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Preoperative VTEs occurred in 10% of cancer patients
SEATTLE – Venous thromboembolism (VTE) is common in cancer, but 10% of asymptomatic patients undergoing major oncologic surgery have a preoperative VTE, according to findings presented at the annual Society of Surgical Oncology Cancer Symposium.
The incidence of preoperative VTE was associated with increasing age, a history of previous VTE, and a diagnosis of sepsis 1 month prior to undergoing oncologic surgery.
Surprisingly, noted study author Dr. Melanie Gainsbury of Cedar’s Sinai Medical Center, Los Angeles, it was not associated with oncologic factors such as locally recurrent disease, metastatic disease, or the receipt of neoadjuvant therapy.
“One may argue that patients undergoing oncologic surgery should receive preoperative lower-extremity duplex screening,” especially those who appear to be at high risk, she said.
About one in five cases of VTE is cancer related, and postoperative VTE is a leading cause of morbidity in cancer patients. However, Dr. Gainsbury noted, the incidence of preoperative VTE has not been well established or studied.
In this study, she and her colleagues evaluated the prevalence and risk factors associated with preoperative VTE in asymptomatic patients who were undergoing major oncologic surgery at an academic medical center.
In their retrospective analysis, the investigators identified 412 patients from the hospital’s database who underwent open abdominopelvic oncologic surgery between 2009 to 2016. All patients in the cohort had received a preoperative lower-extremity venous duplex scan (VDS).
The authors found that the overall incidence of preoperative VTE detected on VDS in this asymptomatic population was 10.1%. Of this group, 48.6% of the VTEs were acute, 42.9% were chronic, and a small subset (8.5%) was classified as subacute.
The majority of VTEs (62.9%) were located below the knee, and all of those patients with above-the-knee VTEs (37.1%) received inferior vena cava filters prior to surgery.
None of the patients in this cohort experienced a postoperative pulmonary embolism.
The investigators also looked at various risk factors that could predispose patients to a higher risk of developing a VTE. They did not find any statistically significant differences between those with a preoperative VTE and those without one when looking at gender, body mass index, or cancer type.
There was, however, a statistically significant difference in age, with older age being significantly associated with preoperative VTE. Further analysis showed that patients were 1.3 times more likely to have a preoperative DVT for every 5-year increase in age (odds ratio, 1.3; 95% confidence interval, 1.1-1.6).
In addition, patients with preoperative VTEs were significantly more likely to experience postoperative complications, with an almost twofold increased incidence (25.7% vs. 13.2%, P = .046).
“Patients with preoperative VTE were 1.95 times more likely to develop a postoperative complication than patients without a preoperative VTE,” Dr. Gainsbury said.
In terms of comorbidities, there was no statistically significant difference in regards to history of a known lung disease, varicose veins, a known coagulation mutation, congestive heart failure, and inflammatory bowel disease.
There were also no statistical differences between hormone use or anticoagulants in patients with and without VTEs.
Of note, a recent history of sepsis appeared to be an important factor that put patients at risk for a subsequent VTE. “The preoperative VTE group had a higher rate of diagnosed sepsis during the month prior to surgery,” she said. “We believe that the preoperative diagnosis of sepsis represents a prior hospitalization and perhaps a sicker population at risk for VTEs.”
There was no funding source disclosed in the abstract. Dr. Gainsbury and her coauthors had no disclosures.
SEATTLE – Venous thromboembolism (VTE) is common in cancer, but 10% of asymptomatic patients undergoing major oncologic surgery have a preoperative VTE, according to findings presented at the annual Society of Surgical Oncology Cancer Symposium.
The incidence of preoperative VTE was associated with increasing age, a history of previous VTE, and a diagnosis of sepsis 1 month prior to undergoing oncologic surgery.
Surprisingly, noted study author Dr. Melanie Gainsbury of Cedar’s Sinai Medical Center, Los Angeles, it was not associated with oncologic factors such as locally recurrent disease, metastatic disease, or the receipt of neoadjuvant therapy.
“One may argue that patients undergoing oncologic surgery should receive preoperative lower-extremity duplex screening,” especially those who appear to be at high risk, she said.
About one in five cases of VTE is cancer related, and postoperative VTE is a leading cause of morbidity in cancer patients. However, Dr. Gainsbury noted, the incidence of preoperative VTE has not been well established or studied.
In this study, she and her colleagues evaluated the prevalence and risk factors associated with preoperative VTE in asymptomatic patients who were undergoing major oncologic surgery at an academic medical center.
In their retrospective analysis, the investigators identified 412 patients from the hospital’s database who underwent open abdominopelvic oncologic surgery between 2009 to 2016. All patients in the cohort had received a preoperative lower-extremity venous duplex scan (VDS).
The authors found that the overall incidence of preoperative VTE detected on VDS in this asymptomatic population was 10.1%. Of this group, 48.6% of the VTEs were acute, 42.9% were chronic, and a small subset (8.5%) was classified as subacute.
The majority of VTEs (62.9%) were located below the knee, and all of those patients with above-the-knee VTEs (37.1%) received inferior vena cava filters prior to surgery.
None of the patients in this cohort experienced a postoperative pulmonary embolism.
The investigators also looked at various risk factors that could predispose patients to a higher risk of developing a VTE. They did not find any statistically significant differences between those with a preoperative VTE and those without one when looking at gender, body mass index, or cancer type.
There was, however, a statistically significant difference in age, with older age being significantly associated with preoperative VTE. Further analysis showed that patients were 1.3 times more likely to have a preoperative DVT for every 5-year increase in age (odds ratio, 1.3; 95% confidence interval, 1.1-1.6).
In addition, patients with preoperative VTEs were significantly more likely to experience postoperative complications, with an almost twofold increased incidence (25.7% vs. 13.2%, P = .046).
“Patients with preoperative VTE were 1.95 times more likely to develop a postoperative complication than patients without a preoperative VTE,” Dr. Gainsbury said.
In terms of comorbidities, there was no statistically significant difference in regards to history of a known lung disease, varicose veins, a known coagulation mutation, congestive heart failure, and inflammatory bowel disease.
There were also no statistical differences between hormone use or anticoagulants in patients with and without VTEs.
Of note, a recent history of sepsis appeared to be an important factor that put patients at risk for a subsequent VTE. “The preoperative VTE group had a higher rate of diagnosed sepsis during the month prior to surgery,” she said. “We believe that the preoperative diagnosis of sepsis represents a prior hospitalization and perhaps a sicker population at risk for VTEs.”
There was no funding source disclosed in the abstract. Dr. Gainsbury and her coauthors had no disclosures.
SEATTLE – Venous thromboembolism (VTE) is common in cancer, but 10% of asymptomatic patients undergoing major oncologic surgery have a preoperative VTE, according to findings presented at the annual Society of Surgical Oncology Cancer Symposium.
The incidence of preoperative VTE was associated with increasing age, a history of previous VTE, and a diagnosis of sepsis 1 month prior to undergoing oncologic surgery.
Surprisingly, noted study author Dr. Melanie Gainsbury of Cedar’s Sinai Medical Center, Los Angeles, it was not associated with oncologic factors such as locally recurrent disease, metastatic disease, or the receipt of neoadjuvant therapy.
“One may argue that patients undergoing oncologic surgery should receive preoperative lower-extremity duplex screening,” especially those who appear to be at high risk, she said.
About one in five cases of VTE is cancer related, and postoperative VTE is a leading cause of morbidity in cancer patients. However, Dr. Gainsbury noted, the incidence of preoperative VTE has not been well established or studied.
In this study, she and her colleagues evaluated the prevalence and risk factors associated with preoperative VTE in asymptomatic patients who were undergoing major oncologic surgery at an academic medical center.
In their retrospective analysis, the investigators identified 412 patients from the hospital’s database who underwent open abdominopelvic oncologic surgery between 2009 to 2016. All patients in the cohort had received a preoperative lower-extremity venous duplex scan (VDS).
The authors found that the overall incidence of preoperative VTE detected on VDS in this asymptomatic population was 10.1%. Of this group, 48.6% of the VTEs were acute, 42.9% were chronic, and a small subset (8.5%) was classified as subacute.
The majority of VTEs (62.9%) were located below the knee, and all of those patients with above-the-knee VTEs (37.1%) received inferior vena cava filters prior to surgery.
None of the patients in this cohort experienced a postoperative pulmonary embolism.
The investigators also looked at various risk factors that could predispose patients to a higher risk of developing a VTE. They did not find any statistically significant differences between those with a preoperative VTE and those without one when looking at gender, body mass index, or cancer type.
There was, however, a statistically significant difference in age, with older age being significantly associated with preoperative VTE. Further analysis showed that patients were 1.3 times more likely to have a preoperative DVT for every 5-year increase in age (odds ratio, 1.3; 95% confidence interval, 1.1-1.6).
In addition, patients with preoperative VTEs were significantly more likely to experience postoperative complications, with an almost twofold increased incidence (25.7% vs. 13.2%, P = .046).
“Patients with preoperative VTE were 1.95 times more likely to develop a postoperative complication than patients without a preoperative VTE,” Dr. Gainsbury said.
In terms of comorbidities, there was no statistically significant difference in regards to history of a known lung disease, varicose veins, a known coagulation mutation, congestive heart failure, and inflammatory bowel disease.
There were also no statistical differences between hormone use or anticoagulants in patients with and without VTEs.
Of note, a recent history of sepsis appeared to be an important factor that put patients at risk for a subsequent VTE. “The preoperative VTE group had a higher rate of diagnosed sepsis during the month prior to surgery,” she said. “We believe that the preoperative diagnosis of sepsis represents a prior hospitalization and perhaps a sicker population at risk for VTEs.”
There was no funding source disclosed in the abstract. Dr. Gainsbury and her coauthors had no disclosures.
AT SSO 2017
Key clinical point: 10% of asymptomatic cancer patients undergoing major cancer surgery have preoperative venous thromboembolism.
Major finding: Patients with preoperative VTEs were significantly more likely to experience postoperative complications, with an almost twofold increased incidence (25.7% vs. 13.2%, P = .046).
Data source: Retrospective analysis that included 412 who underwent open abdominopelvic oncologic surgery at a single academic center.
Disclosures: There was no funding source disclosed in the abstract. Dr. Gainsbury and her coauthors had no disclosures.
Disease site determines QOL, pain in recurrent rectal cancer
SEATTLE – Disease anatomy is the main determinant of subsequent quality of life (QOL) in patients with locally recurrent rectal cancer at both base line and in the long term, according to findings presented at the annual Society of Surgical Oncology Cancer Symposium.
Posterior recurrences were associated with the worst QOL scores and the most severe pain.
Recurrent rectal cancer is a morbid disease state, leading to pain and disability. “Patients experience a multitude of symptoms, including disability as a result of tumor growth in a confined space in the pelvis and invasion of adjacent organs as well as complications from surgery and neoadjuvant treatment,” said lead author Dr. Tarik Sammour of the University of Texas MD Anderson Cancer Center in Houston.
He noted, however, that “it is not all doom and gloom.” Survival outcomes have been improving in this population, with the median 5-year survival now approaching 40%-50%.
“Decade by decade, the 5-year survival outcomes are increasing,” explained Dr. Sammour.
Increasing survival also begs the question: “Are we helping patients or affording them the option of living longer with pain and disability? In other words, we need to measure patient-centered outcomes,” he said.
Data for recurrent rectal cancer are very limited, particularly when it comes to measuring patient outcomes. Most studies have been retrospective in design, making it difficult to gauge symptoms and quality of life.
The majority of studies also have focused on surgery, have short follow-up times, and may be missing data.
“Very few measure baseline quality of life, so it makes it difficult to measure trajectories,” Dr. Sammour said. “So overall we don’t know very much about the quality of life of these patients, so we thought to remedy that with a prospective study.”
Dr. Sammour and his colleagues examined the longitudinal trajectory of cancer survivorship in recurrent rectal cancer over a 7-year period. A total of 104 patients diagnosed with recurrent rectal cancer were enrolled between 2008 and 2015, and they prospectively self reported QOL using the validated EORTC QLQ-C30 and EORTC QLQ-CR29. Pain was measured by the Brief Pain Inventory.
Symptoms were measured at baseline and then every 6 months for 5 years or until death.
Within this cohort, 73 (70.2%) patients were amenable to salvage surgery with curative intent. A variety of types of surgery were performed, and R0 resection was achieved in 75% of cases.
The 30-day complication rate was 49% (21% with grade 3/4), and 5-year disease-free survival was 40%. There was no immediate mortality from the surgery.
When looking at differences between patients who underwent surgery and those who didn’t, there was a significant difference in the location of the disease. The nonsurgical group was more likely to have posterior recurrences (26%) than was the surgical group (19%).
“This makes sense since these are more difficult to achieve a R0 result with, so it may be less likely that they were offered the procedure,” Dr. Sammour said.
There was also a significant difference in estimated 5-year survival. Overall survival was 7.7% in the nonsurgical group vs. 50.9% in the surgical group (P less than .0001), and cancer-specific survival was 11.5% vs. 59.6% (P less than .0001).
As for pain and QOL scores, there were no differences between groups at baseline.
“So when they arrived at clinic they had roughly equivalent quality of life,” he said.
At follow-up, male patients were more likely to experience severe pain, but “we felt it was due to the anatomical location. Men have a narrower pelvis and don’t have the luxury of a uterus to protect the genitourinary organs,” he explained. “We suspect this may have played a role in the severity of their pain.”
Patients with posterior recurrences also had worse pain, and this was true for both surgical and nonsurgical patients.
The only determinant for QOL in those who underwent surgery was a positive margin (global health score 70.4 for negative margin and 61.9 for positive margins [P = .024]), but otherwise there were no differences by type of surgery or postoperative complications.
At a median follow-up of 33 months, patients who underwent surgery showed gradual sustained improvement in QOL but not pain scores.
“We were encouraged to see improvement,” concluded Dr. Sammour. “Surgery does improve quality of life in resectable cases.”
No funding source was disclosed. Dr. Sammour and his coauthors had no disclosures.
SEATTLE – Disease anatomy is the main determinant of subsequent quality of life (QOL) in patients with locally recurrent rectal cancer at both base line and in the long term, according to findings presented at the annual Society of Surgical Oncology Cancer Symposium.
Posterior recurrences were associated with the worst QOL scores and the most severe pain.
Recurrent rectal cancer is a morbid disease state, leading to pain and disability. “Patients experience a multitude of symptoms, including disability as a result of tumor growth in a confined space in the pelvis and invasion of adjacent organs as well as complications from surgery and neoadjuvant treatment,” said lead author Dr. Tarik Sammour of the University of Texas MD Anderson Cancer Center in Houston.
He noted, however, that “it is not all doom and gloom.” Survival outcomes have been improving in this population, with the median 5-year survival now approaching 40%-50%.
“Decade by decade, the 5-year survival outcomes are increasing,” explained Dr. Sammour.
Increasing survival also begs the question: “Are we helping patients or affording them the option of living longer with pain and disability? In other words, we need to measure patient-centered outcomes,” he said.
Data for recurrent rectal cancer are very limited, particularly when it comes to measuring patient outcomes. Most studies have been retrospective in design, making it difficult to gauge symptoms and quality of life.
The majority of studies also have focused on surgery, have short follow-up times, and may be missing data.
“Very few measure baseline quality of life, so it makes it difficult to measure trajectories,” Dr. Sammour said. “So overall we don’t know very much about the quality of life of these patients, so we thought to remedy that with a prospective study.”
Dr. Sammour and his colleagues examined the longitudinal trajectory of cancer survivorship in recurrent rectal cancer over a 7-year period. A total of 104 patients diagnosed with recurrent rectal cancer were enrolled between 2008 and 2015, and they prospectively self reported QOL using the validated EORTC QLQ-C30 and EORTC QLQ-CR29. Pain was measured by the Brief Pain Inventory.
Symptoms were measured at baseline and then every 6 months for 5 years or until death.
Within this cohort, 73 (70.2%) patients were amenable to salvage surgery with curative intent. A variety of types of surgery were performed, and R0 resection was achieved in 75% of cases.
The 30-day complication rate was 49% (21% with grade 3/4), and 5-year disease-free survival was 40%. There was no immediate mortality from the surgery.
When looking at differences between patients who underwent surgery and those who didn’t, there was a significant difference in the location of the disease. The nonsurgical group was more likely to have posterior recurrences (26%) than was the surgical group (19%).
“This makes sense since these are more difficult to achieve a R0 result with, so it may be less likely that they were offered the procedure,” Dr. Sammour said.
There was also a significant difference in estimated 5-year survival. Overall survival was 7.7% in the nonsurgical group vs. 50.9% in the surgical group (P less than .0001), and cancer-specific survival was 11.5% vs. 59.6% (P less than .0001).
As for pain and QOL scores, there were no differences between groups at baseline.
“So when they arrived at clinic they had roughly equivalent quality of life,” he said.
At follow-up, male patients were more likely to experience severe pain, but “we felt it was due to the anatomical location. Men have a narrower pelvis and don’t have the luxury of a uterus to protect the genitourinary organs,” he explained. “We suspect this may have played a role in the severity of their pain.”
Patients with posterior recurrences also had worse pain, and this was true for both surgical and nonsurgical patients.
The only determinant for QOL in those who underwent surgery was a positive margin (global health score 70.4 for negative margin and 61.9 for positive margins [P = .024]), but otherwise there were no differences by type of surgery or postoperative complications.
At a median follow-up of 33 months, patients who underwent surgery showed gradual sustained improvement in QOL but not pain scores.
“We were encouraged to see improvement,” concluded Dr. Sammour. “Surgery does improve quality of life in resectable cases.”
No funding source was disclosed. Dr. Sammour and his coauthors had no disclosures.
SEATTLE – Disease anatomy is the main determinant of subsequent quality of life (QOL) in patients with locally recurrent rectal cancer at both base line and in the long term, according to findings presented at the annual Society of Surgical Oncology Cancer Symposium.
Posterior recurrences were associated with the worst QOL scores and the most severe pain.
Recurrent rectal cancer is a morbid disease state, leading to pain and disability. “Patients experience a multitude of symptoms, including disability as a result of tumor growth in a confined space in the pelvis and invasion of adjacent organs as well as complications from surgery and neoadjuvant treatment,” said lead author Dr. Tarik Sammour of the University of Texas MD Anderson Cancer Center in Houston.
He noted, however, that “it is not all doom and gloom.” Survival outcomes have been improving in this population, with the median 5-year survival now approaching 40%-50%.
“Decade by decade, the 5-year survival outcomes are increasing,” explained Dr. Sammour.
Increasing survival also begs the question: “Are we helping patients or affording them the option of living longer with pain and disability? In other words, we need to measure patient-centered outcomes,” he said.
Data for recurrent rectal cancer are very limited, particularly when it comes to measuring patient outcomes. Most studies have been retrospective in design, making it difficult to gauge symptoms and quality of life.
The majority of studies also have focused on surgery, have short follow-up times, and may be missing data.
“Very few measure baseline quality of life, so it makes it difficult to measure trajectories,” Dr. Sammour said. “So overall we don’t know very much about the quality of life of these patients, so we thought to remedy that with a prospective study.”
Dr. Sammour and his colleagues examined the longitudinal trajectory of cancer survivorship in recurrent rectal cancer over a 7-year period. A total of 104 patients diagnosed with recurrent rectal cancer were enrolled between 2008 and 2015, and they prospectively self reported QOL using the validated EORTC QLQ-C30 and EORTC QLQ-CR29. Pain was measured by the Brief Pain Inventory.
Symptoms were measured at baseline and then every 6 months for 5 years or until death.
Within this cohort, 73 (70.2%) patients were amenable to salvage surgery with curative intent. A variety of types of surgery were performed, and R0 resection was achieved in 75% of cases.
The 30-day complication rate was 49% (21% with grade 3/4), and 5-year disease-free survival was 40%. There was no immediate mortality from the surgery.
When looking at differences between patients who underwent surgery and those who didn’t, there was a significant difference in the location of the disease. The nonsurgical group was more likely to have posterior recurrences (26%) than was the surgical group (19%).
“This makes sense since these are more difficult to achieve a R0 result with, so it may be less likely that they were offered the procedure,” Dr. Sammour said.
There was also a significant difference in estimated 5-year survival. Overall survival was 7.7% in the nonsurgical group vs. 50.9% in the surgical group (P less than .0001), and cancer-specific survival was 11.5% vs. 59.6% (P less than .0001).
As for pain and QOL scores, there were no differences between groups at baseline.
“So when they arrived at clinic they had roughly equivalent quality of life,” he said.
At follow-up, male patients were more likely to experience severe pain, but “we felt it was due to the anatomical location. Men have a narrower pelvis and don’t have the luxury of a uterus to protect the genitourinary organs,” he explained. “We suspect this may have played a role in the severity of their pain.”
Patients with posterior recurrences also had worse pain, and this was true for both surgical and nonsurgical patients.
The only determinant for QOL in those who underwent surgery was a positive margin (global health score 70.4 for negative margin and 61.9 for positive margins [P = .024]), but otherwise there were no differences by type of surgery or postoperative complications.
At a median follow-up of 33 months, patients who underwent surgery showed gradual sustained improvement in QOL but not pain scores.
“We were encouraged to see improvement,” concluded Dr. Sammour. “Surgery does improve quality of life in resectable cases.”
No funding source was disclosed. Dr. Sammour and his coauthors had no disclosures.
AT SSO 2017
Key clinical point: Posterior recurrence in recurrent rectal cancer was associated with worst quality of life and pain.
Major finding: Surgery improved overall survival (7.7% in the nonsurgical group vs. 50.9% in the surgical group [P less than .0001]) and quality of life.
Data source: Prospective study involved 104 patients with recurrent rectal cancer.
Disclosures: No funding source was disclosed. Dr. Sammour and his coauthors had no disclosures.
Complete resection tied to improved survival in low-grade serous ovarian cancer
NATIONAL HARBOR, MD. – Surgical resection to the point of no residual macroscopic disease significantly improved survival among patients with low-grade serous ovarian carcinoma, based on the findings of a large multicenter retrospective cohort study.
Adjuvant platinum-based therapy, however, did not appear to boost survival in the analysis, Tamayaa May, MD, MSc, said at the annual meeting of the Society of Gynecologic Oncology. “Genotyping and targeted sequencing of low-grade serous ovarian carcinoma often identifies actionable mutations, and treatment with MEK-based combination therapy might be a viable therapeutic strategy in patients with KRAS or NRAS mutations,” added Dr. May of Princess Margaret Cancer Center at the University of Toronto. She and her associates plan to examine more subgroups to determine if genomic alterations predict systemic response, she said.
Low-grade (Silverberg grade 1) serous ovarian tumors are slow growing but tend to resist chemotherapy, making optimal debulking a crucial part of treatment. In past studies, debulking that eliminated macroscopic evidence of disease was associated with a median survival time of about 115 months, compared with about 43 months if patients had residual disease, Dr. May noted.
To further explore outcomes after surgical resection, and to help clarify the role of systemic platinum-based therapy in low-grade serous ovarian carcinoma, she and her associates analyzed clinical data from 714 patients with low-grade serous ovarian carcinomas, including 40 from her institution and 674 from the Ovarian Cancer Association Consortium Registry. Most (60%) patients had stage III disease at diagnosis.
Complete data on surgical outcomes were available for 382 patients, of whom 202 (53%) had residual macroscopic disease and 43% did not. Among 439 patients with complete treatment data, 170 (39%) received first-line platinum-based chemotherapy. For the 391 patients with complete data on progression-free survival (PFS), the median follow-up was 4.9 years and median PFS was 3.1 years (95% confidence interval, 2.6-4.5 years). Residual macroscopic disease correlated with shorter PFS (P less than .001), as did higher tumor stage and baseline CA125 (P less than .001), but platinum-based therapy did not (P = .1).
A multivariable analysis of 333 patients confirmed these findings, Dr. May said. Independent correlates of death or disease progression included residual macroscopic disease (hazard ratio, 2.38; 95% CI, 1.68-3.37; P less than .001), older age (HR, 1.15; 95% CI, 1.02-1.30; P = .02), and stage III (HR, 3.28; 95% CI, 1.87-5.76; P less than .001) or stage IV disease (HR, 5.68; 95% CI, 2.73-11.83; P less than .001), compared with stage I disease. In contrast, platinum-based therapy did not correlate with survival (HR, 0.94; 95% CI, 0.69-1.28; P = .69).
The overall survival analysis also linked mortality with higher tumor stage, increased baseline CA125, and residual disease (P less than .001 for each association), but not with platinum-based therapy (P = .2). The multivariable analysis independently tied mortality to older age (HR, 1.25; P less than .001), stage III (HR, 2.31; P = .006) or IV disease (HR, 3.86; P less than .001), and residual disease (HR, 2.53; P less than .001), but not to platinum-based therapy (HR, 1.05; P = .77).
Data consistency and completeness were issues in this study: most notably, 45% of patients had no PFS data, Dr. May commented. Nonetheless, this type of large retrospective multicenter analysis is one of the best ways to study rare tumors, including low-grade serous ovarian carcinoma, she said.
The Ovarian Cancer Research Fund provides financial support for OCAC. Dr. May reported having no conflicts of interest.
NATIONAL HARBOR, MD. – Surgical resection to the point of no residual macroscopic disease significantly improved survival among patients with low-grade serous ovarian carcinoma, based on the findings of a large multicenter retrospective cohort study.
Adjuvant platinum-based therapy, however, did not appear to boost survival in the analysis, Tamayaa May, MD, MSc, said at the annual meeting of the Society of Gynecologic Oncology. “Genotyping and targeted sequencing of low-grade serous ovarian carcinoma often identifies actionable mutations, and treatment with MEK-based combination therapy might be a viable therapeutic strategy in patients with KRAS or NRAS mutations,” added Dr. May of Princess Margaret Cancer Center at the University of Toronto. She and her associates plan to examine more subgroups to determine if genomic alterations predict systemic response, she said.
Low-grade (Silverberg grade 1) serous ovarian tumors are slow growing but tend to resist chemotherapy, making optimal debulking a crucial part of treatment. In past studies, debulking that eliminated macroscopic evidence of disease was associated with a median survival time of about 115 months, compared with about 43 months if patients had residual disease, Dr. May noted.
To further explore outcomes after surgical resection, and to help clarify the role of systemic platinum-based therapy in low-grade serous ovarian carcinoma, she and her associates analyzed clinical data from 714 patients with low-grade serous ovarian carcinomas, including 40 from her institution and 674 from the Ovarian Cancer Association Consortium Registry. Most (60%) patients had stage III disease at diagnosis.
Complete data on surgical outcomes were available for 382 patients, of whom 202 (53%) had residual macroscopic disease and 43% did not. Among 439 patients with complete treatment data, 170 (39%) received first-line platinum-based chemotherapy. For the 391 patients with complete data on progression-free survival (PFS), the median follow-up was 4.9 years and median PFS was 3.1 years (95% confidence interval, 2.6-4.5 years). Residual macroscopic disease correlated with shorter PFS (P less than .001), as did higher tumor stage and baseline CA125 (P less than .001), but platinum-based therapy did not (P = .1).
A multivariable analysis of 333 patients confirmed these findings, Dr. May said. Independent correlates of death or disease progression included residual macroscopic disease (hazard ratio, 2.38; 95% CI, 1.68-3.37; P less than .001), older age (HR, 1.15; 95% CI, 1.02-1.30; P = .02), and stage III (HR, 3.28; 95% CI, 1.87-5.76; P less than .001) or stage IV disease (HR, 5.68; 95% CI, 2.73-11.83; P less than .001), compared with stage I disease. In contrast, platinum-based therapy did not correlate with survival (HR, 0.94; 95% CI, 0.69-1.28; P = .69).
The overall survival analysis also linked mortality with higher tumor stage, increased baseline CA125, and residual disease (P less than .001 for each association), but not with platinum-based therapy (P = .2). The multivariable analysis independently tied mortality to older age (HR, 1.25; P less than .001), stage III (HR, 2.31; P = .006) or IV disease (HR, 3.86; P less than .001), and residual disease (HR, 2.53; P less than .001), but not to platinum-based therapy (HR, 1.05; P = .77).
Data consistency and completeness were issues in this study: most notably, 45% of patients had no PFS data, Dr. May commented. Nonetheless, this type of large retrospective multicenter analysis is one of the best ways to study rare tumors, including low-grade serous ovarian carcinoma, she said.
The Ovarian Cancer Research Fund provides financial support for OCAC. Dr. May reported having no conflicts of interest.
NATIONAL HARBOR, MD. – Surgical resection to the point of no residual macroscopic disease significantly improved survival among patients with low-grade serous ovarian carcinoma, based on the findings of a large multicenter retrospective cohort study.
Adjuvant platinum-based therapy, however, did not appear to boost survival in the analysis, Tamayaa May, MD, MSc, said at the annual meeting of the Society of Gynecologic Oncology. “Genotyping and targeted sequencing of low-grade serous ovarian carcinoma often identifies actionable mutations, and treatment with MEK-based combination therapy might be a viable therapeutic strategy in patients with KRAS or NRAS mutations,” added Dr. May of Princess Margaret Cancer Center at the University of Toronto. She and her associates plan to examine more subgroups to determine if genomic alterations predict systemic response, she said.
Low-grade (Silverberg grade 1) serous ovarian tumors are slow growing but tend to resist chemotherapy, making optimal debulking a crucial part of treatment. In past studies, debulking that eliminated macroscopic evidence of disease was associated with a median survival time of about 115 months, compared with about 43 months if patients had residual disease, Dr. May noted.
To further explore outcomes after surgical resection, and to help clarify the role of systemic platinum-based therapy in low-grade serous ovarian carcinoma, she and her associates analyzed clinical data from 714 patients with low-grade serous ovarian carcinomas, including 40 from her institution and 674 from the Ovarian Cancer Association Consortium Registry. Most (60%) patients had stage III disease at diagnosis.
Complete data on surgical outcomes were available for 382 patients, of whom 202 (53%) had residual macroscopic disease and 43% did not. Among 439 patients with complete treatment data, 170 (39%) received first-line platinum-based chemotherapy. For the 391 patients with complete data on progression-free survival (PFS), the median follow-up was 4.9 years and median PFS was 3.1 years (95% confidence interval, 2.6-4.5 years). Residual macroscopic disease correlated with shorter PFS (P less than .001), as did higher tumor stage and baseline CA125 (P less than .001), but platinum-based therapy did not (P = .1).
A multivariable analysis of 333 patients confirmed these findings, Dr. May said. Independent correlates of death or disease progression included residual macroscopic disease (hazard ratio, 2.38; 95% CI, 1.68-3.37; P less than .001), older age (HR, 1.15; 95% CI, 1.02-1.30; P = .02), and stage III (HR, 3.28; 95% CI, 1.87-5.76; P less than .001) or stage IV disease (HR, 5.68; 95% CI, 2.73-11.83; P less than .001), compared with stage I disease. In contrast, platinum-based therapy did not correlate with survival (HR, 0.94; 95% CI, 0.69-1.28; P = .69).
The overall survival analysis also linked mortality with higher tumor stage, increased baseline CA125, and residual disease (P less than .001 for each association), but not with platinum-based therapy (P = .2). The multivariable analysis independently tied mortality to older age (HR, 1.25; P less than .001), stage III (HR, 2.31; P = .006) or IV disease (HR, 3.86; P less than .001), and residual disease (HR, 2.53; P less than .001), but not to platinum-based therapy (HR, 1.05; P = .77).
Data consistency and completeness were issues in this study: most notably, 45% of patients had no PFS data, Dr. May commented. Nonetheless, this type of large retrospective multicenter analysis is one of the best ways to study rare tumors, including low-grade serous ovarian carcinoma, she said.
The Ovarian Cancer Research Fund provides financial support for OCAC. Dr. May reported having no conflicts of interest.
AT THE ANNUAL MEETING ON WOMEN’S CANCER
Key clinical point: Unlike platinum-based chemotherapy, resection to the point of no residual disease was associated with improved survival among patients with low-grade serous ovarian carcinoma.
Major finding: Independent correlates of death or disease progression included residual macroscopic disease (hazard ratio, 2.38; P less than .001), older age (HR, 1.15; P = .02), and stage III (HR, 3.28; P less than .001) or stage IV (HR, 5.68; P less than .001) disease, compared with stage I disease. Platinum-based therapy was not associated with improved survival (HR, 0.94; P = 69).
Data source: A retrospective cohort study of 714 patients with low-grade (Silverberg grade 1) serous tumors from the Ovarian Cancer Association Consortium Registry.
Disclosures: The Ovarian Cancer Research Fund provides financial support for OCAC. Dr. May reported having no conflicts of interest.
VIDEO: Looking at keloids from a different perspective
ORLANDO – It may be time to start considering new options for treating keloids, according to Amy McMichael, MD, professor of dermatology at Wake Forest University, Winston-Salem, N.C.
At the annual meeting of the American Academy of Dermatology, Dr. McMichael discussed one of the highlights of the annual symposium of the Skin of Color Society, held right before the annual meeting, a presentation by Michael Tirgan, MD, who has treated patients with keloids for about 10 years.
Dr. Tirgan, an oncologist based in New York, has a large database and registry of patients and shared some interesting data at the symposium. “What he’s found is that those who come with the supermassive and massive keloids are those who have had the most surgery on their keloid,” Dr. McMichael said in a video interview at the meeting.
His findings shed light on what she described as “a new perspective in the way that we think about keloids” and a new approach to treatment – considering keloids as tumors – not just a scar.
Dr. McMichael had no relevant disclosures.
The video associated with this article is no longer available on this site. Please view all of our videos on the MDedge YouTube channel
ORLANDO – It may be time to start considering new options for treating keloids, according to Amy McMichael, MD, professor of dermatology at Wake Forest University, Winston-Salem, N.C.
At the annual meeting of the American Academy of Dermatology, Dr. McMichael discussed one of the highlights of the annual symposium of the Skin of Color Society, held right before the annual meeting, a presentation by Michael Tirgan, MD, who has treated patients with keloids for about 10 years.
Dr. Tirgan, an oncologist based in New York, has a large database and registry of patients and shared some interesting data at the symposium. “What he’s found is that those who come with the supermassive and massive keloids are those who have had the most surgery on their keloid,” Dr. McMichael said in a video interview at the meeting.
His findings shed light on what she described as “a new perspective in the way that we think about keloids” and a new approach to treatment – considering keloids as tumors – not just a scar.
Dr. McMichael had no relevant disclosures.
The video associated with this article is no longer available on this site. Please view all of our videos on the MDedge YouTube channel
ORLANDO – It may be time to start considering new options for treating keloids, according to Amy McMichael, MD, professor of dermatology at Wake Forest University, Winston-Salem, N.C.
At the annual meeting of the American Academy of Dermatology, Dr. McMichael discussed one of the highlights of the annual symposium of the Skin of Color Society, held right before the annual meeting, a presentation by Michael Tirgan, MD, who has treated patients with keloids for about 10 years.
Dr. Tirgan, an oncologist based in New York, has a large database and registry of patients and shared some interesting data at the symposium. “What he’s found is that those who come with the supermassive and massive keloids are those who have had the most surgery on their keloid,” Dr. McMichael said in a video interview at the meeting.
His findings shed light on what she described as “a new perspective in the way that we think about keloids” and a new approach to treatment – considering keloids as tumors – not just a scar.
Dr. McMichael had no relevant disclosures.
The video associated with this article is no longer available on this site. Please view all of our videos on the MDedge YouTube channel
AT AAD 17
Preoperative opioid use linked to worse outcomes following abdominal surgery
Surgeons need to do more to identify patients who are taking opioids preoperatively, because this is a population that appears to be at a higher risk of worse surgical outcomes, according to a large retrospective investigation.
“Opioid users represent a potentially high-risk surgical population and may require tailored perioperative care [and] the prevalence and clinical impact of this problem in the general surgery population remain unclear,” wrote the authors of a study, led by David C. Cron, a medical student of the University of Michigan, Ann Arbor. “Given the impact of pain control and gastrointestinal function on hospital stay, it is intuitive that opioid users may have increased hospital length of stay (LOS) and may incur more costs [and] also be at higher risk for surgical complications.”
The study was published in the Annals of Surgery (2017;465[4]696-701).
Mr. Cron and his coauthors made a study cohort retrospectively from abdominopelvic surgery patients from the Michigan Surgical Quality Collaborative (MSQC) database who had surgery between 2008 and 2014. All patients were treated at the University of Michigan, and were admitted within 2 days of undergoing their operation. Any patient with data indicating use of buprenorphine prior to surgery, or those were who opioid naive before admission but received opioids after being admitted, were excluded.
Investigators found a total of 3,107 patients in the MSQC database that underwent abdominopelvic surgery at the University of Michigan during the designated time frame; from that group, 2,413 were ultimately found to match the inclusion criteria for the study. The primary outcomes were 90-day total hospital costs, along with patient LOS, and 30-day rates of complications and readmissions. Data underwent covariate risk adjustment to account for age, race, gender, body mass index, insurance class, and other factors.
“Major complications are recorded by the MSQC and include: surgical site infection, deep venous thrombosis, acute renal failure, postoperative bleeding requiring transfusion, stroke, unplanned intubation, fascial dehiscence, prolonged mechanical ventilation longer than 48 hours, myocardial infarction, pneumonia, pulmonary embolism, sepsis, vascular graft loss, and renal insufficiency,” the authors noted.
Of the 2,413 subjects overall, 502 (20.8%) were found to use opioids before surgery. Differences between opioid users and nonusers were not significant in terms of age (P = .10), gender (P = .76), and race (P = .78). After adjustment, data indicated that preoperative opioid users had 9.2% higher hospital costs than nonusers (95% confidence interval, 2.8%-15.6%, P = .005) and 12.4% longer hospital stay (95% CI, 2.3%-23.5%; P = .015). Complications and readmission rates were quantified by odds ratios, which were also found to be significantly higher in subjects who were preoperative opioid users: OR = 1.36 (95% CI, 1.04-1.78; P = .023) and OR = 1.57 (95% CI, 1.08-2.29; P = .018), respectively.
The study had some limitations, including being conducted at a single center and potentially not generalizable to other types of health care facilities and population types. Additionally, information on opioid dosage and duration of use was lacking, making it that “possible that some opioid users in our study were using opioids over a shorter time period for pain related to their surgical disease,” according to the investigators.
“These results argue the potential cost-effectiveness of intervention in this unique patient population,” Mr. Cron and his colleagues concluded. “Opioid use is a potentially modifiable risk factor, and major surgery can provide powerful leverage to improve health behavior [and] our institution has implemented a preoperative program to optimize high-risk patients for surgery.”
Mr. Cron received funding from the 2015 AOA Carolyn L. Kuckein Student Research Fellowship and the Blue Cross Blue Shield of Michigan Foundation Student Research Award for this study. He and his coauthors reported no relevant financial disclosures.
The opioid epidemic is probably the biggest health care problem in the United States, and it’s getting worse. Opioids are absolutely affecting surgical outcomes on a large scale. Unfortunately, there’s no great solution in terms of how to better manage these patients – in a perfect world, we’d take the time to wean them off opioids before operating, but that isn’t very pragmatic. With such a large and expanding proportion of our patients presenting to the operating room on long-term opioids, we have developed a new cohort of high-risk surgical patients over the past several years.
Michael J. Englesbe, MD , is a professor of surgery at the University of Michigan, Ann Arbor, and a coauthor on this study.
The opioid epidemic is probably the biggest health care problem in the United States, and it’s getting worse. Opioids are absolutely affecting surgical outcomes on a large scale. Unfortunately, there’s no great solution in terms of how to better manage these patients – in a perfect world, we’d take the time to wean them off opioids before operating, but that isn’t very pragmatic. With such a large and expanding proportion of our patients presenting to the operating room on long-term opioids, we have developed a new cohort of high-risk surgical patients over the past several years.
Michael J. Englesbe, MD , is a professor of surgery at the University of Michigan, Ann Arbor, and a coauthor on this study.
The opioid epidemic is probably the biggest health care problem in the United States, and it’s getting worse. Opioids are absolutely affecting surgical outcomes on a large scale. Unfortunately, there’s no great solution in terms of how to better manage these patients – in a perfect world, we’d take the time to wean them off opioids before operating, but that isn’t very pragmatic. With such a large and expanding proportion of our patients presenting to the operating room on long-term opioids, we have developed a new cohort of high-risk surgical patients over the past several years.
Michael J. Englesbe, MD , is a professor of surgery at the University of Michigan, Ann Arbor, and a coauthor on this study.
Surgeons need to do more to identify patients who are taking opioids preoperatively, because this is a population that appears to be at a higher risk of worse surgical outcomes, according to a large retrospective investigation.
“Opioid users represent a potentially high-risk surgical population and may require tailored perioperative care [and] the prevalence and clinical impact of this problem in the general surgery population remain unclear,” wrote the authors of a study, led by David C. Cron, a medical student of the University of Michigan, Ann Arbor. “Given the impact of pain control and gastrointestinal function on hospital stay, it is intuitive that opioid users may have increased hospital length of stay (LOS) and may incur more costs [and] also be at higher risk for surgical complications.”
The study was published in the Annals of Surgery (2017;465[4]696-701).
Mr. Cron and his coauthors made a study cohort retrospectively from abdominopelvic surgery patients from the Michigan Surgical Quality Collaborative (MSQC) database who had surgery between 2008 and 2014. All patients were treated at the University of Michigan, and were admitted within 2 days of undergoing their operation. Any patient with data indicating use of buprenorphine prior to surgery, or those were who opioid naive before admission but received opioids after being admitted, were excluded.
Investigators found a total of 3,107 patients in the MSQC database that underwent abdominopelvic surgery at the University of Michigan during the designated time frame; from that group, 2,413 were ultimately found to match the inclusion criteria for the study. The primary outcomes were 90-day total hospital costs, along with patient LOS, and 30-day rates of complications and readmissions. Data underwent covariate risk adjustment to account for age, race, gender, body mass index, insurance class, and other factors.
“Major complications are recorded by the MSQC and include: surgical site infection, deep venous thrombosis, acute renal failure, postoperative bleeding requiring transfusion, stroke, unplanned intubation, fascial dehiscence, prolonged mechanical ventilation longer than 48 hours, myocardial infarction, pneumonia, pulmonary embolism, sepsis, vascular graft loss, and renal insufficiency,” the authors noted.
Of the 2,413 subjects overall, 502 (20.8%) were found to use opioids before surgery. Differences between opioid users and nonusers were not significant in terms of age (P = .10), gender (P = .76), and race (P = .78). After adjustment, data indicated that preoperative opioid users had 9.2% higher hospital costs than nonusers (95% confidence interval, 2.8%-15.6%, P = .005) and 12.4% longer hospital stay (95% CI, 2.3%-23.5%; P = .015). Complications and readmission rates were quantified by odds ratios, which were also found to be significantly higher in subjects who were preoperative opioid users: OR = 1.36 (95% CI, 1.04-1.78; P = .023) and OR = 1.57 (95% CI, 1.08-2.29; P = .018), respectively.
The study had some limitations, including being conducted at a single center and potentially not generalizable to other types of health care facilities and population types. Additionally, information on opioid dosage and duration of use was lacking, making it that “possible that some opioid users in our study were using opioids over a shorter time period for pain related to their surgical disease,” according to the investigators.
“These results argue the potential cost-effectiveness of intervention in this unique patient population,” Mr. Cron and his colleagues concluded. “Opioid use is a potentially modifiable risk factor, and major surgery can provide powerful leverage to improve health behavior [and] our institution has implemented a preoperative program to optimize high-risk patients for surgery.”
Mr. Cron received funding from the 2015 AOA Carolyn L. Kuckein Student Research Fellowship and the Blue Cross Blue Shield of Michigan Foundation Student Research Award for this study. He and his coauthors reported no relevant financial disclosures.
Surgeons need to do more to identify patients who are taking opioids preoperatively, because this is a population that appears to be at a higher risk of worse surgical outcomes, according to a large retrospective investigation.
“Opioid users represent a potentially high-risk surgical population and may require tailored perioperative care [and] the prevalence and clinical impact of this problem in the general surgery population remain unclear,” wrote the authors of a study, led by David C. Cron, a medical student of the University of Michigan, Ann Arbor. “Given the impact of pain control and gastrointestinal function on hospital stay, it is intuitive that opioid users may have increased hospital length of stay (LOS) and may incur more costs [and] also be at higher risk for surgical complications.”
The study was published in the Annals of Surgery (2017;465[4]696-701).
Mr. Cron and his coauthors made a study cohort retrospectively from abdominopelvic surgery patients from the Michigan Surgical Quality Collaborative (MSQC) database who had surgery between 2008 and 2014. All patients were treated at the University of Michigan, and were admitted within 2 days of undergoing their operation. Any patient with data indicating use of buprenorphine prior to surgery, or those were who opioid naive before admission but received opioids after being admitted, were excluded.
Investigators found a total of 3,107 patients in the MSQC database that underwent abdominopelvic surgery at the University of Michigan during the designated time frame; from that group, 2,413 were ultimately found to match the inclusion criteria for the study. The primary outcomes were 90-day total hospital costs, along with patient LOS, and 30-day rates of complications and readmissions. Data underwent covariate risk adjustment to account for age, race, gender, body mass index, insurance class, and other factors.
“Major complications are recorded by the MSQC and include: surgical site infection, deep venous thrombosis, acute renal failure, postoperative bleeding requiring transfusion, stroke, unplanned intubation, fascial dehiscence, prolonged mechanical ventilation longer than 48 hours, myocardial infarction, pneumonia, pulmonary embolism, sepsis, vascular graft loss, and renal insufficiency,” the authors noted.
Of the 2,413 subjects overall, 502 (20.8%) were found to use opioids before surgery. Differences between opioid users and nonusers were not significant in terms of age (P = .10), gender (P = .76), and race (P = .78). After adjustment, data indicated that preoperative opioid users had 9.2% higher hospital costs than nonusers (95% confidence interval, 2.8%-15.6%, P = .005) and 12.4% longer hospital stay (95% CI, 2.3%-23.5%; P = .015). Complications and readmission rates were quantified by odds ratios, which were also found to be significantly higher in subjects who were preoperative opioid users: OR = 1.36 (95% CI, 1.04-1.78; P = .023) and OR = 1.57 (95% CI, 1.08-2.29; P = .018), respectively.
The study had some limitations, including being conducted at a single center and potentially not generalizable to other types of health care facilities and population types. Additionally, information on opioid dosage and duration of use was lacking, making it that “possible that some opioid users in our study were using opioids over a shorter time period for pain related to their surgical disease,” according to the investigators.
“These results argue the potential cost-effectiveness of intervention in this unique patient population,” Mr. Cron and his colleagues concluded. “Opioid use is a potentially modifiable risk factor, and major surgery can provide powerful leverage to improve health behavior [and] our institution has implemented a preoperative program to optimize high-risk patients for surgery.”
Mr. Cron received funding from the 2015 AOA Carolyn L. Kuckein Student Research Fellowship and the Blue Cross Blue Shield of Michigan Foundation Student Research Award for this study. He and his coauthors reported no relevant financial disclosures.
FROM THE ANNALS OF SURGERY
Key clinical point:
Major finding: Preoperative opioid users had 9.2% higher costs and 12.4% longer LOS, with higher ORs for complications and readmissions, than patients who did not take opioids.
Data source: Retrospective analysis of data on 2,413 abdominopelvic surgery patients during 2008-2014.
Disclosures: Study funded by grants awarded to Mr. Cron from the 2015 AOA Carolyn L. Kuckein Student Research Fellowship and the Blue Cross Blue Shield of Michigan Foundation Student Research Award. Authors reported no relevant financial disclosures.
Gradual increase of nonoperative management of selected abdominal gunshot wounds
Selective nonoperative management of abdominal gunshot wounds has progressed from heresy a few years ago to established practice now, at least at Level I and Level II trauma centers across New England, according to a report published online in the Journal of the American College of Surgeons.
“Mandatory laparotomy used to be the only acceptable standard of care” for this patient population, but many surgeons now realize that a hole in the abdomen doesn’t necessitate immediate laparotomy. “Patients with a reliable clinical exam, who are hemodynamically stable and without signs of peritonitis, can be observed under structured protocols of close monitoring, frequent clinical exams, and appropriate imaging,” said Thomas Peponis, MD, of Massachusetts General Hospital, Boston, and his associates.
Two findings belie the main arguments that opponents of SNOM have made in favor of routine laparotomy: delaying surgery leads to devastating consequences and “unnecessary” laparotomies are virtually harmless.
The first finding was that the 18 patients in the SNOM group (1.9% of the entire study population) who eventually required a delayed laparotomy had few postoperative complications, and none of the complications appeared to be directly related to the delay in surgery. Those SNOM patients who eventually had surgery did not differ in terms of age, sex, location of the gunshot wound, vitals on ED presentation, Glasgow Coma Scale on ED presentation, presence of hemodynamic instability, or presence of diffuse abdominal tenderness on clinical exam.
The second finding concerned the 104 patients who underwent immediate exploratory laparotomy. Dr. Peponis and his associates deemed the immediacy to be nontherapeutic (unnecessary) because “the mere presence of a hole to the abdomen was the only indication” for the surgery. Nearly one in six patients operated on for an abdominal gunshot wound underwent a nontherapeutic laparotomy. Of those, 18 (17.3%) developed postoperative complications, including wound infections, ileus, pneumonia, pleural effusion requiring a chest tube, intra-abdominal abscess, acute kidney injury, sepsis, venous embolus, and a fistula related to a retained bullet.
The rate of abdominal gunshot wounds treated nonoperatively in the centers studied has grown from around 18% before 2010 to 27% in the following years. The increasing use of CT scans has bolstered the trend, but the clinical exam remains the critical element in deciding whether to operate immediately. The investigators recommended immediate surgery for all abdominal gunshot wound patients who are hemodynamically unstable or who exhibit diffuse abdominal tenderness. “There is no other place for a patient with an abdominal gunshot wound and definitively worsening clinical symptoms than the OR. The remaining patients are appropriate for SNOM under close observation, repeat clinical evaluations, and immediate OR availability in case the clinical picture changes.”
The limitations of the study are the following: First, it represents only Level I and II centers with experienced trauma teams. Second, there is no commonly established protocol across trauma centers for SNOM, giving rise to a variability in decision making and care. Third, the definition of immediate and delayed surgery was within a 2-hour window, a somewhat arbitrary time period.
The investigation was sponsored by the Research Consortium of New England Centers for Trauma (ReCoNECT). The authors had no disclosures.
Selective nonoperative management of abdominal gunshot wounds has progressed from heresy a few years ago to established practice now, at least at Level I and Level II trauma centers across New England, according to a report published online in the Journal of the American College of Surgeons.
“Mandatory laparotomy used to be the only acceptable standard of care” for this patient population, but many surgeons now realize that a hole in the abdomen doesn’t necessitate immediate laparotomy. “Patients with a reliable clinical exam, who are hemodynamically stable and without signs of peritonitis, can be observed under structured protocols of close monitoring, frequent clinical exams, and appropriate imaging,” said Thomas Peponis, MD, of Massachusetts General Hospital, Boston, and his associates.
Two findings belie the main arguments that opponents of SNOM have made in favor of routine laparotomy: delaying surgery leads to devastating consequences and “unnecessary” laparotomies are virtually harmless.
The first finding was that the 18 patients in the SNOM group (1.9% of the entire study population) who eventually required a delayed laparotomy had few postoperative complications, and none of the complications appeared to be directly related to the delay in surgery. Those SNOM patients who eventually had surgery did not differ in terms of age, sex, location of the gunshot wound, vitals on ED presentation, Glasgow Coma Scale on ED presentation, presence of hemodynamic instability, or presence of diffuse abdominal tenderness on clinical exam.
The second finding concerned the 104 patients who underwent immediate exploratory laparotomy. Dr. Peponis and his associates deemed the immediacy to be nontherapeutic (unnecessary) because “the mere presence of a hole to the abdomen was the only indication” for the surgery. Nearly one in six patients operated on for an abdominal gunshot wound underwent a nontherapeutic laparotomy. Of those, 18 (17.3%) developed postoperative complications, including wound infections, ileus, pneumonia, pleural effusion requiring a chest tube, intra-abdominal abscess, acute kidney injury, sepsis, venous embolus, and a fistula related to a retained bullet.
The rate of abdominal gunshot wounds treated nonoperatively in the centers studied has grown from around 18% before 2010 to 27% in the following years. The increasing use of CT scans has bolstered the trend, but the clinical exam remains the critical element in deciding whether to operate immediately. The investigators recommended immediate surgery for all abdominal gunshot wound patients who are hemodynamically unstable or who exhibit diffuse abdominal tenderness. “There is no other place for a patient with an abdominal gunshot wound and definitively worsening clinical symptoms than the OR. The remaining patients are appropriate for SNOM under close observation, repeat clinical evaluations, and immediate OR availability in case the clinical picture changes.”
The limitations of the study are the following: First, it represents only Level I and II centers with experienced trauma teams. Second, there is no commonly established protocol across trauma centers for SNOM, giving rise to a variability in decision making and care. Third, the definition of immediate and delayed surgery was within a 2-hour window, a somewhat arbitrary time period.
The investigation was sponsored by the Research Consortium of New England Centers for Trauma (ReCoNECT). The authors had no disclosures.
Selective nonoperative management of abdominal gunshot wounds has progressed from heresy a few years ago to established practice now, at least at Level I and Level II trauma centers across New England, according to a report published online in the Journal of the American College of Surgeons.
“Mandatory laparotomy used to be the only acceptable standard of care” for this patient population, but many surgeons now realize that a hole in the abdomen doesn’t necessitate immediate laparotomy. “Patients with a reliable clinical exam, who are hemodynamically stable and without signs of peritonitis, can be observed under structured protocols of close monitoring, frequent clinical exams, and appropriate imaging,” said Thomas Peponis, MD, of Massachusetts General Hospital, Boston, and his associates.
Two findings belie the main arguments that opponents of SNOM have made in favor of routine laparotomy: delaying surgery leads to devastating consequences and “unnecessary” laparotomies are virtually harmless.
The first finding was that the 18 patients in the SNOM group (1.9% of the entire study population) who eventually required a delayed laparotomy had few postoperative complications, and none of the complications appeared to be directly related to the delay in surgery. Those SNOM patients who eventually had surgery did not differ in terms of age, sex, location of the gunshot wound, vitals on ED presentation, Glasgow Coma Scale on ED presentation, presence of hemodynamic instability, or presence of diffuse abdominal tenderness on clinical exam.
The second finding concerned the 104 patients who underwent immediate exploratory laparotomy. Dr. Peponis and his associates deemed the immediacy to be nontherapeutic (unnecessary) because “the mere presence of a hole to the abdomen was the only indication” for the surgery. Nearly one in six patients operated on for an abdominal gunshot wound underwent a nontherapeutic laparotomy. Of those, 18 (17.3%) developed postoperative complications, including wound infections, ileus, pneumonia, pleural effusion requiring a chest tube, intra-abdominal abscess, acute kidney injury, sepsis, venous embolus, and a fistula related to a retained bullet.
The rate of abdominal gunshot wounds treated nonoperatively in the centers studied has grown from around 18% before 2010 to 27% in the following years. The increasing use of CT scans has bolstered the trend, but the clinical exam remains the critical element in deciding whether to operate immediately. The investigators recommended immediate surgery for all abdominal gunshot wound patients who are hemodynamically unstable or who exhibit diffuse abdominal tenderness. “There is no other place for a patient with an abdominal gunshot wound and definitively worsening clinical symptoms than the OR. The remaining patients are appropriate for SNOM under close observation, repeat clinical evaluations, and immediate OR availability in case the clinical picture changes.”
The limitations of the study are the following: First, it represents only Level I and II centers with experienced trauma teams. Second, there is no commonly established protocol across trauma centers for SNOM, giving rise to a variability in decision making and care. Third, the definition of immediate and delayed surgery was within a 2-hour window, a somewhat arbitrary time period.
The investigation was sponsored by the Research Consortium of New England Centers for Trauma (ReCoNECT). The authors had no disclosures.
FROM THE JOURNAL OF THE AMERICAN COLLEGE OF SURGEONS
Key clinical point: Selective nonoperative management of abdominal gunshot wounds has progressed from heresy a few years ago to established practice now.
Major finding: 197 patients (91.6% of the nonoperative group and 21.4% of the entire study population) were successfully managed nonoperatively and were discharged without requiring any abdominal surgery.
Data source: A retrospective review of the medical records of 922 gunshot wound patients treated at 10 New England trauma centers during a 20-year period.
Disclosures: The investigation was a multicenter study of the Research Consortium of New England Centers for Trauma (ReCoNECT). Dr. Peponis and his associates reported having no relevant financial disclosures.
Onstep hernia repair decreased postop pain during sexual activity
The Onstep technique for inguinal hernia repair is associated with a lower incidence of postoperative pain during sexual activity than the Lichtenstein surgical technique, according to a paper published online in Surgery.
This study was a part of the Onli trial, the objective of which was to evaluate chronic pain and sexual dysfunction after inguinal hernia repair involving mesh fixation with sutures (Lichtenstein), compared with no mesh fixation (Onstep). The investigators reported the findings of a large study: 20.8% of inguinal repair patients experienced pain during sexual activity 1.4-1.7 years after their operation (Pain. 2006;122:258-63).
“The Onstep technique could be considered when surgeons and patients are discussing the optimal technique for repair of an inguinal hernia,” wrote Kristoffer Andresen, MD, of the University of Copenhagen, and his coauthors. “If the patient has pain during sexual activity as part of the complaint from the hernia, the Onstep technique seems to have a greater chance of removing this pain and alleviating the complaints.”
Among the 17 patients in the Onstep group who experienced postoperative pain during sexual activity, 8 had experienced preoperative pain during sexual activity and 7 had not. In the Lichtenstein group, 14 of the 30 patients who experienced postoperative pain had experienced preoperative pain, 14 had not. The remaining patients in both groups reported not having sexual activity before surgery or declined to answer.
The Lichtenstein technique was associated with new pain in 14 of the 70 patients (20%) while 7 of the 74 patients (9%) in the Onstep group reported new pain after surgery.
“For patients who experienced pain during sexual activity preoperatively, the Onstep technique removed the pain during sexual activity in the majority of patients while still resulting in few new cases,” the authors wrote.
Among the Lichtenstein group, 20 patients experienced pain from the surgical scar, compared with 7 patients in the Onstep group.
When asked about the degree of impairment of sexual function because of the postoperative pain, four patients in the Lichtenstein group said they had moderate to severe impairment, but none in the Onstep group reported that level of impairment.
Commenting on the possible mechanisms that might result in pain during sexual activity after hernia repair, the authors noted that mesh has been found to shrink from a mass around the vas deferens after a Lichtenstein repair. Previous studies have also found sutures around the iliohypogastric and the ilioinguinal nerves, which could also result in some pain.
“Because the mesh in the Onstep technique is not fixed with sutures, the risk of capturing nerves during the fixation of mesh is nonexistent,” they wrote. “There could, however, still be a risk of scar tissue and mesh shrinkage.”
PolySoft mesh (Bard Davol) was used for the Lichtenstein group and SoftMesh (Bard Davol) was used for the Onstep group.
In the 6 months’ follow-up period, two patients in the Lichtenstein group and one patient in the Onstep group experienced a recurrence of their hernia.
Three authors reported personal fees and travel grants from private industry – including Bard Medical – outside the submitted work. No other conflicts of interest were declared.
The Onstep technique for inguinal hernia repair is associated with a lower incidence of postoperative pain during sexual activity than the Lichtenstein surgical technique, according to a paper published online in Surgery.
This study was a part of the Onli trial, the objective of which was to evaluate chronic pain and sexual dysfunction after inguinal hernia repair involving mesh fixation with sutures (Lichtenstein), compared with no mesh fixation (Onstep). The investigators reported the findings of a large study: 20.8% of inguinal repair patients experienced pain during sexual activity 1.4-1.7 years after their operation (Pain. 2006;122:258-63).
“The Onstep technique could be considered when surgeons and patients are discussing the optimal technique for repair of an inguinal hernia,” wrote Kristoffer Andresen, MD, of the University of Copenhagen, and his coauthors. “If the patient has pain during sexual activity as part of the complaint from the hernia, the Onstep technique seems to have a greater chance of removing this pain and alleviating the complaints.”
Among the 17 patients in the Onstep group who experienced postoperative pain during sexual activity, 8 had experienced preoperative pain during sexual activity and 7 had not. In the Lichtenstein group, 14 of the 30 patients who experienced postoperative pain had experienced preoperative pain, 14 had not. The remaining patients in both groups reported not having sexual activity before surgery or declined to answer.
The Lichtenstein technique was associated with new pain in 14 of the 70 patients (20%) while 7 of the 74 patients (9%) in the Onstep group reported new pain after surgery.
“For patients who experienced pain during sexual activity preoperatively, the Onstep technique removed the pain during sexual activity in the majority of patients while still resulting in few new cases,” the authors wrote.
Among the Lichtenstein group, 20 patients experienced pain from the surgical scar, compared with 7 patients in the Onstep group.
When asked about the degree of impairment of sexual function because of the postoperative pain, four patients in the Lichtenstein group said they had moderate to severe impairment, but none in the Onstep group reported that level of impairment.
Commenting on the possible mechanisms that might result in pain during sexual activity after hernia repair, the authors noted that mesh has been found to shrink from a mass around the vas deferens after a Lichtenstein repair. Previous studies have also found sutures around the iliohypogastric and the ilioinguinal nerves, which could also result in some pain.
“Because the mesh in the Onstep technique is not fixed with sutures, the risk of capturing nerves during the fixation of mesh is nonexistent,” they wrote. “There could, however, still be a risk of scar tissue and mesh shrinkage.”
PolySoft mesh (Bard Davol) was used for the Lichtenstein group and SoftMesh (Bard Davol) was used for the Onstep group.
In the 6 months’ follow-up period, two patients in the Lichtenstein group and one patient in the Onstep group experienced a recurrence of their hernia.
Three authors reported personal fees and travel grants from private industry – including Bard Medical – outside the submitted work. No other conflicts of interest were declared.
The Onstep technique for inguinal hernia repair is associated with a lower incidence of postoperative pain during sexual activity than the Lichtenstein surgical technique, according to a paper published online in Surgery.
This study was a part of the Onli trial, the objective of which was to evaluate chronic pain and sexual dysfunction after inguinal hernia repair involving mesh fixation with sutures (Lichtenstein), compared with no mesh fixation (Onstep). The investigators reported the findings of a large study: 20.8% of inguinal repair patients experienced pain during sexual activity 1.4-1.7 years after their operation (Pain. 2006;122:258-63).
“The Onstep technique could be considered when surgeons and patients are discussing the optimal technique for repair of an inguinal hernia,” wrote Kristoffer Andresen, MD, of the University of Copenhagen, and his coauthors. “If the patient has pain during sexual activity as part of the complaint from the hernia, the Onstep technique seems to have a greater chance of removing this pain and alleviating the complaints.”
Among the 17 patients in the Onstep group who experienced postoperative pain during sexual activity, 8 had experienced preoperative pain during sexual activity and 7 had not. In the Lichtenstein group, 14 of the 30 patients who experienced postoperative pain had experienced preoperative pain, 14 had not. The remaining patients in both groups reported not having sexual activity before surgery or declined to answer.
The Lichtenstein technique was associated with new pain in 14 of the 70 patients (20%) while 7 of the 74 patients (9%) in the Onstep group reported new pain after surgery.
“For patients who experienced pain during sexual activity preoperatively, the Onstep technique removed the pain during sexual activity in the majority of patients while still resulting in few new cases,” the authors wrote.
Among the Lichtenstein group, 20 patients experienced pain from the surgical scar, compared with 7 patients in the Onstep group.
When asked about the degree of impairment of sexual function because of the postoperative pain, four patients in the Lichtenstein group said they had moderate to severe impairment, but none in the Onstep group reported that level of impairment.
Commenting on the possible mechanisms that might result in pain during sexual activity after hernia repair, the authors noted that mesh has been found to shrink from a mass around the vas deferens after a Lichtenstein repair. Previous studies have also found sutures around the iliohypogastric and the ilioinguinal nerves, which could also result in some pain.
“Because the mesh in the Onstep technique is not fixed with sutures, the risk of capturing nerves during the fixation of mesh is nonexistent,” they wrote. “There could, however, still be a risk of scar tissue and mesh shrinkage.”
PolySoft mesh (Bard Davol) was used for the Lichtenstein group and SoftMesh (Bard Davol) was used for the Onstep group.
In the 6 months’ follow-up period, two patients in the Lichtenstein group and one patient in the Onstep group experienced a recurrence of their hernia.
Three authors reported personal fees and travel grants from private industry – including Bard Medical – outside the submitted work. No other conflicts of interest were declared.
FROM SURGERY
Key clinical point: The Onstep technique for inguinal hernia repair is associated with a lower incidence of pain during sexual activity than the Lichtenstein technique.
Major finding: The Lichtenstein technique was associated with new pain in 14 of the 70 patients (20%) while 7 of the 74 patients (9%) in the Onstep group reported new pain after surgery.
Data source: A randomized trial in 259 patients undergoing inguinal hernia repair.
Disclosures: Three authors reported personal fees and travel grants from private industry – including Bard Medical – outside the submitted work. No other conflicts of interest were declared.
OpenNotes: Patient engagement with low physician hassle
ORLANDO – Early evidence suggests that OpenNotes is helping to engage patients and improve health outcomes while not creating undue burden for physicians.
A 2010 pilot project at Beth Israel Deaconess Medical Center in Boston, Geisinger Health System in Pennsylvania, and Harborview Medical Center in Seattle tested OpenNotes, a program that allows patients to see the entirety of a physician’s notes within their medical record and not just a summarized version.
Homer Chin, MD, of the department of medical informatics and outcomes research at Oregon Health & Science University, Portland, an associate with the OpenNotes Program, and physician champion for the Northwest OpenNotes Consortium, noted that a survey of the 105 primary care physicians participating in the pilot revealed they were apprehensive when they heard their visit notes would be completely available to patients.
Prior to the launch of the pilot, 24% of physicians expected significantly longer visits because of the availability of OpenNotes, 42% said they expected to spend more time addressing patient questions outside of visits, and 39% said they expected to spend more time writing/editing/dictating notes, Dr. Chin said at the annual meeting of the Healthcare Information and Management Systems Society.
Their concerns never quite materialized.
According to a survey of the participating physicians after the yearlong pilot, only 2% reported visits took significantly longer, 3% said they spent more time addressing patient questions outside of visits, and 11% said they spent more time writing/editing/dictating notes.
With regard to writing notes, “what we are finding is that most physicians are saying they are changing the way they write the note a little bit, but it is not taking more time,” Dr. Chin said. “They are just watching for certain terms and writing them in a different way, but it is not necessarily taking more time.”
More than 70% of patients who participated in the trial reported they are taking better care of themselves, more than 77% said they have a better understanding of their medical condition, more than 69% said they are better prepared for visits and more than 60% said they are more adherent to their prescription medication regimens.
Importantly, 85% said the availability of OpenNotes would affect their future choice of providers.
Dr. Chin also discussed the results of a survey of patients using OpenNotes in the Virginia Commonwealth University Health System in Richmond, noting that of roughly 420 respondents, 70% said their contact with their providers did not change, with nearly 20% saying they were contacting their provider less. Just over 40% said that reading their notes made them less worried about something health related, while a little more than 50% said there was no change. Nearly 85% said they thought seeing the notes helped them take better care of themselves. Nearly 90% of patients said that they understood some or all of their doctors’ notes.
It has been incredibly valuable “when the patients use the portal to prepare themselves for the visit with the provider,” Mr. Kravitz said. “They will review their case. They’ll look at past x-rays or reports, any kind of information, the results for laboratory and anything else, but they will message their provider. They are very heavy into messaging. It’s secure messaging within the portal and any type of questions, especially after they’ve had an appointment, they’ve thought of something they didn’t think about in the appointment, they have the opportunity to message back to the provider’s office.”
Geisinger saw 620,000 encounter reviews in OpenNotes out of 2 million patient visits in its last fiscal year, with virtually no complaints about the information in the OpenNotes.
Dr. Chin stressed that the implemented OpenNotes needs to be driven by physicians.
“I would emphasize that this has to be a clinician operational leader supported effort, and not an IT effort, so that when clinicians complain, you can point them to their department head, the chief medical officer, and not the IT people,” he said. “You’ve got to have good communication to providers. Our advice is to start with one department. You might do a pilot for a very short period of time, but there is enough evidence now to really implement it throughout the organization. We encourage people not to allow individual providers to opt out on their own, to make their own decision to opt out, to do it as an organizational effort.”
Michael Day, chief information officer of Ascension Health and Columbia St. Mary’s Health System of Milwaukee, offered the same advice.
“You’ve got to have leadership commitment up front,” Mr. Day said. “This really has to have good, strong physician leadership. The key executive in charge of all of this was the president of our medical group which drove a lot of the change with a lot of support from other areas.”
He noted that at his organization there was “a lot of physician grumbling” when OpenNotes was announced. However, there has been “relatively no impact. I think they’ve all agreed that this has made care better. We’ve also seen an actual improvement in the quality of the documentation.”
None of the presenters reported any conflicts of interest.
ORLANDO – Early evidence suggests that OpenNotes is helping to engage patients and improve health outcomes while not creating undue burden for physicians.
A 2010 pilot project at Beth Israel Deaconess Medical Center in Boston, Geisinger Health System in Pennsylvania, and Harborview Medical Center in Seattle tested OpenNotes, a program that allows patients to see the entirety of a physician’s notes within their medical record and not just a summarized version.
Homer Chin, MD, of the department of medical informatics and outcomes research at Oregon Health & Science University, Portland, an associate with the OpenNotes Program, and physician champion for the Northwest OpenNotes Consortium, noted that a survey of the 105 primary care physicians participating in the pilot revealed they were apprehensive when they heard their visit notes would be completely available to patients.
Prior to the launch of the pilot, 24% of physicians expected significantly longer visits because of the availability of OpenNotes, 42% said they expected to spend more time addressing patient questions outside of visits, and 39% said they expected to spend more time writing/editing/dictating notes, Dr. Chin said at the annual meeting of the Healthcare Information and Management Systems Society.
Their concerns never quite materialized.
According to a survey of the participating physicians after the yearlong pilot, only 2% reported visits took significantly longer, 3% said they spent more time addressing patient questions outside of visits, and 11% said they spent more time writing/editing/dictating notes.
With regard to writing notes, “what we are finding is that most physicians are saying they are changing the way they write the note a little bit, but it is not taking more time,” Dr. Chin said. “They are just watching for certain terms and writing them in a different way, but it is not necessarily taking more time.”
More than 70% of patients who participated in the trial reported they are taking better care of themselves, more than 77% said they have a better understanding of their medical condition, more than 69% said they are better prepared for visits and more than 60% said they are more adherent to their prescription medication regimens.
Importantly, 85% said the availability of OpenNotes would affect their future choice of providers.
Dr. Chin also discussed the results of a survey of patients using OpenNotes in the Virginia Commonwealth University Health System in Richmond, noting that of roughly 420 respondents, 70% said their contact with their providers did not change, with nearly 20% saying they were contacting their provider less. Just over 40% said that reading their notes made them less worried about something health related, while a little more than 50% said there was no change. Nearly 85% said they thought seeing the notes helped them take better care of themselves. Nearly 90% of patients said that they understood some or all of their doctors’ notes.
It has been incredibly valuable “when the patients use the portal to prepare themselves for the visit with the provider,” Mr. Kravitz said. “They will review their case. They’ll look at past x-rays or reports, any kind of information, the results for laboratory and anything else, but they will message their provider. They are very heavy into messaging. It’s secure messaging within the portal and any type of questions, especially after they’ve had an appointment, they’ve thought of something they didn’t think about in the appointment, they have the opportunity to message back to the provider’s office.”
Geisinger saw 620,000 encounter reviews in OpenNotes out of 2 million patient visits in its last fiscal year, with virtually no complaints about the information in the OpenNotes.
Dr. Chin stressed that the implemented OpenNotes needs to be driven by physicians.
“I would emphasize that this has to be a clinician operational leader supported effort, and not an IT effort, so that when clinicians complain, you can point them to their department head, the chief medical officer, and not the IT people,” he said. “You’ve got to have good communication to providers. Our advice is to start with one department. You might do a pilot for a very short period of time, but there is enough evidence now to really implement it throughout the organization. We encourage people not to allow individual providers to opt out on their own, to make their own decision to opt out, to do it as an organizational effort.”
Michael Day, chief information officer of Ascension Health and Columbia St. Mary’s Health System of Milwaukee, offered the same advice.
“You’ve got to have leadership commitment up front,” Mr. Day said. “This really has to have good, strong physician leadership. The key executive in charge of all of this was the president of our medical group which drove a lot of the change with a lot of support from other areas.”
He noted that at his organization there was “a lot of physician grumbling” when OpenNotes was announced. However, there has been “relatively no impact. I think they’ve all agreed that this has made care better. We’ve also seen an actual improvement in the quality of the documentation.”
None of the presenters reported any conflicts of interest.
ORLANDO – Early evidence suggests that OpenNotes is helping to engage patients and improve health outcomes while not creating undue burden for physicians.
A 2010 pilot project at Beth Israel Deaconess Medical Center in Boston, Geisinger Health System in Pennsylvania, and Harborview Medical Center in Seattle tested OpenNotes, a program that allows patients to see the entirety of a physician’s notes within their medical record and not just a summarized version.
Homer Chin, MD, of the department of medical informatics and outcomes research at Oregon Health & Science University, Portland, an associate with the OpenNotes Program, and physician champion for the Northwest OpenNotes Consortium, noted that a survey of the 105 primary care physicians participating in the pilot revealed they were apprehensive when they heard their visit notes would be completely available to patients.
Prior to the launch of the pilot, 24% of physicians expected significantly longer visits because of the availability of OpenNotes, 42% said they expected to spend more time addressing patient questions outside of visits, and 39% said they expected to spend more time writing/editing/dictating notes, Dr. Chin said at the annual meeting of the Healthcare Information and Management Systems Society.
Their concerns never quite materialized.
According to a survey of the participating physicians after the yearlong pilot, only 2% reported visits took significantly longer, 3% said they spent more time addressing patient questions outside of visits, and 11% said they spent more time writing/editing/dictating notes.
With regard to writing notes, “what we are finding is that most physicians are saying they are changing the way they write the note a little bit, but it is not taking more time,” Dr. Chin said. “They are just watching for certain terms and writing them in a different way, but it is not necessarily taking more time.”
More than 70% of patients who participated in the trial reported they are taking better care of themselves, more than 77% said they have a better understanding of their medical condition, more than 69% said they are better prepared for visits and more than 60% said they are more adherent to their prescription medication regimens.
Importantly, 85% said the availability of OpenNotes would affect their future choice of providers.
Dr. Chin also discussed the results of a survey of patients using OpenNotes in the Virginia Commonwealth University Health System in Richmond, noting that of roughly 420 respondents, 70% said their contact with their providers did not change, with nearly 20% saying they were contacting their provider less. Just over 40% said that reading their notes made them less worried about something health related, while a little more than 50% said there was no change. Nearly 85% said they thought seeing the notes helped them take better care of themselves. Nearly 90% of patients said that they understood some or all of their doctors’ notes.
It has been incredibly valuable “when the patients use the portal to prepare themselves for the visit with the provider,” Mr. Kravitz said. “They will review their case. They’ll look at past x-rays or reports, any kind of information, the results for laboratory and anything else, but they will message their provider. They are very heavy into messaging. It’s secure messaging within the portal and any type of questions, especially after they’ve had an appointment, they’ve thought of something they didn’t think about in the appointment, they have the opportunity to message back to the provider’s office.”
Geisinger saw 620,000 encounter reviews in OpenNotes out of 2 million patient visits in its last fiscal year, with virtually no complaints about the information in the OpenNotes.
Dr. Chin stressed that the implemented OpenNotes needs to be driven by physicians.
“I would emphasize that this has to be a clinician operational leader supported effort, and not an IT effort, so that when clinicians complain, you can point them to their department head, the chief medical officer, and not the IT people,” he said. “You’ve got to have good communication to providers. Our advice is to start with one department. You might do a pilot for a very short period of time, but there is enough evidence now to really implement it throughout the organization. We encourage people not to allow individual providers to opt out on their own, to make their own decision to opt out, to do it as an organizational effort.”
Michael Day, chief information officer of Ascension Health and Columbia St. Mary’s Health System of Milwaukee, offered the same advice.
“You’ve got to have leadership commitment up front,” Mr. Day said. “This really has to have good, strong physician leadership. The key executive in charge of all of this was the president of our medical group which drove a lot of the change with a lot of support from other areas.”
He noted that at his organization there was “a lot of physician grumbling” when OpenNotes was announced. However, there has been “relatively no impact. I think they’ve all agreed that this has made care better. We’ve also seen an actual improvement in the quality of the documentation.”
None of the presenters reported any conflicts of interest.
AT HIMSS 2017
VIDEO: Pain and impaired QOL persist after open endometrial cancer surgery
NATIONAL HARBOR, MD. – Patient-reported outcomes from a prospective cohort study of minimally invasive versus open surgery for women with endometrial cancer showed that the disability from open surgery persisted for longer than had previously been recognized. Further, for a subset of patients, impairment in sexual functioning was significant, and persistent, regardless of the type of surgery.
At 3 weeks after surgery, patients who had open surgery had greater pain as measured by the Brief Pain Inventory (minimally important difference greater than 1, P = .0004). By 3 months post surgery, responses on the Functional Assessment of Cancer Therapy–General were still significantly lower for the open-surgery group, compared with the minimally invasive group (P = .0011).
Although patients’ pain and overall state of health were better at 3 weeks post surgery, regardless of whether women had open, laparoscopic, or robotic surgery, the reduced overall quality of life experienced by patients who had open surgery persisted.
“What was a bit different from other studies … is that we found that this is maintained even at 3 months, and it was clinically and statistically different,” Sarah Ferguson, MD, said in a video interview at the annual meeting of the Society of Gynecologic Oncology. “So that was really, I think, an interesting finding, that this doesn’t just impact the very short term. Three months is a fairly long time after a primary surgery, and [it’s] important for women to know this.”
The video associated with this article is no longer available on this site. Please view all of our videos on the MDedge YouTube channel
Patients in the eight-center study had histologically confirmed clinical stage I or II endometrial cancer. The open-surgery arm of the study involved 106 patients, and 414 had minimally invasive surgery (168 laparascopic, 246 robotic).
The robotic and laparoscopic arms showed no statistically significant differences for any patient-reported outcome, even after adjusting for potentially confounding variables, said Dr. Ferguson of Princess Margaret Cancer Centre at the University of Toronto. Accordingly, investigators compared both minimally invasive arms grouped together against open surgery.
Overall, about 80% of patients completed the quality-of-life questionnaires. The response rate for the sexual-functioning questionnaires, however, was much lower, ranging from about a quarter to a half of the participants.
When Dr. Ferguson and her colleagues examined the characteristics of the patients who did complete the sexual-functioning questionnaires, they found that these women were more likely to be younger, partnered, premenopausal and sexually active at the time of diagnosis. Both of the surgical groups “met the clinical cutoff for sexual dysfunction” on the Female Sexual Function Index questionnaire, she said.
For the sexual function questionnaires, differences between the open and minimally invasive groups were not significant at any time point throughout the 26 weeks that patients were studied. “Though it’s a small population, I think these results are important,” said Dr. Ferguson. “These variables may be helpful for us to target patients in our practice, or in future studies, who require intervention.”
Though the study was not randomized, Dr. Ferguson said that the baseline characteristics were similar between groups, and the investigators’ intention-to-treat analysis used a statistical model that adjusted for many potential confounding variables.
Dr. Ferguson reported having no conflicts of interest.
[email protected]
On Twitter @karioakes
NATIONAL HARBOR, MD. – Patient-reported outcomes from a prospective cohort study of minimally invasive versus open surgery for women with endometrial cancer showed that the disability from open surgery persisted for longer than had previously been recognized. Further, for a subset of patients, impairment in sexual functioning was significant, and persistent, regardless of the type of surgery.
At 3 weeks after surgery, patients who had open surgery had greater pain as measured by the Brief Pain Inventory (minimally important difference greater than 1, P = .0004). By 3 months post surgery, responses on the Functional Assessment of Cancer Therapy–General were still significantly lower for the open-surgery group, compared with the minimally invasive group (P = .0011).
Although patients’ pain and overall state of health were better at 3 weeks post surgery, regardless of whether women had open, laparoscopic, or robotic surgery, the reduced overall quality of life experienced by patients who had open surgery persisted.
“What was a bit different from other studies … is that we found that this is maintained even at 3 months, and it was clinically and statistically different,” Sarah Ferguson, MD, said in a video interview at the annual meeting of the Society of Gynecologic Oncology. “So that was really, I think, an interesting finding, that this doesn’t just impact the very short term. Three months is a fairly long time after a primary surgery, and [it’s] important for women to know this.”
The video associated with this article is no longer available on this site. Please view all of our videos on the MDedge YouTube channel
Patients in the eight-center study had histologically confirmed clinical stage I or II endometrial cancer. The open-surgery arm of the study involved 106 patients, and 414 had minimally invasive surgery (168 laparascopic, 246 robotic).
The robotic and laparoscopic arms showed no statistically significant differences for any patient-reported outcome, even after adjusting for potentially confounding variables, said Dr. Ferguson of Princess Margaret Cancer Centre at the University of Toronto. Accordingly, investigators compared both minimally invasive arms grouped together against open surgery.
Overall, about 80% of patients completed the quality-of-life questionnaires. The response rate for the sexual-functioning questionnaires, however, was much lower, ranging from about a quarter to a half of the participants.
When Dr. Ferguson and her colleagues examined the characteristics of the patients who did complete the sexual-functioning questionnaires, they found that these women were more likely to be younger, partnered, premenopausal and sexually active at the time of diagnosis. Both of the surgical groups “met the clinical cutoff for sexual dysfunction” on the Female Sexual Function Index questionnaire, she said.
For the sexual function questionnaires, differences between the open and minimally invasive groups were not significant at any time point throughout the 26 weeks that patients were studied. “Though it’s a small population, I think these results are important,” said Dr. Ferguson. “These variables may be helpful for us to target patients in our practice, or in future studies, who require intervention.”
Though the study was not randomized, Dr. Ferguson said that the baseline characteristics were similar between groups, and the investigators’ intention-to-treat analysis used a statistical model that adjusted for many potential confounding variables.
Dr. Ferguson reported having no conflicts of interest.
[email protected]
On Twitter @karioakes
NATIONAL HARBOR, MD. – Patient-reported outcomes from a prospective cohort study of minimally invasive versus open surgery for women with endometrial cancer showed that the disability from open surgery persisted for longer than had previously been recognized. Further, for a subset of patients, impairment in sexual functioning was significant, and persistent, regardless of the type of surgery.
At 3 weeks after surgery, patients who had open surgery had greater pain as measured by the Brief Pain Inventory (minimally important difference greater than 1, P = .0004). By 3 months post surgery, responses on the Functional Assessment of Cancer Therapy–General were still significantly lower for the open-surgery group, compared with the minimally invasive group (P = .0011).
Although patients’ pain and overall state of health were better at 3 weeks post surgery, regardless of whether women had open, laparoscopic, or robotic surgery, the reduced overall quality of life experienced by patients who had open surgery persisted.
“What was a bit different from other studies … is that we found that this is maintained even at 3 months, and it was clinically and statistically different,” Sarah Ferguson, MD, said in a video interview at the annual meeting of the Society of Gynecologic Oncology. “So that was really, I think, an interesting finding, that this doesn’t just impact the very short term. Three months is a fairly long time after a primary surgery, and [it’s] important for women to know this.”
The video associated with this article is no longer available on this site. Please view all of our videos on the MDedge YouTube channel
Patients in the eight-center study had histologically confirmed clinical stage I or II endometrial cancer. The open-surgery arm of the study involved 106 patients, and 414 had minimally invasive surgery (168 laparascopic, 246 robotic).
The robotic and laparoscopic arms showed no statistically significant differences for any patient-reported outcome, even after adjusting for potentially confounding variables, said Dr. Ferguson of Princess Margaret Cancer Centre at the University of Toronto. Accordingly, investigators compared both minimally invasive arms grouped together against open surgery.
Overall, about 80% of patients completed the quality-of-life questionnaires. The response rate for the sexual-functioning questionnaires, however, was much lower, ranging from about a quarter to a half of the participants.
When Dr. Ferguson and her colleagues examined the characteristics of the patients who did complete the sexual-functioning questionnaires, they found that these women were more likely to be younger, partnered, premenopausal and sexually active at the time of diagnosis. Both of the surgical groups “met the clinical cutoff for sexual dysfunction” on the Female Sexual Function Index questionnaire, she said.
For the sexual function questionnaires, differences between the open and minimally invasive groups were not significant at any time point throughout the 26 weeks that patients were studied. “Though it’s a small population, I think these results are important,” said Dr. Ferguson. “These variables may be helpful for us to target patients in our practice, or in future studies, who require intervention.”
Though the study was not randomized, Dr. Ferguson said that the baseline characteristics were similar between groups, and the investigators’ intention-to-treat analysis used a statistical model that adjusted for many potential confounding variables.
Dr. Ferguson reported having no conflicts of interest.
[email protected]
On Twitter @karioakes
AT THE ANNUAL MEETING ON WOMEN'S CANCER
Match Day: Surgery positions up, other specialties grew more
Despite a record number of applicants and slots filled for first-year residents on the 2017 Match Day, growth in all surgery positions continued to be outpaced by growth in other specialties.
“While it is encouraging to see that the number of categorical surgery positions offered has increased by 101 since 2013, representing an increase of 8.6%, over the same period, the number of positions offered in emergency medicine and family medicine positions have each increased by over 300, representing increases of 17.4% and 11.5%, respectively, and the number of internal medicine positions has increased by over 900, representing an increase of 15.2%,” Patrick Bailey, MD, FACS, medical director of advocacy for the Division of Advocacy and Health Policy at the American College of Surgeons. “The fact that over 35,969 applicants submitted program choices and only 27,688 matched into a PGY-1 position is yet another indication of the need to expand the number of graduate medical education positions available,” he added.
And while more positions may be needed, the number of categorical surgery positions that went unfilled remained low, with only 5 of 1,281 slots remaining unfilled at the conclusion of Match Day 2017, according to the data released by the National Resident Match Program (NRMP).
“This result is consistent with those since 2013 during which time the number of unfilled positions has varied between two and seven positions, e.g., 99.4%-99.8% of categorical surgery positions offered were filled,” Dr. Bailey said.
Still, the ACS is advocating for further changes to the resident matching program to help build the future workforce. “The ACS believes broad reforms in the way graduate medical education is funded and administered are necessary and overdue to ensure that our nation is able to produce the physician workforce capable of meeting the needs of the U.S. population,” he said. To that end, the ACS produced a policy paper that outlined a series of steps relative to reform for which it is advocating.
Broadly, those reforms include the collection of actionable and accurate health care workforce data, maintenance of current GME funding levels with the appropriation of temporary additional funds to modernize the system, the combination of the current GME funding streams into a single stream of funds, and the consideration of a regionalized governance system.
Overall, this is the fifth straight year the NRMP has reported growth in applicants, up 1.4% from the previous year, and applicants matched, to PGY-1 positions up 3.2% from 2016.
One factor driving the increase is the “all-in” policy that required programs registering for the Match to offer all their available positions in the Match or another national matching program. The policy, which began with the 2013 Match, has resulted in significant increases for internal medicine, family medicine, and pediatrics.
Internal medicine residency programs offered 7,233 programs, accounting for about 25% of all PGY-1 positions. This was up from 7,024 programs offered last year. U.S. seniors accounted for 44.9% of the 7,101 slots filled, a rate that was slightly lower than the 46.9% of slots filled by U.S. medical school graduates in 2016.
A record-high 18,539 allopathic medical school seniors submitted program choices and 17,480 (94.3%) were matched to first-year resident programs, a rate that has been consistent for a number of years according to NRMP data.
Of the 1,279 unfilled slots, 1,177 were offered in the Match Week Supplemental Offer and Acceptance Program, the results of which will be available in May.
One trend that stood out for NRMP President and CEO Mona Signer was the decline in both U.S.- and non–U.S.-citizen international medical school graduates (IMGs) who submitted program choices.
“I was surprised that the number of U.S.-citizen and non–U.S.-citizen IMGs declined this year, but on the other hand, the good news is their match rates went up,” Ms. Signer said in an interview.
U.S.-citizen IMGs declined by 254 to 5,069, but 54.8% were matched to first-year residency positions, the highest match rate since 2004. The number of non–U.S.-citizen IMGs declined by 176 to 7,284, but 52.4% were matched to first-year positions, the highest match rate since 2005.
Ms. Signer declined to speculate what caused the decline, noting that NRMP does not collect demographic data.
Despite a record number of applicants and slots filled for first-year residents on the 2017 Match Day, growth in all surgery positions continued to be outpaced by growth in other specialties.
“While it is encouraging to see that the number of categorical surgery positions offered has increased by 101 since 2013, representing an increase of 8.6%, over the same period, the number of positions offered in emergency medicine and family medicine positions have each increased by over 300, representing increases of 17.4% and 11.5%, respectively, and the number of internal medicine positions has increased by over 900, representing an increase of 15.2%,” Patrick Bailey, MD, FACS, medical director of advocacy for the Division of Advocacy and Health Policy at the American College of Surgeons. “The fact that over 35,969 applicants submitted program choices and only 27,688 matched into a PGY-1 position is yet another indication of the need to expand the number of graduate medical education positions available,” he added.
And while more positions may be needed, the number of categorical surgery positions that went unfilled remained low, with only 5 of 1,281 slots remaining unfilled at the conclusion of Match Day 2017, according to the data released by the National Resident Match Program (NRMP).
“This result is consistent with those since 2013 during which time the number of unfilled positions has varied between two and seven positions, e.g., 99.4%-99.8% of categorical surgery positions offered were filled,” Dr. Bailey said.
Still, the ACS is advocating for further changes to the resident matching program to help build the future workforce. “The ACS believes broad reforms in the way graduate medical education is funded and administered are necessary and overdue to ensure that our nation is able to produce the physician workforce capable of meeting the needs of the U.S. population,” he said. To that end, the ACS produced a policy paper that outlined a series of steps relative to reform for which it is advocating.
Broadly, those reforms include the collection of actionable and accurate health care workforce data, maintenance of current GME funding levels with the appropriation of temporary additional funds to modernize the system, the combination of the current GME funding streams into a single stream of funds, and the consideration of a regionalized governance system.
Overall, this is the fifth straight year the NRMP has reported growth in applicants, up 1.4% from the previous year, and applicants matched, to PGY-1 positions up 3.2% from 2016.
One factor driving the increase is the “all-in” policy that required programs registering for the Match to offer all their available positions in the Match or another national matching program. The policy, which began with the 2013 Match, has resulted in significant increases for internal medicine, family medicine, and pediatrics.
Internal medicine residency programs offered 7,233 programs, accounting for about 25% of all PGY-1 positions. This was up from 7,024 programs offered last year. U.S. seniors accounted for 44.9% of the 7,101 slots filled, a rate that was slightly lower than the 46.9% of slots filled by U.S. medical school graduates in 2016.
A record-high 18,539 allopathic medical school seniors submitted program choices and 17,480 (94.3%) were matched to first-year resident programs, a rate that has been consistent for a number of years according to NRMP data.
Of the 1,279 unfilled slots, 1,177 were offered in the Match Week Supplemental Offer and Acceptance Program, the results of which will be available in May.
One trend that stood out for NRMP President and CEO Mona Signer was the decline in both U.S.- and non–U.S.-citizen international medical school graduates (IMGs) who submitted program choices.
“I was surprised that the number of U.S.-citizen and non–U.S.-citizen IMGs declined this year, but on the other hand, the good news is their match rates went up,” Ms. Signer said in an interview.
U.S.-citizen IMGs declined by 254 to 5,069, but 54.8% were matched to first-year residency positions, the highest match rate since 2004. The number of non–U.S.-citizen IMGs declined by 176 to 7,284, but 52.4% were matched to first-year positions, the highest match rate since 2005.
Ms. Signer declined to speculate what caused the decline, noting that NRMP does not collect demographic data.
Despite a record number of applicants and slots filled for first-year residents on the 2017 Match Day, growth in all surgery positions continued to be outpaced by growth in other specialties.
“While it is encouraging to see that the number of categorical surgery positions offered has increased by 101 since 2013, representing an increase of 8.6%, over the same period, the number of positions offered in emergency medicine and family medicine positions have each increased by over 300, representing increases of 17.4% and 11.5%, respectively, and the number of internal medicine positions has increased by over 900, representing an increase of 15.2%,” Patrick Bailey, MD, FACS, medical director of advocacy for the Division of Advocacy and Health Policy at the American College of Surgeons. “The fact that over 35,969 applicants submitted program choices and only 27,688 matched into a PGY-1 position is yet another indication of the need to expand the number of graduate medical education positions available,” he added.
And while more positions may be needed, the number of categorical surgery positions that went unfilled remained low, with only 5 of 1,281 slots remaining unfilled at the conclusion of Match Day 2017, according to the data released by the National Resident Match Program (NRMP).
“This result is consistent with those since 2013 during which time the number of unfilled positions has varied between two and seven positions, e.g., 99.4%-99.8% of categorical surgery positions offered were filled,” Dr. Bailey said.
Still, the ACS is advocating for further changes to the resident matching program to help build the future workforce. “The ACS believes broad reforms in the way graduate medical education is funded and administered are necessary and overdue to ensure that our nation is able to produce the physician workforce capable of meeting the needs of the U.S. population,” he said. To that end, the ACS produced a policy paper that outlined a series of steps relative to reform for which it is advocating.
Broadly, those reforms include the collection of actionable and accurate health care workforce data, maintenance of current GME funding levels with the appropriation of temporary additional funds to modernize the system, the combination of the current GME funding streams into a single stream of funds, and the consideration of a regionalized governance system.
Overall, this is the fifth straight year the NRMP has reported growth in applicants, up 1.4% from the previous year, and applicants matched, to PGY-1 positions up 3.2% from 2016.
One factor driving the increase is the “all-in” policy that required programs registering for the Match to offer all their available positions in the Match or another national matching program. The policy, which began with the 2013 Match, has resulted in significant increases for internal medicine, family medicine, and pediatrics.
Internal medicine residency programs offered 7,233 programs, accounting for about 25% of all PGY-1 positions. This was up from 7,024 programs offered last year. U.S. seniors accounted for 44.9% of the 7,101 slots filled, a rate that was slightly lower than the 46.9% of slots filled by U.S. medical school graduates in 2016.
A record-high 18,539 allopathic medical school seniors submitted program choices and 17,480 (94.3%) were matched to first-year resident programs, a rate that has been consistent for a number of years according to NRMP data.
Of the 1,279 unfilled slots, 1,177 were offered in the Match Week Supplemental Offer and Acceptance Program, the results of which will be available in May.
One trend that stood out for NRMP President and CEO Mona Signer was the decline in both U.S.- and non–U.S.-citizen international medical school graduates (IMGs) who submitted program choices.
“I was surprised that the number of U.S.-citizen and non–U.S.-citizen IMGs declined this year, but on the other hand, the good news is their match rates went up,” Ms. Signer said in an interview.
U.S.-citizen IMGs declined by 254 to 5,069, but 54.8% were matched to first-year residency positions, the highest match rate since 2004. The number of non–U.S.-citizen IMGs declined by 176 to 7,284, but 52.4% were matched to first-year positions, the highest match rate since 2005.
Ms. Signer declined to speculate what caused the decline, noting that NRMP does not collect demographic data.