcomes that we need to make sure whether we’re missing are still rare,” she said. “You couldn’t feel confident that this is the right way to go with a study this small, but it establishes that we can safely and ethically pursue a multicenter trial that would examine the issue with bigger numbers.”
Other groups of investigators, including members of the Pediatric Emergency Care Applied Research Network (PECARN), also have taken up the question of identifying children at low risk of IAI who may not need CT screening after blunt trauma. In 2013, PECARN published a prediction rule using only patient history and physical examination findings intended to obviate use of CT in the lowest-risk patients (Ann. Emerg. Med. 2013;62:107-16.e2).
Dr. Reynolds said that while overuse of CT was a worrisome trend that could have long-term implications for patients, and that it was important to identify ways it might be limited, there is a reason it remains the go-to technology in the ED for detecting IAI. “It’s got very high sensitivity and specificity. If you’re a busy trauma surgeon who’s admitting 20 injured patients in a night, there’s no faster or more efficient way to determine whether the patient in front of you is injured.”
The study was funded by the Carolinas Trauma Network Research Center of Excellence. None of the investigators disclosed conflicts of interest.
FROM SAEM 2015
Key clinical point: Abdominal CT scans without a pelvic portion may diagnose intra-abdominal injury in children as well as do full abdominopelvic scans, with less radiation exposure to patients.
Major finding: Abdominal CT alone was 85% sensitive (95% CI, 65%-96%) and 99% specific (95% CI, 97%-100%) in identifying IAIs. The four missed injuries were solid organ injuries within the radiographic abdomen.
Data source: A retrospective cohort study of 313 patients aged 3-17 years presenting to 12 emergency departments.
Disclosures: The study was funded by the Carolinas Trauma Network Research Center of Excellence. None of the investigators disclosed conflicts of interest.
