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Official Newspaper of the American College of Surgeons
Tertiary center repeat CT scans find additional trauma injuries
HOLLYWOOD, FLA. – Imaging obtained at nontertiary trauma centers probably doesn’t tell the whole story of a trauma patent’s injuries, according to a new retrospective study.
Repeat scans done at a Level 1 trauma center identified new injuries in 76% of patients who were transferred, Morgan Bonds, MD, reported at the annual scientific assembly of the Eastern Association for the Surgery of Trauma. About half of these previously unobserved injuries were considered clinically significant, said Dr. Bonds, a surgical resident at the University of Oklahoma, Oklahoma City.
Her study examined imaging and clinical assessment of 203 trauma patients who were initially worked up at a nontertiary trauma center (NTC), and then transferred to the Level 1 University of Oklahoma tertiary trauma Center (TTC). The facility’s primary radiologist reviewed all of the initial CT scans while blinded to the NTC interpretation. The initial scans and interpretations were then compared with those done at the TTC.
The team split imaging and interpretation disconnects into four categories:
• Type A errors: A missed injury on the NTC scan. “This represents the expertise and experience of our primary radiologist,” Dr. Bonds said.
• Type B errors: Missed injuries on scans where NTC radiologists saw other injuries that the TTC radiologist did not confirm. “This represents the experience of our radiologist and also the inexperience and overreaction of the NTC radiologists.
• Type C errors: New injuries seen on additional TTC imaging of the same body area. “This represents the quality of the image.”
• Type D errors: New injuries found upon any new imaging, whether of a previously scanned or newly scanned body area. “This represents quality of work-up – the decision of the trauma team to more fully investigate the patient’s injuries, as well as the quality of the CT tech performing the scan.”
During the study period, 203 patients presented at the TTC with prior scans conducted at an NTC.
The mean age of the patients was 43 years; most (67%) were men. The mean Injury Severity Score was 16; 97% had experienced blunt trauma. Shock was present in 3% and a traumatic brain injury in 8%. Repeat scans were most common for neck and cervical spine injuries (54%) and thoracic/lumbar spine injuries (53%) and least common for chest injuries (32%).
An inadequate NTC work-up as judged by the TTC attending was the most common reason for getting new images (76%). Poor image quality was the next most common reason (31%).
Among the 203 patients, 99 (49%) had a type A error. Of these injuries missed on the initial scan, 90% were considered to be clinically significant.
Type B errors occurred in 15% of patients.
Type C errors (new injuries in different body area) occurred in 54% of patients and, of these, 76% were considered clinically significant. Type D errors (new injuries seen in any imaging of any area) occurred in 73% of patients.
“This study confirms that images are often repeated or completed after having images done at nontertiary trauma centers,” Dr. Bonds said. “Relying on NTC image interpretation can lead to undertreating our patients. One potential solution to this issue could be image sharing between NTCs and TTCs. This might reduce both the rate of missed injuries and the need for repeat scans.”
Dr. Bonds had no financial disclosures.
On Twitter @Alz_Gal
HOLLYWOOD, FLA. – Imaging obtained at nontertiary trauma centers probably doesn’t tell the whole story of a trauma patent’s injuries, according to a new retrospective study.
Repeat scans done at a Level 1 trauma center identified new injuries in 76% of patients who were transferred, Morgan Bonds, MD, reported at the annual scientific assembly of the Eastern Association for the Surgery of Trauma. About half of these previously unobserved injuries were considered clinically significant, said Dr. Bonds, a surgical resident at the University of Oklahoma, Oklahoma City.
Her study examined imaging and clinical assessment of 203 trauma patients who were initially worked up at a nontertiary trauma center (NTC), and then transferred to the Level 1 University of Oklahoma tertiary trauma Center (TTC). The facility’s primary radiologist reviewed all of the initial CT scans while blinded to the NTC interpretation. The initial scans and interpretations were then compared with those done at the TTC.
The team split imaging and interpretation disconnects into four categories:
• Type A errors: A missed injury on the NTC scan. “This represents the expertise and experience of our primary radiologist,” Dr. Bonds said.
• Type B errors: Missed injuries on scans where NTC radiologists saw other injuries that the TTC radiologist did not confirm. “This represents the experience of our radiologist and also the inexperience and overreaction of the NTC radiologists.
• Type C errors: New injuries seen on additional TTC imaging of the same body area. “This represents the quality of the image.”
• Type D errors: New injuries found upon any new imaging, whether of a previously scanned or newly scanned body area. “This represents quality of work-up – the decision of the trauma team to more fully investigate the patient’s injuries, as well as the quality of the CT tech performing the scan.”
During the study period, 203 patients presented at the TTC with prior scans conducted at an NTC.
The mean age of the patients was 43 years; most (67%) were men. The mean Injury Severity Score was 16; 97% had experienced blunt trauma. Shock was present in 3% and a traumatic brain injury in 8%. Repeat scans were most common for neck and cervical spine injuries (54%) and thoracic/lumbar spine injuries (53%) and least common for chest injuries (32%).
An inadequate NTC work-up as judged by the TTC attending was the most common reason for getting new images (76%). Poor image quality was the next most common reason (31%).
Among the 203 patients, 99 (49%) had a type A error. Of these injuries missed on the initial scan, 90% were considered to be clinically significant.
Type B errors occurred in 15% of patients.
Type C errors (new injuries in different body area) occurred in 54% of patients and, of these, 76% were considered clinically significant. Type D errors (new injuries seen in any imaging of any area) occurred in 73% of patients.
“This study confirms that images are often repeated or completed after having images done at nontertiary trauma centers,” Dr. Bonds said. “Relying on NTC image interpretation can lead to undertreating our patients. One potential solution to this issue could be image sharing between NTCs and TTCs. This might reduce both the rate of missed injuries and the need for repeat scans.”
Dr. Bonds had no financial disclosures.
On Twitter @Alz_Gal
HOLLYWOOD, FLA. – Imaging obtained at nontertiary trauma centers probably doesn’t tell the whole story of a trauma patent’s injuries, according to a new retrospective study.
Repeat scans done at a Level 1 trauma center identified new injuries in 76% of patients who were transferred, Morgan Bonds, MD, reported at the annual scientific assembly of the Eastern Association for the Surgery of Trauma. About half of these previously unobserved injuries were considered clinically significant, said Dr. Bonds, a surgical resident at the University of Oklahoma, Oklahoma City.
Her study examined imaging and clinical assessment of 203 trauma patients who were initially worked up at a nontertiary trauma center (NTC), and then transferred to the Level 1 University of Oklahoma tertiary trauma Center (TTC). The facility’s primary radiologist reviewed all of the initial CT scans while blinded to the NTC interpretation. The initial scans and interpretations were then compared with those done at the TTC.
The team split imaging and interpretation disconnects into four categories:
• Type A errors: A missed injury on the NTC scan. “This represents the expertise and experience of our primary radiologist,” Dr. Bonds said.
• Type B errors: Missed injuries on scans where NTC radiologists saw other injuries that the TTC radiologist did not confirm. “This represents the experience of our radiologist and also the inexperience and overreaction of the NTC radiologists.
• Type C errors: New injuries seen on additional TTC imaging of the same body area. “This represents the quality of the image.”
• Type D errors: New injuries found upon any new imaging, whether of a previously scanned or newly scanned body area. “This represents quality of work-up – the decision of the trauma team to more fully investigate the patient’s injuries, as well as the quality of the CT tech performing the scan.”
During the study period, 203 patients presented at the TTC with prior scans conducted at an NTC.
The mean age of the patients was 43 years; most (67%) were men. The mean Injury Severity Score was 16; 97% had experienced blunt trauma. Shock was present in 3% and a traumatic brain injury in 8%. Repeat scans were most common for neck and cervical spine injuries (54%) and thoracic/lumbar spine injuries (53%) and least common for chest injuries (32%).
An inadequate NTC work-up as judged by the TTC attending was the most common reason for getting new images (76%). Poor image quality was the next most common reason (31%).
Among the 203 patients, 99 (49%) had a type A error. Of these injuries missed on the initial scan, 90% were considered to be clinically significant.
Type B errors occurred in 15% of patients.
Type C errors (new injuries in different body area) occurred in 54% of patients and, of these, 76% were considered clinically significant. Type D errors (new injuries seen in any imaging of any area) occurred in 73% of patients.
“This study confirms that images are often repeated or completed after having images done at nontertiary trauma centers,” Dr. Bonds said. “Relying on NTC image interpretation can lead to undertreating our patients. One potential solution to this issue could be image sharing between NTCs and TTCs. This might reduce both the rate of missed injuries and the need for repeat scans.”
Dr. Bonds had no financial disclosures.
On Twitter @Alz_Gal
Key clinical point:
Major finding: Overall, 76% of patients had missed injuries on their initial CT scans.
Data source: A study of 203 trauma patients.
Disclosures: Dr. Bonds had no financial disclosures.
President Trump hits ground running on ACA repeal
WASHINGTON – President Trump wasted no time in getting the executive branch’s wheels in motion toward repeal of the Affordable Care Act.
Within hours of being sworn in as the 45th president of the United States on Jan. 20, he signed an executive order that announced the incoming administration’s policy “to seek the prompt repeal of the Patient Protection and Affordable Care Act.”
The order opens the door for federal agencies to tackle ACA provisions such as the individual mandate and its tax penalties for not carrying insurance, as well as other financial aspects of the ACA that impact patients, providers, insurers, and manufacturers.
The order directs the secretaries of HHS, the Treasury department, and the Labor department to “exercise all authority and discretion available to them to provide greater flexibility to States and cooperate with them in implementing healthcare programs.”
With this order, President Trump also set the stage for creating a framework to sell insurance products across state lines by directing secretaries with oversight of insurance markets to “encourage the development of a free and open market in interstate commerce for the offering of healthcare services and health insurance, with the goal of achieving and preserving maximum options for patients and consumers.”
Little action is expected on the executive order until secretaries are approved for HHS, Treasury, and Labor. Rep. Tom Price (R-Ga.) is scheduled to appear before the Senate Finance Committee on Jan. 24.
WASHINGTON – President Trump wasted no time in getting the executive branch’s wheels in motion toward repeal of the Affordable Care Act.
Within hours of being sworn in as the 45th president of the United States on Jan. 20, he signed an executive order that announced the incoming administration’s policy “to seek the prompt repeal of the Patient Protection and Affordable Care Act.”
The order opens the door for federal agencies to tackle ACA provisions such as the individual mandate and its tax penalties for not carrying insurance, as well as other financial aspects of the ACA that impact patients, providers, insurers, and manufacturers.
The order directs the secretaries of HHS, the Treasury department, and the Labor department to “exercise all authority and discretion available to them to provide greater flexibility to States and cooperate with them in implementing healthcare programs.”
With this order, President Trump also set the stage for creating a framework to sell insurance products across state lines by directing secretaries with oversight of insurance markets to “encourage the development of a free and open market in interstate commerce for the offering of healthcare services and health insurance, with the goal of achieving and preserving maximum options for patients and consumers.”
Little action is expected on the executive order until secretaries are approved for HHS, Treasury, and Labor. Rep. Tom Price (R-Ga.) is scheduled to appear before the Senate Finance Committee on Jan. 24.
WASHINGTON – President Trump wasted no time in getting the executive branch’s wheels in motion toward repeal of the Affordable Care Act.
Within hours of being sworn in as the 45th president of the United States on Jan. 20, he signed an executive order that announced the incoming administration’s policy “to seek the prompt repeal of the Patient Protection and Affordable Care Act.”
The order opens the door for federal agencies to tackle ACA provisions such as the individual mandate and its tax penalties for not carrying insurance, as well as other financial aspects of the ACA that impact patients, providers, insurers, and manufacturers.
The order directs the secretaries of HHS, the Treasury department, and the Labor department to “exercise all authority and discretion available to them to provide greater flexibility to States and cooperate with them in implementing healthcare programs.”
With this order, President Trump also set the stage for creating a framework to sell insurance products across state lines by directing secretaries with oversight of insurance markets to “encourage the development of a free and open market in interstate commerce for the offering of healthcare services and health insurance, with the goal of achieving and preserving maximum options for patients and consumers.”
Little action is expected on the executive order until secretaries are approved for HHS, Treasury, and Labor. Rep. Tom Price (R-Ga.) is scheduled to appear before the Senate Finance Committee on Jan. 24.
VIDEO: Health law changes under new administration
WASHINGTON – A new president is taking office along with new staffers to lead the country’s top health care agencies.
In this video, Joyce Hall, chair of the American Bar Association Health Law Section, discusses what changes she foresees in health law issues under the new administration and what to expect from the leadership transition. Ms. Hall also speaks on potential alterations to the Medicare Access and CHIP Reauthorization Act of 2015 and whether the potential appointment of Rep. Tom Price (R-Ga.) as U.S. Department of Health and Human Services Secretary will be positive or negative for health care providers.
The video associated with this article is no longer available on this site. Please view all of our videos on the MDedge YouTube channel
[email protected]
On Twitter @legal_med
WASHINGTON – A new president is taking office along with new staffers to lead the country’s top health care agencies.
In this video, Joyce Hall, chair of the American Bar Association Health Law Section, discusses what changes she foresees in health law issues under the new administration and what to expect from the leadership transition. Ms. Hall also speaks on potential alterations to the Medicare Access and CHIP Reauthorization Act of 2015 and whether the potential appointment of Rep. Tom Price (R-Ga.) as U.S. Department of Health and Human Services Secretary will be positive or negative for health care providers.
The video associated with this article is no longer available on this site. Please view all of our videos on the MDedge YouTube channel
[email protected]
On Twitter @legal_med
WASHINGTON – A new president is taking office along with new staffers to lead the country’s top health care agencies.
In this video, Joyce Hall, chair of the American Bar Association Health Law Section, discusses what changes she foresees in health law issues under the new administration and what to expect from the leadership transition. Ms. Hall also speaks on potential alterations to the Medicare Access and CHIP Reauthorization Act of 2015 and whether the potential appointment of Rep. Tom Price (R-Ga.) as U.S. Department of Health and Human Services Secretary will be positive or negative for health care providers.
The video associated with this article is no longer available on this site. Please view all of our videos on the MDedge YouTube channel
[email protected]
On Twitter @legal_med
AT THE WASHINGTON HEALTH LAW SUMMIT
Echocardiography can benefit use of stented bovine graft for MVR in infants
Mitral valve replacement in infants and young children is complicated because appropriately sized prostheses are difficult to come by and these patients need replacements later on as they continue to grow – thus the high rates of reintervention and death. Pediatric cardiac surgery specialists at Boston Children’s Hospital are among the few that have used stented jugular vein grafts in these patients, and they have reported on a refinement of their technique that uses echocardiography before and after graft placement to obtain valuable measurements for sizing and implanting a prosthesis and for identifying patients at risk of complications.
Lindsay R. Freud, MD, and her associates reported in the January 2017 issue of the Journal of Thoracic and Cardiovascular Surgery on pre- and postoperative echocardiograms of 24 patients who had mitral valve replacement (MVR) with the Melody stent-mounted, valved bovine jugular vein graft (Medtronic) (J Thorac Cardiovasc Surg. 2017;153:153-60). The device, which is approved for transcatheter pulmonary valve replacement, was adapted for implantation into the mitral position, an indication that is not yet Food and Drug Administration approved. “With the increasing use of the Melody valve in the mitral position in infants and young children, we sought to provide a framework for both pre- and early postoperative echocardiographic assessment,” Dr. Freud and her coauthors said.
“The potential dimensions often had normal z scores with fair correlation with intraoperative Melody dilation,” the investigators said. They also found that a ratio of the narrowest subaortic region in systole to the actual MV dimension (SubA:MV) less than 0.5 was associated with postoperative left ventricular outflow tract obstruction (LVOTO), which occurred in four patients. The median age of the study group was 8.5 months.
“Postoperatively, mitral gradients substantially improved, with low values relative to the effective orifice area of the Melody valve,” Dr. Freud and her associates said. None of the patients had significant regurgitation or perivalvar leak.
In early reports of the Melody valve in infants and small children, the surgeons determined the size of the replacement valve during the operation itself. Despite encouraging early results, reports of complications such as LVOTO soon followed. The Children’s Hospital Boston researchers undertook the study to determine if echocardiography before surgery would help to identify the correct valve size for expansion and predict which patients would be at risk for LVOTO.
“The preoperative SubA:MV ratio may help assess the risk for postoperative LVOTO, which is an important complication,” Dr. Freud and coauthors said. The presence of LVOTO preoperatively was also a risk factor, but only one of eight patients with an atrioventricular canal defect developed LVOTO. In patients with a SubA:MV ratio less than 0.5, preoperative LVOTO, or any other anatomic risk factor, surgeons should consider options to prevent LVOTO, Dr. Freud and her associates said. Those alternatives include more aggressive resection of stent material, atrial displacement of the valve, or less aggressive distal expansion of the valve.
Postoperative echocardiography enabled Dr. Freud and her coauthors to outline baseline values for the Melody valve in the mitral position by maximum intraoperative balloon diameter, ranging from 1 cm to 1.8 cm in 0.2-cm steps, and depending on five measurements at each step: peak and mean gradients, peak velocity, effective orifice area, and indexed effective orifice area.
“Validation of candidacy for Melody MVR and noninvasive assessment among larger series of patient will be necessary as greater experience with the Melody valve evolves,” Dr. Freud and her associates concluded.
Coauthor Sitaram Emani, MD, has filed a patent for an expandable valve through Boston Children’s Hospital. Dr. Freud and her other coauthors had no financial relationships to disclose.
The Melody valve is an “appealing solution” for MVR in infants and small children, Patrick Myers, MD, of Geneva University Hospitals said in his invited commentary (J Thorac Cardiovasc Surg. 2017;153:151-2) “This contribution brings further data to support Melody MVR,” he said of the report by Dr. Freud and her colleagues.
However, Dr. Myers noted that beyond the Boston Children’s Hospital experience, only two other reports of the Melody valve in the mitral position in children exist. “There are several outstanding technical issues that need to be investigated for the use of the Melody valve in the mitral position,” he said. Among those issues is the length of the stent itself – 28 mm, which can lead to LVOTO after placement “in a diminutive ventricle.” The fact that “only” four patients in the study group developed LVOTO after Melody MVR is “reassuring with regard to this theoretic limitation,” Dr. Myers said. “And the echocardiographic ratio of the narrowest subaortic region in systole to the actual mitral valve dimension could be of use in deciding when to be more aggressive in preventing LVOTO,” he said.
Dr. Myers also said that this report answered some questions about the durability of a venous valve under systemic pressures, but added, “Further echocardiographic and clinical follow-up data in this very challenging population are required,” he said.
Dr. Myers had no financial relationships to disclose.
The Melody valve is an “appealing solution” for MVR in infants and small children, Patrick Myers, MD, of Geneva University Hospitals said in his invited commentary (J Thorac Cardiovasc Surg. 2017;153:151-2) “This contribution brings further data to support Melody MVR,” he said of the report by Dr. Freud and her colleagues.
However, Dr. Myers noted that beyond the Boston Children’s Hospital experience, only two other reports of the Melody valve in the mitral position in children exist. “There are several outstanding technical issues that need to be investigated for the use of the Melody valve in the mitral position,” he said. Among those issues is the length of the stent itself – 28 mm, which can lead to LVOTO after placement “in a diminutive ventricle.” The fact that “only” four patients in the study group developed LVOTO after Melody MVR is “reassuring with regard to this theoretic limitation,” Dr. Myers said. “And the echocardiographic ratio of the narrowest subaortic region in systole to the actual mitral valve dimension could be of use in deciding when to be more aggressive in preventing LVOTO,” he said.
Dr. Myers also said that this report answered some questions about the durability of a venous valve under systemic pressures, but added, “Further echocardiographic and clinical follow-up data in this very challenging population are required,” he said.
Dr. Myers had no financial relationships to disclose.
The Melody valve is an “appealing solution” for MVR in infants and small children, Patrick Myers, MD, of Geneva University Hospitals said in his invited commentary (J Thorac Cardiovasc Surg. 2017;153:151-2) “This contribution brings further data to support Melody MVR,” he said of the report by Dr. Freud and her colleagues.
However, Dr. Myers noted that beyond the Boston Children’s Hospital experience, only two other reports of the Melody valve in the mitral position in children exist. “There are several outstanding technical issues that need to be investigated for the use of the Melody valve in the mitral position,” he said. Among those issues is the length of the stent itself – 28 mm, which can lead to LVOTO after placement “in a diminutive ventricle.” The fact that “only” four patients in the study group developed LVOTO after Melody MVR is “reassuring with regard to this theoretic limitation,” Dr. Myers said. “And the echocardiographic ratio of the narrowest subaortic region in systole to the actual mitral valve dimension could be of use in deciding when to be more aggressive in preventing LVOTO,” he said.
Dr. Myers also said that this report answered some questions about the durability of a venous valve under systemic pressures, but added, “Further echocardiographic and clinical follow-up data in this very challenging population are required,” he said.
Dr. Myers had no financial relationships to disclose.
Mitral valve replacement in infants and young children is complicated because appropriately sized prostheses are difficult to come by and these patients need replacements later on as they continue to grow – thus the high rates of reintervention and death. Pediatric cardiac surgery specialists at Boston Children’s Hospital are among the few that have used stented jugular vein grafts in these patients, and they have reported on a refinement of their technique that uses echocardiography before and after graft placement to obtain valuable measurements for sizing and implanting a prosthesis and for identifying patients at risk of complications.
Lindsay R. Freud, MD, and her associates reported in the January 2017 issue of the Journal of Thoracic and Cardiovascular Surgery on pre- and postoperative echocardiograms of 24 patients who had mitral valve replacement (MVR) with the Melody stent-mounted, valved bovine jugular vein graft (Medtronic) (J Thorac Cardiovasc Surg. 2017;153:153-60). The device, which is approved for transcatheter pulmonary valve replacement, was adapted for implantation into the mitral position, an indication that is not yet Food and Drug Administration approved. “With the increasing use of the Melody valve in the mitral position in infants and young children, we sought to provide a framework for both pre- and early postoperative echocardiographic assessment,” Dr. Freud and her coauthors said.
“The potential dimensions often had normal z scores with fair correlation with intraoperative Melody dilation,” the investigators said. They also found that a ratio of the narrowest subaortic region in systole to the actual MV dimension (SubA:MV) less than 0.5 was associated with postoperative left ventricular outflow tract obstruction (LVOTO), which occurred in four patients. The median age of the study group was 8.5 months.
“Postoperatively, mitral gradients substantially improved, with low values relative to the effective orifice area of the Melody valve,” Dr. Freud and her associates said. None of the patients had significant regurgitation or perivalvar leak.
In early reports of the Melody valve in infants and small children, the surgeons determined the size of the replacement valve during the operation itself. Despite encouraging early results, reports of complications such as LVOTO soon followed. The Children’s Hospital Boston researchers undertook the study to determine if echocardiography before surgery would help to identify the correct valve size for expansion and predict which patients would be at risk for LVOTO.
“The preoperative SubA:MV ratio may help assess the risk for postoperative LVOTO, which is an important complication,” Dr. Freud and coauthors said. The presence of LVOTO preoperatively was also a risk factor, but only one of eight patients with an atrioventricular canal defect developed LVOTO. In patients with a SubA:MV ratio less than 0.5, preoperative LVOTO, or any other anatomic risk factor, surgeons should consider options to prevent LVOTO, Dr. Freud and her associates said. Those alternatives include more aggressive resection of stent material, atrial displacement of the valve, or less aggressive distal expansion of the valve.
Postoperative echocardiography enabled Dr. Freud and her coauthors to outline baseline values for the Melody valve in the mitral position by maximum intraoperative balloon diameter, ranging from 1 cm to 1.8 cm in 0.2-cm steps, and depending on five measurements at each step: peak and mean gradients, peak velocity, effective orifice area, and indexed effective orifice area.
“Validation of candidacy for Melody MVR and noninvasive assessment among larger series of patient will be necessary as greater experience with the Melody valve evolves,” Dr. Freud and her associates concluded.
Coauthor Sitaram Emani, MD, has filed a patent for an expandable valve through Boston Children’s Hospital. Dr. Freud and her other coauthors had no financial relationships to disclose.
Mitral valve replacement in infants and young children is complicated because appropriately sized prostheses are difficult to come by and these patients need replacements later on as they continue to grow – thus the high rates of reintervention and death. Pediatric cardiac surgery specialists at Boston Children’s Hospital are among the few that have used stented jugular vein grafts in these patients, and they have reported on a refinement of their technique that uses echocardiography before and after graft placement to obtain valuable measurements for sizing and implanting a prosthesis and for identifying patients at risk of complications.
Lindsay R. Freud, MD, and her associates reported in the January 2017 issue of the Journal of Thoracic and Cardiovascular Surgery on pre- and postoperative echocardiograms of 24 patients who had mitral valve replacement (MVR) with the Melody stent-mounted, valved bovine jugular vein graft (Medtronic) (J Thorac Cardiovasc Surg. 2017;153:153-60). The device, which is approved for transcatheter pulmonary valve replacement, was adapted for implantation into the mitral position, an indication that is not yet Food and Drug Administration approved. “With the increasing use of the Melody valve in the mitral position in infants and young children, we sought to provide a framework for both pre- and early postoperative echocardiographic assessment,” Dr. Freud and her coauthors said.
“The potential dimensions often had normal z scores with fair correlation with intraoperative Melody dilation,” the investigators said. They also found that a ratio of the narrowest subaortic region in systole to the actual MV dimension (SubA:MV) less than 0.5 was associated with postoperative left ventricular outflow tract obstruction (LVOTO), which occurred in four patients. The median age of the study group was 8.5 months.
“Postoperatively, mitral gradients substantially improved, with low values relative to the effective orifice area of the Melody valve,” Dr. Freud and her associates said. None of the patients had significant regurgitation or perivalvar leak.
In early reports of the Melody valve in infants and small children, the surgeons determined the size of the replacement valve during the operation itself. Despite encouraging early results, reports of complications such as LVOTO soon followed. The Children’s Hospital Boston researchers undertook the study to determine if echocardiography before surgery would help to identify the correct valve size for expansion and predict which patients would be at risk for LVOTO.
“The preoperative SubA:MV ratio may help assess the risk for postoperative LVOTO, which is an important complication,” Dr. Freud and coauthors said. The presence of LVOTO preoperatively was also a risk factor, but only one of eight patients with an atrioventricular canal defect developed LVOTO. In patients with a SubA:MV ratio less than 0.5, preoperative LVOTO, or any other anatomic risk factor, surgeons should consider options to prevent LVOTO, Dr. Freud and her associates said. Those alternatives include more aggressive resection of stent material, atrial displacement of the valve, or less aggressive distal expansion of the valve.
Postoperative echocardiography enabled Dr. Freud and her coauthors to outline baseline values for the Melody valve in the mitral position by maximum intraoperative balloon diameter, ranging from 1 cm to 1.8 cm in 0.2-cm steps, and depending on five measurements at each step: peak and mean gradients, peak velocity, effective orifice area, and indexed effective orifice area.
“Validation of candidacy for Melody MVR and noninvasive assessment among larger series of patient will be necessary as greater experience with the Melody valve evolves,” Dr. Freud and her associates concluded.
Coauthor Sitaram Emani, MD, has filed a patent for an expandable valve through Boston Children’s Hospital. Dr. Freud and her other coauthors had no financial relationships to disclose.
FROM JOURNAL OF THORACIC AND CARDIOVASCULAR SURGERY
Key clinical point: Preoperative echocardiography may help guide placement of modified stented jugular vein grafts in infants and small children with hypoplastic mitral and aortic valves.
Major finding: Echocardiography showed that a ratio of the narrowest subaortic region in systole to the actual mitral valve dimension of less than 0.5 was associated with postoperative left ventricular outflow tract obstruction.
Data source: Single-center, retrospective review of 24 patients who underwent mitral valve replacement with modified stented jugular vein grafts from March 2010 to March 2015.
Disclosures: Coauthor Sitaram Emani, MD, has filed a patent for an expandable valve through Boston Children’s Hospital. Dr. Freud and her other coauthors had no financial relationships to disclose.
Hybrid procedures may be better option for LVOTO in lower-weight neonates
Little outcomes data have been published comparing hybrid and Norwood stage 1 procedures for newborns with critical left ventricular outflow tract obstruction (LVOTO), but a prospective analysis of more than 500 operations over 9 years reported that while the Norwood has better survival rates overall, hybrid procedures may improve survival in low-birth-weight newborns.
“Although lower birth weight was identified as an important risk factor for death for the entire cohort, the detrimental impact of low birth weight was mitigated, to some degree, for patients who underwent a hybrid procedure,” said Travis Wilder, MD, of the Congenital Heart Surgeons’ Society (CHSS) Data Center, and his coauthors. They reported their findings in the January 2017 issue of the Journal of Thoracic and Cardiovascular Surgery (153:163-72).
Norwood operations involve major surgical reconstruction along with exposure to cardiopulmonary bypass (CPB), with either deep hypothermic circulatory arrest (DHCA) or regional cerebral perfusion, during aortic arch reconstruction. Previous reports have linked CPB to postoperative hemodynamic instability, complications, and death (Ann Thorac Surg. 2009 Jun;87:1885-92). “In addition, the early physiological stress imposed on neonates after Norwood operations raises concerns regarding adverse neurodevelopment,” Dr. Wilder and his coauthors wrote.
Dr. Wilder and his coauthors pointed out that the hybrid procedure has emerged to avoid CPB and DHCA or regional cerebral perfusion and the potential resulting physiologic instability. “In this light, hybrid palliation may be perceived as a lower-risk alternative to Norwood operations, especially for patients considered at high risk for mortality,” the researchers said. Despite that perception, the actual survival “remains incompletely defined,” they said.
The overall average 4-year unadjusted survival for the entire study population was 65%, but those who had the NW-RVPA procedure had significantly improved survival (73%) vs. both the NW-BT (61%) and the hybrid groups (60%).
Those who had the hybrid procedure were older at stage 1 (12 days vs. 8 and 6 days, respectively for NW-BT and NW-RVPA) and had lower birth weight (2.9 kg vs. 3.2 kg and 3.15 kg, respectively). Hybrid patients also had a higher prevalence of baseline right ventricle dysfunction, were more likely to have baseline tricuspid valve regurgitation, and had a lower prevalence of aortic and mitral valve atresia.
For all patients, birth weight of 2.0-2.5 kg had a strong association with poor survival, Dr. Wilder and his coauthors reported, but the drop-off in survival for low-birth-weight neonates was greater in the Norwood group than in the hybrid group. “This finding suggests that hybrid procedures may offer a modest survival advantage over NW-RVPA at birth weight less than or equal to 2.0 kg and over NW-BT at birth weight less than or equal to 3.0 kg,” the researchers said.
Dr. Wilder and his coauthors had no financial relationships to disclose.
While the study by Dr. Wilder and his coauthors may have drawn an accurate conclusion about low-birth-weight newborns possibly benefiting from a hybrid procedure for hypoplastic left heart syndrome, the number of patients in each strategy was small, Carlos M. Mery, MD, MPH, of Texas Children’s Hospital/Baylor College of Medicine, Houston, said in his invited commentary (J Thorac Cardiovasc Surg. 2017 Jan;153:173-4).
Dr. Mery noted other limitations of the study, namely the heterogeneity of procedures by participating center. “Of the 20 centers, only 11 performed any hybrid procedures, and 1 center accounted for 42% of all hybrid procedures performed,” he said. “Because centers may be associated with possibly unaccounted risk factors and different learning curves, the conclusions may not be easily generalizable.”
The conclusion that newborns of lower birth weight may benefit from the hybrid procedure helps to bring clarity for which patients may benefit from a specific procedure, Dr. Mery said. “We seem to be getting closer to the ultimate goal of being able to offer each individual patient the management strategy that will lead to the best possible outcome, not only for quantity but also for quality of life,” Dr. Mery said.
Dr. Mery had no financial relationships to disclose.
While the study by Dr. Wilder and his coauthors may have drawn an accurate conclusion about low-birth-weight newborns possibly benefiting from a hybrid procedure for hypoplastic left heart syndrome, the number of patients in each strategy was small, Carlos M. Mery, MD, MPH, of Texas Children’s Hospital/Baylor College of Medicine, Houston, said in his invited commentary (J Thorac Cardiovasc Surg. 2017 Jan;153:173-4).
Dr. Mery noted other limitations of the study, namely the heterogeneity of procedures by participating center. “Of the 20 centers, only 11 performed any hybrid procedures, and 1 center accounted for 42% of all hybrid procedures performed,” he said. “Because centers may be associated with possibly unaccounted risk factors and different learning curves, the conclusions may not be easily generalizable.”
The conclusion that newborns of lower birth weight may benefit from the hybrid procedure helps to bring clarity for which patients may benefit from a specific procedure, Dr. Mery said. “We seem to be getting closer to the ultimate goal of being able to offer each individual patient the management strategy that will lead to the best possible outcome, not only for quantity but also for quality of life,” Dr. Mery said.
Dr. Mery had no financial relationships to disclose.
While the study by Dr. Wilder and his coauthors may have drawn an accurate conclusion about low-birth-weight newborns possibly benefiting from a hybrid procedure for hypoplastic left heart syndrome, the number of patients in each strategy was small, Carlos M. Mery, MD, MPH, of Texas Children’s Hospital/Baylor College of Medicine, Houston, said in his invited commentary (J Thorac Cardiovasc Surg. 2017 Jan;153:173-4).
Dr. Mery noted other limitations of the study, namely the heterogeneity of procedures by participating center. “Of the 20 centers, only 11 performed any hybrid procedures, and 1 center accounted for 42% of all hybrid procedures performed,” he said. “Because centers may be associated with possibly unaccounted risk factors and different learning curves, the conclusions may not be easily generalizable.”
The conclusion that newborns of lower birth weight may benefit from the hybrid procedure helps to bring clarity for which patients may benefit from a specific procedure, Dr. Mery said. “We seem to be getting closer to the ultimate goal of being able to offer each individual patient the management strategy that will lead to the best possible outcome, not only for quantity but also for quality of life,” Dr. Mery said.
Dr. Mery had no financial relationships to disclose.
Little outcomes data have been published comparing hybrid and Norwood stage 1 procedures for newborns with critical left ventricular outflow tract obstruction (LVOTO), but a prospective analysis of more than 500 operations over 9 years reported that while the Norwood has better survival rates overall, hybrid procedures may improve survival in low-birth-weight newborns.
“Although lower birth weight was identified as an important risk factor for death for the entire cohort, the detrimental impact of low birth weight was mitigated, to some degree, for patients who underwent a hybrid procedure,” said Travis Wilder, MD, of the Congenital Heart Surgeons’ Society (CHSS) Data Center, and his coauthors. They reported their findings in the January 2017 issue of the Journal of Thoracic and Cardiovascular Surgery (153:163-72).
Norwood operations involve major surgical reconstruction along with exposure to cardiopulmonary bypass (CPB), with either deep hypothermic circulatory arrest (DHCA) or regional cerebral perfusion, during aortic arch reconstruction. Previous reports have linked CPB to postoperative hemodynamic instability, complications, and death (Ann Thorac Surg. 2009 Jun;87:1885-92). “In addition, the early physiological stress imposed on neonates after Norwood operations raises concerns regarding adverse neurodevelopment,” Dr. Wilder and his coauthors wrote.
Dr. Wilder and his coauthors pointed out that the hybrid procedure has emerged to avoid CPB and DHCA or regional cerebral perfusion and the potential resulting physiologic instability. “In this light, hybrid palliation may be perceived as a lower-risk alternative to Norwood operations, especially for patients considered at high risk for mortality,” the researchers said. Despite that perception, the actual survival “remains incompletely defined,” they said.
The overall average 4-year unadjusted survival for the entire study population was 65%, but those who had the NW-RVPA procedure had significantly improved survival (73%) vs. both the NW-BT (61%) and the hybrid groups (60%).
Those who had the hybrid procedure were older at stage 1 (12 days vs. 8 and 6 days, respectively for NW-BT and NW-RVPA) and had lower birth weight (2.9 kg vs. 3.2 kg and 3.15 kg, respectively). Hybrid patients also had a higher prevalence of baseline right ventricle dysfunction, were more likely to have baseline tricuspid valve regurgitation, and had a lower prevalence of aortic and mitral valve atresia.
For all patients, birth weight of 2.0-2.5 kg had a strong association with poor survival, Dr. Wilder and his coauthors reported, but the drop-off in survival for low-birth-weight neonates was greater in the Norwood group than in the hybrid group. “This finding suggests that hybrid procedures may offer a modest survival advantage over NW-RVPA at birth weight less than or equal to 2.0 kg and over NW-BT at birth weight less than or equal to 3.0 kg,” the researchers said.
Dr. Wilder and his coauthors had no financial relationships to disclose.
Little outcomes data have been published comparing hybrid and Norwood stage 1 procedures for newborns with critical left ventricular outflow tract obstruction (LVOTO), but a prospective analysis of more than 500 operations over 9 years reported that while the Norwood has better survival rates overall, hybrid procedures may improve survival in low-birth-weight newborns.
“Although lower birth weight was identified as an important risk factor for death for the entire cohort, the detrimental impact of low birth weight was mitigated, to some degree, for patients who underwent a hybrid procedure,” said Travis Wilder, MD, of the Congenital Heart Surgeons’ Society (CHSS) Data Center, and his coauthors. They reported their findings in the January 2017 issue of the Journal of Thoracic and Cardiovascular Surgery (153:163-72).
Norwood operations involve major surgical reconstruction along with exposure to cardiopulmonary bypass (CPB), with either deep hypothermic circulatory arrest (DHCA) or regional cerebral perfusion, during aortic arch reconstruction. Previous reports have linked CPB to postoperative hemodynamic instability, complications, and death (Ann Thorac Surg. 2009 Jun;87:1885-92). “In addition, the early physiological stress imposed on neonates after Norwood operations raises concerns regarding adverse neurodevelopment,” Dr. Wilder and his coauthors wrote.
Dr. Wilder and his coauthors pointed out that the hybrid procedure has emerged to avoid CPB and DHCA or regional cerebral perfusion and the potential resulting physiologic instability. “In this light, hybrid palliation may be perceived as a lower-risk alternative to Norwood operations, especially for patients considered at high risk for mortality,” the researchers said. Despite that perception, the actual survival “remains incompletely defined,” they said.
The overall average 4-year unadjusted survival for the entire study population was 65%, but those who had the NW-RVPA procedure had significantly improved survival (73%) vs. both the NW-BT (61%) and the hybrid groups (60%).
Those who had the hybrid procedure were older at stage 1 (12 days vs. 8 and 6 days, respectively for NW-BT and NW-RVPA) and had lower birth weight (2.9 kg vs. 3.2 kg and 3.15 kg, respectively). Hybrid patients also had a higher prevalence of baseline right ventricle dysfunction, were more likely to have baseline tricuspid valve regurgitation, and had a lower prevalence of aortic and mitral valve atresia.
For all patients, birth weight of 2.0-2.5 kg had a strong association with poor survival, Dr. Wilder and his coauthors reported, but the drop-off in survival for low-birth-weight neonates was greater in the Norwood group than in the hybrid group. “This finding suggests that hybrid procedures may offer a modest survival advantage over NW-RVPA at birth weight less than or equal to 2.0 kg and over NW-BT at birth weight less than or equal to 3.0 kg,” the researchers said.
Dr. Wilder and his coauthors had no financial relationships to disclose.
FROM THE JOURNAL OF THORACIC AND CARDIOVASCULAR SURGERY
Key clinical point: Norwood procedures have the best survival rates for neonates with critical left ventricular outflow tract obstruction, but hybrid procedures may improve survival for those with lower birth weight.
Major finding: Risk-adjusted 4-year survival was 76% for the Norwood operation with a right ventricle–to-pulmonary artery conduit, 61% for Norwood with a modified Blalock-Taussig shunt and 60% for the hybrid procedure.
Data source: Prospective observational cohort study of 564 neonates admitted to 21 Congenital Heart Surgeons’ Society institutions from 2005 to 2014.
Disclosures: Dr. Wilder and his coauthors had no financial relationships to disclose.
Sleeve lobectomy appears better than pneumonectomy for NSCLC
Guidelines that recommend sleeve lobectomy as a means of avoiding pneumonectomy for lung cancer have been based on a limited retrospective series, but a large series drawn from a nationwide database in France has confirmed the preference for sleeve lobectomy because it leads to higher rates of survival, despite an increased risk of postoperative pulmonary complications.
“Whenever it is technically possible, surgeons must perform sleeve lobectomy to provide more long-term survival benefits to patients, even with the risk of more postoperative pulmonary complications,” said Pierre-Benoit Pagès, MD, PhD, and his coauthors in the January 2017 issue of the Journal of Thoracic and Cardiovascular Surgery (2017;153:184-95). Dr. Pagès is with the department of thoracic and cardiovascular surgery at the University Hospital Center Dijon (France) and Bocage Hospital.
Three-year overall survival was 71.9% for the sleeve lobectomy group vs. 60.8% for the pneumonectomy group. Three-year disease-free survival was 46.4% for the sleeve lobectomy group and 31.6% for the pneumonectomy group. In addition, compared with the sleeve lobectomy group, the pneumonectomy group had an increased risk of recurrence by matching (hazard ratio, 1.49; 95% CI, 1.1-2).
The researchers performed a propensity-matched analysis that favored sleeve lobectomy for early overall and disease-free survival, but the weighted analysis did not. Patients in the sleeve lobectomy group vs. the pneumonectomy group were younger (60.9 years vs. 61.9), had higher body mass index (25.6 vs. 25.1), had higher average forced expiratory volume (74.1% vs. 62.9%), and had lower American Society of Anesthesiologists scores (73.7% with scores of 1 and 2 vs. 70.8%). Sleeve lobectomy patients also were more likely to have right-sided surgery (69.6% vs. 41%) and squamous cell carcinoma (54.6% vs. 48.3%), and lower T and N stages (T1 and T2, 60.5% vs. 40.6%; N0, 40.9% vs. 26.2%).
Overall mortality after surgery was 5% in the sleeve lobectomy group vs. 5.9% in the pneumonectomy group, but propensity scoring showed far fewer postoperative pulmonary complications in the pneumonectomy group, with an odds ratio of 0.4, Dr. Pagès and his coauthors said. However, with other significant complications – arrhythmia, bronchopleural fistula, empyema, and hemorrhage – pneumonectomy had a propensity-matched odds ratio ranging from 1.6 to 7. “We found no significant difference regarding postoperative mortality in the sleeve lobectomy and pneumonectomy groups, whatever the statistical method used,” Dr. Pagès and his coauthors wrote.
The investigators had no financial relationships to disclose.
The study by Dr. Pagès and his colleagues is unique in the field of surgery for non–small cell lung cancer in that it drew on a nationwide database using data from 103 centers, Betty C. Tong, MD, MHS, of Duke University Medical Center, Durham, said in her invited commentary (J Thorac Cardiovasc Surg. 2017;153:196). “These results are likely as close to real life as possible,” she said.
She acknowledged that no prospective, randomized controlled trials have compared sleeve lobectomy to pneumonectomy, but she added, “it is unlikely that such a trial could be successfully executed.” The 5:1 ratio of patients having pneumonectomy vs. sleeve lobectomy in this study is similar to findings from the Society of Thoracic Surgeons General Thoracic Surgery database (J Thorac Cardiovasc Surg. 2008;132:247-54), Dr. Tong pointed out, “and likely reflects the fact that sleeve lobectomy can be technically more difficult to perform.”
The findings of the French Society of Thoracic and Cardiovascular Surgery group “should strongly encourage thoracic surgeons to perform pneumonectomy as sparingly as possible,” and consider sleeve lobectomy the standard for patients with central tumors, Dr. Tong said.
She had no financial relationships to disclose.
The study by Dr. Pagès and his colleagues is unique in the field of surgery for non–small cell lung cancer in that it drew on a nationwide database using data from 103 centers, Betty C. Tong, MD, MHS, of Duke University Medical Center, Durham, said in her invited commentary (J Thorac Cardiovasc Surg. 2017;153:196). “These results are likely as close to real life as possible,” she said.
She acknowledged that no prospective, randomized controlled trials have compared sleeve lobectomy to pneumonectomy, but she added, “it is unlikely that such a trial could be successfully executed.” The 5:1 ratio of patients having pneumonectomy vs. sleeve lobectomy in this study is similar to findings from the Society of Thoracic Surgeons General Thoracic Surgery database (J Thorac Cardiovasc Surg. 2008;132:247-54), Dr. Tong pointed out, “and likely reflects the fact that sleeve lobectomy can be technically more difficult to perform.”
The findings of the French Society of Thoracic and Cardiovascular Surgery group “should strongly encourage thoracic surgeons to perform pneumonectomy as sparingly as possible,” and consider sleeve lobectomy the standard for patients with central tumors, Dr. Tong said.
She had no financial relationships to disclose.
The study by Dr. Pagès and his colleagues is unique in the field of surgery for non–small cell lung cancer in that it drew on a nationwide database using data from 103 centers, Betty C. Tong, MD, MHS, of Duke University Medical Center, Durham, said in her invited commentary (J Thorac Cardiovasc Surg. 2017;153:196). “These results are likely as close to real life as possible,” she said.
She acknowledged that no prospective, randomized controlled trials have compared sleeve lobectomy to pneumonectomy, but she added, “it is unlikely that such a trial could be successfully executed.” The 5:1 ratio of patients having pneumonectomy vs. sleeve lobectomy in this study is similar to findings from the Society of Thoracic Surgeons General Thoracic Surgery database (J Thorac Cardiovasc Surg. 2008;132:247-54), Dr. Tong pointed out, “and likely reflects the fact that sleeve lobectomy can be technically more difficult to perform.”
The findings of the French Society of Thoracic and Cardiovascular Surgery group “should strongly encourage thoracic surgeons to perform pneumonectomy as sparingly as possible,” and consider sleeve lobectomy the standard for patients with central tumors, Dr. Tong said.
She had no financial relationships to disclose.
Guidelines that recommend sleeve lobectomy as a means of avoiding pneumonectomy for lung cancer have been based on a limited retrospective series, but a large series drawn from a nationwide database in France has confirmed the preference for sleeve lobectomy because it leads to higher rates of survival, despite an increased risk of postoperative pulmonary complications.
“Whenever it is technically possible, surgeons must perform sleeve lobectomy to provide more long-term survival benefits to patients, even with the risk of more postoperative pulmonary complications,” said Pierre-Benoit Pagès, MD, PhD, and his coauthors in the January 2017 issue of the Journal of Thoracic and Cardiovascular Surgery (2017;153:184-95). Dr. Pagès is with the department of thoracic and cardiovascular surgery at the University Hospital Center Dijon (France) and Bocage Hospital.
Three-year overall survival was 71.9% for the sleeve lobectomy group vs. 60.8% for the pneumonectomy group. Three-year disease-free survival was 46.4% for the sleeve lobectomy group and 31.6% for the pneumonectomy group. In addition, compared with the sleeve lobectomy group, the pneumonectomy group had an increased risk of recurrence by matching (hazard ratio, 1.49; 95% CI, 1.1-2).
The researchers performed a propensity-matched analysis that favored sleeve lobectomy for early overall and disease-free survival, but the weighted analysis did not. Patients in the sleeve lobectomy group vs. the pneumonectomy group were younger (60.9 years vs. 61.9), had higher body mass index (25.6 vs. 25.1), had higher average forced expiratory volume (74.1% vs. 62.9%), and had lower American Society of Anesthesiologists scores (73.7% with scores of 1 and 2 vs. 70.8%). Sleeve lobectomy patients also were more likely to have right-sided surgery (69.6% vs. 41%) and squamous cell carcinoma (54.6% vs. 48.3%), and lower T and N stages (T1 and T2, 60.5% vs. 40.6%; N0, 40.9% vs. 26.2%).
Overall mortality after surgery was 5% in the sleeve lobectomy group vs. 5.9% in the pneumonectomy group, but propensity scoring showed far fewer postoperative pulmonary complications in the pneumonectomy group, with an odds ratio of 0.4, Dr. Pagès and his coauthors said. However, with other significant complications – arrhythmia, bronchopleural fistula, empyema, and hemorrhage – pneumonectomy had a propensity-matched odds ratio ranging from 1.6 to 7. “We found no significant difference regarding postoperative mortality in the sleeve lobectomy and pneumonectomy groups, whatever the statistical method used,” Dr. Pagès and his coauthors wrote.
The investigators had no financial relationships to disclose.
Guidelines that recommend sleeve lobectomy as a means of avoiding pneumonectomy for lung cancer have been based on a limited retrospective series, but a large series drawn from a nationwide database in France has confirmed the preference for sleeve lobectomy because it leads to higher rates of survival, despite an increased risk of postoperative pulmonary complications.
“Whenever it is technically possible, surgeons must perform sleeve lobectomy to provide more long-term survival benefits to patients, even with the risk of more postoperative pulmonary complications,” said Pierre-Benoit Pagès, MD, PhD, and his coauthors in the January 2017 issue of the Journal of Thoracic and Cardiovascular Surgery (2017;153:184-95). Dr. Pagès is with the department of thoracic and cardiovascular surgery at the University Hospital Center Dijon (France) and Bocage Hospital.
Three-year overall survival was 71.9% for the sleeve lobectomy group vs. 60.8% for the pneumonectomy group. Three-year disease-free survival was 46.4% for the sleeve lobectomy group and 31.6% for the pneumonectomy group. In addition, compared with the sleeve lobectomy group, the pneumonectomy group had an increased risk of recurrence by matching (hazard ratio, 1.49; 95% CI, 1.1-2).
The researchers performed a propensity-matched analysis that favored sleeve lobectomy for early overall and disease-free survival, but the weighted analysis did not. Patients in the sleeve lobectomy group vs. the pneumonectomy group were younger (60.9 years vs. 61.9), had higher body mass index (25.6 vs. 25.1), had higher average forced expiratory volume (74.1% vs. 62.9%), and had lower American Society of Anesthesiologists scores (73.7% with scores of 1 and 2 vs. 70.8%). Sleeve lobectomy patients also were more likely to have right-sided surgery (69.6% vs. 41%) and squamous cell carcinoma (54.6% vs. 48.3%), and lower T and N stages (T1 and T2, 60.5% vs. 40.6%; N0, 40.9% vs. 26.2%).
Overall mortality after surgery was 5% in the sleeve lobectomy group vs. 5.9% in the pneumonectomy group, but propensity scoring showed far fewer postoperative pulmonary complications in the pneumonectomy group, with an odds ratio of 0.4, Dr. Pagès and his coauthors said. However, with other significant complications – arrhythmia, bronchopleural fistula, empyema, and hemorrhage – pneumonectomy had a propensity-matched odds ratio ranging from 1.6 to 7. “We found no significant difference regarding postoperative mortality in the sleeve lobectomy and pneumonectomy groups, whatever the statistical method used,” Dr. Pagès and his coauthors wrote.
The investigators had no financial relationships to disclose.
Key clinical point: Sleeve lobectomy for non–small cell lung cancer may lead to higher rates of overall and disease-free survival vs. pneumonectomy.
Major finding: Overall postoperative mortality was 5% in the sleeve lobectomy group vs. 5.9% in the pneumonectomy group.
Data source: An analysis of 941 sleeve lobectomy and 5,318 pneumonectomy procedures from 2005 to 2014 in the nationwide French database Epithor.
Disclosures: Dr. Pagès has received research grants from the Nuovo-Soldati Foundation for Cancer Research and the French Society of Thoracic and Cardiovascular Surgery, on whose behalf the study was performed. Dr. Pagès and his coauthors had no financial relationships to disclose.
Gastrografin IDs, treats suspected small bowel obstruction
HOLLYWOOD, FLA – The radiopaque contrast agent Gastrografin accurately diagnosed the majority of small bowel obstructions, allowing surgeons to identify which patients needed emergent surgery and which could be managed conservatively.
When instilled via nasogastric tube, the diatrizoate solution had a 92% positive predictive value for adhesive small bowel obstruction, Martin D. Zielinski, MD, said at the annual scientific assembly of the Eastern Association for the Surgery of Trauma.
Dr. Zielinski of the Mayo Clinic, Rochester, Minn., examined the diagnostic accuracy of the Gastrografin challenge, a small bowel obstruction diagnosis and treatment protocol he developed at the center. The challenge begins with 2 hours of nasogastric suctioning. Patients then receive 100 mL Gastrografin mixed with 50 mL water via the nasogastric tube. The tube is clamped for 8 hours, and then patients have an abdominal x-ray. If the contrast material appears in the colon, or if the patient has a bowel movement in the interim, then the challenge is passed, the tube can be removed, and diet advanced.
If there is no contrast in the colon, or if the patient has no bowel movement, then the surgeon assumes the obstruction remains, and exploratory surgery proceeds.
Dr. Zielinski’s study comprised 316 patients with a suspected adhesive small bowel obstruction. Of these, 173 were managed with the Gastrografin challenge; they were compared to 143 patients who were managed without the contrast agent.
Patients were a mean of 58 years. There were no significant differences in the rate of prior abdominal operations; duration of obstipation; or small bowel feces sign.
The comparator group was managed by a clinical algorithm in which any patient with initial signs of ischemia underwent exploratory surgery, and those without signs of ischemia were managed symptomatically. Patients in the Gastrografin arm who passed the trial were similarly managed, while those who failed it underwent exploratory surgery.
Among those who had the challenge, 130 (75%) passed. Gastrografin had a high diagnostic accuracy for small bowel obstruction, with 87% sensitivity, 71% specificity; and 92% positive predictive value. The negative predictive value was not as good, at 59%.
The Gastrografin protocol was associated with significantly fewer exploratory surgeries (21% vs. 44%), and significantly fewer small bowel resections (7% vs. 21%). That advantage was maintained even among patients in both groups who underwent exploratory surgery, with an ultimate resection rate of 34% vs. 49%. The length of stay was also significantly less in the Gastrografin group, 4 vs. 5 days).
There was no difference in the overall complication rate (12.5% vs. 18%). Complications included acute kidney injury (6% vs. 9%); pneumonia (4% vs. 5%), organ space infection (1% vs. 4%), surgical site infection (3.5% vs. 5%), and anastomotic leak (2% each group).
The rate of missed small bowel strangulation was significantly lower among the Gastrografin group as well (0.6% vs. 7.7%). There were no cases of Gastrografin pneumonitis.
Dr. Zielinski had no financial disclosures.
[email protected]
On Twitter @alz_gal
HOLLYWOOD, FLA – The radiopaque contrast agent Gastrografin accurately diagnosed the majority of small bowel obstructions, allowing surgeons to identify which patients needed emergent surgery and which could be managed conservatively.
When instilled via nasogastric tube, the diatrizoate solution had a 92% positive predictive value for adhesive small bowel obstruction, Martin D. Zielinski, MD, said at the annual scientific assembly of the Eastern Association for the Surgery of Trauma.
Dr. Zielinski of the Mayo Clinic, Rochester, Minn., examined the diagnostic accuracy of the Gastrografin challenge, a small bowel obstruction diagnosis and treatment protocol he developed at the center. The challenge begins with 2 hours of nasogastric suctioning. Patients then receive 100 mL Gastrografin mixed with 50 mL water via the nasogastric tube. The tube is clamped for 8 hours, and then patients have an abdominal x-ray. If the contrast material appears in the colon, or if the patient has a bowel movement in the interim, then the challenge is passed, the tube can be removed, and diet advanced.
If there is no contrast in the colon, or if the patient has no bowel movement, then the surgeon assumes the obstruction remains, and exploratory surgery proceeds.
Dr. Zielinski’s study comprised 316 patients with a suspected adhesive small bowel obstruction. Of these, 173 were managed with the Gastrografin challenge; they were compared to 143 patients who were managed without the contrast agent.
Patients were a mean of 58 years. There were no significant differences in the rate of prior abdominal operations; duration of obstipation; or small bowel feces sign.
The comparator group was managed by a clinical algorithm in which any patient with initial signs of ischemia underwent exploratory surgery, and those without signs of ischemia were managed symptomatically. Patients in the Gastrografin arm who passed the trial were similarly managed, while those who failed it underwent exploratory surgery.
Among those who had the challenge, 130 (75%) passed. Gastrografin had a high diagnostic accuracy for small bowel obstruction, with 87% sensitivity, 71% specificity; and 92% positive predictive value. The negative predictive value was not as good, at 59%.
The Gastrografin protocol was associated with significantly fewer exploratory surgeries (21% vs. 44%), and significantly fewer small bowel resections (7% vs. 21%). That advantage was maintained even among patients in both groups who underwent exploratory surgery, with an ultimate resection rate of 34% vs. 49%. The length of stay was also significantly less in the Gastrografin group, 4 vs. 5 days).
There was no difference in the overall complication rate (12.5% vs. 18%). Complications included acute kidney injury (6% vs. 9%); pneumonia (4% vs. 5%), organ space infection (1% vs. 4%), surgical site infection (3.5% vs. 5%), and anastomotic leak (2% each group).
The rate of missed small bowel strangulation was significantly lower among the Gastrografin group as well (0.6% vs. 7.7%). There were no cases of Gastrografin pneumonitis.
Dr. Zielinski had no financial disclosures.
[email protected]
On Twitter @alz_gal
HOLLYWOOD, FLA – The radiopaque contrast agent Gastrografin accurately diagnosed the majority of small bowel obstructions, allowing surgeons to identify which patients needed emergent surgery and which could be managed conservatively.
When instilled via nasogastric tube, the diatrizoate solution had a 92% positive predictive value for adhesive small bowel obstruction, Martin D. Zielinski, MD, said at the annual scientific assembly of the Eastern Association for the Surgery of Trauma.
Dr. Zielinski of the Mayo Clinic, Rochester, Minn., examined the diagnostic accuracy of the Gastrografin challenge, a small bowel obstruction diagnosis and treatment protocol he developed at the center. The challenge begins with 2 hours of nasogastric suctioning. Patients then receive 100 mL Gastrografin mixed with 50 mL water via the nasogastric tube. The tube is clamped for 8 hours, and then patients have an abdominal x-ray. If the contrast material appears in the colon, or if the patient has a bowel movement in the interim, then the challenge is passed, the tube can be removed, and diet advanced.
If there is no contrast in the colon, or if the patient has no bowel movement, then the surgeon assumes the obstruction remains, and exploratory surgery proceeds.
Dr. Zielinski’s study comprised 316 patients with a suspected adhesive small bowel obstruction. Of these, 173 were managed with the Gastrografin challenge; they were compared to 143 patients who were managed without the contrast agent.
Patients were a mean of 58 years. There were no significant differences in the rate of prior abdominal operations; duration of obstipation; or small bowel feces sign.
The comparator group was managed by a clinical algorithm in which any patient with initial signs of ischemia underwent exploratory surgery, and those without signs of ischemia were managed symptomatically. Patients in the Gastrografin arm who passed the trial were similarly managed, while those who failed it underwent exploratory surgery.
Among those who had the challenge, 130 (75%) passed. Gastrografin had a high diagnostic accuracy for small bowel obstruction, with 87% sensitivity, 71% specificity; and 92% positive predictive value. The negative predictive value was not as good, at 59%.
The Gastrografin protocol was associated with significantly fewer exploratory surgeries (21% vs. 44%), and significantly fewer small bowel resections (7% vs. 21%). That advantage was maintained even among patients in both groups who underwent exploratory surgery, with an ultimate resection rate of 34% vs. 49%. The length of stay was also significantly less in the Gastrografin group, 4 vs. 5 days).
There was no difference in the overall complication rate (12.5% vs. 18%). Complications included acute kidney injury (6% vs. 9%); pneumonia (4% vs. 5%), organ space infection (1% vs. 4%), surgical site infection (3.5% vs. 5%), and anastomotic leak (2% each group).
The rate of missed small bowel strangulation was significantly lower among the Gastrografin group as well (0.6% vs. 7.7%). There were no cases of Gastrografin pneumonitis.
Dr. Zielinski had no financial disclosures.
[email protected]
On Twitter @alz_gal
AT THE EAST ANNUAL SCIENTIFIC ASSEMBLY
Key clinical point: The bowel-imaging agent Gastrografin can both diagnose and treat small bowel obstruction.
Major finding: The agent had a 92% positive predictive value; it was associated with fewer bowel resections (7% vs. 21%) and a day shorter length of stay, compared with those who didn’t receive it.
Data source: The prospective study comprised 316 patients, 173 of whom underwent the Gastrografin challenge.
Disclosures: Dr. Zielinski had no financial disclosures.
ACA repeal would impact adults at higher risk of chronic disease
Individuals at risk of losing health insurance with a potential repeal of the Affordable Care Act have significantly higher rates of self-reported poor health and are more likely to have certain chronic diseases, according to a research letter published Jan. 20 in JAMA Internal Medicine.
Researchers looked at data from the National Health Interview Survey, focusing on the three groups of adults under 65 years who would be most likely to lose their health insurance if the ACA were repealed: those with incomes below 400% of the federal poverty level (FPL) who purchased insurance through the health insurance exchanges, childless adults with incomes below 138% of the FPL who gained coverage via expanded Medicaid, and Medicaid-enrolled parents or adults in families with children who did not receive disability insurance and whose income was 50%-138% of the FPL.
“Approximately 20 million individuals have gained health insurance under the Affordable Care Act (ACA), including young adults covered under parental insurance, those purchasing private insurance on exchanges, and those covered through state Medicaid expansion,” wrote Pinar Karaca-Mandic, PhD, of the University of Minnesota School of Public Health, Minneapolis, and her coauthors. “As of mid-2016, 10.4 million individuals had private insurance policies through the exchanges, of whom 84% had incomes below 400% of the federal poverty level (FPL) and received premium tax credits.”
Compared with adults under 65 who had employer-sponsored health insurance, adults in these three groups were significantly more likely to self-report their health as “fair or poor” (JAMA Intern Med. 2017 Jan 20. doi: 10.1001/jamainternmed.2016.9541).
Adults without children and with incomes below 138% of the federal poverty level also had a significantly greater incidence of hypertension, coronary heart disease, cancer, diabetes, stroke, or any heart condition, compared with individuals with employer-sponsored insurance.
They were also significantly more likely to have visited a physician 10 or more times or visited the emergency department at least twice in the past year, and to have undergone surgery in the past year.
“Our analysis highlights the socioeconomic vulnerability and rates of chronic diseases and health care utilization of individuals at risk to lose health insurance if the ACA is modified or repealed,” according to Dr. Karaca-Mandic. “These consequences point to the challenges Congress should address before enacting new health care legislation.”
The study was supported by the NIH Early Independence Award. One author declared consulting fees from the pharmaceutical industry, and another declared private sector support through Yale University. No other conflicts of interest were declared.
We believe that health care is a right, not a privilege, and all Americans should have access to high-quality health care, regardless of their income or personal circumstances. The United States has the most advanced health care system in the world by many criteria, but access to the system is uneven. Even with the ACA, 29 million people were without health insurance coverage for the entire 2015 calendar year.
The central questions remain of how to attain a health care system that is accessible to all Americans, that provides needed care while avoiding unnecessary care, and that delivers care at an affordable and sustainable price. The next steps are to build on the progress that has been made, which will require further improvements in health insurance coverage, the ability of people to obtain needed medical care regardless of income, and a continued shift away from fee-for-service medicine. The future is about universal health care coverage and access, improved quality, and payment reforms that will have a meaningful impact on the costs of health care and prescription drugs.
Rita F. Redberg, MD, is the editor of JAMA Internal Medicine, Robert Steinbrook, MD, is an editor at large, and Mitchell H. Katz, MD, is deputy editor. Their comments are taken from an accompanying editorial (JAMA Intern Med 2017 Jan 20. doi: 10.1001/jamainternmed.2016.9542). No conflicts of interest were declared.
We believe that health care is a right, not a privilege, and all Americans should have access to high-quality health care, regardless of their income or personal circumstances. The United States has the most advanced health care system in the world by many criteria, but access to the system is uneven. Even with the ACA, 29 million people were without health insurance coverage for the entire 2015 calendar year.
The central questions remain of how to attain a health care system that is accessible to all Americans, that provides needed care while avoiding unnecessary care, and that delivers care at an affordable and sustainable price. The next steps are to build on the progress that has been made, which will require further improvements in health insurance coverage, the ability of people to obtain needed medical care regardless of income, and a continued shift away from fee-for-service medicine. The future is about universal health care coverage and access, improved quality, and payment reforms that will have a meaningful impact on the costs of health care and prescription drugs.
Rita F. Redberg, MD, is the editor of JAMA Internal Medicine, Robert Steinbrook, MD, is an editor at large, and Mitchell H. Katz, MD, is deputy editor. Their comments are taken from an accompanying editorial (JAMA Intern Med 2017 Jan 20. doi: 10.1001/jamainternmed.2016.9542). No conflicts of interest were declared.
We believe that health care is a right, not a privilege, and all Americans should have access to high-quality health care, regardless of their income or personal circumstances. The United States has the most advanced health care system in the world by many criteria, but access to the system is uneven. Even with the ACA, 29 million people were without health insurance coverage for the entire 2015 calendar year.
The central questions remain of how to attain a health care system that is accessible to all Americans, that provides needed care while avoiding unnecessary care, and that delivers care at an affordable and sustainable price. The next steps are to build on the progress that has been made, which will require further improvements in health insurance coverage, the ability of people to obtain needed medical care regardless of income, and a continued shift away from fee-for-service medicine. The future is about universal health care coverage and access, improved quality, and payment reforms that will have a meaningful impact on the costs of health care and prescription drugs.
Rita F. Redberg, MD, is the editor of JAMA Internal Medicine, Robert Steinbrook, MD, is an editor at large, and Mitchell H. Katz, MD, is deputy editor. Their comments are taken from an accompanying editorial (JAMA Intern Med 2017 Jan 20. doi: 10.1001/jamainternmed.2016.9542). No conflicts of interest were declared.
Individuals at risk of losing health insurance with a potential repeal of the Affordable Care Act have significantly higher rates of self-reported poor health and are more likely to have certain chronic diseases, according to a research letter published Jan. 20 in JAMA Internal Medicine.
Researchers looked at data from the National Health Interview Survey, focusing on the three groups of adults under 65 years who would be most likely to lose their health insurance if the ACA were repealed: those with incomes below 400% of the federal poverty level (FPL) who purchased insurance through the health insurance exchanges, childless adults with incomes below 138% of the FPL who gained coverage via expanded Medicaid, and Medicaid-enrolled parents or adults in families with children who did not receive disability insurance and whose income was 50%-138% of the FPL.
“Approximately 20 million individuals have gained health insurance under the Affordable Care Act (ACA), including young adults covered under parental insurance, those purchasing private insurance on exchanges, and those covered through state Medicaid expansion,” wrote Pinar Karaca-Mandic, PhD, of the University of Minnesota School of Public Health, Minneapolis, and her coauthors. “As of mid-2016, 10.4 million individuals had private insurance policies through the exchanges, of whom 84% had incomes below 400% of the federal poverty level (FPL) and received premium tax credits.”
Compared with adults under 65 who had employer-sponsored health insurance, adults in these three groups were significantly more likely to self-report their health as “fair or poor” (JAMA Intern Med. 2017 Jan 20. doi: 10.1001/jamainternmed.2016.9541).
Adults without children and with incomes below 138% of the federal poverty level also had a significantly greater incidence of hypertension, coronary heart disease, cancer, diabetes, stroke, or any heart condition, compared with individuals with employer-sponsored insurance.
They were also significantly more likely to have visited a physician 10 or more times or visited the emergency department at least twice in the past year, and to have undergone surgery in the past year.
“Our analysis highlights the socioeconomic vulnerability and rates of chronic diseases and health care utilization of individuals at risk to lose health insurance if the ACA is modified or repealed,” according to Dr. Karaca-Mandic. “These consequences point to the challenges Congress should address before enacting new health care legislation.”
The study was supported by the NIH Early Independence Award. One author declared consulting fees from the pharmaceutical industry, and another declared private sector support through Yale University. No other conflicts of interest were declared.
Individuals at risk of losing health insurance with a potential repeal of the Affordable Care Act have significantly higher rates of self-reported poor health and are more likely to have certain chronic diseases, according to a research letter published Jan. 20 in JAMA Internal Medicine.
Researchers looked at data from the National Health Interview Survey, focusing on the three groups of adults under 65 years who would be most likely to lose their health insurance if the ACA were repealed: those with incomes below 400% of the federal poverty level (FPL) who purchased insurance through the health insurance exchanges, childless adults with incomes below 138% of the FPL who gained coverage via expanded Medicaid, and Medicaid-enrolled parents or adults in families with children who did not receive disability insurance and whose income was 50%-138% of the FPL.
“Approximately 20 million individuals have gained health insurance under the Affordable Care Act (ACA), including young adults covered under parental insurance, those purchasing private insurance on exchanges, and those covered through state Medicaid expansion,” wrote Pinar Karaca-Mandic, PhD, of the University of Minnesota School of Public Health, Minneapolis, and her coauthors. “As of mid-2016, 10.4 million individuals had private insurance policies through the exchanges, of whom 84% had incomes below 400% of the federal poverty level (FPL) and received premium tax credits.”
Compared with adults under 65 who had employer-sponsored health insurance, adults in these three groups were significantly more likely to self-report their health as “fair or poor” (JAMA Intern Med. 2017 Jan 20. doi: 10.1001/jamainternmed.2016.9541).
Adults without children and with incomes below 138% of the federal poverty level also had a significantly greater incidence of hypertension, coronary heart disease, cancer, diabetes, stroke, or any heart condition, compared with individuals with employer-sponsored insurance.
They were also significantly more likely to have visited a physician 10 or more times or visited the emergency department at least twice in the past year, and to have undergone surgery in the past year.
“Our analysis highlights the socioeconomic vulnerability and rates of chronic diseases and health care utilization of individuals at risk to lose health insurance if the ACA is modified or repealed,” according to Dr. Karaca-Mandic. “These consequences point to the challenges Congress should address before enacting new health care legislation.”
The study was supported by the NIH Early Independence Award. One author declared consulting fees from the pharmaceutical industry, and another declared private sector support through Yale University. No other conflicts of interest were declared.
FROM JAMA INTERNAL MEDICINE
Key clinical point: Adults at risk of losing health coverage if the Affordable Care Act were repealed have significantly higher rates of poor health and are more likely to suffer chronic diseases.
Major finding: Individuals at risk of losing health insurance with the rollback of the Affordable Care Act are significantly more likely than individuals with employer-sponsored health insurance to self-report their health as “fair or poor.”
Data source: An analysis of data from the population-based National Health Interview Survey.
Disclosures: The study was supported by the NIH Early Independence Award. One author declared consulting fees from the pharmaceutical industry, and another declared private sector support through Yale University. No other conflicts of interest were declared.
From the Washington Office: ACS Works to Establish Joint Trauma System in NDAA
I am frequently asked for examples of successes from the College’s advocacy efforts in DC. While many of our successes come in the form of legislation or regulation we are either able to significantly modify into more favorable form or to outright prevent from being enacted, this month’s topic provides an example of how our advocacy efforts are equally successful in obtaining specific provisions in legislation.
Over a year ago, staff of the Division of Advocacy and Health Policy were approached by members and staff of the Military Health System Strategic Partnership American College of Surgeons to assist them in their effort toward the establishment of both a Joint Trauma System (JTS) within the Defense Health Agency (to promote continuous improvement of trauma care provided to members of the Armed Forces) and a Joint Trauma Education and Training Directorate (JTETD) (to ensure military traumatologists maintain readiness with regard to critical surgical skills). I am pleased and proud to report that when the U.S. House of Representatives, on December 2, and the Senate, on December 8, passed the National Defense Authorization Act (NDAA), provisions for both the JTS and the JTETD, in nearly the precise wording as was proposed by ACS, were included in the legislation.
Our success in this effort was strongly supported by both Rep. Joe Heck, DO (R-Nev.), Chairman of the House Armed Services Subcommittee on Military Personnel, and Rep. Brad Wenstrup, DPM (R-Ohio). Rep. Heck, who is a Brigadier General in the Army Reserve, ensured that the language establishing the JTS within the U.S. Department of Defense and the JTETD were included in the House version of the NDAA. Rep. Wenstrup, who also serves in the Army Reserve, was key to securing language providing for review of the military trauma system under the JTS by a “non-government entity with subject matter experts.” This is an activity that the ACS Committee on Trauma Verification, Review, and Consultation Program conducts on a regular basis.
The Joint Trauma System will standardize trauma care in the military by establishing uniform standards for all military medical treatment facilities. The Joint Trauma Education and Training Directorate is charged with ensuring that trauma providers of the U.S. Armed Forces maintain a state of readiness. Under this provision, partnerships will be established with level one trauma centers in civilian academic medical centers and large metropolitan teaching hospitals where combat casualty care teams will embed to provide military surgeons with regular exposure to critically injured patients.
The Senate version of the NDAA did not contain language specifically outlining provisions for either the JTS or the JTETD. Because the House and Senate versions of the NDAA were different, a conference committee from both legislative bodies was appointed to settle the differences between the two versions of the legislation. Over the several months duration of the conference committee process, members of the ACS legislative affairs team met regularly with the offices of several key senators who serve on the Senate Armed Services Committee as well as with committee staff for both the Republican and Democrat members of the committee. During these meetings, we repeatedly “made the case” relative to the critically important nature of these provisions and were able to answer questions and address concerns relative to why ACS felt it was vitally important to include the House language in the final version of the bill. No doubt, these efforts were key in the decision of the Senate negotiators to recede their position and agree to the House language in the final version of the bill relative to these specific provisions.
Prior to the final House vote on the conference committee language of the NDAA, Rep. Wenstrup spoke on the House floor in support of the JTETD.
As I write, the legislation is awaiting signature by President Obama and it is expected he will do so in the coming days.
ACS’ successful efforts toward the establishment of the Joint Trauma System and the Joint Trauma Education and Training Directorate represent a significant achievement toward ensuring that our soldiers, sailors, airmen, Marines and guardsmen continue to receive the best of the best in trauma care while in the service of our nation.
Until next month ….
Dr. Bailey is a pediatric surgeon, and Medical Director, Advocacy, for the Division of Advocacy and Health Policy in the ACS offices in Washington, D.C.
I am frequently asked for examples of successes from the College’s advocacy efforts in DC. While many of our successes come in the form of legislation or regulation we are either able to significantly modify into more favorable form or to outright prevent from being enacted, this month’s topic provides an example of how our advocacy efforts are equally successful in obtaining specific provisions in legislation.
Over a year ago, staff of the Division of Advocacy and Health Policy were approached by members and staff of the Military Health System Strategic Partnership American College of Surgeons to assist them in their effort toward the establishment of both a Joint Trauma System (JTS) within the Defense Health Agency (to promote continuous improvement of trauma care provided to members of the Armed Forces) and a Joint Trauma Education and Training Directorate (JTETD) (to ensure military traumatologists maintain readiness with regard to critical surgical skills). I am pleased and proud to report that when the U.S. House of Representatives, on December 2, and the Senate, on December 8, passed the National Defense Authorization Act (NDAA), provisions for both the JTS and the JTETD, in nearly the precise wording as was proposed by ACS, were included in the legislation.
Our success in this effort was strongly supported by both Rep. Joe Heck, DO (R-Nev.), Chairman of the House Armed Services Subcommittee on Military Personnel, and Rep. Brad Wenstrup, DPM (R-Ohio). Rep. Heck, who is a Brigadier General in the Army Reserve, ensured that the language establishing the JTS within the U.S. Department of Defense and the JTETD were included in the House version of the NDAA. Rep. Wenstrup, who also serves in the Army Reserve, was key to securing language providing for review of the military trauma system under the JTS by a “non-government entity with subject matter experts.” This is an activity that the ACS Committee on Trauma Verification, Review, and Consultation Program conducts on a regular basis.
The Joint Trauma System will standardize trauma care in the military by establishing uniform standards for all military medical treatment facilities. The Joint Trauma Education and Training Directorate is charged with ensuring that trauma providers of the U.S. Armed Forces maintain a state of readiness. Under this provision, partnerships will be established with level one trauma centers in civilian academic medical centers and large metropolitan teaching hospitals where combat casualty care teams will embed to provide military surgeons with regular exposure to critically injured patients.
The Senate version of the NDAA did not contain language specifically outlining provisions for either the JTS or the JTETD. Because the House and Senate versions of the NDAA were different, a conference committee from both legislative bodies was appointed to settle the differences between the two versions of the legislation. Over the several months duration of the conference committee process, members of the ACS legislative affairs team met regularly with the offices of several key senators who serve on the Senate Armed Services Committee as well as with committee staff for both the Republican and Democrat members of the committee. During these meetings, we repeatedly “made the case” relative to the critically important nature of these provisions and were able to answer questions and address concerns relative to why ACS felt it was vitally important to include the House language in the final version of the bill. No doubt, these efforts were key in the decision of the Senate negotiators to recede their position and agree to the House language in the final version of the bill relative to these specific provisions.
Prior to the final House vote on the conference committee language of the NDAA, Rep. Wenstrup spoke on the House floor in support of the JTETD.
As I write, the legislation is awaiting signature by President Obama and it is expected he will do so in the coming days.
ACS’ successful efforts toward the establishment of the Joint Trauma System and the Joint Trauma Education and Training Directorate represent a significant achievement toward ensuring that our soldiers, sailors, airmen, Marines and guardsmen continue to receive the best of the best in trauma care while in the service of our nation.
Until next month ….
Dr. Bailey is a pediatric surgeon, and Medical Director, Advocacy, for the Division of Advocacy and Health Policy in the ACS offices in Washington, D.C.
I am frequently asked for examples of successes from the College’s advocacy efforts in DC. While many of our successes come in the form of legislation or regulation we are either able to significantly modify into more favorable form or to outright prevent from being enacted, this month’s topic provides an example of how our advocacy efforts are equally successful in obtaining specific provisions in legislation.
Over a year ago, staff of the Division of Advocacy and Health Policy were approached by members and staff of the Military Health System Strategic Partnership American College of Surgeons to assist them in their effort toward the establishment of both a Joint Trauma System (JTS) within the Defense Health Agency (to promote continuous improvement of trauma care provided to members of the Armed Forces) and a Joint Trauma Education and Training Directorate (JTETD) (to ensure military traumatologists maintain readiness with regard to critical surgical skills). I am pleased and proud to report that when the U.S. House of Representatives, on December 2, and the Senate, on December 8, passed the National Defense Authorization Act (NDAA), provisions for both the JTS and the JTETD, in nearly the precise wording as was proposed by ACS, were included in the legislation.
Our success in this effort was strongly supported by both Rep. Joe Heck, DO (R-Nev.), Chairman of the House Armed Services Subcommittee on Military Personnel, and Rep. Brad Wenstrup, DPM (R-Ohio). Rep. Heck, who is a Brigadier General in the Army Reserve, ensured that the language establishing the JTS within the U.S. Department of Defense and the JTETD were included in the House version of the NDAA. Rep. Wenstrup, who also serves in the Army Reserve, was key to securing language providing for review of the military trauma system under the JTS by a “non-government entity with subject matter experts.” This is an activity that the ACS Committee on Trauma Verification, Review, and Consultation Program conducts on a regular basis.
The Joint Trauma System will standardize trauma care in the military by establishing uniform standards for all military medical treatment facilities. The Joint Trauma Education and Training Directorate is charged with ensuring that trauma providers of the U.S. Armed Forces maintain a state of readiness. Under this provision, partnerships will be established with level one trauma centers in civilian academic medical centers and large metropolitan teaching hospitals where combat casualty care teams will embed to provide military surgeons with regular exposure to critically injured patients.
The Senate version of the NDAA did not contain language specifically outlining provisions for either the JTS or the JTETD. Because the House and Senate versions of the NDAA were different, a conference committee from both legislative bodies was appointed to settle the differences between the two versions of the legislation. Over the several months duration of the conference committee process, members of the ACS legislative affairs team met regularly with the offices of several key senators who serve on the Senate Armed Services Committee as well as with committee staff for both the Republican and Democrat members of the committee. During these meetings, we repeatedly “made the case” relative to the critically important nature of these provisions and were able to answer questions and address concerns relative to why ACS felt it was vitally important to include the House language in the final version of the bill. No doubt, these efforts were key in the decision of the Senate negotiators to recede their position and agree to the House language in the final version of the bill relative to these specific provisions.
Prior to the final House vote on the conference committee language of the NDAA, Rep. Wenstrup spoke on the House floor in support of the JTETD.
As I write, the legislation is awaiting signature by President Obama and it is expected he will do so in the coming days.
ACS’ successful efforts toward the establishment of the Joint Trauma System and the Joint Trauma Education and Training Directorate represent a significant achievement toward ensuring that our soldiers, sailors, airmen, Marines and guardsmen continue to receive the best of the best in trauma care while in the service of our nation.
Until next month ….
Dr. Bailey is a pediatric surgeon, and Medical Director, Advocacy, for the Division of Advocacy and Health Policy in the ACS offices in Washington, D.C.
From the Editors: One pebble at a time
This is a story about Sarah Prince, FRCS, and thousands of others here and abroad who are surgeons. Only a few of you may have heard of Miss Prince, consultant surgeon from Fort William, Scotland; but she represents to me one of thousands of stories that make surgery such a rich subject that spans more than pure science. Sarah achieved immortality in what she accomplished in 43 short years.
Sarah was trained in the United Kingdom system, attaining specialty training in hepatobiliary disease. While she loved that sort of work she decided, with her internist husband Patrick Byrne, to work in a rural town in northern Scotland. In nine years she built up the hospital there and its training paradigm. She went on to work toward creating a better rural surgical system in Scotland, eventually becoming an expert who spoke all over the world about rural surgery and allocating resources to build surgical capacity in rural areas. She understood the volume debate and the need for rural surgeons to have a connection that was substantive with a larger center in a collaborative way benefiting both locales.
I bring her up because she represents something we all can do. A few surgeons become academic giants known far and wide, but all surgeons have the ability to be local giants, unknown but immortal and essential in their own way. Sarah’s accomplishments confirm that.
Unlike surgery in the United States, the U.K. system is more regimented in many ways and even more political than what the average U.S. surgeon experiences. It is a single-payer system that was there long before Sarah became a surgeon and will be there long after. The fact that the system into which she was born was not of her making did not deter Sarah from taking on that very system to make her corner of the world a better place. I was always surprised when speaking with her that the problems she faced in Scotland were much the same as what I’ve seen in rural surgery in the United States and in other countries. She didn’t bend the whole system but she made a significant dent in how things were done. Isn’t that the challenge for us all?
Recently on the ACS Communities and elsewhere, the debate on single-payer, multitier, and market-driven health care is being argued. In light of the current political environment, the path forward seems bewilderingly tangled. Most surgeons just want to operate. The OR may be the last bastion of control we surgeons have in our professional lives. There may be a barrage of obstacles getting to the OR and hordes of explanations and details postoperatively, but in the OR we still get to do what we think is best at the moment using all those skills we so painfully acquired during a career of learning and practice. To despair is easy until one takes a look at what so many surgeons achieve in their lives.
Like Sarah, most of us try to make the profession a little better. In small town Iowa, that may be getting sonography privileges for FAST exams that improves the lot of trauma patients in that town. In an exburbia hospital, the surgeon may bring new expertise not previously available. It goes on and on with each of us contributing one pebble at a time to a mountain of effort. Any one pebble seems so insignificant in itself and sometimes just placing it on the mountain takes enormous effort, but each is worth the toil to put it there.
Which brings us back to Miss Prince (it is a faux pas to call a consultant surgeon in the U.K. by the honorific doctor). Sarah faced just as many challenges and perhaps more than surgeons elsewhere. Yet she brought her best every day to her hospital until cruel fate delivered her a fatal blow at a young age. Even then facing her imminent death, Sarah made sure that her patients and trainees would be well cared for after her passing. Her indomitable approach to surgical life shows that no matter what the opposition, a surgeon can with grit and wit make life better in his or her town, region, and maybe even the world.
As we face 2017 with all its potential for defeat or victory for our patients, let us remember surgeons like Sarah Prince who made a difference and commit ourselves to the same goal. We can do it one pebble at a time until we’ve created a mountain of accomplishment.
Dr. Hughes is clinical professor in the department of surgery and director of medical education at the Kansas University School of Medicine, Salina Campus, and Co-Editor of ACS Surgery News.
This is a story about Sarah Prince, FRCS, and thousands of others here and abroad who are surgeons. Only a few of you may have heard of Miss Prince, consultant surgeon from Fort William, Scotland; but she represents to me one of thousands of stories that make surgery such a rich subject that spans more than pure science. Sarah achieved immortality in what she accomplished in 43 short years.
Sarah was trained in the United Kingdom system, attaining specialty training in hepatobiliary disease. While she loved that sort of work she decided, with her internist husband Patrick Byrne, to work in a rural town in northern Scotland. In nine years she built up the hospital there and its training paradigm. She went on to work toward creating a better rural surgical system in Scotland, eventually becoming an expert who spoke all over the world about rural surgery and allocating resources to build surgical capacity in rural areas. She understood the volume debate and the need for rural surgeons to have a connection that was substantive with a larger center in a collaborative way benefiting both locales.
I bring her up because she represents something we all can do. A few surgeons become academic giants known far and wide, but all surgeons have the ability to be local giants, unknown but immortal and essential in their own way. Sarah’s accomplishments confirm that.
Unlike surgery in the United States, the U.K. system is more regimented in many ways and even more political than what the average U.S. surgeon experiences. It is a single-payer system that was there long before Sarah became a surgeon and will be there long after. The fact that the system into which she was born was not of her making did not deter Sarah from taking on that very system to make her corner of the world a better place. I was always surprised when speaking with her that the problems she faced in Scotland were much the same as what I’ve seen in rural surgery in the United States and in other countries. She didn’t bend the whole system but she made a significant dent in how things were done. Isn’t that the challenge for us all?
Recently on the ACS Communities and elsewhere, the debate on single-payer, multitier, and market-driven health care is being argued. In light of the current political environment, the path forward seems bewilderingly tangled. Most surgeons just want to operate. The OR may be the last bastion of control we surgeons have in our professional lives. There may be a barrage of obstacles getting to the OR and hordes of explanations and details postoperatively, but in the OR we still get to do what we think is best at the moment using all those skills we so painfully acquired during a career of learning and practice. To despair is easy until one takes a look at what so many surgeons achieve in their lives.
Like Sarah, most of us try to make the profession a little better. In small town Iowa, that may be getting sonography privileges for FAST exams that improves the lot of trauma patients in that town. In an exburbia hospital, the surgeon may bring new expertise not previously available. It goes on and on with each of us contributing one pebble at a time to a mountain of effort. Any one pebble seems so insignificant in itself and sometimes just placing it on the mountain takes enormous effort, but each is worth the toil to put it there.
Which brings us back to Miss Prince (it is a faux pas to call a consultant surgeon in the U.K. by the honorific doctor). Sarah faced just as many challenges and perhaps more than surgeons elsewhere. Yet she brought her best every day to her hospital until cruel fate delivered her a fatal blow at a young age. Even then facing her imminent death, Sarah made sure that her patients and trainees would be well cared for after her passing. Her indomitable approach to surgical life shows that no matter what the opposition, a surgeon can with grit and wit make life better in his or her town, region, and maybe even the world.
As we face 2017 with all its potential for defeat or victory for our patients, let us remember surgeons like Sarah Prince who made a difference and commit ourselves to the same goal. We can do it one pebble at a time until we’ve created a mountain of accomplishment.
Dr. Hughes is clinical professor in the department of surgery and director of medical education at the Kansas University School of Medicine, Salina Campus, and Co-Editor of ACS Surgery News.
This is a story about Sarah Prince, FRCS, and thousands of others here and abroad who are surgeons. Only a few of you may have heard of Miss Prince, consultant surgeon from Fort William, Scotland; but she represents to me one of thousands of stories that make surgery such a rich subject that spans more than pure science. Sarah achieved immortality in what she accomplished in 43 short years.
Sarah was trained in the United Kingdom system, attaining specialty training in hepatobiliary disease. While she loved that sort of work she decided, with her internist husband Patrick Byrne, to work in a rural town in northern Scotland. In nine years she built up the hospital there and its training paradigm. She went on to work toward creating a better rural surgical system in Scotland, eventually becoming an expert who spoke all over the world about rural surgery and allocating resources to build surgical capacity in rural areas. She understood the volume debate and the need for rural surgeons to have a connection that was substantive with a larger center in a collaborative way benefiting both locales.
I bring her up because she represents something we all can do. A few surgeons become academic giants known far and wide, but all surgeons have the ability to be local giants, unknown but immortal and essential in their own way. Sarah’s accomplishments confirm that.
Unlike surgery in the United States, the U.K. system is more regimented in many ways and even more political than what the average U.S. surgeon experiences. It is a single-payer system that was there long before Sarah became a surgeon and will be there long after. The fact that the system into which she was born was not of her making did not deter Sarah from taking on that very system to make her corner of the world a better place. I was always surprised when speaking with her that the problems she faced in Scotland were much the same as what I’ve seen in rural surgery in the United States and in other countries. She didn’t bend the whole system but she made a significant dent in how things were done. Isn’t that the challenge for us all?
Recently on the ACS Communities and elsewhere, the debate on single-payer, multitier, and market-driven health care is being argued. In light of the current political environment, the path forward seems bewilderingly tangled. Most surgeons just want to operate. The OR may be the last bastion of control we surgeons have in our professional lives. There may be a barrage of obstacles getting to the OR and hordes of explanations and details postoperatively, but in the OR we still get to do what we think is best at the moment using all those skills we so painfully acquired during a career of learning and practice. To despair is easy until one takes a look at what so many surgeons achieve in their lives.
Like Sarah, most of us try to make the profession a little better. In small town Iowa, that may be getting sonography privileges for FAST exams that improves the lot of trauma patients in that town. In an exburbia hospital, the surgeon may bring new expertise not previously available. It goes on and on with each of us contributing one pebble at a time to a mountain of effort. Any one pebble seems so insignificant in itself and sometimes just placing it on the mountain takes enormous effort, but each is worth the toil to put it there.
Which brings us back to Miss Prince (it is a faux pas to call a consultant surgeon in the U.K. by the honorific doctor). Sarah faced just as many challenges and perhaps more than surgeons elsewhere. Yet she brought her best every day to her hospital until cruel fate delivered her a fatal blow at a young age. Even then facing her imminent death, Sarah made sure that her patients and trainees would be well cared for after her passing. Her indomitable approach to surgical life shows that no matter what the opposition, a surgeon can with grit and wit make life better in his or her town, region, and maybe even the world.
As we face 2017 with all its potential for defeat or victory for our patients, let us remember surgeons like Sarah Prince who made a difference and commit ourselves to the same goal. We can do it one pebble at a time until we’ve created a mountain of accomplishment.
Dr. Hughes is clinical professor in the department of surgery and director of medical education at the Kansas University School of Medicine, Salina Campus, and Co-Editor of ACS Surgery News.