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The power of quiet
In his insightful book “The Wisdom of Crowds” (New York: Anchor Books, 2004), James Surowiecke makes the convincing argument that many heads are wiser than one, even if that one is the sole expert regarding the subject under discussion. As long as the decision-making group is diverse, with each individual being allowed to come to an independent conclusion, this tenet appears to hold, whether the group is estimating the number of jelly beans in a jar or resolving a difficult issue. The message is clear: As a leader your leadership will be more effective if you solicit input from all members of your group, including those who may be reluctant to offer it.
In another excellent book, “Quiet” (New York: Crown Publishers, 2012), Susan Cain posits that, from early in the 20th century on, despite the considerable value it has to offer, introversion has become a “second-class personality trait.” Although highly valued earlier in our history, the thoughtful, introspective temperament was replaced by the aggressive, decisive character as the ideal.
Emblematic of the shift that was taking place in American culture was the publication in 1936 of one of the first self-help books, “How to Win Friends and Influence People” (Dale Carnegie, New York: Simon and Schuster, 1936), which extolled the virtues of an outgoing, dominant personality. That a gregarious, sociable person was more likely to find success than a quiet, contemplative one became a part of common knowledge. The shift was so extreme that many parents became concerned when they detected shyness in their child and often attempted to correct what was thought by many to be an inferior personality trait.
Cain delves deeply into the substantial differences between extroverts and introverts, acknowledging that there are many gradations between the extremes. Extroverts tend to be loquacious and are seldom hesitant to offer their opinions on complex, difficult issues, even when their understanding of them is limited. They don’t always think before speaking and are less skilled listeners than introverts. They prefer to come to decisions rapidly, sometimes with incomplete data, and are much more decisive than introverts.
Introverts, on the other hand, prefer to listen rather than talk and to thoroughly vet an issue before reaching a decision. When they do, they are uncomfortable expressing it in a group setting. They prefer to work alone rather than in groups and, because of their thoughtful approach, their solutions to problems may be more innovative and sound than the shoot-from-the-hip, rapid answers that extroverts frequently propose. They abhor conflict and are likely to remain silent during controversy. In sum, although more difficult to elicit, obtaining input from the quiet members of the group is very worthwhile.
Often the most timely and ideal resolution is reached by balanced contributions from both personality types, the decision-making extroverts and the more thoughtful but reticent introverts. In fact, some of the best team members are those who are not on either extreme of the extrovert-introvert scale. But considering the fact that one-third to one-half of Americans are introverts (I suspect the fraction is a bit less among surgeons) and hesitant to offer their opinions in a group setting, how is this to be accomplished?
First, as a leader, you need to be sensitive to the fact that the introverts in your group are likely out of their comfort zone during communal meetings. It may even be embarrassing for them if they are called upon to offer their advice or opinion. To some degree this reluctance can be overcome by a leader who always attempts to reach consensus by valuing everyone’s opinion. Even the arrangement of the meeting room is important. The ideal is for all participants to be situated around a table rather than facing an imposing leader at the front of the room. This “leveling of the play field” emphasizes equality, de-emphasizes hierarchy, and encourages all to participate. The least likely to contribute can often be nudged from their quiet solitude by gentle urging from the leader with a statement such as: “Joe, I know you have a thoughtful perspective on this. Can you share it with the group?”
However, even the best-run meeting may not result in satisfactory resolution of difficult issues. In my experience, even those toward the extrovert end of the spectrum may be hesitant to offer their honest opinion in a meeting if it is in conflict with that of the leader. It is not uncommon to come to a consensus resolution of a controversial issue in a group meeting only to find out from hallway chatter that many disagree with the agreement reached. It is essential that the leader have access to this hallway chatter. This can be accomplished by way of confidantes who have the trust of both the troops and the leader.
During my years of leadership, a useful and productive technique I fostered to prompt input from introverts and honest assessments from all was to visit individual offices after the busy work day had quieted down, usually after 5 p.m. Meeting with individual faculty in their offices rather than in mine lent an informality to the conversation that could not be duplicated in the office of the chairman. In these one-on-one encounters, I found that even my relatively quiet faculty members felt comfortable in expressing their views regarding controversial issues facing our department. These informal chats also allowed me to become aware of problems they were facing in their professional and personal lives. They were great opportunities for mentoring and bonding as well. When these individual discussions precede what is anticipated to be a contentious group meeting, the likelihood of a successful conclusion is significantly enhanced.
Although my leadership experience was confined within the walls of academe, I believe these principles apply to anyone invited to lead a group in virtually any setting. Individual meetings are not an efficient way to lead, but they may provide a more effective and, in some cases, more rapid means of reaching consensus than innumerable group meetings with follow-up emails. When the group is too large to conference with everyone individually, one-on-one meetings with several key players may achieve the same result. During the process, don’t forget the quiet ones. They sometimes contribute the best and most innovative solutions to complex problems. There is power in quiet.
Dr. Rikkers is Editor in Chief of ACS Surgery News.
In his insightful book “The Wisdom of Crowds” (New York: Anchor Books, 2004), James Surowiecke makes the convincing argument that many heads are wiser than one, even if that one is the sole expert regarding the subject under discussion. As long as the decision-making group is diverse, with each individual being allowed to come to an independent conclusion, this tenet appears to hold, whether the group is estimating the number of jelly beans in a jar or resolving a difficult issue. The message is clear: As a leader your leadership will be more effective if you solicit input from all members of your group, including those who may be reluctant to offer it.
In another excellent book, “Quiet” (New York: Crown Publishers, 2012), Susan Cain posits that, from early in the 20th century on, despite the considerable value it has to offer, introversion has become a “second-class personality trait.” Although highly valued earlier in our history, the thoughtful, introspective temperament was replaced by the aggressive, decisive character as the ideal.
Emblematic of the shift that was taking place in American culture was the publication in 1936 of one of the first self-help books, “How to Win Friends and Influence People” (Dale Carnegie, New York: Simon and Schuster, 1936), which extolled the virtues of an outgoing, dominant personality. That a gregarious, sociable person was more likely to find success than a quiet, contemplative one became a part of common knowledge. The shift was so extreme that many parents became concerned when they detected shyness in their child and often attempted to correct what was thought by many to be an inferior personality trait.
Cain delves deeply into the substantial differences between extroverts and introverts, acknowledging that there are many gradations between the extremes. Extroverts tend to be loquacious and are seldom hesitant to offer their opinions on complex, difficult issues, even when their understanding of them is limited. They don’t always think before speaking and are less skilled listeners than introverts. They prefer to come to decisions rapidly, sometimes with incomplete data, and are much more decisive than introverts.
Introverts, on the other hand, prefer to listen rather than talk and to thoroughly vet an issue before reaching a decision. When they do, they are uncomfortable expressing it in a group setting. They prefer to work alone rather than in groups and, because of their thoughtful approach, their solutions to problems may be more innovative and sound than the shoot-from-the-hip, rapid answers that extroverts frequently propose. They abhor conflict and are likely to remain silent during controversy. In sum, although more difficult to elicit, obtaining input from the quiet members of the group is very worthwhile.
Often the most timely and ideal resolution is reached by balanced contributions from both personality types, the decision-making extroverts and the more thoughtful but reticent introverts. In fact, some of the best team members are those who are not on either extreme of the extrovert-introvert scale. But considering the fact that one-third to one-half of Americans are introverts (I suspect the fraction is a bit less among surgeons) and hesitant to offer their opinions in a group setting, how is this to be accomplished?
First, as a leader, you need to be sensitive to the fact that the introverts in your group are likely out of their comfort zone during communal meetings. It may even be embarrassing for them if they are called upon to offer their advice or opinion. To some degree this reluctance can be overcome by a leader who always attempts to reach consensus by valuing everyone’s opinion. Even the arrangement of the meeting room is important. The ideal is for all participants to be situated around a table rather than facing an imposing leader at the front of the room. This “leveling of the play field” emphasizes equality, de-emphasizes hierarchy, and encourages all to participate. The least likely to contribute can often be nudged from their quiet solitude by gentle urging from the leader with a statement such as: “Joe, I know you have a thoughtful perspective on this. Can you share it with the group?”
However, even the best-run meeting may not result in satisfactory resolution of difficult issues. In my experience, even those toward the extrovert end of the spectrum may be hesitant to offer their honest opinion in a meeting if it is in conflict with that of the leader. It is not uncommon to come to a consensus resolution of a controversial issue in a group meeting only to find out from hallway chatter that many disagree with the agreement reached. It is essential that the leader have access to this hallway chatter. This can be accomplished by way of confidantes who have the trust of both the troops and the leader.
During my years of leadership, a useful and productive technique I fostered to prompt input from introverts and honest assessments from all was to visit individual offices after the busy work day had quieted down, usually after 5 p.m. Meeting with individual faculty in their offices rather than in mine lent an informality to the conversation that could not be duplicated in the office of the chairman. In these one-on-one encounters, I found that even my relatively quiet faculty members felt comfortable in expressing their views regarding controversial issues facing our department. These informal chats also allowed me to become aware of problems they were facing in their professional and personal lives. They were great opportunities for mentoring and bonding as well. When these individual discussions precede what is anticipated to be a contentious group meeting, the likelihood of a successful conclusion is significantly enhanced.
Although my leadership experience was confined within the walls of academe, I believe these principles apply to anyone invited to lead a group in virtually any setting. Individual meetings are not an efficient way to lead, but they may provide a more effective and, in some cases, more rapid means of reaching consensus than innumerable group meetings with follow-up emails. When the group is too large to conference with everyone individually, one-on-one meetings with several key players may achieve the same result. During the process, don’t forget the quiet ones. They sometimes contribute the best and most innovative solutions to complex problems. There is power in quiet.
Dr. Rikkers is Editor in Chief of ACS Surgery News.
In his insightful book “The Wisdom of Crowds” (New York: Anchor Books, 2004), James Surowiecke makes the convincing argument that many heads are wiser than one, even if that one is the sole expert regarding the subject under discussion. As long as the decision-making group is diverse, with each individual being allowed to come to an independent conclusion, this tenet appears to hold, whether the group is estimating the number of jelly beans in a jar or resolving a difficult issue. The message is clear: As a leader your leadership will be more effective if you solicit input from all members of your group, including those who may be reluctant to offer it.
In another excellent book, “Quiet” (New York: Crown Publishers, 2012), Susan Cain posits that, from early in the 20th century on, despite the considerable value it has to offer, introversion has become a “second-class personality trait.” Although highly valued earlier in our history, the thoughtful, introspective temperament was replaced by the aggressive, decisive character as the ideal.
Emblematic of the shift that was taking place in American culture was the publication in 1936 of one of the first self-help books, “How to Win Friends and Influence People” (Dale Carnegie, New York: Simon and Schuster, 1936), which extolled the virtues of an outgoing, dominant personality. That a gregarious, sociable person was more likely to find success than a quiet, contemplative one became a part of common knowledge. The shift was so extreme that many parents became concerned when they detected shyness in their child and often attempted to correct what was thought by many to be an inferior personality trait.
Cain delves deeply into the substantial differences between extroverts and introverts, acknowledging that there are many gradations between the extremes. Extroverts tend to be loquacious and are seldom hesitant to offer their opinions on complex, difficult issues, even when their understanding of them is limited. They don’t always think before speaking and are less skilled listeners than introverts. They prefer to come to decisions rapidly, sometimes with incomplete data, and are much more decisive than introverts.
Introverts, on the other hand, prefer to listen rather than talk and to thoroughly vet an issue before reaching a decision. When they do, they are uncomfortable expressing it in a group setting. They prefer to work alone rather than in groups and, because of their thoughtful approach, their solutions to problems may be more innovative and sound than the shoot-from-the-hip, rapid answers that extroverts frequently propose. They abhor conflict and are likely to remain silent during controversy. In sum, although more difficult to elicit, obtaining input from the quiet members of the group is very worthwhile.
Often the most timely and ideal resolution is reached by balanced contributions from both personality types, the decision-making extroverts and the more thoughtful but reticent introverts. In fact, some of the best team members are those who are not on either extreme of the extrovert-introvert scale. But considering the fact that one-third to one-half of Americans are introverts (I suspect the fraction is a bit less among surgeons) and hesitant to offer their opinions in a group setting, how is this to be accomplished?
First, as a leader, you need to be sensitive to the fact that the introverts in your group are likely out of their comfort zone during communal meetings. It may even be embarrassing for them if they are called upon to offer their advice or opinion. To some degree this reluctance can be overcome by a leader who always attempts to reach consensus by valuing everyone’s opinion. Even the arrangement of the meeting room is important. The ideal is for all participants to be situated around a table rather than facing an imposing leader at the front of the room. This “leveling of the play field” emphasizes equality, de-emphasizes hierarchy, and encourages all to participate. The least likely to contribute can often be nudged from their quiet solitude by gentle urging from the leader with a statement such as: “Joe, I know you have a thoughtful perspective on this. Can you share it with the group?”
However, even the best-run meeting may not result in satisfactory resolution of difficult issues. In my experience, even those toward the extrovert end of the spectrum may be hesitant to offer their honest opinion in a meeting if it is in conflict with that of the leader. It is not uncommon to come to a consensus resolution of a controversial issue in a group meeting only to find out from hallway chatter that many disagree with the agreement reached. It is essential that the leader have access to this hallway chatter. This can be accomplished by way of confidantes who have the trust of both the troops and the leader.
During my years of leadership, a useful and productive technique I fostered to prompt input from introverts and honest assessments from all was to visit individual offices after the busy work day had quieted down, usually after 5 p.m. Meeting with individual faculty in their offices rather than in mine lent an informality to the conversation that could not be duplicated in the office of the chairman. In these one-on-one encounters, I found that even my relatively quiet faculty members felt comfortable in expressing their views regarding controversial issues facing our department. These informal chats also allowed me to become aware of problems they were facing in their professional and personal lives. They were great opportunities for mentoring and bonding as well. When these individual discussions precede what is anticipated to be a contentious group meeting, the likelihood of a successful conclusion is significantly enhanced.
Although my leadership experience was confined within the walls of academe, I believe these principles apply to anyone invited to lead a group in virtually any setting. Individual meetings are not an efficient way to lead, but they may provide a more effective and, in some cases, more rapid means of reaching consensus than innumerable group meetings with follow-up emails. When the group is too large to conference with everyone individually, one-on-one meetings with several key players may achieve the same result. During the process, don’t forget the quiet ones. They sometimes contribute the best and most innovative solutions to complex problems. There is power in quiet.
Dr. Rikkers is Editor in Chief of ACS Surgery News.
Autism screening rises after process-based training
A 3- to 6-month learning program for pediatric and family medicine providers significantly improved their screening for autism spectrum disorders (ASD) at 18- and 24-month well child visits, based on data from 26 primary care practices that participated in the program and from 43 physicians who completed surveys before and after the program, according to findings published online May 5 in Pediatrics.
“Unlike traditional continuing medical education, the LC [learning collaborative] focused on improvement of processes of care at the practice level,” wrote Dr. Paul S. Carbone and his colleagues of the University of Utah, Salt Lake City. The first signs of ASD can be present as early as 2 years of age, but often remain undiagnosed for lack of screening at 18- and 24-month visits, they noted.
Rates of documented ASD screening among toddlers increased from 16% before starting the program to 91% during the last month of the program, and 70% of the practices sustained the 91% screening rate 4 years later.
Physician self-efficacy improved significantly from baseline to after the program on the nine autism conditions (such as sleep problems, constipation, and attention deficit/hyperactivity disorder [ADHD]) and seven autism needs (such as making referrals, addressing developmental concerns, and identifying community support services) included in the survey. On a scale of 1 to 10, the average physician’s progress rating was 6.5 after completing the program.
“A LC using the methods we describe is a successful approach to improving the early identification and ongoing care of children with ASD in primary care practices,” they researchers said.
Read the whole article at Pediatrics (2016 May. doi: 10.1542/peds.2015-1850).
A 3- to 6-month learning program for pediatric and family medicine providers significantly improved their screening for autism spectrum disorders (ASD) at 18- and 24-month well child visits, based on data from 26 primary care practices that participated in the program and from 43 physicians who completed surveys before and after the program, according to findings published online May 5 in Pediatrics.
“Unlike traditional continuing medical education, the LC [learning collaborative] focused on improvement of processes of care at the practice level,” wrote Dr. Paul S. Carbone and his colleagues of the University of Utah, Salt Lake City. The first signs of ASD can be present as early as 2 years of age, but often remain undiagnosed for lack of screening at 18- and 24-month visits, they noted.
Rates of documented ASD screening among toddlers increased from 16% before starting the program to 91% during the last month of the program, and 70% of the practices sustained the 91% screening rate 4 years later.
Physician self-efficacy improved significantly from baseline to after the program on the nine autism conditions (such as sleep problems, constipation, and attention deficit/hyperactivity disorder [ADHD]) and seven autism needs (such as making referrals, addressing developmental concerns, and identifying community support services) included in the survey. On a scale of 1 to 10, the average physician’s progress rating was 6.5 after completing the program.
“A LC using the methods we describe is a successful approach to improving the early identification and ongoing care of children with ASD in primary care practices,” they researchers said.
Read the whole article at Pediatrics (2016 May. doi: 10.1542/peds.2015-1850).
A 3- to 6-month learning program for pediatric and family medicine providers significantly improved their screening for autism spectrum disorders (ASD) at 18- and 24-month well child visits, based on data from 26 primary care practices that participated in the program and from 43 physicians who completed surveys before and after the program, according to findings published online May 5 in Pediatrics.
“Unlike traditional continuing medical education, the LC [learning collaborative] focused on improvement of processes of care at the practice level,” wrote Dr. Paul S. Carbone and his colleagues of the University of Utah, Salt Lake City. The first signs of ASD can be present as early as 2 years of age, but often remain undiagnosed for lack of screening at 18- and 24-month visits, they noted.
Rates of documented ASD screening among toddlers increased from 16% before starting the program to 91% during the last month of the program, and 70% of the practices sustained the 91% screening rate 4 years later.
Physician self-efficacy improved significantly from baseline to after the program on the nine autism conditions (such as sleep problems, constipation, and attention deficit/hyperactivity disorder [ADHD]) and seven autism needs (such as making referrals, addressing developmental concerns, and identifying community support services) included in the survey. On a scale of 1 to 10, the average physician’s progress rating was 6.5 after completing the program.
“A LC using the methods we describe is a successful approach to improving the early identification and ongoing care of children with ASD in primary care practices,” they researchers said.
Read the whole article at Pediatrics (2016 May. doi: 10.1542/peds.2015-1850).
FROM PEDIATRICS
Vedolizumab use linked to high rate of postoperative complications in IBD patients
LOS ANGELES – Overall, 44% of inflammatory bowel disease (IBD) patients on vedolizumab had some form of infectious complication following intra-abdominal or anorectal surgery, results from a small single-center study suggest.
According to lead study author Dr. Samuel Eisenstein, there are currently no published surgical outcomes of patients receiving vedolizumab, an integrin receptor antagonist which was approved in May 2014 for the treatment of adults with moderate to severe ulcerative colitis as well as those with moderate to severe Crohn’s disease. “We’re not trying to alienate people who are proponents of the medication,” Dr. Eisenstein said in an interview in advance of the annual meeting of the American Society of Colon and Rectal Surgeons. “It’s an effective medication for treating Crohn’s and ulcerative colitis. We need to have a high index of suspicion that patients may have complications after these surgeries and to treat them with caution until we have better data.”
Dr. Eisenstein and his associates in the section of colon and rectal surgery at Moores Cancer Center, University of California, San Diego, Health System, retrospectively analyzed the medical records of 26 patients with IBD who underwent intra-abdominal or anorectal surgery at the center following treatment with vedolizumab. The patients underwent a total of 36 operations: 27 that were intra-abdominal and 9 that were anorectal. Their mean age was 31 years and 46% were female.
Dr. Eisenstein reported that 17 of the 26 patients (65%) had a Clavien-Dindo grade II or greater complication following 19 operations. In all, 26 complications occurred following these 19 operations, and 53% were infectious in nature. The overall rate of infectious complications following any operation was 44%. In addition, the rate of anastomotic leak was 15%, and two patients died from culture-negative sepsis following abdominal surgery, for an overall mortality rate of 7.7%.
The researchers also observed that there were 23 visits to the emergency room following surgery and 10 hospital readmissions. The only preoperative characteristics that differed significantly between patients who had complications and those who did not were level of hemoglobin (10.6 g/dL vs. 11.9 g/dL, respectively; P = .02) and platelet count (349 vs. 287 K/mm3; P = .025). No differences in the rate of complications were observed based on the number of biologic medications each patient failed prior to the initiation of vedolizumab (P = .718). Compared with patients who had no postoperative complications, those who did were more likely to have undergone intra-abdominal surgery (17 vs. 10 patients; P = .034), require postoperative transfusion (4 vs. none; P = .045), visit the emergency department (10 vs. none; P less than .001), or require hospital readmission (10 vs. none; P less than .001).
Dr. Eisenstein acknowledged certain limitations of the study including its small sample size, single-center, retrospective design, and the potential for selection bias. “The patients who were getting vedolizumab are the patients who failed all of the anti-TNFs, so we’re really selecting patients with the worst, most medically refractory disease,” he noted. “Because of that we can’t say for sure [if the complications] are due to their severity of disease or due to the medication itself.”
The data are “preliminary and retrospectively analyzed, but there is some concern that patients on these types of medications may have an increased risk of postoperative complications,” he concluded. “What we really need are bigger studies. To that end, we are actually starting an IBD collaborative based on some of the findings we have here, because we really want to analyze these data over a much larger population of patients.”
The researchers reported having no financial disclosures.
LOS ANGELES – Overall, 44% of inflammatory bowel disease (IBD) patients on vedolizumab had some form of infectious complication following intra-abdominal or anorectal surgery, results from a small single-center study suggest.
According to lead study author Dr. Samuel Eisenstein, there are currently no published surgical outcomes of patients receiving vedolizumab, an integrin receptor antagonist which was approved in May 2014 for the treatment of adults with moderate to severe ulcerative colitis as well as those with moderate to severe Crohn’s disease. “We’re not trying to alienate people who are proponents of the medication,” Dr. Eisenstein said in an interview in advance of the annual meeting of the American Society of Colon and Rectal Surgeons. “It’s an effective medication for treating Crohn’s and ulcerative colitis. We need to have a high index of suspicion that patients may have complications after these surgeries and to treat them with caution until we have better data.”
Dr. Eisenstein and his associates in the section of colon and rectal surgery at Moores Cancer Center, University of California, San Diego, Health System, retrospectively analyzed the medical records of 26 patients with IBD who underwent intra-abdominal or anorectal surgery at the center following treatment with vedolizumab. The patients underwent a total of 36 operations: 27 that were intra-abdominal and 9 that were anorectal. Their mean age was 31 years and 46% were female.
Dr. Eisenstein reported that 17 of the 26 patients (65%) had a Clavien-Dindo grade II or greater complication following 19 operations. In all, 26 complications occurred following these 19 operations, and 53% were infectious in nature. The overall rate of infectious complications following any operation was 44%. In addition, the rate of anastomotic leak was 15%, and two patients died from culture-negative sepsis following abdominal surgery, for an overall mortality rate of 7.7%.
The researchers also observed that there were 23 visits to the emergency room following surgery and 10 hospital readmissions. The only preoperative characteristics that differed significantly between patients who had complications and those who did not were level of hemoglobin (10.6 g/dL vs. 11.9 g/dL, respectively; P = .02) and platelet count (349 vs. 287 K/mm3; P = .025). No differences in the rate of complications were observed based on the number of biologic medications each patient failed prior to the initiation of vedolizumab (P = .718). Compared with patients who had no postoperative complications, those who did were more likely to have undergone intra-abdominal surgery (17 vs. 10 patients; P = .034), require postoperative transfusion (4 vs. none; P = .045), visit the emergency department (10 vs. none; P less than .001), or require hospital readmission (10 vs. none; P less than .001).
Dr. Eisenstein acknowledged certain limitations of the study including its small sample size, single-center, retrospective design, and the potential for selection bias. “The patients who were getting vedolizumab are the patients who failed all of the anti-TNFs, so we’re really selecting patients with the worst, most medically refractory disease,” he noted. “Because of that we can’t say for sure [if the complications] are due to their severity of disease or due to the medication itself.”
The data are “preliminary and retrospectively analyzed, but there is some concern that patients on these types of medications may have an increased risk of postoperative complications,” he concluded. “What we really need are bigger studies. To that end, we are actually starting an IBD collaborative based on some of the findings we have here, because we really want to analyze these data over a much larger population of patients.”
The researchers reported having no financial disclosures.
LOS ANGELES – Overall, 44% of inflammatory bowel disease (IBD) patients on vedolizumab had some form of infectious complication following intra-abdominal or anorectal surgery, results from a small single-center study suggest.
According to lead study author Dr. Samuel Eisenstein, there are currently no published surgical outcomes of patients receiving vedolizumab, an integrin receptor antagonist which was approved in May 2014 for the treatment of adults with moderate to severe ulcerative colitis as well as those with moderate to severe Crohn’s disease. “We’re not trying to alienate people who are proponents of the medication,” Dr. Eisenstein said in an interview in advance of the annual meeting of the American Society of Colon and Rectal Surgeons. “It’s an effective medication for treating Crohn’s and ulcerative colitis. We need to have a high index of suspicion that patients may have complications after these surgeries and to treat them with caution until we have better data.”
Dr. Eisenstein and his associates in the section of colon and rectal surgery at Moores Cancer Center, University of California, San Diego, Health System, retrospectively analyzed the medical records of 26 patients with IBD who underwent intra-abdominal or anorectal surgery at the center following treatment with vedolizumab. The patients underwent a total of 36 operations: 27 that were intra-abdominal and 9 that were anorectal. Their mean age was 31 years and 46% were female.
Dr. Eisenstein reported that 17 of the 26 patients (65%) had a Clavien-Dindo grade II or greater complication following 19 operations. In all, 26 complications occurred following these 19 operations, and 53% were infectious in nature. The overall rate of infectious complications following any operation was 44%. In addition, the rate of anastomotic leak was 15%, and two patients died from culture-negative sepsis following abdominal surgery, for an overall mortality rate of 7.7%.
The researchers also observed that there were 23 visits to the emergency room following surgery and 10 hospital readmissions. The only preoperative characteristics that differed significantly between patients who had complications and those who did not were level of hemoglobin (10.6 g/dL vs. 11.9 g/dL, respectively; P = .02) and platelet count (349 vs. 287 K/mm3; P = .025). No differences in the rate of complications were observed based on the number of biologic medications each patient failed prior to the initiation of vedolizumab (P = .718). Compared with patients who had no postoperative complications, those who did were more likely to have undergone intra-abdominal surgery (17 vs. 10 patients; P = .034), require postoperative transfusion (4 vs. none; P = .045), visit the emergency department (10 vs. none; P less than .001), or require hospital readmission (10 vs. none; P less than .001).
Dr. Eisenstein acknowledged certain limitations of the study including its small sample size, single-center, retrospective design, and the potential for selection bias. “The patients who were getting vedolizumab are the patients who failed all of the anti-TNFs, so we’re really selecting patients with the worst, most medically refractory disease,” he noted. “Because of that we can’t say for sure [if the complications] are due to their severity of disease or due to the medication itself.”
The data are “preliminary and retrospectively analyzed, but there is some concern that patients on these types of medications may have an increased risk of postoperative complications,” he concluded. “What we really need are bigger studies. To that end, we are actually starting an IBD collaborative based on some of the findings we have here, because we really want to analyze these data over a much larger population of patients.”
The researchers reported having no financial disclosures.
AT THE ASCRS ANNUAL MEETING
Key clinical point:Patients on vedolizumab have a high rate of postoperative complications.
Major finding: The overall rate of infectious complications following intra-abdominal or anorectal surgery was 44%.
Data source: A retrospective study of 26 patients with IBD who underwent intra-abdominal or anorectal surgery following treatment with vedolizumab.
Disclosures: Dr. Eisenstein reported having no financial disclosures.
Study eyes mortality among octogenarians after emergency Hartmann’s procedure
LOS ANGELES – Patients over the age of 80 who present with diverticulitis requiring an emergent Hartmann’s procedure have a 30-day mortality rate of 20%, results from a study of national data demonstrated.
“Given the high morbidity and mortality described in this study, further work to elucidate whether an elective surgical therapy should be pursued in the octogenarian population is warranted,” lead study author Dr. Ian C. Bostock said in an interview in advance of the annual meeting of the American Society of Colon and Rectal Surgeons.
In an effort to investigate the 30-day outcomes for patients undergoing emergent Hartmann’s procedures for diverticular disease, Dr. Bostock of the department of general surgery at Dartmouth Hitchcock Medical Center, Lebanon, N.H., and his associates queried the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database from 2005 to 2013 to identify all patients aged 80 years or older who underwent an open and laparoscopic Hartmann’s procedure in an emergency setting for diverticular disease. They divided patients into two groups: those with 30-day postoperative mortality (expired) and those alive after 30 days (alive), and used univariate analysis to assess the risk of mortality and to identify associated risk factors.
Of the 464 patients who met inclusion criteria, 91 expired within 30 days postoperatively, for a mortality rate of 20%. No statistically significant differences were observed between the expired and alive groups in terms of age, gender distribution, body mass index, smoking status, alcohol use, prior chemotherapy/radiotherapy, comorbid conditions such as diabetes, hypertension, current hemodialysis use, and operative time. Factors identified to be associated with a higher risk for death were congestive heart failure (odds ratio, 3.0), steroid use (OR, 3.0), chronic obstructive pulmonary disease (OR, 2.1), and ASA classification of greater than 3 (OR, 2.9). Additionally, the development of postoperative cardiac arrest (OR, 22.9), MI (OR, 8.7), renal failure (OR, 6.3), respiratory failure (OR, 4.7), and septic shock (OR, 5.6) were associated with death. A laparoscopic procedure was shown to have a protective effect (0.169).
“Interestingly, the most common complication in both groups was respiratory failure,” Dr. Bostock said. “These results suggest that the elderly are more prone to respiratory complications as a whole. These results have been corroborated in prior studies in patients exposed to major abdominal operations.”
Dr. Bostock acknowledged certain limitations of the study, including the fact that ACS-NSQIP is unable to track procedure-specific complications that might occur after surgery. “It mainly helps us to determine the morbidity rate after specific types of procedures,” he said. “Additionally, the exact indication for emergent operation in the patients included in our analysis is unknown since we don’t have any access to specific patient data and/or chart review.”
The researchers reported having no financial disclosures.
LOS ANGELES – Patients over the age of 80 who present with diverticulitis requiring an emergent Hartmann’s procedure have a 30-day mortality rate of 20%, results from a study of national data demonstrated.
“Given the high morbidity and mortality described in this study, further work to elucidate whether an elective surgical therapy should be pursued in the octogenarian population is warranted,” lead study author Dr. Ian C. Bostock said in an interview in advance of the annual meeting of the American Society of Colon and Rectal Surgeons.
In an effort to investigate the 30-day outcomes for patients undergoing emergent Hartmann’s procedures for diverticular disease, Dr. Bostock of the department of general surgery at Dartmouth Hitchcock Medical Center, Lebanon, N.H., and his associates queried the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database from 2005 to 2013 to identify all patients aged 80 years or older who underwent an open and laparoscopic Hartmann’s procedure in an emergency setting for diverticular disease. They divided patients into two groups: those with 30-day postoperative mortality (expired) and those alive after 30 days (alive), and used univariate analysis to assess the risk of mortality and to identify associated risk factors.
Of the 464 patients who met inclusion criteria, 91 expired within 30 days postoperatively, for a mortality rate of 20%. No statistically significant differences were observed between the expired and alive groups in terms of age, gender distribution, body mass index, smoking status, alcohol use, prior chemotherapy/radiotherapy, comorbid conditions such as diabetes, hypertension, current hemodialysis use, and operative time. Factors identified to be associated with a higher risk for death were congestive heart failure (odds ratio, 3.0), steroid use (OR, 3.0), chronic obstructive pulmonary disease (OR, 2.1), and ASA classification of greater than 3 (OR, 2.9). Additionally, the development of postoperative cardiac arrest (OR, 22.9), MI (OR, 8.7), renal failure (OR, 6.3), respiratory failure (OR, 4.7), and septic shock (OR, 5.6) were associated with death. A laparoscopic procedure was shown to have a protective effect (0.169).
“Interestingly, the most common complication in both groups was respiratory failure,” Dr. Bostock said. “These results suggest that the elderly are more prone to respiratory complications as a whole. These results have been corroborated in prior studies in patients exposed to major abdominal operations.”
Dr. Bostock acknowledged certain limitations of the study, including the fact that ACS-NSQIP is unable to track procedure-specific complications that might occur after surgery. “It mainly helps us to determine the morbidity rate after specific types of procedures,” he said. “Additionally, the exact indication for emergent operation in the patients included in our analysis is unknown since we don’t have any access to specific patient data and/or chart review.”
The researchers reported having no financial disclosures.
LOS ANGELES – Patients over the age of 80 who present with diverticulitis requiring an emergent Hartmann’s procedure have a 30-day mortality rate of 20%, results from a study of national data demonstrated.
“Given the high morbidity and mortality described in this study, further work to elucidate whether an elective surgical therapy should be pursued in the octogenarian population is warranted,” lead study author Dr. Ian C. Bostock said in an interview in advance of the annual meeting of the American Society of Colon and Rectal Surgeons.
In an effort to investigate the 30-day outcomes for patients undergoing emergent Hartmann’s procedures for diverticular disease, Dr. Bostock of the department of general surgery at Dartmouth Hitchcock Medical Center, Lebanon, N.H., and his associates queried the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database from 2005 to 2013 to identify all patients aged 80 years or older who underwent an open and laparoscopic Hartmann’s procedure in an emergency setting for diverticular disease. They divided patients into two groups: those with 30-day postoperative mortality (expired) and those alive after 30 days (alive), and used univariate analysis to assess the risk of mortality and to identify associated risk factors.
Of the 464 patients who met inclusion criteria, 91 expired within 30 days postoperatively, for a mortality rate of 20%. No statistically significant differences were observed between the expired and alive groups in terms of age, gender distribution, body mass index, smoking status, alcohol use, prior chemotherapy/radiotherapy, comorbid conditions such as diabetes, hypertension, current hemodialysis use, and operative time. Factors identified to be associated with a higher risk for death were congestive heart failure (odds ratio, 3.0), steroid use (OR, 3.0), chronic obstructive pulmonary disease (OR, 2.1), and ASA classification of greater than 3 (OR, 2.9). Additionally, the development of postoperative cardiac arrest (OR, 22.9), MI (OR, 8.7), renal failure (OR, 6.3), respiratory failure (OR, 4.7), and septic shock (OR, 5.6) were associated with death. A laparoscopic procedure was shown to have a protective effect (0.169).
“Interestingly, the most common complication in both groups was respiratory failure,” Dr. Bostock said. “These results suggest that the elderly are more prone to respiratory complications as a whole. These results have been corroborated in prior studies in patients exposed to major abdominal operations.”
Dr. Bostock acknowledged certain limitations of the study, including the fact that ACS-NSQIP is unable to track procedure-specific complications that might occur after surgery. “It mainly helps us to determine the morbidity rate after specific types of procedures,” he said. “Additionally, the exact indication for emergent operation in the patients included in our analysis is unknown since we don’t have any access to specific patient data and/or chart review.”
The researchers reported having no financial disclosures.
AT THE ASCRS ANNUAL MEETING
Key clinical point: One in five octogenarians with diverticulitis who undergo an emergency Hartmann’s procedure die within 30 days postoperatively.
Major finding: The 30-day postoperative mortality rate for octogenarians who underwent an emergency Hartmann’s procedure for diverticular disease was 20%.
Data source: An analysis of American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) data from 464 patients aged 80 and older who underwent an open and laparoscopic Hartmann’s procedure in an emergency setting for diverticular disease.
Disclosures: Dr. Bostock reported having no financial disclosures.
Robotic vascular surgery: Ready for prime time?
A single-center experience using the da Vinci robotic system to perform vascular procedures demonstrated the safety and feasibility of this technique in different areas of vascular surgery.
Dr. Petr Štádler and his colleagues at the No Homolce Hospital in Prague reported on 310 robotic-assisted vascular procedures performed between November 2005 and May 2014 with the aid of the da Vinci system. They concluded that robotic-assisted vascular procedures added to the speed and relative simplicity of construction of vascular anastomoses.
The patient cohort had procedures consisting of 224 robotic occlusive disease treatments (group 1), 65 robotic aorto-illiac aneurysm surgeries (group II), and 21 other robotic procedures (group III) as reported online in the European Journal of Vascular and Endovascular Surgery (2016. doi: 10.1016/j.ejvs.2016.02.016).
A total of 298 cases (96.1%) were successfully completed robotically, with conversion required in 10 cases; 2 patients were inoperable. The overall 30-day mortality rate was 0.3% for the entire cohort, and only two (0.6%) late prosthetic infections were seen. The median operating time was 204 min, the median anastomosis time was 29 min, and median blood loss was 571 mL.
In comparing groups I and II, group I required an operative time of 194 min, compared with 253 min in group II. Mean aortic cross-clamp time was 37 min in group I and 93 min in group II, while the mean blood loss was greater in group II (1,210 mL) as compared with group 1 (320 mL).
“The robotic system provides a real opportunity for minimally invasive surgery in the field of vascular surgery ... with all its advantages. Robotic AAA [abdominal aortic aneurysm] and aortofemoral bypass represent the standard operations in vascular surgery and they are not only possible, but safe and effective,” said Dr. Štádler and his colleagues. They added, however, that “further randomized studies are needed to ensure its benefits and the cost-effectiveness of robotic vascular surgery, compared with open and laparoscopic repair.”
Dr, Štádler and his colleagues reported that they had no disclosures.
When we examine the data presented by the authors of this paper closely, we see vast differences between the group I patients (bypasses for aortoiliac occlusive disease) and the group II patients (repair of aortoiliac aneurysms). In the occlusive group (group I), the operative time averaged 194 minutes. However, in the aneurysm group, the surgical repair of an aneurysm took over 4 hours. Another broad discrepancy between groups I and II is evident in examining cross-clamp time. In the occlusive group, the cross-clamp was 37 minutes; however, aneurysm patients required 93 minutes of cross-clamp to complete the proximal anastomosis. Similar disparities are seen in mean blood loss. Patients with occlusive disease lost an average of 320 mL of blood, while aneurysm patients lost 1,210 mL
|
Dr. Mark A. Adelman |
The authors have been clever in combining these two groups as a single cohort.
However, I might argue that by segregating the groups, we might find that occlusive disease is well treated with robotically assisted surgery, but aneurysm repair should be left to open or endovascular techniques.
In addition to the data disparities, there are several practical limitations to performing robotic aortic surgery. Learning robotic techniques requires significant additional surgical training that is typically not within the skill set of a vascular surgeon. Who will devote the time and resources toward training vascular surgeons? Presently, there are increased hardware and operating room times associated with robotic-assisted surgeries. Because of the bulkiness of the robotic system and need for space for mechanical arms, large operating rooms must be utilized to perform robotic procedures.
Although I have not performed robotic surgery, I understand the tactile feedback, or haptics are significantly reduced when operating with the robot. Lastly, during this era of value-based medicine, is robotic surgery too expensive? The current cost of a robot approaches $2 million, and robotic arms have a limited life expectancy.
In summary, the authors have not demonstrated that this procedure is safe in aneurysm patients, or generalizable across all vascular surgeons given the lack of training paradigm. Further, robotic procedures are probably not cost effective in this very cost-sensitive health care environment. When I was training under Dr. Frank Cole Spencer in general surgery, he was fond of saying “just because you can teach a dog to ride a bicycle, it does not mean that you should.” As Dr. Juan Parodi will remind us, if the technology becomes more affordable, and changes significantly, we must all remain open minded. But currently, this technology is not yet ready for prime time. In its current state, this dog will not be learning to ride this robotic bike.
Dr. Mark A. Adelman is the Frank J. Veith, MD Professor, chief of vascular and endovascular surgery, and vice chair for strategy and business development, department of surgery, NYU Langone Medical Center, New York.
When we examine the data presented by the authors of this paper closely, we see vast differences between the group I patients (bypasses for aortoiliac occlusive disease) and the group II patients (repair of aortoiliac aneurysms). In the occlusive group (group I), the operative time averaged 194 minutes. However, in the aneurysm group, the surgical repair of an aneurysm took over 4 hours. Another broad discrepancy between groups I and II is evident in examining cross-clamp time. In the occlusive group, the cross-clamp was 37 minutes; however, aneurysm patients required 93 minutes of cross-clamp to complete the proximal anastomosis. Similar disparities are seen in mean blood loss. Patients with occlusive disease lost an average of 320 mL of blood, while aneurysm patients lost 1,210 mL
|
|
Dr. Mark A. Adelman |
The authors have been clever in combining these two groups as a single cohort.
However, I might argue that by segregating the groups, we might find that occlusive disease is well treated with robotically assisted surgery, but aneurysm repair should be left to open or endovascular techniques.
In addition to the data disparities, there are several practical limitations to performing robotic aortic surgery. Learning robotic techniques requires significant additional surgical training that is typically not within the skill set of a vascular surgeon. Who will devote the time and resources toward training vascular surgeons? Presently, there are increased hardware and operating room times associated with robotic-assisted surgeries. Because of the bulkiness of the robotic system and need for space for mechanical arms, large operating rooms must be utilized to perform robotic procedures.
Although I have not performed robotic surgery, I understand the tactile feedback, or haptics are significantly reduced when operating with the robot. Lastly, during this era of value-based medicine, is robotic surgery too expensive? The current cost of a robot approaches $2 million, and robotic arms have a limited life expectancy.
In summary, the authors have not demonstrated that this procedure is safe in aneurysm patients, or generalizable across all vascular surgeons given the lack of training paradigm. Further, robotic procedures are probably not cost effective in this very cost-sensitive health care environment. When I was training under Dr. Frank Cole Spencer in general surgery, he was fond of saying “just because you can teach a dog to ride a bicycle, it does not mean that you should.” As Dr. Juan Parodi will remind us, if the technology becomes more affordable, and changes significantly, we must all remain open minded. But currently, this technology is not yet ready for prime time. In its current state, this dog will not be learning to ride this robotic bike.
Dr. Mark A. Adelman is the Frank J. Veith, MD Professor, chief of vascular and endovascular surgery, and vice chair for strategy and business development, department of surgery, NYU Langone Medical Center, New York.
When we examine the data presented by the authors of this paper closely, we see vast differences between the group I patients (bypasses for aortoiliac occlusive disease) and the group II patients (repair of aortoiliac aneurysms). In the occlusive group (group I), the operative time averaged 194 minutes. However, in the aneurysm group, the surgical repair of an aneurysm took over 4 hours. Another broad discrepancy between groups I and II is evident in examining cross-clamp time. In the occlusive group, the cross-clamp was 37 minutes; however, aneurysm patients required 93 minutes of cross-clamp to complete the proximal anastomosis. Similar disparities are seen in mean blood loss. Patients with occlusive disease lost an average of 320 mL of blood, while aneurysm patients lost 1,210 mL
|
|
Dr. Mark A. Adelman |
The authors have been clever in combining these two groups as a single cohort.
However, I might argue that by segregating the groups, we might find that occlusive disease is well treated with robotically assisted surgery, but aneurysm repair should be left to open or endovascular techniques.
In addition to the data disparities, there are several practical limitations to performing robotic aortic surgery. Learning robotic techniques requires significant additional surgical training that is typically not within the skill set of a vascular surgeon. Who will devote the time and resources toward training vascular surgeons? Presently, there are increased hardware and operating room times associated with robotic-assisted surgeries. Because of the bulkiness of the robotic system and need for space for mechanical arms, large operating rooms must be utilized to perform robotic procedures.
Although I have not performed robotic surgery, I understand the tactile feedback, or haptics are significantly reduced when operating with the robot. Lastly, during this era of value-based medicine, is robotic surgery too expensive? The current cost of a robot approaches $2 million, and robotic arms have a limited life expectancy.
In summary, the authors have not demonstrated that this procedure is safe in aneurysm patients, or generalizable across all vascular surgeons given the lack of training paradigm. Further, robotic procedures are probably not cost effective in this very cost-sensitive health care environment. When I was training under Dr. Frank Cole Spencer in general surgery, he was fond of saying “just because you can teach a dog to ride a bicycle, it does not mean that you should.” As Dr. Juan Parodi will remind us, if the technology becomes more affordable, and changes significantly, we must all remain open minded. But currently, this technology is not yet ready for prime time. In its current state, this dog will not be learning to ride this robotic bike.
Dr. Mark A. Adelman is the Frank J. Veith, MD Professor, chief of vascular and endovascular surgery, and vice chair for strategy and business development, department of surgery, NYU Langone Medical Center, New York.
A single-center experience using the da Vinci robotic system to perform vascular procedures demonstrated the safety and feasibility of this technique in different areas of vascular surgery.
Dr. Petr Štádler and his colleagues at the No Homolce Hospital in Prague reported on 310 robotic-assisted vascular procedures performed between November 2005 and May 2014 with the aid of the da Vinci system. They concluded that robotic-assisted vascular procedures added to the speed and relative simplicity of construction of vascular anastomoses.
The patient cohort had procedures consisting of 224 robotic occlusive disease treatments (group 1), 65 robotic aorto-illiac aneurysm surgeries (group II), and 21 other robotic procedures (group III) as reported online in the European Journal of Vascular and Endovascular Surgery (2016. doi: 10.1016/j.ejvs.2016.02.016).
A total of 298 cases (96.1%) were successfully completed robotically, with conversion required in 10 cases; 2 patients were inoperable. The overall 30-day mortality rate was 0.3% for the entire cohort, and only two (0.6%) late prosthetic infections were seen. The median operating time was 204 min, the median anastomosis time was 29 min, and median blood loss was 571 mL.
In comparing groups I and II, group I required an operative time of 194 min, compared with 253 min in group II. Mean aortic cross-clamp time was 37 min in group I and 93 min in group II, while the mean blood loss was greater in group II (1,210 mL) as compared with group 1 (320 mL).
“The robotic system provides a real opportunity for minimally invasive surgery in the field of vascular surgery ... with all its advantages. Robotic AAA [abdominal aortic aneurysm] and aortofemoral bypass represent the standard operations in vascular surgery and they are not only possible, but safe and effective,” said Dr. Štádler and his colleagues. They added, however, that “further randomized studies are needed to ensure its benefits and the cost-effectiveness of robotic vascular surgery, compared with open and laparoscopic repair.”
Dr, Štádler and his colleagues reported that they had no disclosures.
A single-center experience using the da Vinci robotic system to perform vascular procedures demonstrated the safety and feasibility of this technique in different areas of vascular surgery.
Dr. Petr Štádler and his colleagues at the No Homolce Hospital in Prague reported on 310 robotic-assisted vascular procedures performed between November 2005 and May 2014 with the aid of the da Vinci system. They concluded that robotic-assisted vascular procedures added to the speed and relative simplicity of construction of vascular anastomoses.
The patient cohort had procedures consisting of 224 robotic occlusive disease treatments (group 1), 65 robotic aorto-illiac aneurysm surgeries (group II), and 21 other robotic procedures (group III) as reported online in the European Journal of Vascular and Endovascular Surgery (2016. doi: 10.1016/j.ejvs.2016.02.016).
A total of 298 cases (96.1%) were successfully completed robotically, with conversion required in 10 cases; 2 patients were inoperable. The overall 30-day mortality rate was 0.3% for the entire cohort, and only two (0.6%) late prosthetic infections were seen. The median operating time was 204 min, the median anastomosis time was 29 min, and median blood loss was 571 mL.
In comparing groups I and II, group I required an operative time of 194 min, compared with 253 min in group II. Mean aortic cross-clamp time was 37 min in group I and 93 min in group II, while the mean blood loss was greater in group II (1,210 mL) as compared with group 1 (320 mL).
“The robotic system provides a real opportunity for minimally invasive surgery in the field of vascular surgery ... with all its advantages. Robotic AAA [abdominal aortic aneurysm] and aortofemoral bypass represent the standard operations in vascular surgery and they are not only possible, but safe and effective,” said Dr. Štádler and his colleagues. They added, however, that “further randomized studies are needed to ensure its benefits and the cost-effectiveness of robotic vascular surgery, compared with open and laparoscopic repair.”
Dr, Štádler and his colleagues reported that they had no disclosures.
FROM EUROPEAN JOURNAL OF VASCULAR AND ENDOVASCULAR SURGERY
Key clinical point: Robotic-assisted vascular surgery procedures appeared safe and provided benefits in speed and simplicity for vascular anastomoses.
Major finding: A total of 298 (96.1%) cases were successfully completed robotically, with a 30-day mortality of 0.3% and two (0.6%) late prosthetic infections seen.
Data source: A prospective study was performed assessing 310 robotic-assisted vascular procedures.
Disclosures: The authors reported that they had no disclosures.
Parathyroidectomy before kidney transplant may reduce complications
BALTIMORE – Performing a parathyroidectomy in kidney transplant patients before their transplant can reduce the risk of graft failure and provide other benefits, the findings of a retrospective study of 913 patients suggest.
Uremic hyperparathyroidism (UHPT) is common in patients with end-stage kidney disease, and elevated parathyroid hormone (PTH) levels have been linked with delayed graft function after kidney transplants, but current guidelines for PTH levels may not go far enough to reduce the risk of graft failure and other post–kidney transplant complications in people with elevated PTH before transplant, according to Dr. Glenda G. Callender of Yale University, New Haven, Conn., and her colleagues.
“Uremic hyperparathyroidism was associated with an increased risk of complications in the first year post kidney transplant,” Dr. Callender said at the annual meeting of the American Association of Endocrine Surgeons. “Pre–kidney transplant parathyroidectomy was associated with a decreased risk of post–kidney transplant graft failure. This implies that pre–kidney transplant reduction of PTH levels should be considered in patients with UPHT.”
The Yale researchers reviewed outcomes of 913 patients at their institution who had a kidney transplant from 2005 to 2014. They analyzed biochemical values before kidney transplant and at three intervals post transplant: at 1 month, 6 months, and 1 year. Among the outcomes they evaluated were calcium and PTH levels, estimated glomerular filtration rate, complications, delayed graft function, and graft failure. The overall graft survival rate was 97.8% 1 year after kidney transplantation.
Overall, 49.4% of patients (451) had a diagnosis with UHPT before kidney transplant; 6.2% of all patients (57) had parathyroidectomy before kidney transplant and another 2% (18) had parathyroidectomy at some point after their kidney transplant operations. Median baseline PTH levels were higher in the UHPT patients: 206 pg/mL vs. 159 pg/mL for the non-UHPT group, Dr. Callender reported.
The researchers captured complete data on 37 of the 57 patients who had pretransplant parathyroidectomy. Twenty-four (65% of the group) had subtotal parathyroidectomy in which 3.5 glands were removed, and 12 (32%) had fewer than 3.5 glands removed. One patient had total parathyroidectomy, she said.
Among the patients with UHPT, the median pre–kidney transplant PTH was similar between the pretransplant parathyroidectomy and the no-parathyroidectomy groups: 218 pg/mL and 180 pg/mL, respectively, Dr. Callender said.
Pre–kidney transplant diagnosis of UHPT had an odds ratio of 1.44 for complications in the first year after transplant surgery, but not necessarily a greater risk for graft function or graft failure, she said. However, those relative risks changed with the degree of PTH above normal. Patients with UHPT who had pretransplant parathyroidectomy had a lower risk of graft failure, with an odds ratio of 0.547.
Current Kidney Disease Improving Global Outcomes (KDIGO) guidelines recommend maintaining PTH levels in patients with UHPT before they have kidney transplant surgery at no more than nine times normal. To test the optimal PTH levels before kidney transplant, the researchers analyzed thresholds ranging from two to nine times the normal limit.
“A pre–kidney transplant [PTH] level greater than or equal to six times normal was associated with post-transplant graft failure but not with delayed graft function or complications in the first year post kidney transplant,” Dr. Callender said. “Although the thresholds at two and four times normal were statistically significant, there was a continued risk significant for graft failure above six times normal.”
This finding “suggests that perhaps the current KDIGO guideline of maintaining patient PTH at up to nine times normal is too liberal,” Dr. Callender said.
She acknowledged several limitations of the study: its retrospective nature, small sample size, and “many missing data points” because a wide variety of dialysis centers with varying documentation standards collected information.
“However,” Dr. Callender said, “we believe these findings support the design and implementation of a multi-institutional, prospective, randomized control trial to evaluate whether a change in management of patients with uremic hyperparathyroidism is warranted.”
Dr. Callender and her coauthors had no financial relationships to disclose.
BALTIMORE – Performing a parathyroidectomy in kidney transplant patients before their transplant can reduce the risk of graft failure and provide other benefits, the findings of a retrospective study of 913 patients suggest.
Uremic hyperparathyroidism (UHPT) is common in patients with end-stage kidney disease, and elevated parathyroid hormone (PTH) levels have been linked with delayed graft function after kidney transplants, but current guidelines for PTH levels may not go far enough to reduce the risk of graft failure and other post–kidney transplant complications in people with elevated PTH before transplant, according to Dr. Glenda G. Callender of Yale University, New Haven, Conn., and her colleagues.
“Uremic hyperparathyroidism was associated with an increased risk of complications in the first year post kidney transplant,” Dr. Callender said at the annual meeting of the American Association of Endocrine Surgeons. “Pre–kidney transplant parathyroidectomy was associated with a decreased risk of post–kidney transplant graft failure. This implies that pre–kidney transplant reduction of PTH levels should be considered in patients with UPHT.”
The Yale researchers reviewed outcomes of 913 patients at their institution who had a kidney transplant from 2005 to 2014. They analyzed biochemical values before kidney transplant and at three intervals post transplant: at 1 month, 6 months, and 1 year. Among the outcomes they evaluated were calcium and PTH levels, estimated glomerular filtration rate, complications, delayed graft function, and graft failure. The overall graft survival rate was 97.8% 1 year after kidney transplantation.
Overall, 49.4% of patients (451) had a diagnosis with UHPT before kidney transplant; 6.2% of all patients (57) had parathyroidectomy before kidney transplant and another 2% (18) had parathyroidectomy at some point after their kidney transplant operations. Median baseline PTH levels were higher in the UHPT patients: 206 pg/mL vs. 159 pg/mL for the non-UHPT group, Dr. Callender reported.
The researchers captured complete data on 37 of the 57 patients who had pretransplant parathyroidectomy. Twenty-four (65% of the group) had subtotal parathyroidectomy in which 3.5 glands were removed, and 12 (32%) had fewer than 3.5 glands removed. One patient had total parathyroidectomy, she said.
Among the patients with UHPT, the median pre–kidney transplant PTH was similar between the pretransplant parathyroidectomy and the no-parathyroidectomy groups: 218 pg/mL and 180 pg/mL, respectively, Dr. Callender said.
Pre–kidney transplant diagnosis of UHPT had an odds ratio of 1.44 for complications in the first year after transplant surgery, but not necessarily a greater risk for graft function or graft failure, she said. However, those relative risks changed with the degree of PTH above normal. Patients with UHPT who had pretransplant parathyroidectomy had a lower risk of graft failure, with an odds ratio of 0.547.
Current Kidney Disease Improving Global Outcomes (KDIGO) guidelines recommend maintaining PTH levels in patients with UHPT before they have kidney transplant surgery at no more than nine times normal. To test the optimal PTH levels before kidney transplant, the researchers analyzed thresholds ranging from two to nine times the normal limit.
“A pre–kidney transplant [PTH] level greater than or equal to six times normal was associated with post-transplant graft failure but not with delayed graft function or complications in the first year post kidney transplant,” Dr. Callender said. “Although the thresholds at two and four times normal were statistically significant, there was a continued risk significant for graft failure above six times normal.”
This finding “suggests that perhaps the current KDIGO guideline of maintaining patient PTH at up to nine times normal is too liberal,” Dr. Callender said.
She acknowledged several limitations of the study: its retrospective nature, small sample size, and “many missing data points” because a wide variety of dialysis centers with varying documentation standards collected information.
“However,” Dr. Callender said, “we believe these findings support the design and implementation of a multi-institutional, prospective, randomized control trial to evaluate whether a change in management of patients with uremic hyperparathyroidism is warranted.”
Dr. Callender and her coauthors had no financial relationships to disclose.
BALTIMORE – Performing a parathyroidectomy in kidney transplant patients before their transplant can reduce the risk of graft failure and provide other benefits, the findings of a retrospective study of 913 patients suggest.
Uremic hyperparathyroidism (UHPT) is common in patients with end-stage kidney disease, and elevated parathyroid hormone (PTH) levels have been linked with delayed graft function after kidney transplants, but current guidelines for PTH levels may not go far enough to reduce the risk of graft failure and other post–kidney transplant complications in people with elevated PTH before transplant, according to Dr. Glenda G. Callender of Yale University, New Haven, Conn., and her colleagues.
“Uremic hyperparathyroidism was associated with an increased risk of complications in the first year post kidney transplant,” Dr. Callender said at the annual meeting of the American Association of Endocrine Surgeons. “Pre–kidney transplant parathyroidectomy was associated with a decreased risk of post–kidney transplant graft failure. This implies that pre–kidney transplant reduction of PTH levels should be considered in patients with UPHT.”
The Yale researchers reviewed outcomes of 913 patients at their institution who had a kidney transplant from 2005 to 2014. They analyzed biochemical values before kidney transplant and at three intervals post transplant: at 1 month, 6 months, and 1 year. Among the outcomes they evaluated were calcium and PTH levels, estimated glomerular filtration rate, complications, delayed graft function, and graft failure. The overall graft survival rate was 97.8% 1 year after kidney transplantation.
Overall, 49.4% of patients (451) had a diagnosis with UHPT before kidney transplant; 6.2% of all patients (57) had parathyroidectomy before kidney transplant and another 2% (18) had parathyroidectomy at some point after their kidney transplant operations. Median baseline PTH levels were higher in the UHPT patients: 206 pg/mL vs. 159 pg/mL for the non-UHPT group, Dr. Callender reported.
The researchers captured complete data on 37 of the 57 patients who had pretransplant parathyroidectomy. Twenty-four (65% of the group) had subtotal parathyroidectomy in which 3.5 glands were removed, and 12 (32%) had fewer than 3.5 glands removed. One patient had total parathyroidectomy, she said.
Among the patients with UHPT, the median pre–kidney transplant PTH was similar between the pretransplant parathyroidectomy and the no-parathyroidectomy groups: 218 pg/mL and 180 pg/mL, respectively, Dr. Callender said.
Pre–kidney transplant diagnosis of UHPT had an odds ratio of 1.44 for complications in the first year after transplant surgery, but not necessarily a greater risk for graft function or graft failure, she said. However, those relative risks changed with the degree of PTH above normal. Patients with UHPT who had pretransplant parathyroidectomy had a lower risk of graft failure, with an odds ratio of 0.547.
Current Kidney Disease Improving Global Outcomes (KDIGO) guidelines recommend maintaining PTH levels in patients with UHPT before they have kidney transplant surgery at no more than nine times normal. To test the optimal PTH levels before kidney transplant, the researchers analyzed thresholds ranging from two to nine times the normal limit.
“A pre–kidney transplant [PTH] level greater than or equal to six times normal was associated with post-transplant graft failure but not with delayed graft function or complications in the first year post kidney transplant,” Dr. Callender said. “Although the thresholds at two and four times normal were statistically significant, there was a continued risk significant for graft failure above six times normal.”
This finding “suggests that perhaps the current KDIGO guideline of maintaining patient PTH at up to nine times normal is too liberal,” Dr. Callender said.
She acknowledged several limitations of the study: its retrospective nature, small sample size, and “many missing data points” because a wide variety of dialysis centers with varying documentation standards collected information.
“However,” Dr. Callender said, “we believe these findings support the design and implementation of a multi-institutional, prospective, randomized control trial to evaluate whether a change in management of patients with uremic hyperparathyroidism is warranted.”
Dr. Callender and her coauthors had no financial relationships to disclose.
AT AAES 2016
Key clinical point: Parathyroidectomy reduces graft failure in individuals with uremic hyperparathyroidism (UHPT) who undergo kidney transplant.
Major finding: Pre–kidney transplant diagnosis of UHPT had an odds ratio of 1.44 of complications a year after transplant; patients who had parathyroidectomy before transplant had a reduced 0.547 odds ratio risk of graft failure.
Data source: Review of 913 patients who had kidney transplant from 2005 to 2014 at a single institution.
Disclosures: Dr. Callender and her coauthors reported having no financial disclosures.
Light mesh doesn’t outweigh heavy mesh for hernia repair
Lightweight mesh has no significant benefit over heavyweight mesh for inguinal hernia repair and was associated with greater pain and higher risk of recurrence, based on data from a randomized trial of 950 patients published in the May issue of the Annals of Surgery.
Although the use of mesh for hernia surgery has been associated with lower recurrence rates and less chronic pain in open hernia repair procedures, the benefits of lightweight vs. heavyweight mesh for laparoscopic procedures has not been well studied, “and there is no consensus which type of mesh is optimal in these procedures,” wrote Dr. Josephina P.J. Burgmans of Diakonessenhuis Utrecht/Zeist (the Netherlands) and colleagues (Ann. Surg. 2016;263[5]:862-6).
To compare the clinical outcomes for patients who received lightweight vs. heavyweight mesh in hernia repairs, the researchers randomized 478 patients to a lightweight-mesh group and 471 to a heavyweight-mesh group. One patient was excluded because the type of mesh was unknown. The study population included men older than 18 years with a primary, reducible, unilateral inguinal hernia who underwent surgery at a single center with one of four surgeons between March 2010 and October 2012. Demographic characteristics were similar between the two groups, as were preoperation pain, operation time, and complications during and after surgery.
At 1 year post surgery, the prevalence of reported relevant pain was significantly higher in the lightweight group, compared with the heavyweight group (2.9% vs. 0.7%). The difference remained statistically significant at 2 years’ follow-up, with relevant pain reported in 3.0% of the lightweight group and 0.9% of the heavyweight group; the difference also remained significant after controlling for factors including age, body mass index, hernia type, severe preoperative pain, recurrence, and surgeon).
Recurrence rates were similar between the two groups at 3 months (two cases in each group), but recurrences became more common in the lightweight group, compared with the heavyweight group, at 1 year (1.7% vs. 0.6%) and significantly more common at 2 years (2.7% vs. 0.8%). The difference remained significant after controlling for multiple variables including hernia type, operating time, surgeon, and body mass index.
No significant differences in foreign body feeling, testicular pain, or sexual-related pain or discomfort were reported between the two groups at the 1-year and 2-year follow-ups.
The study’s strengths include the large patient population and prospective data collection, the researchers noted. The findings were limited by the small number of patients with relevant pain at 1 and 2 years; the homogenous, male-only study population; and the use of questionnaires, which might affect the accuracy of recurrence-rate reports. The results, however, suggest that “there is no benefit for lightweight [meshes] and a conventional heavyweight standard polypropylene 10 cm × 15 cm mesh is recommended for laparoscopic inguinal hernia repair,” Dr. Burgmans and associates wrote
The study was sponsored in part by a grant to the Hernia Centre Zeist from Johnson & Johnston. The researchers had no other relevant financial conflicts to disclose.
Lightweight mesh has no significant benefit over heavyweight mesh for inguinal hernia repair and was associated with greater pain and higher risk of recurrence, based on data from a randomized trial of 950 patients published in the May issue of the Annals of Surgery.
Although the use of mesh for hernia surgery has been associated with lower recurrence rates and less chronic pain in open hernia repair procedures, the benefits of lightweight vs. heavyweight mesh for laparoscopic procedures has not been well studied, “and there is no consensus which type of mesh is optimal in these procedures,” wrote Dr. Josephina P.J. Burgmans of Diakonessenhuis Utrecht/Zeist (the Netherlands) and colleagues (Ann. Surg. 2016;263[5]:862-6).
To compare the clinical outcomes for patients who received lightweight vs. heavyweight mesh in hernia repairs, the researchers randomized 478 patients to a lightweight-mesh group and 471 to a heavyweight-mesh group. One patient was excluded because the type of mesh was unknown. The study population included men older than 18 years with a primary, reducible, unilateral inguinal hernia who underwent surgery at a single center with one of four surgeons between March 2010 and October 2012. Demographic characteristics were similar between the two groups, as were preoperation pain, operation time, and complications during and after surgery.
At 1 year post surgery, the prevalence of reported relevant pain was significantly higher in the lightweight group, compared with the heavyweight group (2.9% vs. 0.7%). The difference remained statistically significant at 2 years’ follow-up, with relevant pain reported in 3.0% of the lightweight group and 0.9% of the heavyweight group; the difference also remained significant after controlling for factors including age, body mass index, hernia type, severe preoperative pain, recurrence, and surgeon).
Recurrence rates were similar between the two groups at 3 months (two cases in each group), but recurrences became more common in the lightweight group, compared with the heavyweight group, at 1 year (1.7% vs. 0.6%) and significantly more common at 2 years (2.7% vs. 0.8%). The difference remained significant after controlling for multiple variables including hernia type, operating time, surgeon, and body mass index.
No significant differences in foreign body feeling, testicular pain, or sexual-related pain or discomfort were reported between the two groups at the 1-year and 2-year follow-ups.
The study’s strengths include the large patient population and prospective data collection, the researchers noted. The findings were limited by the small number of patients with relevant pain at 1 and 2 years; the homogenous, male-only study population; and the use of questionnaires, which might affect the accuracy of recurrence-rate reports. The results, however, suggest that “there is no benefit for lightweight [meshes] and a conventional heavyweight standard polypropylene 10 cm × 15 cm mesh is recommended for laparoscopic inguinal hernia repair,” Dr. Burgmans and associates wrote
The study was sponsored in part by a grant to the Hernia Centre Zeist from Johnson & Johnston. The researchers had no other relevant financial conflicts to disclose.
Lightweight mesh has no significant benefit over heavyweight mesh for inguinal hernia repair and was associated with greater pain and higher risk of recurrence, based on data from a randomized trial of 950 patients published in the May issue of the Annals of Surgery.
Although the use of mesh for hernia surgery has been associated with lower recurrence rates and less chronic pain in open hernia repair procedures, the benefits of lightweight vs. heavyweight mesh for laparoscopic procedures has not been well studied, “and there is no consensus which type of mesh is optimal in these procedures,” wrote Dr. Josephina P.J. Burgmans of Diakonessenhuis Utrecht/Zeist (the Netherlands) and colleagues (Ann. Surg. 2016;263[5]:862-6).
To compare the clinical outcomes for patients who received lightweight vs. heavyweight mesh in hernia repairs, the researchers randomized 478 patients to a lightweight-mesh group and 471 to a heavyweight-mesh group. One patient was excluded because the type of mesh was unknown. The study population included men older than 18 years with a primary, reducible, unilateral inguinal hernia who underwent surgery at a single center with one of four surgeons between March 2010 and October 2012. Demographic characteristics were similar between the two groups, as were preoperation pain, operation time, and complications during and after surgery.
At 1 year post surgery, the prevalence of reported relevant pain was significantly higher in the lightweight group, compared with the heavyweight group (2.9% vs. 0.7%). The difference remained statistically significant at 2 years’ follow-up, with relevant pain reported in 3.0% of the lightweight group and 0.9% of the heavyweight group; the difference also remained significant after controlling for factors including age, body mass index, hernia type, severe preoperative pain, recurrence, and surgeon).
Recurrence rates were similar between the two groups at 3 months (two cases in each group), but recurrences became more common in the lightweight group, compared with the heavyweight group, at 1 year (1.7% vs. 0.6%) and significantly more common at 2 years (2.7% vs. 0.8%). The difference remained significant after controlling for multiple variables including hernia type, operating time, surgeon, and body mass index.
No significant differences in foreign body feeling, testicular pain, or sexual-related pain or discomfort were reported between the two groups at the 1-year and 2-year follow-ups.
The study’s strengths include the large patient population and prospective data collection, the researchers noted. The findings were limited by the small number of patients with relevant pain at 1 and 2 years; the homogenous, male-only study population; and the use of questionnaires, which might affect the accuracy of recurrence-rate reports. The results, however, suggest that “there is no benefit for lightweight [meshes] and a conventional heavyweight standard polypropylene 10 cm × 15 cm mesh is recommended for laparoscopic inguinal hernia repair,” Dr. Burgmans and associates wrote
The study was sponsored in part by a grant to the Hernia Centre Zeist from Johnson & Johnston. The researchers had no other relevant financial conflicts to disclose.
FROM ANNALS OF SURGERY
Key clinical point: Lightweight mesh was associated with more pain and higher recurrence risk 1 and 2 years after surgery.
Major finding: Two years after surgery, relevant pain was reported in 3.0% of the lightweight-mesh patients vs. 0.9% of heavyweight-mesh patients.
Data source: A randomized trial including 950 adult men with inguinal hernias.
Disclosures: The study was sponsored in part by a grant to the Hernia Centre Zeist from Johnson & Johnston. The researchers had no other relevant financial conflicts to disclose.
FIRST reflections: Impact of ACGME duty hours on CT practitioners
Several months ago, Dr. Bilimoria and his colleagues published the long awaited study in NEJM essentially contradicting adverse effects of strict duty hours on patient outcomes (N Engl J Med. 2016 374:713-2). The study, known as the FIRST trial, was published in the March issue of Thoracic Surgery News. Although the study enrolled general surgery residents, its conclusion impacts no specialty more than cardiothoracic surgery, where frequent handoffs complicate tedious perioperative care of sick patients stall learning opportunities for young trainees.
As Dr. Shari Meyerson eloquently noted in her perspective piece for Thoracic Surgery News (March 2016, page 4), surgery training needs to adapt to meet the modern day needs of trainees to rest and spend time with family and friends, with those of exposure to complex clinical scenarios in a short residency period. Arguably, CT surgery trainees are some of the most motivated and driven; to limit their experience on a national level may be shortsighted. On the other hand, appropriate incorporation of advanced practice providers (APPs) may help allay some patient care challenges, free valuable family time, and allow thoracic residents to function well in a more flexible ACGME duty-hour paradigm. To add thoracic relevance to the findings of Dr. Bilimoria and his colleagues, the debate is brought to Thoracic Surgery News by our colleagues from different training pathways below:
Dr. Antonoff: “Due to the timing of my medical school matriculation, I completed my surgical clerkships in the preregulated duty-hour era. I had expectations of what my life would be like as a surgeon when I applied for the general surgery match, and frankly, my expectations prepared me for a life that would revolve around my education, my technical training, and my commitment to patient care. During my years as a junior resident, my surgical training program gradually adapted in recognition of the new guidelines, but it took time. I spent 3 years in the research lab, and, after I came out as a senior resident, I discovered that the rules of the game had totally changed. While duty hours for me, as a senior trainee, were still fairly open, I found that my interns and junior residents had to play by completely new rules. In some ways, on rare occasions, I felt frustrated and resentful of the fact that my duties as a chief resident and thoracic fellow included many of the tasks that I’d done as an intern, because my interns would ‘expire’ after 16 hours. However, much more often, I felt bad for those who came after me.
They seemed desperate to operate, eager to see their patients’ problems through to resolution, and embarrassed to have to end their days earlier than the more senior members of the team. I feel fortunate that I had years of frequent in-house call after long days in the operating room and followed by post-call days of more operating. I finished my junior years without fear of any sick patient in the hospital, I finished my general surgery training without fear of any emergent operation, and I finished my fellowship with confidence that I could get a patient through just about anything if I had access to a cannula.
My early experiences as an attending have certainly kept me humble, and I’ve spent many a night worried about my patients, rethinking choices that I’ve made and stitches that I’ve thrown. But I thank my lucky stars that I was exposed to phenomenal training, and that I had the privilege and opportunity to work the hours needed to reach a reasonable level of safety! I can only imagine that if I’d have spent fewer nights in the hospital, that I’d feel even more anxiety and nausea at this early stage of my surgical career.
As elaborated in the editorial by Dr. Birkmeyer (N Engl J Med. 2016;374:783-4), it is not surprising that patient outcomes did not immediately depend on whether the programs had adhered strictly to the ACGME duty-hour rules. Limited numbers of patients experience critical events during shift change, and hospitals are evolving to function with greater reliance on midlevel practitioners and attending physicians. I would not expect the short-term results of duty-hour flexibility to demonstrate any impact on patient care. However, I do fear that there will be a mid-term impact on trainee accountability and autonomy, which will ultimately impact the competence of the attending surgeons of the future, and downstream potential long-term impact on day-to-day patient outcomes.
As a wife and mother of 3, I recognize that we, as a specialty, need to find ways to support our trainees and their families and to help them live happy lives conducive to functioning outside the hospital. I believe that we can do this with support, mentorship, and advocacy; I do not believe that it requires cutting back on the training that we are all, in the end, so incredibly grateful to receive.”
Dr. Mara Antonoff is an assistant professor of thoracic and cardiovascular surgery at UT MD Anderson Cancer Center. She performed her General Surgery training at the University of Minnesota, 2004-2012, and her Thoracic Surgery Training at Washington University, as a traditional 2-year resident, 2012-2014.
Dr. Stephens: “There is nothing that replaces being bedside. Whether it be a postoperative patient struggling with low cardiac output syndrome overnight, or a patient with a high pressor requirement the etiology of which you are trying to uncover, or a patient you have been following who suddenly arrests, the value of seeing a patient’s trajectory longitudinally is critical to developing clinical acumen. When as an attending I will get called in the middle of the night about a postoperative patient not “doing well,” I will be drawing on my years of being on call and being bedside with my patients.
Patient care is the ultimate goal, and it is clear that overworked residents are at higher risk for making mistakes that jeopardize patient care, which nobody wants. However, the restrictions that duty hours place don’t allow the flexibility necessary for a specialty such as ours, and in fact strict adherence to such regulations inhibits opportunities for our learning. Also concerning is the “shift-work” mentality that seems to be increasingly pervasive with the implementation of duty hours. As has been well documented, and as I have seen personally, the constant patient handoffs that are requisite to implementation of duty hours pose their own perils in terms of patient safety.
Ultimately, these are our patients and we are responsible. Once we are attendings, those responsibilities will not be turned off after we have reached some prespecified hour limit.
The question then remains how best to implement a system across a wide variety of programs that ensures both patient safety and adequate clinical experience in the context of a culture of patient responsibility for the residents. As the NEJM study (N Engl J Med. 2016 374:713-2) shows, flexibility in implementation of duty hours did not result in increased complications, but resulted in improved resident satisfaction in continuity of care and handoffs. In my opinion, this study then encourages specialties such as ours to be more flexible in work hours, to encourage residents when there is a learning opportunity that previously they would be prohibited from taking part in to take hold of that opportunity, and to use this flexibility in implementation of duty hours to combat the invading “shift-work” mentality that will only jeopardize patient care.”
Dr. Elizabeth H. Stephens, MD, PhD is a Cardiothoracic Surgery, resident, PGY4, at Columbia University, New York, as an Integrated I-6 Resident.
Dr. Brown: “I took the traditional 5-year of General Surgery + 2 years of Cardiothoracic Surgery training route to becoming a General Thoracic Surgeon. My General Surgery experience was invaluable to my development as a surgeon. However, after all of those years of General Surgery cases and minimal exposure to Cardiothoracic Surgery cases, coupled with minimal overlap between the two specialties with regard to patient care, I found the learning curve in fellowship to be very steep. I was fortunate to train in a program with phenomenal physician extender support [APPs] in addition to top-notch colleagues in other specialties and excellent nursing, which allowed me to spend the majority of those 2 years in the operating room and completely focused on patient care. During that final phase of training, I welcomed flexibility with regard to the work-hour restrictions to ensure that I was acquiring the experience I needed prior to starting my own practice.”
Lisa M. Brown, MD, MAS, Assistant Professor of Thoracic Surgery, UC Davis Health System, Calif.; Training Institution: Washington University
Dr. Lee: “I started my surgical training in 2005, 2 years after the implementation of the 80-hour workweek restriction. Fortunately for my personal life, my training program took the restriction very seriously and strictly enforced it. As a result, I had scheduled periods off from work, and rarely worked more than 80 hours per week over the course of general surgery. On those occasions that I did, the next weeks, or preceding weeks would be shorter, to compensate. As a product of a 4+3 Thoracic Surgery residency in this environment, the 80-hour workweek extended to my subspecialty training. Our cardiac surgery time strictly enforced the go-home post-call policy. As a result, I believe my duty hours during Thoracic Surgery are likely shorter overall than many other programs.
Everyone hears the rumors of other programs lying about their duty hours. Fortunately, mine was not one of these. Despite this, or because of this, I received top-notch training. At the same time and more importantly, I started a family. I married my wife a week before my internship started, and am still married to the same person. We had two precious daughters during my Thoracic Surgery years. I don’t believe this would have been possible without duty-hours restrictions.
To create an environment where such a task was possible, my program hired an army of mid-level practitioners to deal with the day-to-day tasks of providing cardiothoracic surgical care to the patients, both in the intensive care unit and on the ward.
I rarely had to write a history and physical during Thoracic Surgery training. I consented fewer patients than I have fingers on my hands. I pulled even fewer chest tubes. I can now no longer remember having pulled a central line. I learned these tasks when I was a junior resident. What I did instead as a senior resident was perform over 900 cardiothoracic procedures as the primary surgeon. Now, as an attending surgeon, I still don’t write full histories and physicals by myself. I certainly don’t pull chest tubes and central lines. I consent patients by having a conversation with them, which I did as a resident, but I don’t bring a piece of paper with me in to the clinic room. I have a physician assistant who helps me fill in the gaps.
In 8 months of practice, I have performed over 15 thoracic organ transplants, repaired over 15 aortic dissections, half of whom required root replacements, performed more double-valve surgeries than straightforward single-valve replacements, started a minimally invasive atrial fibrillation surgical program, and applied almost every shred of knowledge and experience gained in 3 years of Thoracic Surgery Residency to a busy clinical practice. Most importantly, I continue to come home and watch my two daughters grow up.
With that perspective, I don’t believe the question should be whether or not programs should have the flexibility to enforce or not enforce duty-hours restrictions. It should be, how could every program find a way to effectively train residents to be good physicians and still allow them a personal life?”
Dr. Anson Lee is an Assistant Professor of Cardiac Surgery, Stanford University, Calif.; Training: 4+3 CT Residency, at Washington University, St. Louis.
Ms. Bohlman: “As a physician assistant in cardiac surgery, I represent the reality that physicians with a critical patient population appreciate consistency in their patient management. However, working in a university hospital setting also requires that surgical residents receive appropriate training. With the recently implemented duty restriction hours on resident training programs, advanced practice providers (APPs) have been utilized as an excellent solution for scheduling conflicts without compromising patient care. An example to this point is evident in my own place of work.
Approximately 1 year ago, our surgical intensive care unit transitioned from resident care to a combination of residents and APPs. At that time, the APPs were tasked with the complete care of all cardiac surgery patients. This change reduced the quantity and acuity of patients for which the residents were responsible and therefore allowed for more flexible hours along with a more manageable patient load. These changes, among others, have contributed to improved patient outcomes in the cardiac surgery patient population within our institution. With the increase in APPs that have training in various specialties, there comes an increasing ability to not only fill the gaps in scheduling but to do so with an extension of the providing physician. Although the NEJM article demonstrated no difference in patient outcomes between resident programs with restricted duty hours versus more flexible duty-hour policies, I foresee the future of medicine focusing on trained APPs as a complement to the care that the residents provide.”
Allison Bohlman is a Physician Assistant at Rush University Medical Center in the Integrated cardiovascular thoracic intensive care unit.
Several months ago, Dr. Bilimoria and his colleagues published the long awaited study in NEJM essentially contradicting adverse effects of strict duty hours on patient outcomes (N Engl J Med. 2016 374:713-2). The study, known as the FIRST trial, was published in the March issue of Thoracic Surgery News. Although the study enrolled general surgery residents, its conclusion impacts no specialty more than cardiothoracic surgery, where frequent handoffs complicate tedious perioperative care of sick patients stall learning opportunities for young trainees.
As Dr. Shari Meyerson eloquently noted in her perspective piece for Thoracic Surgery News (March 2016, page 4), surgery training needs to adapt to meet the modern day needs of trainees to rest and spend time with family and friends, with those of exposure to complex clinical scenarios in a short residency period. Arguably, CT surgery trainees are some of the most motivated and driven; to limit their experience on a national level may be shortsighted. On the other hand, appropriate incorporation of advanced practice providers (APPs) may help allay some patient care challenges, free valuable family time, and allow thoracic residents to function well in a more flexible ACGME duty-hour paradigm. To add thoracic relevance to the findings of Dr. Bilimoria and his colleagues, the debate is brought to Thoracic Surgery News by our colleagues from different training pathways below:
Dr. Antonoff: “Due to the timing of my medical school matriculation, I completed my surgical clerkships in the preregulated duty-hour era. I had expectations of what my life would be like as a surgeon when I applied for the general surgery match, and frankly, my expectations prepared me for a life that would revolve around my education, my technical training, and my commitment to patient care. During my years as a junior resident, my surgical training program gradually adapted in recognition of the new guidelines, but it took time. I spent 3 years in the research lab, and, after I came out as a senior resident, I discovered that the rules of the game had totally changed. While duty hours for me, as a senior trainee, were still fairly open, I found that my interns and junior residents had to play by completely new rules. In some ways, on rare occasions, I felt frustrated and resentful of the fact that my duties as a chief resident and thoracic fellow included many of the tasks that I’d done as an intern, because my interns would ‘expire’ after 16 hours. However, much more often, I felt bad for those who came after me.
They seemed desperate to operate, eager to see their patients’ problems through to resolution, and embarrassed to have to end their days earlier than the more senior members of the team. I feel fortunate that I had years of frequent in-house call after long days in the operating room and followed by post-call days of more operating. I finished my junior years without fear of any sick patient in the hospital, I finished my general surgery training without fear of any emergent operation, and I finished my fellowship with confidence that I could get a patient through just about anything if I had access to a cannula.
My early experiences as an attending have certainly kept me humble, and I’ve spent many a night worried about my patients, rethinking choices that I’ve made and stitches that I’ve thrown. But I thank my lucky stars that I was exposed to phenomenal training, and that I had the privilege and opportunity to work the hours needed to reach a reasonable level of safety! I can only imagine that if I’d have spent fewer nights in the hospital, that I’d feel even more anxiety and nausea at this early stage of my surgical career.
As elaborated in the editorial by Dr. Birkmeyer (N Engl J Med. 2016;374:783-4), it is not surprising that patient outcomes did not immediately depend on whether the programs had adhered strictly to the ACGME duty-hour rules. Limited numbers of patients experience critical events during shift change, and hospitals are evolving to function with greater reliance on midlevel practitioners and attending physicians. I would not expect the short-term results of duty-hour flexibility to demonstrate any impact on patient care. However, I do fear that there will be a mid-term impact on trainee accountability and autonomy, which will ultimately impact the competence of the attending surgeons of the future, and downstream potential long-term impact on day-to-day patient outcomes.
As a wife and mother of 3, I recognize that we, as a specialty, need to find ways to support our trainees and their families and to help them live happy lives conducive to functioning outside the hospital. I believe that we can do this with support, mentorship, and advocacy; I do not believe that it requires cutting back on the training that we are all, in the end, so incredibly grateful to receive.”
Dr. Mara Antonoff is an assistant professor of thoracic and cardiovascular surgery at UT MD Anderson Cancer Center. She performed her General Surgery training at the University of Minnesota, 2004-2012, and her Thoracic Surgery Training at Washington University, as a traditional 2-year resident, 2012-2014.
Dr. Stephens: “There is nothing that replaces being bedside. Whether it be a postoperative patient struggling with low cardiac output syndrome overnight, or a patient with a high pressor requirement the etiology of which you are trying to uncover, or a patient you have been following who suddenly arrests, the value of seeing a patient’s trajectory longitudinally is critical to developing clinical acumen. When as an attending I will get called in the middle of the night about a postoperative patient not “doing well,” I will be drawing on my years of being on call and being bedside with my patients.
Patient care is the ultimate goal, and it is clear that overworked residents are at higher risk for making mistakes that jeopardize patient care, which nobody wants. However, the restrictions that duty hours place don’t allow the flexibility necessary for a specialty such as ours, and in fact strict adherence to such regulations inhibits opportunities for our learning. Also concerning is the “shift-work” mentality that seems to be increasingly pervasive with the implementation of duty hours. As has been well documented, and as I have seen personally, the constant patient handoffs that are requisite to implementation of duty hours pose their own perils in terms of patient safety.
Ultimately, these are our patients and we are responsible. Once we are attendings, those responsibilities will not be turned off after we have reached some prespecified hour limit.
The question then remains how best to implement a system across a wide variety of programs that ensures both patient safety and adequate clinical experience in the context of a culture of patient responsibility for the residents. As the NEJM study (N Engl J Med. 2016 374:713-2) shows, flexibility in implementation of duty hours did not result in increased complications, but resulted in improved resident satisfaction in continuity of care and handoffs. In my opinion, this study then encourages specialties such as ours to be more flexible in work hours, to encourage residents when there is a learning opportunity that previously they would be prohibited from taking part in to take hold of that opportunity, and to use this flexibility in implementation of duty hours to combat the invading “shift-work” mentality that will only jeopardize patient care.”
Dr. Elizabeth H. Stephens, MD, PhD is a Cardiothoracic Surgery, resident, PGY4, at Columbia University, New York, as an Integrated I-6 Resident.
Dr. Brown: “I took the traditional 5-year of General Surgery + 2 years of Cardiothoracic Surgery training route to becoming a General Thoracic Surgeon. My General Surgery experience was invaluable to my development as a surgeon. However, after all of those years of General Surgery cases and minimal exposure to Cardiothoracic Surgery cases, coupled with minimal overlap between the two specialties with regard to patient care, I found the learning curve in fellowship to be very steep. I was fortunate to train in a program with phenomenal physician extender support [APPs] in addition to top-notch colleagues in other specialties and excellent nursing, which allowed me to spend the majority of those 2 years in the operating room and completely focused on patient care. During that final phase of training, I welcomed flexibility with regard to the work-hour restrictions to ensure that I was acquiring the experience I needed prior to starting my own practice.”
Lisa M. Brown, MD, MAS, Assistant Professor of Thoracic Surgery, UC Davis Health System, Calif.; Training Institution: Washington University
Dr. Lee: “I started my surgical training in 2005, 2 years after the implementation of the 80-hour workweek restriction. Fortunately for my personal life, my training program took the restriction very seriously and strictly enforced it. As a result, I had scheduled periods off from work, and rarely worked more than 80 hours per week over the course of general surgery. On those occasions that I did, the next weeks, or preceding weeks would be shorter, to compensate. As a product of a 4+3 Thoracic Surgery residency in this environment, the 80-hour workweek extended to my subspecialty training. Our cardiac surgery time strictly enforced the go-home post-call policy. As a result, I believe my duty hours during Thoracic Surgery are likely shorter overall than many other programs.
Everyone hears the rumors of other programs lying about their duty hours. Fortunately, mine was not one of these. Despite this, or because of this, I received top-notch training. At the same time and more importantly, I started a family. I married my wife a week before my internship started, and am still married to the same person. We had two precious daughters during my Thoracic Surgery years. I don’t believe this would have been possible without duty-hours restrictions.
To create an environment where such a task was possible, my program hired an army of mid-level practitioners to deal with the day-to-day tasks of providing cardiothoracic surgical care to the patients, both in the intensive care unit and on the ward.
I rarely had to write a history and physical during Thoracic Surgery training. I consented fewer patients than I have fingers on my hands. I pulled even fewer chest tubes. I can now no longer remember having pulled a central line. I learned these tasks when I was a junior resident. What I did instead as a senior resident was perform over 900 cardiothoracic procedures as the primary surgeon. Now, as an attending surgeon, I still don’t write full histories and physicals by myself. I certainly don’t pull chest tubes and central lines. I consent patients by having a conversation with them, which I did as a resident, but I don’t bring a piece of paper with me in to the clinic room. I have a physician assistant who helps me fill in the gaps.
In 8 months of practice, I have performed over 15 thoracic organ transplants, repaired over 15 aortic dissections, half of whom required root replacements, performed more double-valve surgeries than straightforward single-valve replacements, started a minimally invasive atrial fibrillation surgical program, and applied almost every shred of knowledge and experience gained in 3 years of Thoracic Surgery Residency to a busy clinical practice. Most importantly, I continue to come home and watch my two daughters grow up.
With that perspective, I don’t believe the question should be whether or not programs should have the flexibility to enforce or not enforce duty-hours restrictions. It should be, how could every program find a way to effectively train residents to be good physicians and still allow them a personal life?”
Dr. Anson Lee is an Assistant Professor of Cardiac Surgery, Stanford University, Calif.; Training: 4+3 CT Residency, at Washington University, St. Louis.
Ms. Bohlman: “As a physician assistant in cardiac surgery, I represent the reality that physicians with a critical patient population appreciate consistency in their patient management. However, working in a university hospital setting also requires that surgical residents receive appropriate training. With the recently implemented duty restriction hours on resident training programs, advanced practice providers (APPs) have been utilized as an excellent solution for scheduling conflicts without compromising patient care. An example to this point is evident in my own place of work.
Approximately 1 year ago, our surgical intensive care unit transitioned from resident care to a combination of residents and APPs. At that time, the APPs were tasked with the complete care of all cardiac surgery patients. This change reduced the quantity and acuity of patients for which the residents were responsible and therefore allowed for more flexible hours along with a more manageable patient load. These changes, among others, have contributed to improved patient outcomes in the cardiac surgery patient population within our institution. With the increase in APPs that have training in various specialties, there comes an increasing ability to not only fill the gaps in scheduling but to do so with an extension of the providing physician. Although the NEJM article demonstrated no difference in patient outcomes between resident programs with restricted duty hours versus more flexible duty-hour policies, I foresee the future of medicine focusing on trained APPs as a complement to the care that the residents provide.”
Allison Bohlman is a Physician Assistant at Rush University Medical Center in the Integrated cardiovascular thoracic intensive care unit.
Several months ago, Dr. Bilimoria and his colleagues published the long awaited study in NEJM essentially contradicting adverse effects of strict duty hours on patient outcomes (N Engl J Med. 2016 374:713-2). The study, known as the FIRST trial, was published in the March issue of Thoracic Surgery News. Although the study enrolled general surgery residents, its conclusion impacts no specialty more than cardiothoracic surgery, where frequent handoffs complicate tedious perioperative care of sick patients stall learning opportunities for young trainees.
As Dr. Shari Meyerson eloquently noted in her perspective piece for Thoracic Surgery News (March 2016, page 4), surgery training needs to adapt to meet the modern day needs of trainees to rest and spend time with family and friends, with those of exposure to complex clinical scenarios in a short residency period. Arguably, CT surgery trainees are some of the most motivated and driven; to limit their experience on a national level may be shortsighted. On the other hand, appropriate incorporation of advanced practice providers (APPs) may help allay some patient care challenges, free valuable family time, and allow thoracic residents to function well in a more flexible ACGME duty-hour paradigm. To add thoracic relevance to the findings of Dr. Bilimoria and his colleagues, the debate is brought to Thoracic Surgery News by our colleagues from different training pathways below:
Dr. Antonoff: “Due to the timing of my medical school matriculation, I completed my surgical clerkships in the preregulated duty-hour era. I had expectations of what my life would be like as a surgeon when I applied for the general surgery match, and frankly, my expectations prepared me for a life that would revolve around my education, my technical training, and my commitment to patient care. During my years as a junior resident, my surgical training program gradually adapted in recognition of the new guidelines, but it took time. I spent 3 years in the research lab, and, after I came out as a senior resident, I discovered that the rules of the game had totally changed. While duty hours for me, as a senior trainee, were still fairly open, I found that my interns and junior residents had to play by completely new rules. In some ways, on rare occasions, I felt frustrated and resentful of the fact that my duties as a chief resident and thoracic fellow included many of the tasks that I’d done as an intern, because my interns would ‘expire’ after 16 hours. However, much more often, I felt bad for those who came after me.
They seemed desperate to operate, eager to see their patients’ problems through to resolution, and embarrassed to have to end their days earlier than the more senior members of the team. I feel fortunate that I had years of frequent in-house call after long days in the operating room and followed by post-call days of more operating. I finished my junior years without fear of any sick patient in the hospital, I finished my general surgery training without fear of any emergent operation, and I finished my fellowship with confidence that I could get a patient through just about anything if I had access to a cannula.
My early experiences as an attending have certainly kept me humble, and I’ve spent many a night worried about my patients, rethinking choices that I’ve made and stitches that I’ve thrown. But I thank my lucky stars that I was exposed to phenomenal training, and that I had the privilege and opportunity to work the hours needed to reach a reasonable level of safety! I can only imagine that if I’d have spent fewer nights in the hospital, that I’d feel even more anxiety and nausea at this early stage of my surgical career.
As elaborated in the editorial by Dr. Birkmeyer (N Engl J Med. 2016;374:783-4), it is not surprising that patient outcomes did not immediately depend on whether the programs had adhered strictly to the ACGME duty-hour rules. Limited numbers of patients experience critical events during shift change, and hospitals are evolving to function with greater reliance on midlevel practitioners and attending physicians. I would not expect the short-term results of duty-hour flexibility to demonstrate any impact on patient care. However, I do fear that there will be a mid-term impact on trainee accountability and autonomy, which will ultimately impact the competence of the attending surgeons of the future, and downstream potential long-term impact on day-to-day patient outcomes.
As a wife and mother of 3, I recognize that we, as a specialty, need to find ways to support our trainees and their families and to help them live happy lives conducive to functioning outside the hospital. I believe that we can do this with support, mentorship, and advocacy; I do not believe that it requires cutting back on the training that we are all, in the end, so incredibly grateful to receive.”
Dr. Mara Antonoff is an assistant professor of thoracic and cardiovascular surgery at UT MD Anderson Cancer Center. She performed her General Surgery training at the University of Minnesota, 2004-2012, and her Thoracic Surgery Training at Washington University, as a traditional 2-year resident, 2012-2014.
Dr. Stephens: “There is nothing that replaces being bedside. Whether it be a postoperative patient struggling with low cardiac output syndrome overnight, or a patient with a high pressor requirement the etiology of which you are trying to uncover, or a patient you have been following who suddenly arrests, the value of seeing a patient’s trajectory longitudinally is critical to developing clinical acumen. When as an attending I will get called in the middle of the night about a postoperative patient not “doing well,” I will be drawing on my years of being on call and being bedside with my patients.
Patient care is the ultimate goal, and it is clear that overworked residents are at higher risk for making mistakes that jeopardize patient care, which nobody wants. However, the restrictions that duty hours place don’t allow the flexibility necessary for a specialty such as ours, and in fact strict adherence to such regulations inhibits opportunities for our learning. Also concerning is the “shift-work” mentality that seems to be increasingly pervasive with the implementation of duty hours. As has been well documented, and as I have seen personally, the constant patient handoffs that are requisite to implementation of duty hours pose their own perils in terms of patient safety.
Ultimately, these are our patients and we are responsible. Once we are attendings, those responsibilities will not be turned off after we have reached some prespecified hour limit.
The question then remains how best to implement a system across a wide variety of programs that ensures both patient safety and adequate clinical experience in the context of a culture of patient responsibility for the residents. As the NEJM study (N Engl J Med. 2016 374:713-2) shows, flexibility in implementation of duty hours did not result in increased complications, but resulted in improved resident satisfaction in continuity of care and handoffs. In my opinion, this study then encourages specialties such as ours to be more flexible in work hours, to encourage residents when there is a learning opportunity that previously they would be prohibited from taking part in to take hold of that opportunity, and to use this flexibility in implementation of duty hours to combat the invading “shift-work” mentality that will only jeopardize patient care.”
Dr. Elizabeth H. Stephens, MD, PhD is a Cardiothoracic Surgery, resident, PGY4, at Columbia University, New York, as an Integrated I-6 Resident.
Dr. Brown: “I took the traditional 5-year of General Surgery + 2 years of Cardiothoracic Surgery training route to becoming a General Thoracic Surgeon. My General Surgery experience was invaluable to my development as a surgeon. However, after all of those years of General Surgery cases and minimal exposure to Cardiothoracic Surgery cases, coupled with minimal overlap between the two specialties with regard to patient care, I found the learning curve in fellowship to be very steep. I was fortunate to train in a program with phenomenal physician extender support [APPs] in addition to top-notch colleagues in other specialties and excellent nursing, which allowed me to spend the majority of those 2 years in the operating room and completely focused on patient care. During that final phase of training, I welcomed flexibility with regard to the work-hour restrictions to ensure that I was acquiring the experience I needed prior to starting my own practice.”
Lisa M. Brown, MD, MAS, Assistant Professor of Thoracic Surgery, UC Davis Health System, Calif.; Training Institution: Washington University
Dr. Lee: “I started my surgical training in 2005, 2 years after the implementation of the 80-hour workweek restriction. Fortunately for my personal life, my training program took the restriction very seriously and strictly enforced it. As a result, I had scheduled periods off from work, and rarely worked more than 80 hours per week over the course of general surgery. On those occasions that I did, the next weeks, or preceding weeks would be shorter, to compensate. As a product of a 4+3 Thoracic Surgery residency in this environment, the 80-hour workweek extended to my subspecialty training. Our cardiac surgery time strictly enforced the go-home post-call policy. As a result, I believe my duty hours during Thoracic Surgery are likely shorter overall than many other programs.
Everyone hears the rumors of other programs lying about their duty hours. Fortunately, mine was not one of these. Despite this, or because of this, I received top-notch training. At the same time and more importantly, I started a family. I married my wife a week before my internship started, and am still married to the same person. We had two precious daughters during my Thoracic Surgery years. I don’t believe this would have been possible without duty-hours restrictions.
To create an environment where such a task was possible, my program hired an army of mid-level practitioners to deal with the day-to-day tasks of providing cardiothoracic surgical care to the patients, both in the intensive care unit and on the ward.
I rarely had to write a history and physical during Thoracic Surgery training. I consented fewer patients than I have fingers on my hands. I pulled even fewer chest tubes. I can now no longer remember having pulled a central line. I learned these tasks when I was a junior resident. What I did instead as a senior resident was perform over 900 cardiothoracic procedures as the primary surgeon. Now, as an attending surgeon, I still don’t write full histories and physicals by myself. I certainly don’t pull chest tubes and central lines. I consent patients by having a conversation with them, which I did as a resident, but I don’t bring a piece of paper with me in to the clinic room. I have a physician assistant who helps me fill in the gaps.
In 8 months of practice, I have performed over 15 thoracic organ transplants, repaired over 15 aortic dissections, half of whom required root replacements, performed more double-valve surgeries than straightforward single-valve replacements, started a minimally invasive atrial fibrillation surgical program, and applied almost every shred of knowledge and experience gained in 3 years of Thoracic Surgery Residency to a busy clinical practice. Most importantly, I continue to come home and watch my two daughters grow up.
With that perspective, I don’t believe the question should be whether or not programs should have the flexibility to enforce or not enforce duty-hours restrictions. It should be, how could every program find a way to effectively train residents to be good physicians and still allow them a personal life?”
Dr. Anson Lee is an Assistant Professor of Cardiac Surgery, Stanford University, Calif.; Training: 4+3 CT Residency, at Washington University, St. Louis.
Ms. Bohlman: “As a physician assistant in cardiac surgery, I represent the reality that physicians with a critical patient population appreciate consistency in their patient management. However, working in a university hospital setting also requires that surgical residents receive appropriate training. With the recently implemented duty restriction hours on resident training programs, advanced practice providers (APPs) have been utilized as an excellent solution for scheduling conflicts without compromising patient care. An example to this point is evident in my own place of work.
Approximately 1 year ago, our surgical intensive care unit transitioned from resident care to a combination of residents and APPs. At that time, the APPs were tasked with the complete care of all cardiac surgery patients. This change reduced the quantity and acuity of patients for which the residents were responsible and therefore allowed for more flexible hours along with a more manageable patient load. These changes, among others, have contributed to improved patient outcomes in the cardiac surgery patient population within our institution. With the increase in APPs that have training in various specialties, there comes an increasing ability to not only fill the gaps in scheduling but to do so with an extension of the providing physician. Although the NEJM article demonstrated no difference in patient outcomes between resident programs with restricted duty hours versus more flexible duty-hour policies, I foresee the future of medicine focusing on trained APPs as a complement to the care that the residents provide.”
Allison Bohlman is a Physician Assistant at Rush University Medical Center in the Integrated cardiovascular thoracic intensive care unit.
Diverticulitis recurs more with observation vs. elective resection
CHICAGO – Observation, compared with elective resection, was associated with significantly increased recurrence rates in a single-center randomized, controlled trial of patients who had successfully recovered via nonoperative management from their first episode of acute sigmoid diverticulitis with extraluminal air/abscess.
Recurrence rates in 111 patients randomized to observation or elective resection were 31% in the observation group and 7% in the resection group, at 15 and 18 months, respectively, Dr. Ryan Bendl of State University of New York, Stony Brook reported at the annual meeting of the American Surgical Association.
Patients in the two groups were comparable with respect to age, sex, body mass index, Colorectal Physiologic and Operative Severity Score for the Enumeration of Mortality and Morbidity (CR-POSSUM), and comorbidities, he noted.
Subjects included in the single-center study were adults admitted for a first episode of acute diverticulitis with abscess or extraluminal air who were managed nonoperatively with intravenous antibiotics, a period of nothing by mouth, drainage, and total parenteral nutrition followed by colonoscopy. They were randomized 3:1 to observation or resection, and 68% of the elective resection patients underwent minimally invasive surgery. The study’s primary endpoint was recurrent diverticulitis defined as an acute episode confirmed by computed tomography and requiring hospitalization with intravenous antibiotics.
Diverticulitis accounted for more than 300,000 hospital admissions in 2010 in the United States alone, and 10%-20% of patients had abscess formation. At one time, most patients were managed with immediate operative intervention, but medical and radiologic advances have led to a shift toward nonoperative management, Dr. Bendl said.
Some prior studies have suggested that recurrence rates are higher with nonoperative management, and the current study supports those data.
However, despite the significant increase in the recurrence rate with observation vs. resection, most patients in the observation group did not experience recurrence, and of those who did, none had peritonitis.
“All those with recurrences were successfully treated again using nonoperative management,” he said.
This study was supported in part by grants from Merck and Covidien. Dr. Bendl reported having no relevant financial disclosures.
CHICAGO – Observation, compared with elective resection, was associated with significantly increased recurrence rates in a single-center randomized, controlled trial of patients who had successfully recovered via nonoperative management from their first episode of acute sigmoid diverticulitis with extraluminal air/abscess.
Recurrence rates in 111 patients randomized to observation or elective resection were 31% in the observation group and 7% in the resection group, at 15 and 18 months, respectively, Dr. Ryan Bendl of State University of New York, Stony Brook reported at the annual meeting of the American Surgical Association.
Patients in the two groups were comparable with respect to age, sex, body mass index, Colorectal Physiologic and Operative Severity Score for the Enumeration of Mortality and Morbidity (CR-POSSUM), and comorbidities, he noted.
Subjects included in the single-center study were adults admitted for a first episode of acute diverticulitis with abscess or extraluminal air who were managed nonoperatively with intravenous antibiotics, a period of nothing by mouth, drainage, and total parenteral nutrition followed by colonoscopy. They were randomized 3:1 to observation or resection, and 68% of the elective resection patients underwent minimally invasive surgery. The study’s primary endpoint was recurrent diverticulitis defined as an acute episode confirmed by computed tomography and requiring hospitalization with intravenous antibiotics.
Diverticulitis accounted for more than 300,000 hospital admissions in 2010 in the United States alone, and 10%-20% of patients had abscess formation. At one time, most patients were managed with immediate operative intervention, but medical and radiologic advances have led to a shift toward nonoperative management, Dr. Bendl said.
Some prior studies have suggested that recurrence rates are higher with nonoperative management, and the current study supports those data.
However, despite the significant increase in the recurrence rate with observation vs. resection, most patients in the observation group did not experience recurrence, and of those who did, none had peritonitis.
“All those with recurrences were successfully treated again using nonoperative management,” he said.
This study was supported in part by grants from Merck and Covidien. Dr. Bendl reported having no relevant financial disclosures.
CHICAGO – Observation, compared with elective resection, was associated with significantly increased recurrence rates in a single-center randomized, controlled trial of patients who had successfully recovered via nonoperative management from their first episode of acute sigmoid diverticulitis with extraluminal air/abscess.
Recurrence rates in 111 patients randomized to observation or elective resection were 31% in the observation group and 7% in the resection group, at 15 and 18 months, respectively, Dr. Ryan Bendl of State University of New York, Stony Brook reported at the annual meeting of the American Surgical Association.
Patients in the two groups were comparable with respect to age, sex, body mass index, Colorectal Physiologic and Operative Severity Score for the Enumeration of Mortality and Morbidity (CR-POSSUM), and comorbidities, he noted.
Subjects included in the single-center study were adults admitted for a first episode of acute diverticulitis with abscess or extraluminal air who were managed nonoperatively with intravenous antibiotics, a period of nothing by mouth, drainage, and total parenteral nutrition followed by colonoscopy. They were randomized 3:1 to observation or resection, and 68% of the elective resection patients underwent minimally invasive surgery. The study’s primary endpoint was recurrent diverticulitis defined as an acute episode confirmed by computed tomography and requiring hospitalization with intravenous antibiotics.
Diverticulitis accounted for more than 300,000 hospital admissions in 2010 in the United States alone, and 10%-20% of patients had abscess formation. At one time, most patients were managed with immediate operative intervention, but medical and radiologic advances have led to a shift toward nonoperative management, Dr. Bendl said.
Some prior studies have suggested that recurrence rates are higher with nonoperative management, and the current study supports those data.
However, despite the significant increase in the recurrence rate with observation vs. resection, most patients in the observation group did not experience recurrence, and of those who did, none had peritonitis.
“All those with recurrences were successfully treated again using nonoperative management,” he said.
This study was supported in part by grants from Merck and Covidien. Dr. Bendl reported having no relevant financial disclosures.
AT THE ASA ANNUAL MEETING
Key clinical point: Observation vs. elective resection was associated with significantly increased recurrence rates in patients who had recovered via nonoperative management from their first episode of acute sigmoid diverticulitis with extraluminal air/abscess.
Major finding: Recurrence rates in 111 patients randomized to observation or elective resection were 31% in the observation group and 7% in the resection group, at 15 and 18 months, respectively.
Data source: A randomized, controlled trial involving 111 patients.
Disclosures: This study was supported in part by grants from Merck and Covidien. Dr. Bendl reported having no relevant financial disclosures.
Racial disparities in colon cancer survival mainly driven by tumor stage at presentation
Although black patients with colon cancer received significantly less treatment than white patients, particularly for late stage disease, much of the overall survival disparity between black and white patients was explained by tumor presentation at diagnosis rather than treatment differences, according to an analysis of SEER data.
Among demographically matched black and white patients, the 5-year survival difference was 8.3% (P less than .0001). Presentation match reduced the difference to 5.0% (P less than .0001), which accounted for 39.8% of the overall disparity. Additional matching by treatment reduced the difference only slightly to 4.9% (P less than .0001), which accounted for 1.2% of the overall disparity. Black patients had lower rates for most treatments, including surgery, than presentation-matched white patients (88.5% vs. 91.4%), and these differences were most pronounced at advanced stages. For example, significant differences between black and white patients in the use of chemotherapy was observed for stage III (53.1% vs. 64.2%; P less than .0001) and stage IV (56.1% vs. 63.3%; P = .001).
“Our results indicate that tumor presentation, including tumor stage, is indeed one of the most important factors contributing to the racial disparity in colon cancer survival. We observed that, after controlling for demographic factors, black patients in comparison with white patients had a significantly higher proportion of stage IV and lower proportions of stages I and II disease. Adequately matching on tumor presentation variables (e.g., stage, grade, size, and comorbidity) significantly reduced survival disparities,” wrote Dr. Yinzhi Lai of the Department of Medical Oncology at Sidney Kimmel Cancer Center, Philadelphia, and colleagues (Gastroenterology. 2016 Apr 4. doi: 10.1053/j.gastro.2016.01.030).
Treatment differences in advanced-stage patients, compared with early-stage patients, explained a higher proportion of the demographic-matched survival disparity. For example, in stage II patients, treatment match resulted in modest reductions in 2-, 3-, and 5-year survival rate disparities (2.7%-2.8%, 4.1%-3.6%, and 4.6%-4.0%, respectively); by contrast, in stage III patients, treatment match resulted in more substantial reductions in 2-, 3-, and 5-year survival rate disparities (4.5%-2.2%, 3.1%-2.0%, and 4.3%-2.8%, respectively). A similar effect was observed in patients with stage IV disease. The results suggest that, “to control survival disparity, more efforts may need to be tailored to minimize treatment disparities (especially chemotherapy use) in patients with advanced-stage disease,” the investigators wrote.
The retrospective data analysis used patient information from 68,141 patients (6,190 black, 61,951 white) aged 66 years and older with colon cancer identified from the National Cancer Institute SEER-Medicare database. Using a novel minimum distance matching strategy, investigators drew from the pool of white patients to match three distinct comparison cohorts to the same 6,190 black patients. Close matches between black and white patients bypassed the need for model-based analysis.
The primary matching analysis was limited by the inability to control for substantial differences in socioeconomic status, marital status, and urban/rural residence. A subcohort analysis of 2,000 matched black and white patients showed that when socioeconomic status was added to the demographic match, survival differences were reduced, indicating the important role of socioeconomic status on racial survival disparities.
Significantly better survival was observed in all patients who were diagnosed in 2004 or later, the year the Food and Drug Administration approved the important chemotherapy medicines oxaliplatin and bevacizumab. Separating the cohorts into those who were diagnosed before and after 2004 revealed that the racial survival disparity was lower in the more recent group, indicating a favorable impact of oxaliplatin and/or bevacizumab in reducing the survival disparity.
Prior studies have documented racial disparities in the incidence and outcomes of colon cancer in the United States. Black men and women have a higher overall incidence and more advanced stage of disease at diagnosis than white men and women, while being less likely to receive guideline-concordant treatment.
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| Dr. Jennifer Lund |
To extend this work, the authors evaluated treatment disparities between black and white colon cancer patients aged 66 years and older and examined the impact of a variety of patient characteristics on racial disparities in overall survival using a novel, sequential matching algorithm that minimized the overall distance between black and white patients based on demographic-, tumor specific–, and treatment-related variables. The authors found that differences in overall survival were mainly driven by tumor presentation; however, advanced-stage black colon cancer patients received less guideline concordant-treatment than white patients. While this minimum-distance algorithm provided close black-white matches on prespecified factors, it could not accommodate other factors (for example, socioeconomic, marital, and urban/rural status); therefore, methodologic improvements to this method and comparisons to other commonly used approaches (that is, propensity score matching and weighting) are warranted.
Finally, these results apply to older black and white colon cancer patients with Medicare fee-for-service coverage only. Additional research using similar methods in older Medicare Advantage populations or younger adults may uncover unique drivers of overall survival disparities by race, which may require tailored interventions.
Jennifer L. Lund, Ph.D., is an assistant professor, department of epidemiology, University of North Carolina at Chapel Hill. She receives research support from the UNC Oncology Clinical Translational Research Training Program (K12 CA120780), as well as through a Research Starter Award from the PhRMA Foundation to the UNC Department of Epidemiology.
Prior studies have documented racial disparities in the incidence and outcomes of colon cancer in the United States. Black men and women have a higher overall incidence and more advanced stage of disease at diagnosis than white men and women, while being less likely to receive guideline-concordant treatment.
|
|
| Dr. Jennifer Lund |
To extend this work, the authors evaluated treatment disparities between black and white colon cancer patients aged 66 years and older and examined the impact of a variety of patient characteristics on racial disparities in overall survival using a novel, sequential matching algorithm that minimized the overall distance between black and white patients based on demographic-, tumor specific–, and treatment-related variables. The authors found that differences in overall survival were mainly driven by tumor presentation; however, advanced-stage black colon cancer patients received less guideline concordant-treatment than white patients. While this minimum-distance algorithm provided close black-white matches on prespecified factors, it could not accommodate other factors (for example, socioeconomic, marital, and urban/rural status); therefore, methodologic improvements to this method and comparisons to other commonly used approaches (that is, propensity score matching and weighting) are warranted.
Finally, these results apply to older black and white colon cancer patients with Medicare fee-for-service coverage only. Additional research using similar methods in older Medicare Advantage populations or younger adults may uncover unique drivers of overall survival disparities by race, which may require tailored interventions.
Jennifer L. Lund, Ph.D., is an assistant professor, department of epidemiology, University of North Carolina at Chapel Hill. She receives research support from the UNC Oncology Clinical Translational Research Training Program (K12 CA120780), as well as through a Research Starter Award from the PhRMA Foundation to the UNC Department of Epidemiology.
Prior studies have documented racial disparities in the incidence and outcomes of colon cancer in the United States. Black men and women have a higher overall incidence and more advanced stage of disease at diagnosis than white men and women, while being less likely to receive guideline-concordant treatment.
|
|
| Dr. Jennifer Lund |
To extend this work, the authors evaluated treatment disparities between black and white colon cancer patients aged 66 years and older and examined the impact of a variety of patient characteristics on racial disparities in overall survival using a novel, sequential matching algorithm that minimized the overall distance between black and white patients based on demographic-, tumor specific–, and treatment-related variables. The authors found that differences in overall survival were mainly driven by tumor presentation; however, advanced-stage black colon cancer patients received less guideline concordant-treatment than white patients. While this minimum-distance algorithm provided close black-white matches on prespecified factors, it could not accommodate other factors (for example, socioeconomic, marital, and urban/rural status); therefore, methodologic improvements to this method and comparisons to other commonly used approaches (that is, propensity score matching and weighting) are warranted.
Finally, these results apply to older black and white colon cancer patients with Medicare fee-for-service coverage only. Additional research using similar methods in older Medicare Advantage populations or younger adults may uncover unique drivers of overall survival disparities by race, which may require tailored interventions.
Jennifer L. Lund, Ph.D., is an assistant professor, department of epidemiology, University of North Carolina at Chapel Hill. She receives research support from the UNC Oncology Clinical Translational Research Training Program (K12 CA120780), as well as through a Research Starter Award from the PhRMA Foundation to the UNC Department of Epidemiology.
Although black patients with colon cancer received significantly less treatment than white patients, particularly for late stage disease, much of the overall survival disparity between black and white patients was explained by tumor presentation at diagnosis rather than treatment differences, according to an analysis of SEER data.
Among demographically matched black and white patients, the 5-year survival difference was 8.3% (P less than .0001). Presentation match reduced the difference to 5.0% (P less than .0001), which accounted for 39.8% of the overall disparity. Additional matching by treatment reduced the difference only slightly to 4.9% (P less than .0001), which accounted for 1.2% of the overall disparity. Black patients had lower rates for most treatments, including surgery, than presentation-matched white patients (88.5% vs. 91.4%), and these differences were most pronounced at advanced stages. For example, significant differences between black and white patients in the use of chemotherapy was observed for stage III (53.1% vs. 64.2%; P less than .0001) and stage IV (56.1% vs. 63.3%; P = .001).
“Our results indicate that tumor presentation, including tumor stage, is indeed one of the most important factors contributing to the racial disparity in colon cancer survival. We observed that, after controlling for demographic factors, black patients in comparison with white patients had a significantly higher proportion of stage IV and lower proportions of stages I and II disease. Adequately matching on tumor presentation variables (e.g., stage, grade, size, and comorbidity) significantly reduced survival disparities,” wrote Dr. Yinzhi Lai of the Department of Medical Oncology at Sidney Kimmel Cancer Center, Philadelphia, and colleagues (Gastroenterology. 2016 Apr 4. doi: 10.1053/j.gastro.2016.01.030).
Treatment differences in advanced-stage patients, compared with early-stage patients, explained a higher proportion of the demographic-matched survival disparity. For example, in stage II patients, treatment match resulted in modest reductions in 2-, 3-, and 5-year survival rate disparities (2.7%-2.8%, 4.1%-3.6%, and 4.6%-4.0%, respectively); by contrast, in stage III patients, treatment match resulted in more substantial reductions in 2-, 3-, and 5-year survival rate disparities (4.5%-2.2%, 3.1%-2.0%, and 4.3%-2.8%, respectively). A similar effect was observed in patients with stage IV disease. The results suggest that, “to control survival disparity, more efforts may need to be tailored to minimize treatment disparities (especially chemotherapy use) in patients with advanced-stage disease,” the investigators wrote.
The retrospective data analysis used patient information from 68,141 patients (6,190 black, 61,951 white) aged 66 years and older with colon cancer identified from the National Cancer Institute SEER-Medicare database. Using a novel minimum distance matching strategy, investigators drew from the pool of white patients to match three distinct comparison cohorts to the same 6,190 black patients. Close matches between black and white patients bypassed the need for model-based analysis.
The primary matching analysis was limited by the inability to control for substantial differences in socioeconomic status, marital status, and urban/rural residence. A subcohort analysis of 2,000 matched black and white patients showed that when socioeconomic status was added to the demographic match, survival differences were reduced, indicating the important role of socioeconomic status on racial survival disparities.
Significantly better survival was observed in all patients who were diagnosed in 2004 or later, the year the Food and Drug Administration approved the important chemotherapy medicines oxaliplatin and bevacizumab. Separating the cohorts into those who were diagnosed before and after 2004 revealed that the racial survival disparity was lower in the more recent group, indicating a favorable impact of oxaliplatin and/or bevacizumab in reducing the survival disparity.
Although black patients with colon cancer received significantly less treatment than white patients, particularly for late stage disease, much of the overall survival disparity between black and white patients was explained by tumor presentation at diagnosis rather than treatment differences, according to an analysis of SEER data.
Among demographically matched black and white patients, the 5-year survival difference was 8.3% (P less than .0001). Presentation match reduced the difference to 5.0% (P less than .0001), which accounted for 39.8% of the overall disparity. Additional matching by treatment reduced the difference only slightly to 4.9% (P less than .0001), which accounted for 1.2% of the overall disparity. Black patients had lower rates for most treatments, including surgery, than presentation-matched white patients (88.5% vs. 91.4%), and these differences were most pronounced at advanced stages. For example, significant differences between black and white patients in the use of chemotherapy was observed for stage III (53.1% vs. 64.2%; P less than .0001) and stage IV (56.1% vs. 63.3%; P = .001).
“Our results indicate that tumor presentation, including tumor stage, is indeed one of the most important factors contributing to the racial disparity in colon cancer survival. We observed that, after controlling for demographic factors, black patients in comparison with white patients had a significantly higher proportion of stage IV and lower proportions of stages I and II disease. Adequately matching on tumor presentation variables (e.g., stage, grade, size, and comorbidity) significantly reduced survival disparities,” wrote Dr. Yinzhi Lai of the Department of Medical Oncology at Sidney Kimmel Cancer Center, Philadelphia, and colleagues (Gastroenterology. 2016 Apr 4. doi: 10.1053/j.gastro.2016.01.030).
Treatment differences in advanced-stage patients, compared with early-stage patients, explained a higher proportion of the demographic-matched survival disparity. For example, in stage II patients, treatment match resulted in modest reductions in 2-, 3-, and 5-year survival rate disparities (2.7%-2.8%, 4.1%-3.6%, and 4.6%-4.0%, respectively); by contrast, in stage III patients, treatment match resulted in more substantial reductions in 2-, 3-, and 5-year survival rate disparities (4.5%-2.2%, 3.1%-2.0%, and 4.3%-2.8%, respectively). A similar effect was observed in patients with stage IV disease. The results suggest that, “to control survival disparity, more efforts may need to be tailored to minimize treatment disparities (especially chemotherapy use) in patients with advanced-stage disease,” the investigators wrote.
The retrospective data analysis used patient information from 68,141 patients (6,190 black, 61,951 white) aged 66 years and older with colon cancer identified from the National Cancer Institute SEER-Medicare database. Using a novel minimum distance matching strategy, investigators drew from the pool of white patients to match three distinct comparison cohorts to the same 6,190 black patients. Close matches between black and white patients bypassed the need for model-based analysis.
The primary matching analysis was limited by the inability to control for substantial differences in socioeconomic status, marital status, and urban/rural residence. A subcohort analysis of 2,000 matched black and white patients showed that when socioeconomic status was added to the demographic match, survival differences were reduced, indicating the important role of socioeconomic status on racial survival disparities.
Significantly better survival was observed in all patients who were diagnosed in 2004 or later, the year the Food and Drug Administration approved the important chemotherapy medicines oxaliplatin and bevacizumab. Separating the cohorts into those who were diagnosed before and after 2004 revealed that the racial survival disparity was lower in the more recent group, indicating a favorable impact of oxaliplatin and/or bevacizumab in reducing the survival disparity.
FROM GASTROENTEROLOGY
Key clinical point: Tumor stage at diagnosis had a greater effect on survival disparities between black and white patients with colon cancer than treatment differences.
Major finding: Among demographically matched black and white patients, the 5-year survival difference was 8.3% (P less than .0001); matching by presentation reduced the difference to 5.0% (P less than .0001), and additional matching by treatment reduced the difference only slightly to 4.9% (P less than .0001).
Data sources: In total, 68,141 patients (6,190 black, 61,951 white) aged 66 years and older with colon cancer were identified from the National Cancer Institute SEER-Medicare database. Three white comparison cohorts were assembled and matched to the same 6,190 black patients.
Disclosures: Dr. Lai and coauthors reported having no disclosures.
