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Anti-mesh trend may be felt by surgeons doing hernia repairs
LAS VEGAS – Hernia surgeons are square in the path of a growing backlash against the use of mesh in surgery, a fellow surgeon says, and he’s warning colleagues to take heed of the trend.
“I tell you, it’s coming,” B. Todd Heniford, MD,, professor and chief of gastrointestinal and minimally invasive surgery at Carolinas Medical Center, Charlotte, N.C., declared in a presentation at the Annual Minimally Invasive Surgery Symposium by Global Academy for Medical Education.
“This is no time to abandon surgical mesh in hernia procedures,” he argued. Instead, he said surgeons should engage in better communication with patients. Otherwise, “we are not helping ourselves as surgeons.”
In the United States, most of the controversy around the use of mesh in surgery has revolved around transvaginal procedures in women. As a 2017 historical review explained, “mesh used to augment transvaginal repair of [pelvic organ prolapse] was introduced in the United States in 2005 without clinical safety and efficacy data. In the subsequent years of use, both major and minor complications were increasingly reported, leading to several [Food and Drug Administration] notifications and warnings” (Int Urogynecol J. 2017 Apr;28[4]:527-35).
An FDA safety alert in 2011 and new requirements for postmarked surveillance orders convinced most manufacturers to stop marketing surgical mesh for transvaginal repair of pelvic organ prolapse. According to a 2018 report, an estimated 73,000 patients in the United States have filed product liability claims regarding complications from mesh used in transvaginal procedures (Female Pelvic Med Reconstr Surg. 2018 Jan/Feb;24[1]:21-25).
Outside the United States, Dr. Heniford said, concerns about surgical mesh have spawned a global outcry about its use in another kind of procedure – hernia surgery. “It is gaining speed in Europe, Australia and New Zealand,” he said.
Indeed, these are some recent headlines in Australian and British news outlets: “Concern grows over hernia mesh as more patients share post-surgery horror stories,” “Hernia mesh concerns grow among men as more patients report surgery complications,” “Pelvic and hernia mesh patients will confront politicians and bureaucrats in April over the medical device industry,” and “Mesh implants: Man speaks of procedure’s devastating impact.”
“When people read this, it influences them,” Dr. Heniford said. “And mesh companies are not helping us, let’s be frank about it,” he added, noting that manufacturers have launched recalls due to problems and complications.
Is the anti-mesh frenzy regarding hernias coming to the United States? “Absolutely,” said Dr. Heniford, noting that an online search will turn up many legal websites devoted to hernia mesh lawsuits. And, he said, hernia patients are already concerned because of commercials they’ve seen on TV. “One of the issues is that the lawyers in the United States have become real experts on mesh for pelvic slings,” he said. “They’ve just about run through that.” It’s not just lawyers who are taking advantage of the anti-mesh trend. “If you go online and you type in ‘no-mesh surgery,’ ” he said, “you’ll see loads of surgeons who are trying to take advantage of this.”
In reality, research supports the use of mesh in hernia procedures. A 2018 Cochrane Library review found that “overall, hernia repairs with and without mesh both proved effective in the treatment of hernias, although mesh repairs demonstrated fewer hernia recurrences, a shorter operation time and faster return to normal activities. Non-mesh repairs are still widely used, often due to the cost and poor availability of the mesh product itself” (Cochrane Database Syst Rev. 2018, Issue 9.)
Dr. Heniford suggested that surgeons can do much more to calm patients about the use of mesh. One strategy, he said, is to help them understand that they may face pain after their procedures that has nothing to do with surgical mesh.
“We do not counsel our patients enough about postoperative pain,” he said. “If you see someone who had real pain prior to the operation, you really have to counsel them about postoperation pain. Patients who present with pain are much more likely to have pain after surgery.”
He noted that surgical mesh isn’t appropriate for all patients.
Dr. Heniford left colleagues with this message: “If we use mesh, there’s no question we improve our outcomes long term. But we’ve got to be careful about how we place it and the patients we choose.”
Global Academy for Medical Education and this news organization are owned by the same parent company. Dr. Heniford disclosed relationships with Allergan, Stryker, and W.L. Gore.
LAS VEGAS – Hernia surgeons are square in the path of a growing backlash against the use of mesh in surgery, a fellow surgeon says, and he’s warning colleagues to take heed of the trend.
“I tell you, it’s coming,” B. Todd Heniford, MD,, professor and chief of gastrointestinal and minimally invasive surgery at Carolinas Medical Center, Charlotte, N.C., declared in a presentation at the Annual Minimally Invasive Surgery Symposium by Global Academy for Medical Education.
“This is no time to abandon surgical mesh in hernia procedures,” he argued. Instead, he said surgeons should engage in better communication with patients. Otherwise, “we are not helping ourselves as surgeons.”
In the United States, most of the controversy around the use of mesh in surgery has revolved around transvaginal procedures in women. As a 2017 historical review explained, “mesh used to augment transvaginal repair of [pelvic organ prolapse] was introduced in the United States in 2005 without clinical safety and efficacy data. In the subsequent years of use, both major and minor complications were increasingly reported, leading to several [Food and Drug Administration] notifications and warnings” (Int Urogynecol J. 2017 Apr;28[4]:527-35).
An FDA safety alert in 2011 and new requirements for postmarked surveillance orders convinced most manufacturers to stop marketing surgical mesh for transvaginal repair of pelvic organ prolapse. According to a 2018 report, an estimated 73,000 patients in the United States have filed product liability claims regarding complications from mesh used in transvaginal procedures (Female Pelvic Med Reconstr Surg. 2018 Jan/Feb;24[1]:21-25).
Outside the United States, Dr. Heniford said, concerns about surgical mesh have spawned a global outcry about its use in another kind of procedure – hernia surgery. “It is gaining speed in Europe, Australia and New Zealand,” he said.
Indeed, these are some recent headlines in Australian and British news outlets: “Concern grows over hernia mesh as more patients share post-surgery horror stories,” “Hernia mesh concerns grow among men as more patients report surgery complications,” “Pelvic and hernia mesh patients will confront politicians and bureaucrats in April over the medical device industry,” and “Mesh implants: Man speaks of procedure’s devastating impact.”
“When people read this, it influences them,” Dr. Heniford said. “And mesh companies are not helping us, let’s be frank about it,” he added, noting that manufacturers have launched recalls due to problems and complications.
Is the anti-mesh frenzy regarding hernias coming to the United States? “Absolutely,” said Dr. Heniford, noting that an online search will turn up many legal websites devoted to hernia mesh lawsuits. And, he said, hernia patients are already concerned because of commercials they’ve seen on TV. “One of the issues is that the lawyers in the United States have become real experts on mesh for pelvic slings,” he said. “They’ve just about run through that.” It’s not just lawyers who are taking advantage of the anti-mesh trend. “If you go online and you type in ‘no-mesh surgery,’ ” he said, “you’ll see loads of surgeons who are trying to take advantage of this.”
In reality, research supports the use of mesh in hernia procedures. A 2018 Cochrane Library review found that “overall, hernia repairs with and without mesh both proved effective in the treatment of hernias, although mesh repairs demonstrated fewer hernia recurrences, a shorter operation time and faster return to normal activities. Non-mesh repairs are still widely used, often due to the cost and poor availability of the mesh product itself” (Cochrane Database Syst Rev. 2018, Issue 9.)
Dr. Heniford suggested that surgeons can do much more to calm patients about the use of mesh. One strategy, he said, is to help them understand that they may face pain after their procedures that has nothing to do with surgical mesh.
“We do not counsel our patients enough about postoperative pain,” he said. “If you see someone who had real pain prior to the operation, you really have to counsel them about postoperation pain. Patients who present with pain are much more likely to have pain after surgery.”
He noted that surgical mesh isn’t appropriate for all patients.
Dr. Heniford left colleagues with this message: “If we use mesh, there’s no question we improve our outcomes long term. But we’ve got to be careful about how we place it and the patients we choose.”
Global Academy for Medical Education and this news organization are owned by the same parent company. Dr. Heniford disclosed relationships with Allergan, Stryker, and W.L. Gore.
LAS VEGAS – Hernia surgeons are square in the path of a growing backlash against the use of mesh in surgery, a fellow surgeon says, and he’s warning colleagues to take heed of the trend.
“I tell you, it’s coming,” B. Todd Heniford, MD,, professor and chief of gastrointestinal and minimally invasive surgery at Carolinas Medical Center, Charlotte, N.C., declared in a presentation at the Annual Minimally Invasive Surgery Symposium by Global Academy for Medical Education.
“This is no time to abandon surgical mesh in hernia procedures,” he argued. Instead, he said surgeons should engage in better communication with patients. Otherwise, “we are not helping ourselves as surgeons.”
In the United States, most of the controversy around the use of mesh in surgery has revolved around transvaginal procedures in women. As a 2017 historical review explained, “mesh used to augment transvaginal repair of [pelvic organ prolapse] was introduced in the United States in 2005 without clinical safety and efficacy data. In the subsequent years of use, both major and minor complications were increasingly reported, leading to several [Food and Drug Administration] notifications and warnings” (Int Urogynecol J. 2017 Apr;28[4]:527-35).
An FDA safety alert in 2011 and new requirements for postmarked surveillance orders convinced most manufacturers to stop marketing surgical mesh for transvaginal repair of pelvic organ prolapse. According to a 2018 report, an estimated 73,000 patients in the United States have filed product liability claims regarding complications from mesh used in transvaginal procedures (Female Pelvic Med Reconstr Surg. 2018 Jan/Feb;24[1]:21-25).
Outside the United States, Dr. Heniford said, concerns about surgical mesh have spawned a global outcry about its use in another kind of procedure – hernia surgery. “It is gaining speed in Europe, Australia and New Zealand,” he said.
Indeed, these are some recent headlines in Australian and British news outlets: “Concern grows over hernia mesh as more patients share post-surgery horror stories,” “Hernia mesh concerns grow among men as more patients report surgery complications,” “Pelvic and hernia mesh patients will confront politicians and bureaucrats in April over the medical device industry,” and “Mesh implants: Man speaks of procedure’s devastating impact.”
“When people read this, it influences them,” Dr. Heniford said. “And mesh companies are not helping us, let’s be frank about it,” he added, noting that manufacturers have launched recalls due to problems and complications.
Is the anti-mesh frenzy regarding hernias coming to the United States? “Absolutely,” said Dr. Heniford, noting that an online search will turn up many legal websites devoted to hernia mesh lawsuits. And, he said, hernia patients are already concerned because of commercials they’ve seen on TV. “One of the issues is that the lawyers in the United States have become real experts on mesh for pelvic slings,” he said. “They’ve just about run through that.” It’s not just lawyers who are taking advantage of the anti-mesh trend. “If you go online and you type in ‘no-mesh surgery,’ ” he said, “you’ll see loads of surgeons who are trying to take advantage of this.”
In reality, research supports the use of mesh in hernia procedures. A 2018 Cochrane Library review found that “overall, hernia repairs with and without mesh both proved effective in the treatment of hernias, although mesh repairs demonstrated fewer hernia recurrences, a shorter operation time and faster return to normal activities. Non-mesh repairs are still widely used, often due to the cost and poor availability of the mesh product itself” (Cochrane Database Syst Rev. 2018, Issue 9.)
Dr. Heniford suggested that surgeons can do much more to calm patients about the use of mesh. One strategy, he said, is to help them understand that they may face pain after their procedures that has nothing to do with surgical mesh.
“We do not counsel our patients enough about postoperative pain,” he said. “If you see someone who had real pain prior to the operation, you really have to counsel them about postoperation pain. Patients who present with pain are much more likely to have pain after surgery.”
He noted that surgical mesh isn’t appropriate for all patients.
Dr. Heniford left colleagues with this message: “If we use mesh, there’s no question we improve our outcomes long term. But we’ve got to be careful about how we place it and the patients we choose.”
Global Academy for Medical Education and this news organization are owned by the same parent company. Dr. Heniford disclosed relationships with Allergan, Stryker, and W.L. Gore.
REPORTING FROM MISS
Experts offer insight on embracing diversity in the profession
Physicians have had diverse patients as long as there have been physicians (and patients). But diversity among health professionals remains elusive.
Can we do better? Absolutely, says a team of experts who will offer perspective to colleagues in a Wednesday morning session titled, “Best Practices and Tips for Developing Diversity in a Hospitalist Group.”
“The goals of our session are to review best practices for recruiting and retaining a diverse health care workforce, discuss strategies for dealing with implicit and explicit bias, and identify ways in which we can achieve common goals when working across cultures,” said hospitalist Amira del Pino-Jones, MD, assistant professor of medicine at the University of Colorado at Denver, Aurora, and director of the CU Hospitalist Scholars Program.
“Those who are interested in achieving excellence in hospital medicine through prioritizing diversity and equity efforts within their divisions, departments, and groups should attend,” said Dr. del Pino-Jones, who will be one of the speakers at the session.
Why is diversity important in hospital medicine? “Studies have shown that diversity enhances learning and work environments, promotes innovation, broadens research agendas, and improves the quality of care we provide for patients,” Dr. del Pino-Jones said. “In short, it is central to achieving excellence in hospital medicine.”
The session will focus on diverse groups, which have been historically underrepresented or discriminated against in medicine, including racial and ethnic minorities, women, LGBTQ+ individuals, and those with disabilities.
All speakers at the session are physicians, and each has seen or experienced challenges in diversifying their groups and divisions. “We hope to share our experiences, what we have learned, and ways to approach each of these issues. We also are hoping to hear from others and come up with new ways to approach these issues as a collective,” Dr. del Pino-Jones said.
Women and members of minority groups often have small numbers in their hospital medicine workplaces, especially in higher-level positions, and have trouble developing the critical mass to make progress on the diversity front, she said. Even when leaders recognize the importance of a diverse workforce, she said, “there is often a disconnect between motivation for increasing diversity and the ability to develop tangible, evidence-based methods that can be used to increase diversity.”
The session will tackle more than diversity at the workplace. Speakers also will discuss the relationship between medical professionals and patients.
“We will focus on the importance of inclusion and belonging, both of which are essential for creating a positive climate for all individuals,” Dr. del Pino-Jones said. “We will also discuss ways in which to cultivate cultural intelligence and enhance cross-cultural interactions between patients and providers. And we’ll look at ways to reduce and/or mitigate implicit and explicit bias in medicine.”
Dr. del Pino-Jones has no relevant disclosures.
Best Practices and Tips
for Developing Diversity in a Hospitalist Group
Wednesday, 10 - 11:30 a.m.
Potomac 4-6
Physicians have had diverse patients as long as there have been physicians (and patients). But diversity among health professionals remains elusive.
Can we do better? Absolutely, says a team of experts who will offer perspective to colleagues in a Wednesday morning session titled, “Best Practices and Tips for Developing Diversity in a Hospitalist Group.”
“The goals of our session are to review best practices for recruiting and retaining a diverse health care workforce, discuss strategies for dealing with implicit and explicit bias, and identify ways in which we can achieve common goals when working across cultures,” said hospitalist Amira del Pino-Jones, MD, assistant professor of medicine at the University of Colorado at Denver, Aurora, and director of the CU Hospitalist Scholars Program.
“Those who are interested in achieving excellence in hospital medicine through prioritizing diversity and equity efforts within their divisions, departments, and groups should attend,” said Dr. del Pino-Jones, who will be one of the speakers at the session.
Why is diversity important in hospital medicine? “Studies have shown that diversity enhances learning and work environments, promotes innovation, broadens research agendas, and improves the quality of care we provide for patients,” Dr. del Pino-Jones said. “In short, it is central to achieving excellence in hospital medicine.”
The session will focus on diverse groups, which have been historically underrepresented or discriminated against in medicine, including racial and ethnic minorities, women, LGBTQ+ individuals, and those with disabilities.
All speakers at the session are physicians, and each has seen or experienced challenges in diversifying their groups and divisions. “We hope to share our experiences, what we have learned, and ways to approach each of these issues. We also are hoping to hear from others and come up with new ways to approach these issues as a collective,” Dr. del Pino-Jones said.
Women and members of minority groups often have small numbers in their hospital medicine workplaces, especially in higher-level positions, and have trouble developing the critical mass to make progress on the diversity front, she said. Even when leaders recognize the importance of a diverse workforce, she said, “there is often a disconnect between motivation for increasing diversity and the ability to develop tangible, evidence-based methods that can be used to increase diversity.”
The session will tackle more than diversity at the workplace. Speakers also will discuss the relationship between medical professionals and patients.
“We will focus on the importance of inclusion and belonging, both of which are essential for creating a positive climate for all individuals,” Dr. del Pino-Jones said. “We will also discuss ways in which to cultivate cultural intelligence and enhance cross-cultural interactions between patients and providers. And we’ll look at ways to reduce and/or mitigate implicit and explicit bias in medicine.”
Dr. del Pino-Jones has no relevant disclosures.
Best Practices and Tips
for Developing Diversity in a Hospitalist Group
Wednesday, 10 - 11:30 a.m.
Potomac 4-6
Physicians have had diverse patients as long as there have been physicians (and patients). But diversity among health professionals remains elusive.
Can we do better? Absolutely, says a team of experts who will offer perspective to colleagues in a Wednesday morning session titled, “Best Practices and Tips for Developing Diversity in a Hospitalist Group.”
“The goals of our session are to review best practices for recruiting and retaining a diverse health care workforce, discuss strategies for dealing with implicit and explicit bias, and identify ways in which we can achieve common goals when working across cultures,” said hospitalist Amira del Pino-Jones, MD, assistant professor of medicine at the University of Colorado at Denver, Aurora, and director of the CU Hospitalist Scholars Program.
“Those who are interested in achieving excellence in hospital medicine through prioritizing diversity and equity efforts within their divisions, departments, and groups should attend,” said Dr. del Pino-Jones, who will be one of the speakers at the session.
Why is diversity important in hospital medicine? “Studies have shown that diversity enhances learning and work environments, promotes innovation, broadens research agendas, and improves the quality of care we provide for patients,” Dr. del Pino-Jones said. “In short, it is central to achieving excellence in hospital medicine.”
The session will focus on diverse groups, which have been historically underrepresented or discriminated against in medicine, including racial and ethnic minorities, women, LGBTQ+ individuals, and those with disabilities.
All speakers at the session are physicians, and each has seen or experienced challenges in diversifying their groups and divisions. “We hope to share our experiences, what we have learned, and ways to approach each of these issues. We also are hoping to hear from others and come up with new ways to approach these issues as a collective,” Dr. del Pino-Jones said.
Women and members of minority groups often have small numbers in their hospital medicine workplaces, especially in higher-level positions, and have trouble developing the critical mass to make progress on the diversity front, she said. Even when leaders recognize the importance of a diverse workforce, she said, “there is often a disconnect between motivation for increasing diversity and the ability to develop tangible, evidence-based methods that can be used to increase diversity.”
The session will tackle more than diversity at the workplace. Speakers also will discuss the relationship between medical professionals and patients.
“We will focus on the importance of inclusion and belonging, both of which are essential for creating a positive climate for all individuals,” Dr. del Pino-Jones said. “We will also discuss ways in which to cultivate cultural intelligence and enhance cross-cultural interactions between patients and providers. And we’ll look at ways to reduce and/or mitigate implicit and explicit bias in medicine.”
Dr. del Pino-Jones has no relevant disclosures.
Best Practices and Tips
for Developing Diversity in a Hospitalist Group
Wednesday, 10 - 11:30 a.m.
Potomac 4-6
Atypical used in Parkinson’s lifts hallucinations, delusions in refractory schizophrenia
Pimavanserin (Nuplazid), an atypical antipsychotic approved to treat hallucinations and delusions in Parkinson’s disease, shows promise as a treatment for patients with refractory schizophrenia who fail to respond to clozapine, a retrospective study suggests.
“Within a month, sometimes 2 months, hallucinations and delusions that have persisted for years were completely gone,” said lead author Henry A. Nasrallah, MD, in an interview. The study was published in Schizophrenia Research.
Dr. Nasrallah and his colleagues launched the study in a bid to help “the most desperate group of patients” with schizophrenia – the 60% of those with refractory psychosis who do not respond to clozapine.
“This group of patients is so desperate that psychiatrists have used everything in our pharmacopeia,” said Dr. Nasrallah, the Sydney W. Souers Endowed Chair and professor and chairman of the department of psychiatry and behavioral neuroscience at Saint Louis University. “Nothing has been shown to work. We decided to give them this medication [pimavanserin], which was approved by the FDA [Food and Drug Administration] 2 years ago for hallucinations and delusions for Parkinson’s disease.”
For the new study, Dr. Nasrallah and his coauthors gave 34 mg/day of pimavanserin to 10 patients, aged 21-77 years, with schizophrenia or schizoaffective disorder and refractory hallucinations and delusions. The subjects, all of whom live in a residential group home, had either failed clozapine (n = 6) or failed several antipsychotics but had not yet received clozapine (n = 4).
The results, Dr. Nasrallah said, were remarkable. “Not only did they get relief from their delusions and hallucinations, but nursing staff reported they were much more sociable and affable, getting out of their rooms, and mixing and mingling. It seems to help them beyond suppressing delusions and hallucinations. It made them more sociable and pleasant.”
Patients were able to avoid blood tests and the “sometimes life-threatening side effects of clozapine,” he said. According to the study, no patients needed to discontinue treatment because of safety or tolerability.
However, pimavanserin is expensive. According to GoodRx.com, monthly prices for 60 tablets of 17 mg pimavanserin – equal to the daily dose in this study – run from $2,759 to $2,907 with a free coupon.
Should psychiatrists prescribe the drug now for treatment-resistant schizophrenia? “We use drugs off label all the time for patients who do not have any FDA-approved medication,” Dr. Nasrallah said. “Sometimes, off-label use in psychiatry is a necessity, because around 80% of DSM-5 disorders do not have any approved drugs at this time.”
“It would also be interesting to test pimavanserin in first-episode psychosis to identify a ‘serotonergic subtype’ of the schizophrenia syndrome but also to completely avoid the extrapyramidal side effects of dopamine antagonists, to which first-episode psychosis patients are especially susceptible.”
No outside funding was reported. Dr. Nasrallah reported advisory board and consultant and speaker’s bureau relationships with Acadia, Alkermes, Allergan, Janssen, Lundbeck, Neurocrine Biosciences, Otsuka Pharmaceutical, Sunovion, and Teva. Another author reported no disclosures, and a third author reported numerous disclosures.
SOURCE: Nasrallah HA et al. Schizophr Res. 2019 Mar 2. doi: 10/1016/j.schres.2019.02.018.
Pimavanserin (Nuplazid), an atypical antipsychotic approved to treat hallucinations and delusions in Parkinson’s disease, shows promise as a treatment for patients with refractory schizophrenia who fail to respond to clozapine, a retrospective study suggests.
“Within a month, sometimes 2 months, hallucinations and delusions that have persisted for years were completely gone,” said lead author Henry A. Nasrallah, MD, in an interview. The study was published in Schizophrenia Research.
Dr. Nasrallah and his colleagues launched the study in a bid to help “the most desperate group of patients” with schizophrenia – the 60% of those with refractory psychosis who do not respond to clozapine.
“This group of patients is so desperate that psychiatrists have used everything in our pharmacopeia,” said Dr. Nasrallah, the Sydney W. Souers Endowed Chair and professor and chairman of the department of psychiatry and behavioral neuroscience at Saint Louis University. “Nothing has been shown to work. We decided to give them this medication [pimavanserin], which was approved by the FDA [Food and Drug Administration] 2 years ago for hallucinations and delusions for Parkinson’s disease.”
For the new study, Dr. Nasrallah and his coauthors gave 34 mg/day of pimavanserin to 10 patients, aged 21-77 years, with schizophrenia or schizoaffective disorder and refractory hallucinations and delusions. The subjects, all of whom live in a residential group home, had either failed clozapine (n = 6) or failed several antipsychotics but had not yet received clozapine (n = 4).
The results, Dr. Nasrallah said, were remarkable. “Not only did they get relief from their delusions and hallucinations, but nursing staff reported they were much more sociable and affable, getting out of their rooms, and mixing and mingling. It seems to help them beyond suppressing delusions and hallucinations. It made them more sociable and pleasant.”
Patients were able to avoid blood tests and the “sometimes life-threatening side effects of clozapine,” he said. According to the study, no patients needed to discontinue treatment because of safety or tolerability.
However, pimavanserin is expensive. According to GoodRx.com, monthly prices for 60 tablets of 17 mg pimavanserin – equal to the daily dose in this study – run from $2,759 to $2,907 with a free coupon.
Should psychiatrists prescribe the drug now for treatment-resistant schizophrenia? “We use drugs off label all the time for patients who do not have any FDA-approved medication,” Dr. Nasrallah said. “Sometimes, off-label use in psychiatry is a necessity, because around 80% of DSM-5 disorders do not have any approved drugs at this time.”
“It would also be interesting to test pimavanserin in first-episode psychosis to identify a ‘serotonergic subtype’ of the schizophrenia syndrome but also to completely avoid the extrapyramidal side effects of dopamine antagonists, to which first-episode psychosis patients are especially susceptible.”
No outside funding was reported. Dr. Nasrallah reported advisory board and consultant and speaker’s bureau relationships with Acadia, Alkermes, Allergan, Janssen, Lundbeck, Neurocrine Biosciences, Otsuka Pharmaceutical, Sunovion, and Teva. Another author reported no disclosures, and a third author reported numerous disclosures.
SOURCE: Nasrallah HA et al. Schizophr Res. 2019 Mar 2. doi: 10/1016/j.schres.2019.02.018.
Pimavanserin (Nuplazid), an atypical antipsychotic approved to treat hallucinations and delusions in Parkinson’s disease, shows promise as a treatment for patients with refractory schizophrenia who fail to respond to clozapine, a retrospective study suggests.
“Within a month, sometimes 2 months, hallucinations and delusions that have persisted for years were completely gone,” said lead author Henry A. Nasrallah, MD, in an interview. The study was published in Schizophrenia Research.
Dr. Nasrallah and his colleagues launched the study in a bid to help “the most desperate group of patients” with schizophrenia – the 60% of those with refractory psychosis who do not respond to clozapine.
“This group of patients is so desperate that psychiatrists have used everything in our pharmacopeia,” said Dr. Nasrallah, the Sydney W. Souers Endowed Chair and professor and chairman of the department of psychiatry and behavioral neuroscience at Saint Louis University. “Nothing has been shown to work. We decided to give them this medication [pimavanserin], which was approved by the FDA [Food and Drug Administration] 2 years ago for hallucinations and delusions for Parkinson’s disease.”
For the new study, Dr. Nasrallah and his coauthors gave 34 mg/day of pimavanserin to 10 patients, aged 21-77 years, with schizophrenia or schizoaffective disorder and refractory hallucinations and delusions. The subjects, all of whom live in a residential group home, had either failed clozapine (n = 6) or failed several antipsychotics but had not yet received clozapine (n = 4).
The results, Dr. Nasrallah said, were remarkable. “Not only did they get relief from their delusions and hallucinations, but nursing staff reported they were much more sociable and affable, getting out of their rooms, and mixing and mingling. It seems to help them beyond suppressing delusions and hallucinations. It made them more sociable and pleasant.”
Patients were able to avoid blood tests and the “sometimes life-threatening side effects of clozapine,” he said. According to the study, no patients needed to discontinue treatment because of safety or tolerability.
However, pimavanserin is expensive. According to GoodRx.com, monthly prices for 60 tablets of 17 mg pimavanserin – equal to the daily dose in this study – run from $2,759 to $2,907 with a free coupon.
Should psychiatrists prescribe the drug now for treatment-resistant schizophrenia? “We use drugs off label all the time for patients who do not have any FDA-approved medication,” Dr. Nasrallah said. “Sometimes, off-label use in psychiatry is a necessity, because around 80% of DSM-5 disorders do not have any approved drugs at this time.”
“It would also be interesting to test pimavanserin in first-episode psychosis to identify a ‘serotonergic subtype’ of the schizophrenia syndrome but also to completely avoid the extrapyramidal side effects of dopamine antagonists, to which first-episode psychosis patients are especially susceptible.”
No outside funding was reported. Dr. Nasrallah reported advisory board and consultant and speaker’s bureau relationships with Acadia, Alkermes, Allergan, Janssen, Lundbeck, Neurocrine Biosciences, Otsuka Pharmaceutical, Sunovion, and Teva. Another author reported no disclosures, and a third author reported numerous disclosures.
SOURCE: Nasrallah HA et al. Schizophr Res. 2019 Mar 2. doi: 10/1016/j.schres.2019.02.018.
FROM SCHIZOPHRENIA RESEARCH
SHM honors extraordinary leader, editor
When Andrew Auerbach, MD, MPH, SFHM, started as a hospitalist, his specialty didn’t have a name. His title was simply “medical director.” Now, 2 decades later, he is a professor of medicine at the University of California, San Francisco, and one of the most experienced and influential hospitalists in the field.
SHM will honor Dr. Auerbach and celebrate his achievements today at HM19, at the Awards plenary following the Chapter Awards of Excellence ceremony that begins at 8:30 a.m. SHM president Nasim Afsar, MD, SFHM, will present him with a plaque and review his contributions to the growth of the Journal of Hospital Medicine.
Throughout his career, even going back to the days he helped to found the Society of Hospital Medicine, Dr. Auerbach has played a crucial role in defining how a hospitalist works and thinks. Over the last 7 years, he led the Journal of Hospital Medicine through an extraordinary period of growth that has secured its reputation as a crucial resource for hospitalists and beyond.
“Andy Auerbach transformed the Journal of Hospital Medicine from the status of a ‘start-up’ Version 1.0 to a polished, efficient machine – Version 2.0. His efforts garnered the national respect that JHM deserves,” said Mark Williams, MD, MHM, University of Kentucky HealthCare hospital medicine division chief and tenured professor of medicine. Dr. Williams served as editor in chief of the journal immediately prior to Dr. Auerbach. “I hope Andy will be known as the editor who transformed an acceptable journal into a stellar example of what a medical journal can become.”
Samir S. Shah, MD, MSCE, MHM, who has replaced Dr. Auerbach as editor in chief of the journal, also has praise for his predecessor. “Andy has really invested in advancing scholarship in hospital medicine and ensuring that great work is broadly disseminated,” said Dr. Shah, chief of hospital medicine at Cincinnati Children’s Hospital Medical Center.
Dr. Auerbach said his interest in inpatient and perioperative care sparked his focus on hospital medicine. “My initial research was foundational for the field. I wanted to understand, refine, and improve our role: Do hospitalists improve care and outcomes? Do they affect patient perceptions of their doctors?”
At the time, hospital medicine felt like a 1990s dot-com startup, he recalled, but one that was destined to last. “It was clear that hospital medicine was going to take off, but the academic pursuits were taking longer to get going. We were starting from zero.”
Enter the Journal of Hospital Medicine. The publication received about 200 submissions a year when Dr. Auerbach took over as editor in chief. Now, it receives more than 800.
The higher number of submissions allows editors to be more selective about the papers that are published. At the same time, the growth in the journal’s profile and influence has allowed it to evolve into a more wide-ranging publication, Dr. Auerbach said.
“Geriatricians and nephrologists are sending us papers,” he said. “They believe our work is important, and they understand that we’re publishing research about topics such as acute kidney injury, delirium, inpatient safety issues, and transfer of care.”
According to Dr. Williams, his successor has played a crucial role in the journal’s success. “Andy improved the response rate of JHM, dramatically shortening the time for reviews while maintaining and even improving the quality of reviews,” he said. “This single act profoundly impacted author satisfaction and drove the increased number of article submissions.”
Dr. Auerbach also revolutionized the journal’s approach to technology. “Under his leadership, the journal pioneered the use of social media to engage readers in ways that were fundamentally different from established processes at the time,” said new editor in chief Dr. Shah. “For example, the journal has created roles for social media editors, and it routinely publishes visual abstracts to provide readers with a quick overview of journal research. We also hold regular dialogues with readers via our #JHMChat Twitter journal club to engage them in discussing the latest research published in JHM.”
Dr. Shah also noted that Dr. Auerbach boosted hospital medicine and the journal in other ways during his tenure. “He encouraged the team of editors to engage with our authors in meaningful and substantive ways. That meant encouraging thoughtful feedback and also reaching out to authors directly to provide additional guidance as they revised their manuscript and, oftentimes, as they prepared to submit their manuscript elsewhere,” he said.
In addition, Dr. Shah said that his colleague “also created the JHM editorial fellowship as a way to help develop the pipeline for academic leadership. This fellowship provides chief residents, academic hospital medicine fellows, and junior faculty an opportunity to learn about medical publishing, hone their skills in evaluating research and writing, and network with leaders in the field.”
For his part, Dr. Auerbach hopes his legacy at the journal will include an expansion, perhaps within a year or 2. “I’d love to see the journal come out twice a month,” he said. “There’s enough potential science out there, and I think it could be in that position soon.”
Awards of Excellence
Tuesday, 8:30 – 9:10 a.m.
Potomac ABCD
When Andrew Auerbach, MD, MPH, SFHM, started as a hospitalist, his specialty didn’t have a name. His title was simply “medical director.” Now, 2 decades later, he is a professor of medicine at the University of California, San Francisco, and one of the most experienced and influential hospitalists in the field.
SHM will honor Dr. Auerbach and celebrate his achievements today at HM19, at the Awards plenary following the Chapter Awards of Excellence ceremony that begins at 8:30 a.m. SHM president Nasim Afsar, MD, SFHM, will present him with a plaque and review his contributions to the growth of the Journal of Hospital Medicine.
Throughout his career, even going back to the days he helped to found the Society of Hospital Medicine, Dr. Auerbach has played a crucial role in defining how a hospitalist works and thinks. Over the last 7 years, he led the Journal of Hospital Medicine through an extraordinary period of growth that has secured its reputation as a crucial resource for hospitalists and beyond.
“Andy Auerbach transformed the Journal of Hospital Medicine from the status of a ‘start-up’ Version 1.0 to a polished, efficient machine – Version 2.0. His efforts garnered the national respect that JHM deserves,” said Mark Williams, MD, MHM, University of Kentucky HealthCare hospital medicine division chief and tenured professor of medicine. Dr. Williams served as editor in chief of the journal immediately prior to Dr. Auerbach. “I hope Andy will be known as the editor who transformed an acceptable journal into a stellar example of what a medical journal can become.”
Samir S. Shah, MD, MSCE, MHM, who has replaced Dr. Auerbach as editor in chief of the journal, also has praise for his predecessor. “Andy has really invested in advancing scholarship in hospital medicine and ensuring that great work is broadly disseminated,” said Dr. Shah, chief of hospital medicine at Cincinnati Children’s Hospital Medical Center.
Dr. Auerbach said his interest in inpatient and perioperative care sparked his focus on hospital medicine. “My initial research was foundational for the field. I wanted to understand, refine, and improve our role: Do hospitalists improve care and outcomes? Do they affect patient perceptions of their doctors?”
At the time, hospital medicine felt like a 1990s dot-com startup, he recalled, but one that was destined to last. “It was clear that hospital medicine was going to take off, but the academic pursuits were taking longer to get going. We were starting from zero.”
Enter the Journal of Hospital Medicine. The publication received about 200 submissions a year when Dr. Auerbach took over as editor in chief. Now, it receives more than 800.
The higher number of submissions allows editors to be more selective about the papers that are published. At the same time, the growth in the journal’s profile and influence has allowed it to evolve into a more wide-ranging publication, Dr. Auerbach said.
“Geriatricians and nephrologists are sending us papers,” he said. “They believe our work is important, and they understand that we’re publishing research about topics such as acute kidney injury, delirium, inpatient safety issues, and transfer of care.”
According to Dr. Williams, his successor has played a crucial role in the journal’s success. “Andy improved the response rate of JHM, dramatically shortening the time for reviews while maintaining and even improving the quality of reviews,” he said. “This single act profoundly impacted author satisfaction and drove the increased number of article submissions.”
Dr. Auerbach also revolutionized the journal’s approach to technology. “Under his leadership, the journal pioneered the use of social media to engage readers in ways that were fundamentally different from established processes at the time,” said new editor in chief Dr. Shah. “For example, the journal has created roles for social media editors, and it routinely publishes visual abstracts to provide readers with a quick overview of journal research. We also hold regular dialogues with readers via our #JHMChat Twitter journal club to engage them in discussing the latest research published in JHM.”
Dr. Shah also noted that Dr. Auerbach boosted hospital medicine and the journal in other ways during his tenure. “He encouraged the team of editors to engage with our authors in meaningful and substantive ways. That meant encouraging thoughtful feedback and also reaching out to authors directly to provide additional guidance as they revised their manuscript and, oftentimes, as they prepared to submit their manuscript elsewhere,” he said.
In addition, Dr. Shah said that his colleague “also created the JHM editorial fellowship as a way to help develop the pipeline for academic leadership. This fellowship provides chief residents, academic hospital medicine fellows, and junior faculty an opportunity to learn about medical publishing, hone their skills in evaluating research and writing, and network with leaders in the field.”
For his part, Dr. Auerbach hopes his legacy at the journal will include an expansion, perhaps within a year or 2. “I’d love to see the journal come out twice a month,” he said. “There’s enough potential science out there, and I think it could be in that position soon.”
Awards of Excellence
Tuesday, 8:30 – 9:10 a.m.
Potomac ABCD
When Andrew Auerbach, MD, MPH, SFHM, started as a hospitalist, his specialty didn’t have a name. His title was simply “medical director.” Now, 2 decades later, he is a professor of medicine at the University of California, San Francisco, and one of the most experienced and influential hospitalists in the field.
SHM will honor Dr. Auerbach and celebrate his achievements today at HM19, at the Awards plenary following the Chapter Awards of Excellence ceremony that begins at 8:30 a.m. SHM president Nasim Afsar, MD, SFHM, will present him with a plaque and review his contributions to the growth of the Journal of Hospital Medicine.
Throughout his career, even going back to the days he helped to found the Society of Hospital Medicine, Dr. Auerbach has played a crucial role in defining how a hospitalist works and thinks. Over the last 7 years, he led the Journal of Hospital Medicine through an extraordinary period of growth that has secured its reputation as a crucial resource for hospitalists and beyond.
“Andy Auerbach transformed the Journal of Hospital Medicine from the status of a ‘start-up’ Version 1.0 to a polished, efficient machine – Version 2.0. His efforts garnered the national respect that JHM deserves,” said Mark Williams, MD, MHM, University of Kentucky HealthCare hospital medicine division chief and tenured professor of medicine. Dr. Williams served as editor in chief of the journal immediately prior to Dr. Auerbach. “I hope Andy will be known as the editor who transformed an acceptable journal into a stellar example of what a medical journal can become.”
Samir S. Shah, MD, MSCE, MHM, who has replaced Dr. Auerbach as editor in chief of the journal, also has praise for his predecessor. “Andy has really invested in advancing scholarship in hospital medicine and ensuring that great work is broadly disseminated,” said Dr. Shah, chief of hospital medicine at Cincinnati Children’s Hospital Medical Center.
Dr. Auerbach said his interest in inpatient and perioperative care sparked his focus on hospital medicine. “My initial research was foundational for the field. I wanted to understand, refine, and improve our role: Do hospitalists improve care and outcomes? Do they affect patient perceptions of their doctors?”
At the time, hospital medicine felt like a 1990s dot-com startup, he recalled, but one that was destined to last. “It was clear that hospital medicine was going to take off, but the academic pursuits were taking longer to get going. We were starting from zero.”
Enter the Journal of Hospital Medicine. The publication received about 200 submissions a year when Dr. Auerbach took over as editor in chief. Now, it receives more than 800.
The higher number of submissions allows editors to be more selective about the papers that are published. At the same time, the growth in the journal’s profile and influence has allowed it to evolve into a more wide-ranging publication, Dr. Auerbach said.
“Geriatricians and nephrologists are sending us papers,” he said. “They believe our work is important, and they understand that we’re publishing research about topics such as acute kidney injury, delirium, inpatient safety issues, and transfer of care.”
According to Dr. Williams, his successor has played a crucial role in the journal’s success. “Andy improved the response rate of JHM, dramatically shortening the time for reviews while maintaining and even improving the quality of reviews,” he said. “This single act profoundly impacted author satisfaction and drove the increased number of article submissions.”
Dr. Auerbach also revolutionized the journal’s approach to technology. “Under his leadership, the journal pioneered the use of social media to engage readers in ways that were fundamentally different from established processes at the time,” said new editor in chief Dr. Shah. “For example, the journal has created roles for social media editors, and it routinely publishes visual abstracts to provide readers with a quick overview of journal research. We also hold regular dialogues with readers via our #JHMChat Twitter journal club to engage them in discussing the latest research published in JHM.”
Dr. Shah also noted that Dr. Auerbach boosted hospital medicine and the journal in other ways during his tenure. “He encouraged the team of editors to engage with our authors in meaningful and substantive ways. That meant encouraging thoughtful feedback and also reaching out to authors directly to provide additional guidance as they revised their manuscript and, oftentimes, as they prepared to submit their manuscript elsewhere,” he said.
In addition, Dr. Shah said that his colleague “also created the JHM editorial fellowship as a way to help develop the pipeline for academic leadership. This fellowship provides chief residents, academic hospital medicine fellows, and junior faculty an opportunity to learn about medical publishing, hone their skills in evaluating research and writing, and network with leaders in the field.”
For his part, Dr. Auerbach hopes his legacy at the journal will include an expansion, perhaps within a year or 2. “I’d love to see the journal come out twice a month,” he said. “There’s enough potential science out there, and I think it could be in that position soon.”
Awards of Excellence
Tuesday, 8:30 – 9:10 a.m.
Potomac ABCD
In transgender care, questions are the answer
New York OBGYN Zoe I. Rodriguez, MD, a pioneer in the care of transgender people, has witnessed a remarkable evolution in medicine.
Years ago, providers knew little to nothing about the unique needs of transgender patients. Now, Dr. Rodriguez said, “there’s tremendous interest in being able to competently treat and address transgender individuals.”
But increased awareness has come with a dose of worry. Providers are often afraid they’ll say or do the wrong thing.
Dr. Rodriguez, who is an assistant professor at the Icahn School of Medicine at Mount Sinai, New York, will help hospitalists gain confidence in treating transgender patients at an HM19 session on Tuesday. “I hope to eliminate this element of fear,” she said. “It’s just really about treating people with respect and dignity and having the knowledge to care for them appropriately.”
The United States is home to an estimated 1.4 million transgender people, and every one has a preferred name and preferred pronouns. It’s crucial for physicians to understand name and pronoun preferences and use them, Dr. Rodriguez said.
At her practice, an intake form asks patients how they wish to be addressed. “I know this information by the time I walk into the exam room,” she said.
For hospitalists, she said, getting this information beforehand may not be possible. In that case, she said, ask questions of the patient and don’t be afraid to get it wrong.
“Mistakes happen all the time,” Dr. Rodriguez said. “People will correct you if you misgender them or call them other than their preferred name. As long as the mistakes are not willful, apologize and move on.”
It’s also important to understand the special needs that transgender patients may – or may not – have. For example, not every transgender patient takes hormones. Even if a patient does, the hormones may not affect as many body processes as you might assume, Dr. Rodriguez said.
Also, not every transgender person has had surgery. However, it can be helpful to understand what surgery entails. “If they get their surgery done in Thailand, a popular destination, and they need treatment in Topeka for an issue related to their surgery, it would be good for the hospitalist to understand what’s done during the surgery.”
In her session, Dr. Rodriguez will also talk about creating an LGBT-friendly environment. “These patients are already feeling very vulnerable and marginalized within these vast health systems,” she said. “It makes a big difference to know that someone is there and gets it.”
Dr. Rodriguez also plans to emphasize the importance of staying aware and up to date about transgender issues. “It’s a continuum,” she said. “There will be more evolution as people come up with new terminologies and words to describe their gender expression and identity. It will be crucially important for physicians to be aware and respectful.”
What Hospitalists Need to Know About Caring for Transgender Patients
Tuesday, 3:50 - 4:30 p.m.
Maryland A/1-3
New York OBGYN Zoe I. Rodriguez, MD, a pioneer in the care of transgender people, has witnessed a remarkable evolution in medicine.
Years ago, providers knew little to nothing about the unique needs of transgender patients. Now, Dr. Rodriguez said, “there’s tremendous interest in being able to competently treat and address transgender individuals.”
But increased awareness has come with a dose of worry. Providers are often afraid they’ll say or do the wrong thing.
Dr. Rodriguez, who is an assistant professor at the Icahn School of Medicine at Mount Sinai, New York, will help hospitalists gain confidence in treating transgender patients at an HM19 session on Tuesday. “I hope to eliminate this element of fear,” she said. “It’s just really about treating people with respect and dignity and having the knowledge to care for them appropriately.”
The United States is home to an estimated 1.4 million transgender people, and every one has a preferred name and preferred pronouns. It’s crucial for physicians to understand name and pronoun preferences and use them, Dr. Rodriguez said.
At her practice, an intake form asks patients how they wish to be addressed. “I know this information by the time I walk into the exam room,” she said.
For hospitalists, she said, getting this information beforehand may not be possible. In that case, she said, ask questions of the patient and don’t be afraid to get it wrong.
“Mistakes happen all the time,” Dr. Rodriguez said. “People will correct you if you misgender them or call them other than their preferred name. As long as the mistakes are not willful, apologize and move on.”
It’s also important to understand the special needs that transgender patients may – or may not – have. For example, not every transgender patient takes hormones. Even if a patient does, the hormones may not affect as many body processes as you might assume, Dr. Rodriguez said.
Also, not every transgender person has had surgery. However, it can be helpful to understand what surgery entails. “If they get their surgery done in Thailand, a popular destination, and they need treatment in Topeka for an issue related to their surgery, it would be good for the hospitalist to understand what’s done during the surgery.”
In her session, Dr. Rodriguez will also talk about creating an LGBT-friendly environment. “These patients are already feeling very vulnerable and marginalized within these vast health systems,” she said. “It makes a big difference to know that someone is there and gets it.”
Dr. Rodriguez also plans to emphasize the importance of staying aware and up to date about transgender issues. “It’s a continuum,” she said. “There will be more evolution as people come up with new terminologies and words to describe their gender expression and identity. It will be crucially important for physicians to be aware and respectful.”
What Hospitalists Need to Know About Caring for Transgender Patients
Tuesday, 3:50 - 4:30 p.m.
Maryland A/1-3
New York OBGYN Zoe I. Rodriguez, MD, a pioneer in the care of transgender people, has witnessed a remarkable evolution in medicine.
Years ago, providers knew little to nothing about the unique needs of transgender patients. Now, Dr. Rodriguez said, “there’s tremendous interest in being able to competently treat and address transgender individuals.”
But increased awareness has come with a dose of worry. Providers are often afraid they’ll say or do the wrong thing.
Dr. Rodriguez, who is an assistant professor at the Icahn School of Medicine at Mount Sinai, New York, will help hospitalists gain confidence in treating transgender patients at an HM19 session on Tuesday. “I hope to eliminate this element of fear,” she said. “It’s just really about treating people with respect and dignity and having the knowledge to care for them appropriately.”
The United States is home to an estimated 1.4 million transgender people, and every one has a preferred name and preferred pronouns. It’s crucial for physicians to understand name and pronoun preferences and use them, Dr. Rodriguez said.
At her practice, an intake form asks patients how they wish to be addressed. “I know this information by the time I walk into the exam room,” she said.
For hospitalists, she said, getting this information beforehand may not be possible. In that case, she said, ask questions of the patient and don’t be afraid to get it wrong.
“Mistakes happen all the time,” Dr. Rodriguez said. “People will correct you if you misgender them or call them other than their preferred name. As long as the mistakes are not willful, apologize and move on.”
It’s also important to understand the special needs that transgender patients may – or may not – have. For example, not every transgender patient takes hormones. Even if a patient does, the hormones may not affect as many body processes as you might assume, Dr. Rodriguez said.
Also, not every transgender person has had surgery. However, it can be helpful to understand what surgery entails. “If they get their surgery done in Thailand, a popular destination, and they need treatment in Topeka for an issue related to their surgery, it would be good for the hospitalist to understand what’s done during the surgery.”
In her session, Dr. Rodriguez will also talk about creating an LGBT-friendly environment. “These patients are already feeling very vulnerable and marginalized within these vast health systems,” she said. “It makes a big difference to know that someone is there and gets it.”
Dr. Rodriguez also plans to emphasize the importance of staying aware and up to date about transgender issues. “It’s a continuum,” she said. “There will be more evolution as people come up with new terminologies and words to describe their gender expression and identity. It will be crucially important for physicians to be aware and respectful.”
What Hospitalists Need to Know About Caring for Transgender Patients
Tuesday, 3:50 - 4:30 p.m.
Maryland A/1-3
Stop-smoking rule before hernia repairs: Time for a rethink?
LAS VEGAS – Smoking cessation is mandatory before many hernia operations. Now, a surgeon is urging colleagues to examine the evidence and question whether this standard should still stand.
"Quality improvement is not a static process. It requires constant reassessment to make sure you’re doing a good job,” said Michael J. Rosen, MD, director of the Cleveland Clinic Comprehensive Hernia Center, in a presentation at the Annual Minimally Invasive Surgery Symposium by Global Academy for Medical Education.
It’s worth raising questions since much of the data regarding surgical risks “does not come from hernia patients,” he said. “It’s extrapolated from other surgeries and might not be applicable.”
Dr. Rosen was careful to tell the audience that he’s not an apologist for tobacco users. He listed the downsides of lighting up, including harms to pulmonary function, cardiovascular function, immune response, tissue healing,and hepatic metabolism of drugs. “I’m not crazy. I know that smoking is not healthy,” he said, “and I don’t work for a tobacco company.”
But do current smokers actually pay a price in terms of hernia repair complications? Dr. Rosen and his colleagues examined the question in a 2019 study that matched two groups of 418 ventral hernia repair patients (Surgery. 2019 Feb;165[2]:406-11).
They found no statically significant difference between current smokers and never-smokers in surgical site infections, surgical site occurrences requiring procedural intervention, reoperation, and 30-day morbidity. Seromas were more common in smokers, however (5.5% vs. 1.2%; P = .0005)
Two recent studies warned about risks in current smokers who undergo hernia operations. But, Dr. Rosen said, they actually revealed minimal differences in hernia outcomes between never-smokers and current smokers (Am J Surg. 2018 Sep;216[3]:471-4; Surg Endosc. 2017 Feb;31[2]:917-21).
Tobacco use as a risk factor for hernia complications “might not be as bad as we thought it was, at least for wound morbidity,” he said. “It might not be necessary to cancel the case” because of smoking habits, he said, adding that “you should question canceling folks.”
However, he said, amount of smoking and complexity of the operations still are important factors to consider.
In his presentation, Dr. Rosen questioned another common standard in hernia procedures: The use of postoperative epidurals in elective ventral hernia repair.
He coauthored a 2018 study that compared two matched groups of hernia patients – 763 who received epidurals and 763 who did not. Patients who received epidurals had longer length of stay (5 days vs. 4 days) and higher postop complications (26% vs. 21%; P less than .05; Ann Surg. 2018 May;26[5]:971-6). Epidurals also were linked to worse outcomes in a subset of high-risk pulmonary patients.
Factors such as high rate of improper placement, extra fluid received, and Foley catheter and thromboprophylaxis issues may explain the higher rates of problems in epidurals, he said.
According to Dr. Rosen, a study into an alternative treatment, transversus abdominis plane block, is underway.
Global Academy for Medical Education and this news organization are owned by the same parent company. Dr. Rosen disclosed having research support from Miromatrix, Intuitive, and Pacira, servicing as a board member for Ariste Medical, and serving as medical director for the Americas Hernia Society Quality Collaborative.
LAS VEGAS – Smoking cessation is mandatory before many hernia operations. Now, a surgeon is urging colleagues to examine the evidence and question whether this standard should still stand.
"Quality improvement is not a static process. It requires constant reassessment to make sure you’re doing a good job,” said Michael J. Rosen, MD, director of the Cleveland Clinic Comprehensive Hernia Center, in a presentation at the Annual Minimally Invasive Surgery Symposium by Global Academy for Medical Education.
It’s worth raising questions since much of the data regarding surgical risks “does not come from hernia patients,” he said. “It’s extrapolated from other surgeries and might not be applicable.”
Dr. Rosen was careful to tell the audience that he’s not an apologist for tobacco users. He listed the downsides of lighting up, including harms to pulmonary function, cardiovascular function, immune response, tissue healing,and hepatic metabolism of drugs. “I’m not crazy. I know that smoking is not healthy,” he said, “and I don’t work for a tobacco company.”
But do current smokers actually pay a price in terms of hernia repair complications? Dr. Rosen and his colleagues examined the question in a 2019 study that matched two groups of 418 ventral hernia repair patients (Surgery. 2019 Feb;165[2]:406-11).
They found no statically significant difference between current smokers and never-smokers in surgical site infections, surgical site occurrences requiring procedural intervention, reoperation, and 30-day morbidity. Seromas were more common in smokers, however (5.5% vs. 1.2%; P = .0005)
Two recent studies warned about risks in current smokers who undergo hernia operations. But, Dr. Rosen said, they actually revealed minimal differences in hernia outcomes between never-smokers and current smokers (Am J Surg. 2018 Sep;216[3]:471-4; Surg Endosc. 2017 Feb;31[2]:917-21).
Tobacco use as a risk factor for hernia complications “might not be as bad as we thought it was, at least for wound morbidity,” he said. “It might not be necessary to cancel the case” because of smoking habits, he said, adding that “you should question canceling folks.”
However, he said, amount of smoking and complexity of the operations still are important factors to consider.
In his presentation, Dr. Rosen questioned another common standard in hernia procedures: The use of postoperative epidurals in elective ventral hernia repair.
He coauthored a 2018 study that compared two matched groups of hernia patients – 763 who received epidurals and 763 who did not. Patients who received epidurals had longer length of stay (5 days vs. 4 days) and higher postop complications (26% vs. 21%; P less than .05; Ann Surg. 2018 May;26[5]:971-6). Epidurals also were linked to worse outcomes in a subset of high-risk pulmonary patients.
Factors such as high rate of improper placement, extra fluid received, and Foley catheter and thromboprophylaxis issues may explain the higher rates of problems in epidurals, he said.
According to Dr. Rosen, a study into an alternative treatment, transversus abdominis plane block, is underway.
Global Academy for Medical Education and this news organization are owned by the same parent company. Dr. Rosen disclosed having research support from Miromatrix, Intuitive, and Pacira, servicing as a board member for Ariste Medical, and serving as medical director for the Americas Hernia Society Quality Collaborative.
LAS VEGAS – Smoking cessation is mandatory before many hernia operations. Now, a surgeon is urging colleagues to examine the evidence and question whether this standard should still stand.
"Quality improvement is not a static process. It requires constant reassessment to make sure you’re doing a good job,” said Michael J. Rosen, MD, director of the Cleveland Clinic Comprehensive Hernia Center, in a presentation at the Annual Minimally Invasive Surgery Symposium by Global Academy for Medical Education.
It’s worth raising questions since much of the data regarding surgical risks “does not come from hernia patients,” he said. “It’s extrapolated from other surgeries and might not be applicable.”
Dr. Rosen was careful to tell the audience that he’s not an apologist for tobacco users. He listed the downsides of lighting up, including harms to pulmonary function, cardiovascular function, immune response, tissue healing,and hepatic metabolism of drugs. “I’m not crazy. I know that smoking is not healthy,” he said, “and I don’t work for a tobacco company.”
But do current smokers actually pay a price in terms of hernia repair complications? Dr. Rosen and his colleagues examined the question in a 2019 study that matched two groups of 418 ventral hernia repair patients (Surgery. 2019 Feb;165[2]:406-11).
They found no statically significant difference between current smokers and never-smokers in surgical site infections, surgical site occurrences requiring procedural intervention, reoperation, and 30-day morbidity. Seromas were more common in smokers, however (5.5% vs. 1.2%; P = .0005)
Two recent studies warned about risks in current smokers who undergo hernia operations. But, Dr. Rosen said, they actually revealed minimal differences in hernia outcomes between never-smokers and current smokers (Am J Surg. 2018 Sep;216[3]:471-4; Surg Endosc. 2017 Feb;31[2]:917-21).
Tobacco use as a risk factor for hernia complications “might not be as bad as we thought it was, at least for wound morbidity,” he said. “It might not be necessary to cancel the case” because of smoking habits, he said, adding that “you should question canceling folks.”
However, he said, amount of smoking and complexity of the operations still are important factors to consider.
In his presentation, Dr. Rosen questioned another common standard in hernia procedures: The use of postoperative epidurals in elective ventral hernia repair.
He coauthored a 2018 study that compared two matched groups of hernia patients – 763 who received epidurals and 763 who did not. Patients who received epidurals had longer length of stay (5 days vs. 4 days) and higher postop complications (26% vs. 21%; P less than .05; Ann Surg. 2018 May;26[5]:971-6). Epidurals also were linked to worse outcomes in a subset of high-risk pulmonary patients.
Factors such as high rate of improper placement, extra fluid received, and Foley catheter and thromboprophylaxis issues may explain the higher rates of problems in epidurals, he said.
According to Dr. Rosen, a study into an alternative treatment, transversus abdominis plane block, is underway.
Global Academy for Medical Education and this news organization are owned by the same parent company. Dr. Rosen disclosed having research support from Miromatrix, Intuitive, and Pacira, servicing as a board member for Ariste Medical, and serving as medical director for the Americas Hernia Society Quality Collaborative.
REPORTING FROM MISS
Evidence weak for robotic inguinal hernia surgery
LAS VEGAS – Ajita Prabhu, MD, is intrigued enough by to study it extensively. Her verdict: In general, it’s just not ready for prime time.
“Right now, I don’t think I have any compelling evidence to tell a laparoscopic surgeon with good surgical times and good outcomes to convert to robotic surgery,” said Dr. Prabhu, an associate professor of surgery at the Cleveland Clinic Foundation, in a presentation the Annual Minimally Invasive Surgery Symposium by Global Academy for Medical Education.
According to Dr. Prabhu, the number of robotic inguinal hernia surgeries in the United States has shot up over the past 8 years, but research into the technique has remained sparse and retrospective.
“There’s not a lot out there,” she said. “If I stood here and went through every one of those studies detail by detail, I think I could do it in 15 minutes.”
It is true, she said, that robotic surgery has possible advantages, such as better ergonomics for surgeons and, perhaps, a shorter learning curve than laparoscopy. Still, she said, “for those of us who grew up on it [laparoscopy], it’s a lot less hassle for us to get in and get out and get the job done,” even though the technique can hard to both learn and teach.
Robotic surgery has some disadvantages too, she said. “We’re finding additional evidence that it adds OR [operating room] time, and it’s expensive.” She pointed to an analysis that determined the average total cost for robotic unilateral inguinal hernia repair is $5,517 versus $3,269 for laparoscopic procedures (P less than .001). The cost difference is driven by fixed costs, particularly medical device expenses (Surg Endosc. 2018 Dec 7. doi: 10.1007/s00464-018-06606-9).
Moving forward, she said, robotic inguinal hernia surgery should be tested so “we can make sure it’s actually better, not just cool. We need to be able to justify our utilization.”
To that end, a multicenter, randomized, controlled study is now comparing robotic with laparoscopic surgery in inguinal hernias with 50 patients in each group, Dr. Prabhu said. Her institution, Cleveland Clinic Foundation, is one of the centers in the study (www.clinicaltrials.gov/ct2/show/NCT02816658).
In an interview, Dr. Prabhu said the study just finished enrollment; publication is expected within the next few months.
Dr. Prabhu disclosed relationships with Intuitive Surgical (research support and honoraria), Bard Davol (honoraria) and Medtronic (advisory board).
Global Academy for Medical Education and this news organization are owned by the same parent company.
LAS VEGAS – Ajita Prabhu, MD, is intrigued enough by to study it extensively. Her verdict: In general, it’s just not ready for prime time.
“Right now, I don’t think I have any compelling evidence to tell a laparoscopic surgeon with good surgical times and good outcomes to convert to robotic surgery,” said Dr. Prabhu, an associate professor of surgery at the Cleveland Clinic Foundation, in a presentation the Annual Minimally Invasive Surgery Symposium by Global Academy for Medical Education.
According to Dr. Prabhu, the number of robotic inguinal hernia surgeries in the United States has shot up over the past 8 years, but research into the technique has remained sparse and retrospective.
“There’s not a lot out there,” she said. “If I stood here and went through every one of those studies detail by detail, I think I could do it in 15 minutes.”
It is true, she said, that robotic surgery has possible advantages, such as better ergonomics for surgeons and, perhaps, a shorter learning curve than laparoscopy. Still, she said, “for those of us who grew up on it [laparoscopy], it’s a lot less hassle for us to get in and get out and get the job done,” even though the technique can hard to both learn and teach.
Robotic surgery has some disadvantages too, she said. “We’re finding additional evidence that it adds OR [operating room] time, and it’s expensive.” She pointed to an analysis that determined the average total cost for robotic unilateral inguinal hernia repair is $5,517 versus $3,269 for laparoscopic procedures (P less than .001). The cost difference is driven by fixed costs, particularly medical device expenses (Surg Endosc. 2018 Dec 7. doi: 10.1007/s00464-018-06606-9).
Moving forward, she said, robotic inguinal hernia surgery should be tested so “we can make sure it’s actually better, not just cool. We need to be able to justify our utilization.”
To that end, a multicenter, randomized, controlled study is now comparing robotic with laparoscopic surgery in inguinal hernias with 50 patients in each group, Dr. Prabhu said. Her institution, Cleveland Clinic Foundation, is one of the centers in the study (www.clinicaltrials.gov/ct2/show/NCT02816658).
In an interview, Dr. Prabhu said the study just finished enrollment; publication is expected within the next few months.
Dr. Prabhu disclosed relationships with Intuitive Surgical (research support and honoraria), Bard Davol (honoraria) and Medtronic (advisory board).
Global Academy for Medical Education and this news organization are owned by the same parent company.
LAS VEGAS – Ajita Prabhu, MD, is intrigued enough by to study it extensively. Her verdict: In general, it’s just not ready for prime time.
“Right now, I don’t think I have any compelling evidence to tell a laparoscopic surgeon with good surgical times and good outcomes to convert to robotic surgery,” said Dr. Prabhu, an associate professor of surgery at the Cleveland Clinic Foundation, in a presentation the Annual Minimally Invasive Surgery Symposium by Global Academy for Medical Education.
According to Dr. Prabhu, the number of robotic inguinal hernia surgeries in the United States has shot up over the past 8 years, but research into the technique has remained sparse and retrospective.
“There’s not a lot out there,” she said. “If I stood here and went through every one of those studies detail by detail, I think I could do it in 15 minutes.”
It is true, she said, that robotic surgery has possible advantages, such as better ergonomics for surgeons and, perhaps, a shorter learning curve than laparoscopy. Still, she said, “for those of us who grew up on it [laparoscopy], it’s a lot less hassle for us to get in and get out and get the job done,” even though the technique can hard to both learn and teach.
Robotic surgery has some disadvantages too, she said. “We’re finding additional evidence that it adds OR [operating room] time, and it’s expensive.” She pointed to an analysis that determined the average total cost for robotic unilateral inguinal hernia repair is $5,517 versus $3,269 for laparoscopic procedures (P less than .001). The cost difference is driven by fixed costs, particularly medical device expenses (Surg Endosc. 2018 Dec 7. doi: 10.1007/s00464-018-06606-9).
Moving forward, she said, robotic inguinal hernia surgery should be tested so “we can make sure it’s actually better, not just cool. We need to be able to justify our utilization.”
To that end, a multicenter, randomized, controlled study is now comparing robotic with laparoscopic surgery in inguinal hernias with 50 patients in each group, Dr. Prabhu said. Her institution, Cleveland Clinic Foundation, is one of the centers in the study (www.clinicaltrials.gov/ct2/show/NCT02816658).
In an interview, Dr. Prabhu said the study just finished enrollment; publication is expected within the next few months.
Dr. Prabhu disclosed relationships with Intuitive Surgical (research support and honoraria), Bard Davol (honoraria) and Medtronic (advisory board).
Global Academy for Medical Education and this news organization are owned by the same parent company.
EXPERT ANALYSIS FROM MISS
Hospital-onset sepsis twice as lethal as community-onset disease
SAN DIEGO – Patients who develop sepsis in the hospital appear to be in greater risk for mortality than those who bring it with them, a new study suggests. Patients with hospital-onset sepsis were twice as likely to die as those infected in the outside world.
“There could be some differences in quality of care that explains the difference in mortality,” said study lead author Chanu Rhee, MD, assistant professor of population medicine at Harvard Medical School, Boston, in a presentation about the findings at the Critical Care Congress sponsored by the Society of Critical Care Medicine.
In an interview, Dr. Rhee said researchers launched the study to gain a greater understanding of the epidemiology of sepsis in the hospital. They relied on a new Centers for Disease Control and Prevention definition of sepsis that is “enhancing the consistency of surveillance across hospitals and allowing more precise differentiation between hospital-onset versus community-onset sepsis.”
The study authors retrospectively tracked more than 2.2 million patients who were treated at 136 U.S. hospitals from 2009 to 2015. In general, hospital-onset sepsis was defined as patients who had a blood culture, initial antibiotic therapy, and organ dysfunction on their third day in the hospital or later.*
Of the patients, 83,600 had community-onset sepsis and 11,500 had hospital-onset sepsis. Those with sepsis were more likely to be men and have comorbidities such as cancer, congestive heart failure, diabetes, and renal disease.
Patients with hospital-onset sepsis had longer median lengths of stay (19 days) than the community-onset group (8 days) and the no-sepsis group (4 days). The hospital-onset group also had a greater likelihood of ICU admission (61%) than the community-onset (44%) and no-sepsis (9%) groups.
About 34% of those with hospital-onset sepsis died, compared with 17% of the community-onset group and 2% of the patients who didn’t have sepsis. After adjustment, those with hospital-onset sepsis were still more likely to have died (odds ratio, 2.1; 95% confidence interval, 2.0-2.2).
“Other studies have suggested that there may be delays in the recognition and care of patients who develop sepsis in the hospital as opposed to presenting to the hospital with sepsis,” Dr. Rhee said. “It is also possible that hospital-onset sepsis tends to be caused by organisms that are more virulent and resistant to antibiotics.”
Overall, he said, “our findings underscore the importance of targeting hospital-onset sepsis with surveillance, prevention, and quality improvement efforts.”
The study was funded by the CDC and the Agency for Healthcare Research and Quality. The authors reported no relevant disclosures.
SOURCE: Rhee C et al. CCC48, Abstract 29.
*Correction, 3/19/19: An earlier version of this article misstated the definition of sepsis.
SAN DIEGO – Patients who develop sepsis in the hospital appear to be in greater risk for mortality than those who bring it with them, a new study suggests. Patients with hospital-onset sepsis were twice as likely to die as those infected in the outside world.
“There could be some differences in quality of care that explains the difference in mortality,” said study lead author Chanu Rhee, MD, assistant professor of population medicine at Harvard Medical School, Boston, in a presentation about the findings at the Critical Care Congress sponsored by the Society of Critical Care Medicine.
In an interview, Dr. Rhee said researchers launched the study to gain a greater understanding of the epidemiology of sepsis in the hospital. They relied on a new Centers for Disease Control and Prevention definition of sepsis that is “enhancing the consistency of surveillance across hospitals and allowing more precise differentiation between hospital-onset versus community-onset sepsis.”
The study authors retrospectively tracked more than 2.2 million patients who were treated at 136 U.S. hospitals from 2009 to 2015. In general, hospital-onset sepsis was defined as patients who had a blood culture, initial antibiotic therapy, and organ dysfunction on their third day in the hospital or later.*
Of the patients, 83,600 had community-onset sepsis and 11,500 had hospital-onset sepsis. Those with sepsis were more likely to be men and have comorbidities such as cancer, congestive heart failure, diabetes, and renal disease.
Patients with hospital-onset sepsis had longer median lengths of stay (19 days) than the community-onset group (8 days) and the no-sepsis group (4 days). The hospital-onset group also had a greater likelihood of ICU admission (61%) than the community-onset (44%) and no-sepsis (9%) groups.
About 34% of those with hospital-onset sepsis died, compared with 17% of the community-onset group and 2% of the patients who didn’t have sepsis. After adjustment, those with hospital-onset sepsis were still more likely to have died (odds ratio, 2.1; 95% confidence interval, 2.0-2.2).
“Other studies have suggested that there may be delays in the recognition and care of patients who develop sepsis in the hospital as opposed to presenting to the hospital with sepsis,” Dr. Rhee said. “It is also possible that hospital-onset sepsis tends to be caused by organisms that are more virulent and resistant to antibiotics.”
Overall, he said, “our findings underscore the importance of targeting hospital-onset sepsis with surveillance, prevention, and quality improvement efforts.”
The study was funded by the CDC and the Agency for Healthcare Research and Quality. The authors reported no relevant disclosures.
SOURCE: Rhee C et al. CCC48, Abstract 29.
*Correction, 3/19/19: An earlier version of this article misstated the definition of sepsis.
SAN DIEGO – Patients who develop sepsis in the hospital appear to be in greater risk for mortality than those who bring it with them, a new study suggests. Patients with hospital-onset sepsis were twice as likely to die as those infected in the outside world.
“There could be some differences in quality of care that explains the difference in mortality,” said study lead author Chanu Rhee, MD, assistant professor of population medicine at Harvard Medical School, Boston, in a presentation about the findings at the Critical Care Congress sponsored by the Society of Critical Care Medicine.
In an interview, Dr. Rhee said researchers launched the study to gain a greater understanding of the epidemiology of sepsis in the hospital. They relied on a new Centers for Disease Control and Prevention definition of sepsis that is “enhancing the consistency of surveillance across hospitals and allowing more precise differentiation between hospital-onset versus community-onset sepsis.”
The study authors retrospectively tracked more than 2.2 million patients who were treated at 136 U.S. hospitals from 2009 to 2015. In general, hospital-onset sepsis was defined as patients who had a blood culture, initial antibiotic therapy, and organ dysfunction on their third day in the hospital or later.*
Of the patients, 83,600 had community-onset sepsis and 11,500 had hospital-onset sepsis. Those with sepsis were more likely to be men and have comorbidities such as cancer, congestive heart failure, diabetes, and renal disease.
Patients with hospital-onset sepsis had longer median lengths of stay (19 days) than the community-onset group (8 days) and the no-sepsis group (4 days). The hospital-onset group also had a greater likelihood of ICU admission (61%) than the community-onset (44%) and no-sepsis (9%) groups.
About 34% of those with hospital-onset sepsis died, compared with 17% of the community-onset group and 2% of the patients who didn’t have sepsis. After adjustment, those with hospital-onset sepsis were still more likely to have died (odds ratio, 2.1; 95% confidence interval, 2.0-2.2).
“Other studies have suggested that there may be delays in the recognition and care of patients who develop sepsis in the hospital as opposed to presenting to the hospital with sepsis,” Dr. Rhee said. “It is also possible that hospital-onset sepsis tends to be caused by organisms that are more virulent and resistant to antibiotics.”
Overall, he said, “our findings underscore the importance of targeting hospital-onset sepsis with surveillance, prevention, and quality improvement efforts.”
The study was funded by the CDC and the Agency for Healthcare Research and Quality. The authors reported no relevant disclosures.
SOURCE: Rhee C et al. CCC48, Abstract 29.
*Correction, 3/19/19: An earlier version of this article misstated the definition of sepsis.
REPORTING FROM CCC48
Best practices lower postsepsis risk, but only if implemented
SAN DIEGO – North Carolina health care workers often failed to provide best-practice follow-up to patients who were released after hospitalization for sepsis, a small study has found. There may be a cost to this gap:
“It’s disappointing to see that we are not providing these seemingly common-sense care processes to our sepsis patients at discharge,” said study lead author Stephanie Parks Taylor, MD, of Atrium Health’s Carolinas Medical Center in Charlotte, in an interview following the presentation of the study findings at the Critical Care Congress sponsored by the Society of Critical Care Medicine. “We need to develop and implement strategies to improve outcomes for sepsis patients, not just while they are in the hospital, but after discharge as well.”
A 2017 report estimated that 1.7 million adults were hospitalized for sepsis in the United States in 2014, and 270,000 died (JAMA. 2017;318[13]:1241-9). Age-adjusted sepsis death rates in the United States are highest in states in the Eastern and Southern regions, a 2017 report from the Centers for Disease Control and Prevention suggested; North Carolina has the 32nd-worst sepsis death rate in the country (12.4 deaths per 100,000 population).
Dr. Taylor said some recent news about sepsis is promising. “We’ve seen decreasing mortality rates from initiatives that improve the early detection of sepsis and rapid delivery of antibiotics, fluids, and other treatment. However, there is growing evidence that patients who survive an episode of sepsis face residual health deficits. Many sepsis survivors are left with new functional, cognitive, or mental health declines or worsening of their underlying comorbidities. Unfortunately, these patients have high rates of mortality and hospital readmission that persist for multiple years after hospitalization.”
Indeed, a 2013 report linked sepsis to significantly higher mortality risk over 5 years, after accounting for comorbidities. Postsepsis patients were 13 times more likely to die over the first year after hospitalization than counterparts who didn’t have sepsis (BMJ Open. 2014;4:e004283).
For the new study, Dr. Taylor said, “we aimed to evaluate current care practices with the hope to identify a postsepsis management strategy that could help nudge these patients towards a more meaningful recovery.”
The researchers retrospectively tracked a random sample of 100 patients (median age, 63 years), who were discharged following an admission for sepsis in 2017. They were treated at eight acute care hospitals in western and central North Carolina and hospitalized for a median of 5 days; 75 were discharged to home (17 received home health services there), 17 went to skilled nursing or long-term care facilities, and 8 went to hospice or another location.
The researchers analyzed whether the patients received four kinds of postsepsis care within 90 days, as recommended by a 2018 review: screening for common functional impairments (53/100 patients received this screening); adjustment of medications as needed following discharge (53/100 patients); monitoring for common and preventable causes for health deterioration, such as infection, chronic lung disease, or heart failure exacerbation (37/100); and assessment for palliative care (25/100 patients) (JAMA. 2018;319[1]:62-75).
Within 90 days of discharge, 34 patients were readmitted and 17 died. The 32 patients who received at least two recommended kinds of postsepsis care were less likely to be readmitted or die (9/32) than those who got zero or one recommended kind of care (34/68; odds ratio, 0.26; 95% confidence ratio, 0.09-0.82).
In an interview, study coauthor Marc Kowalkowski, PhD, associate professor with Atrium Health’s Center for Outcomes Research and Evaluation, said he was hesitant to only allocate blame to hospitals or outpatient providers. “Transition out of the hospital is an extremely complex event, involving often fragmented care settings, and sepsis patients tend to be more complicated than other patients. It probably makes sense to provide an added layer of support during the transition out of the hospital for patients who are at high risk for poor outcomes.”
Overall, the findings are “a call for clinicians to realize sepsis is more than just an acute illness. The combination of a growing number of sepsis survivors and the increased health problems following an episode of sepsis creates an urgent public health challenge,” Dr. Taylor said.
Is more home health an important part of a solution? It may be helpful, Dr. Taylor said, but “our data suggest that there really needs to be better coordination to bridge between the inpatient and outpatient transition. We are currently conducting a randomized study to investigate whether these types of care processes can be delivered effectively through a nurse navigator to improve patient outcomes.”
Fortunately, she said, the findings suggest “we don’t have to reinvent the wheel. We just have to work on implementation of strategies for care processes that we are already familiar with.”
No funding was reported. None of the study authors reported relevant disclosures.
SOURCE: Taylor SP et al. CCC48, Abstract 1320.
SAN DIEGO – North Carolina health care workers often failed to provide best-practice follow-up to patients who were released after hospitalization for sepsis, a small study has found. There may be a cost to this gap:
“It’s disappointing to see that we are not providing these seemingly common-sense care processes to our sepsis patients at discharge,” said study lead author Stephanie Parks Taylor, MD, of Atrium Health’s Carolinas Medical Center in Charlotte, in an interview following the presentation of the study findings at the Critical Care Congress sponsored by the Society of Critical Care Medicine. “We need to develop and implement strategies to improve outcomes for sepsis patients, not just while they are in the hospital, but after discharge as well.”
A 2017 report estimated that 1.7 million adults were hospitalized for sepsis in the United States in 2014, and 270,000 died (JAMA. 2017;318[13]:1241-9). Age-adjusted sepsis death rates in the United States are highest in states in the Eastern and Southern regions, a 2017 report from the Centers for Disease Control and Prevention suggested; North Carolina has the 32nd-worst sepsis death rate in the country (12.4 deaths per 100,000 population).
Dr. Taylor said some recent news about sepsis is promising. “We’ve seen decreasing mortality rates from initiatives that improve the early detection of sepsis and rapid delivery of antibiotics, fluids, and other treatment. However, there is growing evidence that patients who survive an episode of sepsis face residual health deficits. Many sepsis survivors are left with new functional, cognitive, or mental health declines or worsening of their underlying comorbidities. Unfortunately, these patients have high rates of mortality and hospital readmission that persist for multiple years after hospitalization.”
Indeed, a 2013 report linked sepsis to significantly higher mortality risk over 5 years, after accounting for comorbidities. Postsepsis patients were 13 times more likely to die over the first year after hospitalization than counterparts who didn’t have sepsis (BMJ Open. 2014;4:e004283).
For the new study, Dr. Taylor said, “we aimed to evaluate current care practices with the hope to identify a postsepsis management strategy that could help nudge these patients towards a more meaningful recovery.”
The researchers retrospectively tracked a random sample of 100 patients (median age, 63 years), who were discharged following an admission for sepsis in 2017. They were treated at eight acute care hospitals in western and central North Carolina and hospitalized for a median of 5 days; 75 were discharged to home (17 received home health services there), 17 went to skilled nursing or long-term care facilities, and 8 went to hospice or another location.
The researchers analyzed whether the patients received four kinds of postsepsis care within 90 days, as recommended by a 2018 review: screening for common functional impairments (53/100 patients received this screening); adjustment of medications as needed following discharge (53/100 patients); monitoring for common and preventable causes for health deterioration, such as infection, chronic lung disease, or heart failure exacerbation (37/100); and assessment for palliative care (25/100 patients) (JAMA. 2018;319[1]:62-75).
Within 90 days of discharge, 34 patients were readmitted and 17 died. The 32 patients who received at least two recommended kinds of postsepsis care were less likely to be readmitted or die (9/32) than those who got zero or one recommended kind of care (34/68; odds ratio, 0.26; 95% confidence ratio, 0.09-0.82).
In an interview, study coauthor Marc Kowalkowski, PhD, associate professor with Atrium Health’s Center for Outcomes Research and Evaluation, said he was hesitant to only allocate blame to hospitals or outpatient providers. “Transition out of the hospital is an extremely complex event, involving often fragmented care settings, and sepsis patients tend to be more complicated than other patients. It probably makes sense to provide an added layer of support during the transition out of the hospital for patients who are at high risk for poor outcomes.”
Overall, the findings are “a call for clinicians to realize sepsis is more than just an acute illness. The combination of a growing number of sepsis survivors and the increased health problems following an episode of sepsis creates an urgent public health challenge,” Dr. Taylor said.
Is more home health an important part of a solution? It may be helpful, Dr. Taylor said, but “our data suggest that there really needs to be better coordination to bridge between the inpatient and outpatient transition. We are currently conducting a randomized study to investigate whether these types of care processes can be delivered effectively through a nurse navigator to improve patient outcomes.”
Fortunately, she said, the findings suggest “we don’t have to reinvent the wheel. We just have to work on implementation of strategies for care processes that we are already familiar with.”
No funding was reported. None of the study authors reported relevant disclosures.
SOURCE: Taylor SP et al. CCC48, Abstract 1320.
SAN DIEGO – North Carolina health care workers often failed to provide best-practice follow-up to patients who were released after hospitalization for sepsis, a small study has found. There may be a cost to this gap:
“It’s disappointing to see that we are not providing these seemingly common-sense care processes to our sepsis patients at discharge,” said study lead author Stephanie Parks Taylor, MD, of Atrium Health’s Carolinas Medical Center in Charlotte, in an interview following the presentation of the study findings at the Critical Care Congress sponsored by the Society of Critical Care Medicine. “We need to develop and implement strategies to improve outcomes for sepsis patients, not just while they are in the hospital, but after discharge as well.”
A 2017 report estimated that 1.7 million adults were hospitalized for sepsis in the United States in 2014, and 270,000 died (JAMA. 2017;318[13]:1241-9). Age-adjusted sepsis death rates in the United States are highest in states in the Eastern and Southern regions, a 2017 report from the Centers for Disease Control and Prevention suggested; North Carolina has the 32nd-worst sepsis death rate in the country (12.4 deaths per 100,000 population).
Dr. Taylor said some recent news about sepsis is promising. “We’ve seen decreasing mortality rates from initiatives that improve the early detection of sepsis and rapid delivery of antibiotics, fluids, and other treatment. However, there is growing evidence that patients who survive an episode of sepsis face residual health deficits. Many sepsis survivors are left with new functional, cognitive, or mental health declines or worsening of their underlying comorbidities. Unfortunately, these patients have high rates of mortality and hospital readmission that persist for multiple years after hospitalization.”
Indeed, a 2013 report linked sepsis to significantly higher mortality risk over 5 years, after accounting for comorbidities. Postsepsis patients were 13 times more likely to die over the first year after hospitalization than counterparts who didn’t have sepsis (BMJ Open. 2014;4:e004283).
For the new study, Dr. Taylor said, “we aimed to evaluate current care practices with the hope to identify a postsepsis management strategy that could help nudge these patients towards a more meaningful recovery.”
The researchers retrospectively tracked a random sample of 100 patients (median age, 63 years), who were discharged following an admission for sepsis in 2017. They were treated at eight acute care hospitals in western and central North Carolina and hospitalized for a median of 5 days; 75 were discharged to home (17 received home health services there), 17 went to skilled nursing or long-term care facilities, and 8 went to hospice or another location.
The researchers analyzed whether the patients received four kinds of postsepsis care within 90 days, as recommended by a 2018 review: screening for common functional impairments (53/100 patients received this screening); adjustment of medications as needed following discharge (53/100 patients); monitoring for common and preventable causes for health deterioration, such as infection, chronic lung disease, or heart failure exacerbation (37/100); and assessment for palliative care (25/100 patients) (JAMA. 2018;319[1]:62-75).
Within 90 days of discharge, 34 patients were readmitted and 17 died. The 32 patients who received at least two recommended kinds of postsepsis care were less likely to be readmitted or die (9/32) than those who got zero or one recommended kind of care (34/68; odds ratio, 0.26; 95% confidence ratio, 0.09-0.82).
In an interview, study coauthor Marc Kowalkowski, PhD, associate professor with Atrium Health’s Center for Outcomes Research and Evaluation, said he was hesitant to only allocate blame to hospitals or outpatient providers. “Transition out of the hospital is an extremely complex event, involving often fragmented care settings, and sepsis patients tend to be more complicated than other patients. It probably makes sense to provide an added layer of support during the transition out of the hospital for patients who are at high risk for poor outcomes.”
Overall, the findings are “a call for clinicians to realize sepsis is more than just an acute illness. The combination of a growing number of sepsis survivors and the increased health problems following an episode of sepsis creates an urgent public health challenge,” Dr. Taylor said.
Is more home health an important part of a solution? It may be helpful, Dr. Taylor said, but “our data suggest that there really needs to be better coordination to bridge between the inpatient and outpatient transition. We are currently conducting a randomized study to investigate whether these types of care processes can be delivered effectively through a nurse navigator to improve patient outcomes.”
Fortunately, she said, the findings suggest “we don’t have to reinvent the wheel. We just have to work on implementation of strategies for care processes that we are already familiar with.”
No funding was reported. None of the study authors reported relevant disclosures.
SOURCE: Taylor SP et al. CCC48, Abstract 1320.
REPORTING FROM CCC48
Vitamin C for sepsis? Experts take sides in sharp debate
SAN DIEGO –
“There is evidence supporting benefit, and ample evidence supporting safety,” Michael H. Hooper, MD, who practices in Norfolk, Va., said in a pro-and-con debate over the use of vitamin C in sepsis at the Critical Care Congress sponsored by the Society of Critical Care Medicine.
Dr. Hooper’s debate opponent countered by noting the lack of quality research into vitamin C in sepsis and declared that its time has not yet come. “We need more data to know the safety of this drug,” said Andre Kalil, MD, professor of internal medicine and director of Transplant Infectious Diseases at the University of Nebraska Medical Center, Omaha.
Dr. Hooper was part of a member of a team led by Paul E. Marik, MD, FCCP, of Eastern Virginia Medical School, Norfolk, that made waves in 2017 with a study in Chest suggesting IV vitamin C has tremendous potential as a treatment for sepsis (Chest. 2017 Jun;151[6]:1229-38).
The retrospective study compared two groups of 47 patients with sepsis – a control group and a group that received treatment with intravenous vitamin C, hydrocortisone, and thiamine. Remarkably, the team found that 9% (4 of 47) of those in the treatment group died in the hospital, compared with 40% (19 of 47) in the control group (P less than .001).
The findings make sense, Dr. Hooper said, in light of the fact that “our patients are remarkably deficient” in vitamin C. He pointed to a 2017 study that found nearly 40% of 24 patients with septic shock were deficient in vitamin C – despite getting recommended enteral nutrition, parenteral nutrition or both – compared with 25% of patients who were not septic. The study authors believe the difference is probably due to “increased metabolism due to the enhanced inflammatory response observed in septic shock” (Crit Care. 2017 Dec 11;21[1]:300).
“We’re dealing with a population of patients who need some sort of repletion of this vitamin,” Dr. Hooper said.
Why not try oral administration of vitamin C? “Oral administration at regular doses doesn’t work,” he said. “If you have normal volunteers who are made deficient, then you administer the recommended allowance, it takes days or weeks to return levels to normal.”
Dr. Hooper added that the goal of vitamin C therapy isn’t simply to restore proper levels in plasma. In addition, he said, “we’re trying to restore levels in crucial organs.”
He said the cost of treatment with IV vitamin C is low, and no serious adverse events have been seen in studies of the vitamin’s use in critical care.
In his comments at the debate, Dr. Kalil pointed to several weaknesses in the 2017 study of vitamin C in sepsis. According to him, it had many problems, including a sample size that lacked statistical power and imbalances in the two groups. He raised concerns about the study in a 2017 letter published in Chest titled “Vitamin C Is Not Ready for Prime Time in Sepsis but a Solution Is Close,” noting that the control group was sicker and none of those patients had their vitamin C levels measured (Chest. 2017 Sep;152[3]:676).
He added that “acute renal failure is associated with high doses of vitamin C.”
As of July 2018, several clinical trials into vitamin C, hydrocortisone, and thiamine for the treatment of septic shock were underway or planned, according to a report that described the current randomized, placebo-controlled, multicenter Ascorbic Acid, Corticosteroids, and Thiamine in Sepsis (ACTS) trial in the United States. The report notes that “robust evidence” for this approach is lacking, although “the potential effectiveness of this medication combination is rooted in biologic plausibility and supported by small clinical trials of the various individual components.” (Crit Care. 2018;22:283)
Dr. Hooper is an executive committee member and principal investigator with the Vitamin C, Thiamine And Steroids in Sepsis (VICTAS) study. Dr. Kalil reports no relevant disclosures.
SAN DIEGO –
“There is evidence supporting benefit, and ample evidence supporting safety,” Michael H. Hooper, MD, who practices in Norfolk, Va., said in a pro-and-con debate over the use of vitamin C in sepsis at the Critical Care Congress sponsored by the Society of Critical Care Medicine.
Dr. Hooper’s debate opponent countered by noting the lack of quality research into vitamin C in sepsis and declared that its time has not yet come. “We need more data to know the safety of this drug,” said Andre Kalil, MD, professor of internal medicine and director of Transplant Infectious Diseases at the University of Nebraska Medical Center, Omaha.
Dr. Hooper was part of a member of a team led by Paul E. Marik, MD, FCCP, of Eastern Virginia Medical School, Norfolk, that made waves in 2017 with a study in Chest suggesting IV vitamin C has tremendous potential as a treatment for sepsis (Chest. 2017 Jun;151[6]:1229-38).
The retrospective study compared two groups of 47 patients with sepsis – a control group and a group that received treatment with intravenous vitamin C, hydrocortisone, and thiamine. Remarkably, the team found that 9% (4 of 47) of those in the treatment group died in the hospital, compared with 40% (19 of 47) in the control group (P less than .001).
The findings make sense, Dr. Hooper said, in light of the fact that “our patients are remarkably deficient” in vitamin C. He pointed to a 2017 study that found nearly 40% of 24 patients with septic shock were deficient in vitamin C – despite getting recommended enteral nutrition, parenteral nutrition or both – compared with 25% of patients who were not septic. The study authors believe the difference is probably due to “increased metabolism due to the enhanced inflammatory response observed in septic shock” (Crit Care. 2017 Dec 11;21[1]:300).
“We’re dealing with a population of patients who need some sort of repletion of this vitamin,” Dr. Hooper said.
Why not try oral administration of vitamin C? “Oral administration at regular doses doesn’t work,” he said. “If you have normal volunteers who are made deficient, then you administer the recommended allowance, it takes days or weeks to return levels to normal.”
Dr. Hooper added that the goal of vitamin C therapy isn’t simply to restore proper levels in plasma. In addition, he said, “we’re trying to restore levels in crucial organs.”
He said the cost of treatment with IV vitamin C is low, and no serious adverse events have been seen in studies of the vitamin’s use in critical care.
In his comments at the debate, Dr. Kalil pointed to several weaknesses in the 2017 study of vitamin C in sepsis. According to him, it had many problems, including a sample size that lacked statistical power and imbalances in the two groups. He raised concerns about the study in a 2017 letter published in Chest titled “Vitamin C Is Not Ready for Prime Time in Sepsis but a Solution Is Close,” noting that the control group was sicker and none of those patients had their vitamin C levels measured (Chest. 2017 Sep;152[3]:676).
He added that “acute renal failure is associated with high doses of vitamin C.”
As of July 2018, several clinical trials into vitamin C, hydrocortisone, and thiamine for the treatment of septic shock were underway or planned, according to a report that described the current randomized, placebo-controlled, multicenter Ascorbic Acid, Corticosteroids, and Thiamine in Sepsis (ACTS) trial in the United States. The report notes that “robust evidence” for this approach is lacking, although “the potential effectiveness of this medication combination is rooted in biologic plausibility and supported by small clinical trials of the various individual components.” (Crit Care. 2018;22:283)
Dr. Hooper is an executive committee member and principal investigator with the Vitamin C, Thiamine And Steroids in Sepsis (VICTAS) study. Dr. Kalil reports no relevant disclosures.
SAN DIEGO –
“There is evidence supporting benefit, and ample evidence supporting safety,” Michael H. Hooper, MD, who practices in Norfolk, Va., said in a pro-and-con debate over the use of vitamin C in sepsis at the Critical Care Congress sponsored by the Society of Critical Care Medicine.
Dr. Hooper’s debate opponent countered by noting the lack of quality research into vitamin C in sepsis and declared that its time has not yet come. “We need more data to know the safety of this drug,” said Andre Kalil, MD, professor of internal medicine and director of Transplant Infectious Diseases at the University of Nebraska Medical Center, Omaha.
Dr. Hooper was part of a member of a team led by Paul E. Marik, MD, FCCP, of Eastern Virginia Medical School, Norfolk, that made waves in 2017 with a study in Chest suggesting IV vitamin C has tremendous potential as a treatment for sepsis (Chest. 2017 Jun;151[6]:1229-38).
The retrospective study compared two groups of 47 patients with sepsis – a control group and a group that received treatment with intravenous vitamin C, hydrocortisone, and thiamine. Remarkably, the team found that 9% (4 of 47) of those in the treatment group died in the hospital, compared with 40% (19 of 47) in the control group (P less than .001).
The findings make sense, Dr. Hooper said, in light of the fact that “our patients are remarkably deficient” in vitamin C. He pointed to a 2017 study that found nearly 40% of 24 patients with septic shock were deficient in vitamin C – despite getting recommended enteral nutrition, parenteral nutrition or both – compared with 25% of patients who were not septic. The study authors believe the difference is probably due to “increased metabolism due to the enhanced inflammatory response observed in septic shock” (Crit Care. 2017 Dec 11;21[1]:300).
“We’re dealing with a population of patients who need some sort of repletion of this vitamin,” Dr. Hooper said.
Why not try oral administration of vitamin C? “Oral administration at regular doses doesn’t work,” he said. “If you have normal volunteers who are made deficient, then you administer the recommended allowance, it takes days or weeks to return levels to normal.”
Dr. Hooper added that the goal of vitamin C therapy isn’t simply to restore proper levels in plasma. In addition, he said, “we’re trying to restore levels in crucial organs.”
He said the cost of treatment with IV vitamin C is low, and no serious adverse events have been seen in studies of the vitamin’s use in critical care.
In his comments at the debate, Dr. Kalil pointed to several weaknesses in the 2017 study of vitamin C in sepsis. According to him, it had many problems, including a sample size that lacked statistical power and imbalances in the two groups. He raised concerns about the study in a 2017 letter published in Chest titled “Vitamin C Is Not Ready for Prime Time in Sepsis but a Solution Is Close,” noting that the control group was sicker and none of those patients had their vitamin C levels measured (Chest. 2017 Sep;152[3]:676).
He added that “acute renal failure is associated with high doses of vitamin C.”
As of July 2018, several clinical trials into vitamin C, hydrocortisone, and thiamine for the treatment of septic shock were underway or planned, according to a report that described the current randomized, placebo-controlled, multicenter Ascorbic Acid, Corticosteroids, and Thiamine in Sepsis (ACTS) trial in the United States. The report notes that “robust evidence” for this approach is lacking, although “the potential effectiveness of this medication combination is rooted in biologic plausibility and supported by small clinical trials of the various individual components.” (Crit Care. 2018;22:283)
Dr. Hooper is an executive committee member and principal investigator with the Vitamin C, Thiamine And Steroids in Sepsis (VICTAS) study. Dr. Kalil reports no relevant disclosures.
EXPERT ANALYSIS FROM CCC48