ACS Surgery News

SAN DIEGO - An intra-arterial infusion drug cocktail of nicardipine, verapamil, and nitroglycerin appears to work better than nicardipine or verapamil alone – the usual approach – to open up cerebral vasospasms after subarachnoid hemorrhage. The early results are so promising that lead investigator Dr. Peng Roc Chen, a cerebrovascular neurosurgeon at the University of Texas, Houston, and his colleagues are following up with a randomized controlled trial. Dr. Chen explained the project to us at this year’s International Stroke Conference.

SAN DIEGO - An intra-arterial infusion drug cocktail of nicardipine, verapamil, and nitroglycerin appears to work better than nicardipine or verapamil alone – the usual approach – to open up cerebral vasospasms after subarachnoid hemorrhage. The early results are so promising that lead investigator Dr. Peng Roc Chen, a cerebrovascular neurosurgeon at the University of Texas, Houston, and his colleagues are following up with a randomized controlled trial. Dr. Chen explained the project to us at this year’s International Stroke Conference.

SAN DIEGO - An intra-arterial infusion drug cocktail of nicardipine, verapamil, and nitroglycerin appears to work better than nicardipine or verapamil alone – the usual approach – to open up cerebral vasospasms after subarachnoid hemorrhage. The early results are so promising that lead investigator Dr. Peng Roc Chen, a cerebrovascular neurosurgeon at the University of Texas, Houston, and his colleagues are following up with a randomized controlled trial. Dr. Chen explained the project to us at this year’s International Stroke Conference.

SAN DIEGO – Cerebral vasospasms open up, on average, 34.9% more when patients are infused with an intra-arterial cocktail of nicardipine, verapamil, and nitroglycerin, instead of the usual approach of nicardipine or verapamil alone, according to a retrospective study from the University of Texas, Houston.

Investigators there compared the cocktail to single-agent infusions in patients with vasospasms due to aneurysmal subarachnoid hemorrhages, after the offending aneurysms had been clipped or coiled.

Fifty-four patients with 116 spasmed vessels were infused with verapamil 10 mg or nicardipine 5 mg per vascular territory. Another 50 patients with 106 spasmed vessels were infused with verapamil 10 mg, nicardipine 5 mg, and nitroglycerin 200 mcg per vascular territory. The patients underwent repeat cerebral angiography at least 15 minutes after treatment.

In addition to having greater average dilation, the cocktail group had significantly greater improvement in the ratio of arterial lumen diameter before and after treatment than did the single-agent group (45.8% vs. 10.9%, respectively). The effect was independent of age.

There was a trend toward more modified Rankin Scale (mRS) scores of 0-2 in the multiple-agent group, but it was not statistically significant. Lead investigator Dr. Peng Roc Chen, a cerebrovascular neurosurgeon at the University of Texas, Houston, has launched a prospective randomized trial with his colleagues to investigate the matter further. Nine medical centers have signed up so far, and they are looking for more.

Single-agent infusion is standard practice in the United States, usually with verapamil, but it doesn’t work well, "and there’s no conclusive literature suggesting the best intra-arterial infusion regimen for vasospasm, particularly when balloon angioplasty is not feasible," Dr. Chen said at the International Stroke Conference, sponsored by the American Heart Association.

The team hoped for synergistic effects by combining commonly used intra-arterial vasodilators with different mechanisms of action, while avoiding the cardiovascular instability that comes with high-dose infusion of single agents. Verapamil and nicardipine are both calcium-channel blockers, but they work on different receptors, he said.

At discharge, 24 (44.4%) patients in the single-agent group had an mRS score of 0-2, 28 (51.9%) had an mRS score of 3-5, and 2 (3.7%) had died. At 3 months, 25 of the 34 patients not lost to follow-up (73.5%) had an mRS score of 0-2, seven (20.6%) had an mRS score of 3-5, and 2 (5.9%) had died.

In the multiagent group, 31 (62%) had an mRS score of 0-2 at discharge, 16 (32%) had an mRS score of 3-5, and 3 patients (6%) had died. At 3 months, 29 of the 36 patients not lost to follow-up (80.6%) had an mRS score of 0-2, 4 (11.1%) had an mRS score of 3-5, and 3 (8.3%) had died.

Small numbers and follow-up loss may have contributed to the lack of outcome significance. It’s also possible that subarachnoid hemorrhage drove outcomes, regardless of vasospasm treatment. In any case, multiagent infusion is now the standard approach at Dr. Chen’s medical center; the single-agent patients were historical controls, he said.

Sixteen (29.6%) patients in the single-agent arm needed additional treatment, either repeat infusions or balloon angioplasties. Twenty-two (44%) needed additional treatment in the multiple-agent group (P = .128).

Dr. Chen did not report patient demographics, but said there were no differences in post-treatment blood pressures, heart rate changes, or intracranial pressures between the two treatment groups. Patients who had balloon angioplasties before vasodilation were excluded from the study.

Verapamil and nicardipine were infused at a rate of 1 mg/min and nitroglycerin, at a rate of 100 mcg/min. In the single-agent arm, the investigators found no differences in vessel diameter change between verapamil and nicardipine.

The investigators reported having no relevant financial disclosures.

SAN DIEGO – Cerebral vasospasms open up, on average, 34.9% more when patients are infused with an intra-arterial cocktail of nicardipine, verapamil, and nitroglycerin, instead of the usual approach of nicardipine or verapamil alone, according to a retrospective study from the University of Texas, Houston.

Investigators there compared the cocktail to single-agent infusions in patients with vasospasms due to aneurysmal subarachnoid hemorrhages, after the offending aneurysms had been clipped or coiled.

Fifty-four patients with 116 spasmed vessels were infused with verapamil 10 mg or nicardipine 5 mg per vascular territory. Another 50 patients with 106 spasmed vessels were infused with verapamil 10 mg, nicardipine 5 mg, and nitroglycerin 200 mcg per vascular territory. The patients underwent repeat cerebral angiography at least 15 minutes after treatment.

In addition to having greater average dilation, the cocktail group had significantly greater improvement in the ratio of arterial lumen diameter before and after treatment than did the single-agent group (45.8% vs. 10.9%, respectively). The effect was independent of age.

There was a trend toward more modified Rankin Scale (mRS) scores of 0-2 in the multiple-agent group, but it was not statistically significant. Lead investigator Dr. Peng Roc Chen, a cerebrovascular neurosurgeon at the University of Texas, Houston, has launched a prospective randomized trial with his colleagues to investigate the matter further. Nine medical centers have signed up so far, and they are looking for more.

Single-agent infusion is standard practice in the United States, usually with verapamil, but it doesn’t work well, "and there’s no conclusive literature suggesting the best intra-arterial infusion regimen for vasospasm, particularly when balloon angioplasty is not feasible," Dr. Chen said at the International Stroke Conference, sponsored by the American Heart Association.

The team hoped for synergistic effects by combining commonly used intra-arterial vasodilators with different mechanisms of action, while avoiding the cardiovascular instability that comes with high-dose infusion of single agents. Verapamil and nicardipine are both calcium-channel blockers, but they work on different receptors, he said.

At discharge, 24 (44.4%) patients in the single-agent group had an mRS score of 0-2, 28 (51.9%) had an mRS score of 3-5, and 2 (3.7%) had died. At 3 months, 25 of the 34 patients not lost to follow-up (73.5%) had an mRS score of 0-2, seven (20.6%) had an mRS score of 3-5, and 2 (5.9%) had died.

In the multiagent group, 31 (62%) had an mRS score of 0-2 at discharge, 16 (32%) had an mRS score of 3-5, and 3 patients (6%) had died. At 3 months, 29 of the 36 patients not lost to follow-up (80.6%) had an mRS score of 0-2, 4 (11.1%) had an mRS score of 3-5, and 3 (8.3%) had died.

Small numbers and follow-up loss may have contributed to the lack of outcome significance. It’s also possible that subarachnoid hemorrhage drove outcomes, regardless of vasospasm treatment. In any case, multiagent infusion is now the standard approach at Dr. Chen’s medical center; the single-agent patients were historical controls, he said.

Sixteen (29.6%) patients in the single-agent arm needed additional treatment, either repeat infusions or balloon angioplasties. Twenty-two (44%) needed additional treatment in the multiple-agent group (P = .128).

Dr. Chen did not report patient demographics, but said there were no differences in post-treatment blood pressures, heart rate changes, or intracranial pressures between the two treatment groups. Patients who had balloon angioplasties before vasodilation were excluded from the study.

Verapamil and nicardipine were infused at a rate of 1 mg/min and nitroglycerin, at a rate of 100 mcg/min. In the single-agent arm, the investigators found no differences in vessel diameter change between verapamil and nicardipine.

The investigators reported having no relevant financial disclosures.

SAN DIEGO – Cerebral vasospasms open up, on average, 34.9% more when patients are infused with an intra-arterial cocktail of nicardipine, verapamil, and nitroglycerin, instead of the usual approach of nicardipine or verapamil alone, according to a retrospective study from the University of Texas, Houston.

Investigators there compared the cocktail to single-agent infusions in patients with vasospasms due to aneurysmal subarachnoid hemorrhages, after the offending aneurysms had been clipped or coiled.

Fifty-four patients with 116 spasmed vessels were infused with verapamil 10 mg or nicardipine 5 mg per vascular territory. Another 50 patients with 106 spasmed vessels were infused with verapamil 10 mg, nicardipine 5 mg, and nitroglycerin 200 mcg per vascular territory. The patients underwent repeat cerebral angiography at least 15 minutes after treatment.

In addition to having greater average dilation, the cocktail group had significantly greater improvement in the ratio of arterial lumen diameter before and after treatment than did the single-agent group (45.8% vs. 10.9%, respectively). The effect was independent of age.

There was a trend toward more modified Rankin Scale (mRS) scores of 0-2 in the multiple-agent group, but it was not statistically significant. Lead investigator Dr. Peng Roc Chen, a cerebrovascular neurosurgeon at the University of Texas, Houston, has launched a prospective randomized trial with his colleagues to investigate the matter further. Nine medical centers have signed up so far, and they are looking for more.

Single-agent infusion is standard practice in the United States, usually with verapamil, but it doesn’t work well, "and there’s no conclusive literature suggesting the best intra-arterial infusion regimen for vasospasm, particularly when balloon angioplasty is not feasible," Dr. Chen said at the International Stroke Conference, sponsored by the American Heart Association.

The team hoped for synergistic effects by combining commonly used intra-arterial vasodilators with different mechanisms of action, while avoiding the cardiovascular instability that comes with high-dose infusion of single agents. Verapamil and nicardipine are both calcium-channel blockers, but they work on different receptors, he said.

At discharge, 24 (44.4%) patients in the single-agent group had an mRS score of 0-2, 28 (51.9%) had an mRS score of 3-5, and 2 (3.7%) had died. At 3 months, 25 of the 34 patients not lost to follow-up (73.5%) had an mRS score of 0-2, seven (20.6%) had an mRS score of 3-5, and 2 (5.9%) had died.

In the multiagent group, 31 (62%) had an mRS score of 0-2 at discharge, 16 (32%) had an mRS score of 3-5, and 3 patients (6%) had died. At 3 months, 29 of the 36 patients not lost to follow-up (80.6%) had an mRS score of 0-2, 4 (11.1%) had an mRS score of 3-5, and 3 (8.3%) had died.

Small numbers and follow-up loss may have contributed to the lack of outcome significance. It’s also possible that subarachnoid hemorrhage drove outcomes, regardless of vasospasm treatment. In any case, multiagent infusion is now the standard approach at Dr. Chen’s medical center; the single-agent patients were historical controls, he said.

Sixteen (29.6%) patients in the single-agent arm needed additional treatment, either repeat infusions or balloon angioplasties. Twenty-two (44%) needed additional treatment in the multiple-agent group (P = .128).

Dr. Chen did not report patient demographics, but said there were no differences in post-treatment blood pressures, heart rate changes, or intracranial pressures between the two treatment groups. Patients who had balloon angioplasties before vasodilation were excluded from the study.

Verapamil and nicardipine were infused at a rate of 1 mg/min and nitroglycerin, at a rate of 100 mcg/min. In the single-agent arm, the investigators found no differences in vessel diameter change between verapamil and nicardipine.

The investigators reported having no relevant financial disclosures.

SAN FRANCISCO – Palliative care is not just for the dying.

Understanding that premise is the first step to integrating palliative care into intensive care units, Dr. Zara Cooper said. Palliative care treats patient illness and can be delivered concurrently in the ICU with curative care that treats disease.

As options for curative treatment decrease, the role of palliative care may increase and does not stop at the patient’s death. "It’s important that we provide ongoing bereavement support not only to family members and survivors but also to caregivers and members of our medical team," added Dr. Cooper, an assistant professor of surgery at Harvard Medical School and a surgical intensivist at Brigham and Women’s Hospital, Boston.

Getting intensive care colleagues to agree on a definition of palliative care is the first barrier to integrating palliative care into an ICU, Dr. Cooper said. She paraphrased the World Health Organization’s definition by saying, "Palliative care makes patients feel better." It is specialized medical care that focuses on preventing and relieving symptoms, pain, and stress associated with life-threatening illness – whatever the diagnosis – and is appropriate at any stage in a serious illness.

Nick Piegari/Frontline Medical Media

Typically provided by a team, palliative care may involve physicians, nurses, social workers, pharmacists, chaplains, pain experts, ethicists, rehabilitation therapists, psychiatry consultants, and bereavement counselors. The team can take a load off busy intensivists by handling the often lengthy conversations with patients and families facing life-threatening illness, she said at the Critical Care Congress, sponsored by the Society for Critical Care Medicine.

Palliative care providers can be embedded in ICUs or in a team that’s available as consultants. "I think we have to do both" models, depending on the needs of individual institutions, said Dr. Cooper.

Once a definition is agreed upon, the next steps to convincing colleagues and administrators to make better use of palliative care are to make it relevant for them and to normalize its presence in the ICU, she said. "Palliative care is just as essential as med management, antibiotics, pharmacology – it’s part of what we do well."

Predicting which patients will die, and when, is difficult. Patient preferences for care or end-of-life treatment often are unclear. The goals of treatment depend on the patient’s condition and must be dynamic. "Is it end-of-life care if we don’t know the patient is dying?" she asked.

One way to consider which ICU patients might benefit from palliative care is to ask, "Would I be surprised if this patient died within a year?" even if discharged from the ICU or the hospital, she suggested.

Four studies in the medical literature separately reported that 20% of Americans die in the hospital after an ICU admission, 80% of deaths in ICUs occur after life support is withdrawn or withheld, nearly half of dying patients receive unwanted therapy, and a majority of dying patients experience pain and suffering, Dr. Cooper said. Five other studies reported high mortality rates in patients with sepsis, acute respiratory distress syndrome, ICU stays longer than 14 days, admission to long-term acute care, or initiation of dialysis in the elderly.

A recent study of 25,558 elderly patients undergoing emergency surgery reported 30-day mortality rates of 37% in those with preexisting do-not-resuscitate (DNR) orders and 22% in those without DNR orders. Major complications occurred in more than 40% in each group (Ann. Surg. 2012;256:453-61). Risk factors increase the likelihood of death, but "all of these patients are experiencing serious illness" and would benefit from palliative care, Dr. Cooper said.

One recent study of 518 patients in three ICUs found good adherence to only two of nine palliative care processes – pain assessment and management. Interdisciplinary family meetings had been held by day 5 in the ICU for less than 20% of patients, and adherence to six other palliative care practices ranged from 8% to 43% (Crit. Care Med. 2012;40:1105-12).

Normalizing palliative care in the ICU means adopting the attitude that "it’s just part of what we do, the same way that we manage our vents, etc." Dr. Cooper said.

Adopting proactive screening criteria (patient factors) that trigger palliative care consultations would reduce utilization of ICUs without increasing mortality, and would increase the availability of palliative care for patients and families, according to a recent report from the Improving Palliative Care in the ICU Project’s advisory board (Crit. Care Med. 2013;41:2318-27).

The triggers should be specific to each ICU and patient population and developed through a process with stakeholders, with outcomes evaluated. "This is not a one-size-fits-all strategy," Dr. Cooper said. "The triggers in the MICU [medical ICU] and the SICU [surgical ICU] cannot be the same. It won’t work. I’ve actually seen that in my own institution," Dr. Cooper said.

The triggers also shouldn’t focus only on the patients most obviously likely to die or they will perpetuate the misconception that palliative care is only for the dying, she added.

To integrate palliative care into an ICU, "just do it," she said. "Commit yourself" to intensive symptom management and multidisciplinary family meetings within 72 hours of ICU admission. Institute an intensive communication plan to provide emotional, educational, and decision support for patients and families. Offer pastoral and psychosocial support. Start end-of-life-care discussions sooner, and provide bereavement services when patients die.

Lastly, don’t hesitate to bill insurers for these services, Dr. Cooper said. In-person or phone meetings about treatment options when the patient lacks the capacity to decide can be billed as critical care, as can discussions about DNR codes. Also bill for treating acute pain, agitation, delirium, and other life-threatening symptoms as critical care.

Dr. Cooper reported having no financial disclosures.

[email protected]

On Twitter @sherryboschert

SAN FRANCISCO – Palliative care is not just for the dying.

Understanding that premise is the first step to integrating palliative care into intensive care units, Dr. Zara Cooper said. Palliative care treats patient illness and can be delivered concurrently in the ICU with curative care that treats disease.

As options for curative treatment decrease, the role of palliative care may increase and does not stop at the patient’s death. "It’s important that we provide ongoing bereavement support not only to family members and survivors but also to caregivers and members of our medical team," added Dr. Cooper, an assistant professor of surgery at Harvard Medical School and a surgical intensivist at Brigham and Women’s Hospital, Boston.

Getting intensive care colleagues to agree on a definition of palliative care is the first barrier to integrating palliative care into an ICU, Dr. Cooper said. She paraphrased the World Health Organization’s definition by saying, "Palliative care makes patients feel better." It is specialized medical care that focuses on preventing and relieving symptoms, pain, and stress associated with life-threatening illness – whatever the diagnosis – and is appropriate at any stage in a serious illness.

Nick Piegari/Frontline Medical Media

Typically provided by a team, palliative care may involve physicians, nurses, social workers, pharmacists, chaplains, pain experts, ethicists, rehabilitation therapists, psychiatry consultants, and bereavement counselors. The team can take a load off busy intensivists by handling the often lengthy conversations with patients and families facing life-threatening illness, she said at the Critical Care Congress, sponsored by the Society for Critical Care Medicine.

Palliative care providers can be embedded in ICUs or in a team that’s available as consultants. "I think we have to do both" models, depending on the needs of individual institutions, said Dr. Cooper.

Once a definition is agreed upon, the next steps to convincing colleagues and administrators to make better use of palliative care are to make it relevant for them and to normalize its presence in the ICU, she said. "Palliative care is just as essential as med management, antibiotics, pharmacology – it’s part of what we do well."

Predicting which patients will die, and when, is difficult. Patient preferences for care or end-of-life treatment often are unclear. The goals of treatment depend on the patient’s condition and must be dynamic. "Is it end-of-life care if we don’t know the patient is dying?" she asked.

One way to consider which ICU patients might benefit from palliative care is to ask, "Would I be surprised if this patient died within a year?" even if discharged from the ICU or the hospital, she suggested.

Four studies in the medical literature separately reported that 20% of Americans die in the hospital after an ICU admission, 80% of deaths in ICUs occur after life support is withdrawn or withheld, nearly half of dying patients receive unwanted therapy, and a majority of dying patients experience pain and suffering, Dr. Cooper said. Five other studies reported high mortality rates in patients with sepsis, acute respiratory distress syndrome, ICU stays longer than 14 days, admission to long-term acute care, or initiation of dialysis in the elderly.

A recent study of 25,558 elderly patients undergoing emergency surgery reported 30-day mortality rates of 37% in those with preexisting do-not-resuscitate (DNR) orders and 22% in those without DNR orders. Major complications occurred in more than 40% in each group (Ann. Surg. 2012;256:453-61). Risk factors increase the likelihood of death, but "all of these patients are experiencing serious illness" and would benefit from palliative care, Dr. Cooper said.

One recent study of 518 patients in three ICUs found good adherence to only two of nine palliative care processes – pain assessment and management. Interdisciplinary family meetings had been held by day 5 in the ICU for less than 20% of patients, and adherence to six other palliative care practices ranged from 8% to 43% (Crit. Care Med. 2012;40:1105-12).

Normalizing palliative care in the ICU means adopting the attitude that "it’s just part of what we do, the same way that we manage our vents, etc." Dr. Cooper said.

Adopting proactive screening criteria (patient factors) that trigger palliative care consultations would reduce utilization of ICUs without increasing mortality, and would increase the availability of palliative care for patients and families, according to a recent report from the Improving Palliative Care in the ICU Project’s advisory board (Crit. Care Med. 2013;41:2318-27).

The triggers should be specific to each ICU and patient population and developed through a process with stakeholders, with outcomes evaluated. "This is not a one-size-fits-all strategy," Dr. Cooper said. "The triggers in the MICU [medical ICU] and the SICU [surgical ICU] cannot be the same. It won’t work. I’ve actually seen that in my own institution," Dr. Cooper said.

The triggers also shouldn’t focus only on the patients most obviously likely to die or they will perpetuate the misconception that palliative care is only for the dying, she added.

To integrate palliative care into an ICU, "just do it," she said. "Commit yourself" to intensive symptom management and multidisciplinary family meetings within 72 hours of ICU admission. Institute an intensive communication plan to provide emotional, educational, and decision support for patients and families. Offer pastoral and psychosocial support. Start end-of-life-care discussions sooner, and provide bereavement services when patients die.

Lastly, don’t hesitate to bill insurers for these services, Dr. Cooper said. In-person or phone meetings about treatment options when the patient lacks the capacity to decide can be billed as critical care, as can discussions about DNR codes. Also bill for treating acute pain, agitation, delirium, and other life-threatening symptoms as critical care.

Dr. Cooper reported having no financial disclosures.

[email protected]

On Twitter @sherryboschert

SAN FRANCISCO – Palliative care is not just for the dying.

Understanding that premise is the first step to integrating palliative care into intensive care units, Dr. Zara Cooper said. Palliative care treats patient illness and can be delivered concurrently in the ICU with curative care that treats disease.

As options for curative treatment decrease, the role of palliative care may increase and does not stop at the patient’s death. "It’s important that we provide ongoing bereavement support not only to family members and survivors but also to caregivers and members of our medical team," added Dr. Cooper, an assistant professor of surgery at Harvard Medical School and a surgical intensivist at Brigham and Women’s Hospital, Boston.

Getting intensive care colleagues to agree on a definition of palliative care is the first barrier to integrating palliative care into an ICU, Dr. Cooper said. She paraphrased the World Health Organization’s definition by saying, "Palliative care makes patients feel better." It is specialized medical care that focuses on preventing and relieving symptoms, pain, and stress associated with life-threatening illness – whatever the diagnosis – and is appropriate at any stage in a serious illness.

Nick Piegari/Frontline Medical Media

Typically provided by a team, palliative care may involve physicians, nurses, social workers, pharmacists, chaplains, pain experts, ethicists, rehabilitation therapists, psychiatry consultants, and bereavement counselors. The team can take a load off busy intensivists by handling the often lengthy conversations with patients and families facing life-threatening illness, she said at the Critical Care Congress, sponsored by the Society for Critical Care Medicine.

Palliative care providers can be embedded in ICUs or in a team that’s available as consultants. "I think we have to do both" models, depending on the needs of individual institutions, said Dr. Cooper.

Once a definition is agreed upon, the next steps to convincing colleagues and administrators to make better use of palliative care are to make it relevant for them and to normalize its presence in the ICU, she said. "Palliative care is just as essential as med management, antibiotics, pharmacology – it’s part of what we do well."

Predicting which patients will die, and when, is difficult. Patient preferences for care or end-of-life treatment often are unclear. The goals of treatment depend on the patient’s condition and must be dynamic. "Is it end-of-life care if we don’t know the patient is dying?" she asked.

One way to consider which ICU patients might benefit from palliative care is to ask, "Would I be surprised if this patient died within a year?" even if discharged from the ICU or the hospital, she suggested.

Four studies in the medical literature separately reported that 20% of Americans die in the hospital after an ICU admission, 80% of deaths in ICUs occur after life support is withdrawn or withheld, nearly half of dying patients receive unwanted therapy, and a majority of dying patients experience pain and suffering, Dr. Cooper said. Five other studies reported high mortality rates in patients with sepsis, acute respiratory distress syndrome, ICU stays longer than 14 days, admission to long-term acute care, or initiation of dialysis in the elderly.

A recent study of 25,558 elderly patients undergoing emergency surgery reported 30-day mortality rates of 37% in those with preexisting do-not-resuscitate (DNR) orders and 22% in those without DNR orders. Major complications occurred in more than 40% in each group (Ann. Surg. 2012;256:453-61). Risk factors increase the likelihood of death, but "all of these patients are experiencing serious illness" and would benefit from palliative care, Dr. Cooper said.

One recent study of 518 patients in three ICUs found good adherence to only two of nine palliative care processes – pain assessment and management. Interdisciplinary family meetings had been held by day 5 in the ICU for less than 20% of patients, and adherence to six other palliative care practices ranged from 8% to 43% (Crit. Care Med. 2012;40:1105-12).

Normalizing palliative care in the ICU means adopting the attitude that "it’s just part of what we do, the same way that we manage our vents, etc." Dr. Cooper said.

Adopting proactive screening criteria (patient factors) that trigger palliative care consultations would reduce utilization of ICUs without increasing mortality, and would increase the availability of palliative care for patients and families, according to a recent report from the Improving Palliative Care in the ICU Project’s advisory board (Crit. Care Med. 2013;41:2318-27).

The triggers should be specific to each ICU and patient population and developed through a process with stakeholders, with outcomes evaluated. "This is not a one-size-fits-all strategy," Dr. Cooper said. "The triggers in the MICU [medical ICU] and the SICU [surgical ICU] cannot be the same. It won’t work. I’ve actually seen that in my own institution," Dr. Cooper said.

The triggers also shouldn’t focus only on the patients most obviously likely to die or they will perpetuate the misconception that palliative care is only for the dying, she added.

To integrate palliative care into an ICU, "just do it," she said. "Commit yourself" to intensive symptom management and multidisciplinary family meetings within 72 hours of ICU admission. Institute an intensive communication plan to provide emotional, educational, and decision support for patients and families. Offer pastoral and psychosocial support. Start end-of-life-care discussions sooner, and provide bereavement services when patients die.

Lastly, don’t hesitate to bill insurers for these services, Dr. Cooper said. In-person or phone meetings about treatment options when the patient lacks the capacity to decide can be billed as critical care, as can discussions about DNR codes. Also bill for treating acute pain, agitation, delirium, and other life-threatening symptoms as critical care.

Dr. Cooper reported having no financial disclosures.

[email protected]

On Twitter @sherryboschert

If you have been paying attention at all, you are aware that the International Classification of Diseases, 10th Revision (ICD-10) will be implemented later this year. So why – if you’re like most of the physicians I’ve talked with recently – have you done little or nothing about it? Since the launch is more than 6 months away, why am I telling you (and I am) that this is a very bad idea?

Because there is much to do before the deadline arrives. On Sept. 30, you will be using ICD-9 codes, and the next day you will have to begin using ICD-10. There is no transition period; all ICD-9–coded claims will be rejected from Oct. 1 forward, and no ICD-10 codes can be used before that date. Failure to prepare will be an unmitigated disaster for your practice’s cash flow.

The Centers for Medicare & Medicaid Services has already rejected a request from medical organizations for another 1-year delay (in addition to the one granted last year), so further extensions are highly unlikely. So you’ll need to be ready if you expect to be paid come October.

First, you will need to decide which parts of your coding and billing systems, and electronic health record (EHR, if you have one) need to be upgraded, how you will do it, and what it will cost. Then, you must get familiar with the new system.

Coders and billers will need the most training on the new methodology, but physicians and other providers also must learn how the new codes are different from the old ones. In general, the biggest differences are in level of documentation and specificity, but there are many brand-new codes as well.

I suggest that you start by identifying your 20 or 30 most-used diagnosis codes and then study in detail the differences between the ICD-9 and ICD-10 versions of them. Once you have mastered those, you can go on to other, less-used codes. Take as much time as you need to do this; remember, everything changes abruptly on Oct. 1, and you will have to get it right the first time.

Be sure to cross-train your coders and other staff members. If a crucial employee quits in the middle of September, you don’t want to have to start from square one. Also, ask your employees to plan their vacations well in advance – and not during the last 3 months of the year. This will not be a good time for the office to run short staffed.

Next, I suggest that you contact all of your third-party payers, billing services, and clearinghouses. Start with the payers responsible for the majority of your claims. Be aggressive; ask them how, exactly, they are preparing for the changeover, and stay in continuous contact with them. Unfortunately, many of these organizations are as behind as most medical practices in their preparations.

Many payers and clearinghouses (including CMS) will be staging "test runs," during which you will be able to submit "practice claims" using the new system. Payers will determine whether your ICD-10 code is in the right place and in the right format, whether the code you’ve used is appropriate, and whether the claim would have been accepted, rejected, or held pending additional information. You will have to do this for each payer, because each will have different coding policies; those policies have not yet been released, and in some cases, have not even been developed.

The CMS will run its first testing opportunity in March; you can register for it, or for future tests, through your local Medicare Administrative Contractor (MAC) website.

You can use these testing opportunities to test your internal system as well, ensuring that everything works smoothly from the time you code a claim until payment is received. Select commonly used ICD-9 claims and practice coding them in ICD-10. The American Academy of Dermatology offers a nice ICD-9/ICD-10 "crosswalk," along with other training aids, at its website.

Even the best laid plans can go awry, so it would be prudent to put aside a cash reserve, or secure a line of credit, to cover expenses during the first few months of the transition, in case the payment machinery falters and large numbers of claims go unpaid. For the same reason, consider postponing major capital investments from mid-year until early 2015.

You may have heard that ICD-10 is only a transition system; that ICD-11 will be following closely on its heels, only a year or 2 later. Many of the experts that I’ve spoken with feel that this highly unlikely, and I agree. So don’t feel that you are wasting your time adjusting to ICD-10; in all probability, we will be using it a lot longer than CMS is expecting.

Dr. Eastern practices dermatology and dermatologic surgery in Belleville, N.J. He is the author of numerous articles and textbook chapters, and is a long-time monthly columnist for Skin & Allergy News.

If you have been paying attention at all, you are aware that the International Classification of Diseases, 10th Revision (ICD-10) will be implemented later this year. So why – if you’re like most of the physicians I’ve talked with recently – have you done little or nothing about it? Since the launch is more than 6 months away, why am I telling you (and I am) that this is a very bad idea?

Because there is much to do before the deadline arrives. On Sept. 30, you will be using ICD-9 codes, and the next day you will have to begin using ICD-10. There is no transition period; all ICD-9–coded claims will be rejected from Oct. 1 forward, and no ICD-10 codes can be used before that date. Failure to prepare will be an unmitigated disaster for your practice’s cash flow.

The Centers for Medicare & Medicaid Services has already rejected a request from medical organizations for another 1-year delay (in addition to the one granted last year), so further extensions are highly unlikely. So you’ll need to be ready if you expect to be paid come October.

First, you will need to decide which parts of your coding and billing systems, and electronic health record (EHR, if you have one) need to be upgraded, how you will do it, and what it will cost. Then, you must get familiar with the new system.

Coders and billers will need the most training on the new methodology, but physicians and other providers also must learn how the new codes are different from the old ones. In general, the biggest differences are in level of documentation and specificity, but there are many brand-new codes as well.

I suggest that you start by identifying your 20 or 30 most-used diagnosis codes and then study in detail the differences between the ICD-9 and ICD-10 versions of them. Once you have mastered those, you can go on to other, less-used codes. Take as much time as you need to do this; remember, everything changes abruptly on Oct. 1, and you will have to get it right the first time.

Be sure to cross-train your coders and other staff members. If a crucial employee quits in the middle of September, you don’t want to have to start from square one. Also, ask your employees to plan their vacations well in advance – and not during the last 3 months of the year. This will not be a good time for the office to run short staffed.

Next, I suggest that you contact all of your third-party payers, billing services, and clearinghouses. Start with the payers responsible for the majority of your claims. Be aggressive; ask them how, exactly, they are preparing for the changeover, and stay in continuous contact with them. Unfortunately, many of these organizations are as behind as most medical practices in their preparations.

Many payers and clearinghouses (including CMS) will be staging "test runs," during which you will be able to submit "practice claims" using the new system. Payers will determine whether your ICD-10 code is in the right place and in the right format, whether the code you’ve used is appropriate, and whether the claim would have been accepted, rejected, or held pending additional information. You will have to do this for each payer, because each will have different coding policies; those policies have not yet been released, and in some cases, have not even been developed.

The CMS will run its first testing opportunity in March; you can register for it, or for future tests, through your local Medicare Administrative Contractor (MAC) website.

You can use these testing opportunities to test your internal system as well, ensuring that everything works smoothly from the time you code a claim until payment is received. Select commonly used ICD-9 claims and practice coding them in ICD-10. The American Academy of Dermatology offers a nice ICD-9/ICD-10 "crosswalk," along with other training aids, at its website.

Even the best laid plans can go awry, so it would be prudent to put aside a cash reserve, or secure a line of credit, to cover expenses during the first few months of the transition, in case the payment machinery falters and large numbers of claims go unpaid. For the same reason, consider postponing major capital investments from mid-year until early 2015.

You may have heard that ICD-10 is only a transition system; that ICD-11 will be following closely on its heels, only a year or 2 later. Many of the experts that I’ve spoken with feel that this highly unlikely, and I agree. So don’t feel that you are wasting your time adjusting to ICD-10; in all probability, we will be using it a lot longer than CMS is expecting.

Dr. Eastern practices dermatology and dermatologic surgery in Belleville, N.J. He is the author of numerous articles and textbook chapters, and is a long-time monthly columnist for Skin & Allergy News.

If you have been paying attention at all, you are aware that the International Classification of Diseases, 10th Revision (ICD-10) will be implemented later this year. So why – if you’re like most of the physicians I’ve talked with recently – have you done little or nothing about it? Since the launch is more than 6 months away, why am I telling you (and I am) that this is a very bad idea?

Because there is much to do before the deadline arrives. On Sept. 30, you will be using ICD-9 codes, and the next day you will have to begin using ICD-10. There is no transition period; all ICD-9–coded claims will be rejected from Oct. 1 forward, and no ICD-10 codes can be used before that date. Failure to prepare will be an unmitigated disaster for your practice’s cash flow.

The Centers for Medicare & Medicaid Services has already rejected a request from medical organizations for another 1-year delay (in addition to the one granted last year), so further extensions are highly unlikely. So you’ll need to be ready if you expect to be paid come October.

First, you will need to decide which parts of your coding and billing systems, and electronic health record (EHR, if you have one) need to be upgraded, how you will do it, and what it will cost. Then, you must get familiar with the new system.

Coders and billers will need the most training on the new methodology, but physicians and other providers also must learn how the new codes are different from the old ones. In general, the biggest differences are in level of documentation and specificity, but there are many brand-new codes as well.

I suggest that you start by identifying your 20 or 30 most-used diagnosis codes and then study in detail the differences between the ICD-9 and ICD-10 versions of them. Once you have mastered those, you can go on to other, less-used codes. Take as much time as you need to do this; remember, everything changes abruptly on Oct. 1, and you will have to get it right the first time.

Be sure to cross-train your coders and other staff members. If a crucial employee quits in the middle of September, you don’t want to have to start from square one. Also, ask your employees to plan their vacations well in advance – and not during the last 3 months of the year. This will not be a good time for the office to run short staffed.

Next, I suggest that you contact all of your third-party payers, billing services, and clearinghouses. Start with the payers responsible for the majority of your claims. Be aggressive; ask them how, exactly, they are preparing for the changeover, and stay in continuous contact with them. Unfortunately, many of these organizations are as behind as most medical practices in their preparations.

Many payers and clearinghouses (including CMS) will be staging "test runs," during which you will be able to submit "practice claims" using the new system. Payers will determine whether your ICD-10 code is in the right place and in the right format, whether the code you’ve used is appropriate, and whether the claim would have been accepted, rejected, or held pending additional information. You will have to do this for each payer, because each will have different coding policies; those policies have not yet been released, and in some cases, have not even been developed.

The CMS will run its first testing opportunity in March; you can register for it, or for future tests, through your local Medicare Administrative Contractor (MAC) website.

You can use these testing opportunities to test your internal system as well, ensuring that everything works smoothly from the time you code a claim until payment is received. Select commonly used ICD-9 claims and practice coding them in ICD-10. The American Academy of Dermatology offers a nice ICD-9/ICD-10 "crosswalk," along with other training aids, at its website.

Even the best laid plans can go awry, so it would be prudent to put aside a cash reserve, or secure a line of credit, to cover expenses during the first few months of the transition, in case the payment machinery falters and large numbers of claims go unpaid. For the same reason, consider postponing major capital investments from mid-year until early 2015.

You may have heard that ICD-10 is only a transition system; that ICD-11 will be following closely on its heels, only a year or 2 later. Many of the experts that I’ve spoken with feel that this highly unlikely, and I agree. So don’t feel that you are wasting your time adjusting to ICD-10; in all probability, we will be using it a lot longer than CMS is expecting.

Dr. Eastern practices dermatology and dermatologic surgery in Belleville, N.J. He is the author of numerous articles and textbook chapters, and is a long-time monthly columnist for Skin & Allergy News.

NAPLES, FLA. – Complication rates are similar for advanced clinical practitioners and resident physicians performing key routine procedures in the ICU or trauma setting, a retrospective study found.

Advanced clinical practitioners (ACPs) performed 555 procedures with 11 complications (2%), while resident physicians (RPs) performed 1,020 procedures with 20 complications (2%).

Procedures consisted of arterial lines, central venous lines, bronchoalveolar lavage, thoracotomy tubes, percutaneous endoscopic gastrostomy (PEG), and tracheostomies, Massanu Sirleaf, a board-certified acute care nurse practitioner, said at the annual scientific assembly of the Eastern Association for the Surgery of Trauma.

No differences were observed between the ACP and RP groups in mean ICU length of stay (3.7 days vs. 3.9 days) or hospital stay (13.3 days vs. 12.2 days).

Mortality rates were also similar for ACPs and RPs (9.7% vs. 11%; P = .07), despite significantly higher age (mean 54.5 years vs. 49.9 years; P less than .05) and APACHE III scores for the ACP group (mean 47.7 vs. 40.8; P less than .05).

"Our results demonstrate that ACPs have become a very important part of our health care team and substantiate the safety of ACPs in performing surgical procedures in critically ill patients," Ms. Sirleaf said.

Restrictions in resident work hours have imposed workload challenges on trauma centers, leading some to recruit nurse practitioners and physician assistants to care for critically ill patients in the ICU and to perform invasive procedures previously done exclusively by physicians, she observed. Very few studies, however, have addressed ACPs’ procedural competence and complication rates.

The retrospective study included all procedures performed from January to December 2011 in the trauma and surgical ICUs at the F.H. "Sammy" Ross Jr. Trauma Center, Carolinas Medical Center in Charlotte, N.C. Eight ACPs performed invasive procedures for surgical critical care patients under attending supervision, while three postgraduate year two (PGY2) surgical and emergency residents performed procedures for trauma patients.

Invited discussant Dr. Jeffrey Claridge, director of trauma, critical care, and burns at MetroHealth Medical Center in Cleveland, agreed with the study’s conclusion that complications were similar between ACPs and RPs, but went on to say that 2% is extremely low and that "something is missing or oversimplified."

In particular, he pressed Ms. Sirleaf on where the procedures were performed, the level of supervision provided to ACPs, and how extensive the review of complications was other than procedural notes. For example, did the authors look at whether chest tubes fell out within 24 hours because they were inappropriately secured, PEG or tracheostomy sites that got infected, or breaks occurred in sterile technique.

"Determining a more comprehensive complication panel would give more power to detect differences and, truthfully, more credibility to the paper," Dr. Claridge said.

Ms. Sirleaf replied that in addition to reviewing postprocedural notes, radiologists looked for complications 24 hours after chest tube placement and patients with a tracheostomy were followed for complications for 7 days by the attending.

Urgency of the procedure was not evaluated since the procedures were elective and most were performed at the bedside.

"For the ACPs with a level of competency, just like interns at the beginning, they assisted the attending and as they got better, the majority of the procedure was performed by the ACP at the bedside with the attending scrubbed in," she said.

At the time of the study, three ACPs had 1 year of experience, with up to 7 years’ experience in the remaining ACPs. Senior ACPs provided training along with the attendings, and both ACPs and RPs underwent quarterly simulation lab training on procedures. To maintain competency, Carolinas Medical Center also requires ACPs perform a set number of each type of procedure on a yearly basis and have these procedures witnessed and signed off on by an attending, said Ms. Sirleaf, now with Sharp Memorial Hospital, San Diego.

Ms. Sirleaf and her coauthors reported having no financial disclosures.

[email protected]

NAPLES, FLA. – Complication rates are similar for advanced clinical practitioners and resident physicians performing key routine procedures in the ICU or trauma setting, a retrospective study found.

Advanced clinical practitioners (ACPs) performed 555 procedures with 11 complications (2%), while resident physicians (RPs) performed 1,020 procedures with 20 complications (2%).

Procedures consisted of arterial lines, central venous lines, bronchoalveolar lavage, thoracotomy tubes, percutaneous endoscopic gastrostomy (PEG), and tracheostomies, Massanu Sirleaf, a board-certified acute care nurse practitioner, said at the annual scientific assembly of the Eastern Association for the Surgery of Trauma.

No differences were observed between the ACP and RP groups in mean ICU length of stay (3.7 days vs. 3.9 days) or hospital stay (13.3 days vs. 12.2 days).

Mortality rates were also similar for ACPs and RPs (9.7% vs. 11%; P = .07), despite significantly higher age (mean 54.5 years vs. 49.9 years; P less than .05) and APACHE III scores for the ACP group (mean 47.7 vs. 40.8; P less than .05).

"Our results demonstrate that ACPs have become a very important part of our health care team and substantiate the safety of ACPs in performing surgical procedures in critically ill patients," Ms. Sirleaf said.

Restrictions in resident work hours have imposed workload challenges on trauma centers, leading some to recruit nurse practitioners and physician assistants to care for critically ill patients in the ICU and to perform invasive procedures previously done exclusively by physicians, she observed. Very few studies, however, have addressed ACPs’ procedural competence and complication rates.

The retrospective study included all procedures performed from January to December 2011 in the trauma and surgical ICUs at the F.H. "Sammy" Ross Jr. Trauma Center, Carolinas Medical Center in Charlotte, N.C. Eight ACPs performed invasive procedures for surgical critical care patients under attending supervision, while three postgraduate year two (PGY2) surgical and emergency residents performed procedures for trauma patients.

Invited discussant Dr. Jeffrey Claridge, director of trauma, critical care, and burns at MetroHealth Medical Center in Cleveland, agreed with the study’s conclusion that complications were similar between ACPs and RPs, but went on to say that 2% is extremely low and that "something is missing or oversimplified."

In particular, he pressed Ms. Sirleaf on where the procedures were performed, the level of supervision provided to ACPs, and how extensive the review of complications was other than procedural notes. For example, did the authors look at whether chest tubes fell out within 24 hours because they were inappropriately secured, PEG or tracheostomy sites that got infected, or breaks occurred in sterile technique.

"Determining a more comprehensive complication panel would give more power to detect differences and, truthfully, more credibility to the paper," Dr. Claridge said.

Ms. Sirleaf replied that in addition to reviewing postprocedural notes, radiologists looked for complications 24 hours after chest tube placement and patients with a tracheostomy were followed for complications for 7 days by the attending.

Urgency of the procedure was not evaluated since the procedures were elective and most were performed at the bedside.

"For the ACPs with a level of competency, just like interns at the beginning, they assisted the attending and as they got better, the majority of the procedure was performed by the ACP at the bedside with the attending scrubbed in," she said.

At the time of the study, three ACPs had 1 year of experience, with up to 7 years’ experience in the remaining ACPs. Senior ACPs provided training along with the attendings, and both ACPs and RPs underwent quarterly simulation lab training on procedures. To maintain competency, Carolinas Medical Center also requires ACPs perform a set number of each type of procedure on a yearly basis and have these procedures witnessed and signed off on by an attending, said Ms. Sirleaf, now with Sharp Memorial Hospital, San Diego.

Ms. Sirleaf and her coauthors reported having no financial disclosures.

[email protected]

NAPLES, FLA. – Complication rates are similar for advanced clinical practitioners and resident physicians performing key routine procedures in the ICU or trauma setting, a retrospective study found.

Advanced clinical practitioners (ACPs) performed 555 procedures with 11 complications (2%), while resident physicians (RPs) performed 1,020 procedures with 20 complications (2%).

Procedures consisted of arterial lines, central venous lines, bronchoalveolar lavage, thoracotomy tubes, percutaneous endoscopic gastrostomy (PEG), and tracheostomies, Massanu Sirleaf, a board-certified acute care nurse practitioner, said at the annual scientific assembly of the Eastern Association for the Surgery of Trauma.

No differences were observed between the ACP and RP groups in mean ICU length of stay (3.7 days vs. 3.9 days) or hospital stay (13.3 days vs. 12.2 days).

Mortality rates were also similar for ACPs and RPs (9.7% vs. 11%; P = .07), despite significantly higher age (mean 54.5 years vs. 49.9 years; P less than .05) and APACHE III scores for the ACP group (mean 47.7 vs. 40.8; P less than .05).

"Our results demonstrate that ACPs have become a very important part of our health care team and substantiate the safety of ACPs in performing surgical procedures in critically ill patients," Ms. Sirleaf said.

Restrictions in resident work hours have imposed workload challenges on trauma centers, leading some to recruit nurse practitioners and physician assistants to care for critically ill patients in the ICU and to perform invasive procedures previously done exclusively by physicians, she observed. Very few studies, however, have addressed ACPs’ procedural competence and complication rates.

The retrospective study included all procedures performed from January to December 2011 in the trauma and surgical ICUs at the F.H. "Sammy" Ross Jr. Trauma Center, Carolinas Medical Center in Charlotte, N.C. Eight ACPs performed invasive procedures for surgical critical care patients under attending supervision, while three postgraduate year two (PGY2) surgical and emergency residents performed procedures for trauma patients.

Invited discussant Dr. Jeffrey Claridge, director of trauma, critical care, and burns at MetroHealth Medical Center in Cleveland, agreed with the study’s conclusion that complications were similar between ACPs and RPs, but went on to say that 2% is extremely low and that "something is missing or oversimplified."

In particular, he pressed Ms. Sirleaf on where the procedures were performed, the level of supervision provided to ACPs, and how extensive the review of complications was other than procedural notes. For example, did the authors look at whether chest tubes fell out within 24 hours because they were inappropriately secured, PEG or tracheostomy sites that got infected, or breaks occurred in sterile technique.

"Determining a more comprehensive complication panel would give more power to detect differences and, truthfully, more credibility to the paper," Dr. Claridge said.

Ms. Sirleaf replied that in addition to reviewing postprocedural notes, radiologists looked for complications 24 hours after chest tube placement and patients with a tracheostomy were followed for complications for 7 days by the attending.

Urgency of the procedure was not evaluated since the procedures were elective and most were performed at the bedside.

"For the ACPs with a level of competency, just like interns at the beginning, they assisted the attending and as they got better, the majority of the procedure was performed by the ACP at the bedside with the attending scrubbed in," she said.

At the time of the study, three ACPs had 1 year of experience, with up to 7 years’ experience in the remaining ACPs. Senior ACPs provided training along with the attendings, and both ACPs and RPs underwent quarterly simulation lab training on procedures. To maintain competency, Carolinas Medical Center also requires ACPs perform a set number of each type of procedure on a yearly basis and have these procedures witnessed and signed off on by an attending, said Ms. Sirleaf, now with Sharp Memorial Hospital, San Diego.

Ms. Sirleaf and her coauthors reported having no financial disclosures.

[email protected]

ORLANDO – Age and increased lung allocation score are among factors associated with risk of lung retransplantation, according to an analysis of data from the United Network for Organ Sharing.

Of 24,194 consecutive patients who underwent lung transplantation between 1987 and 2012 and who were included in the nationwide registry, 941 (3.9%) underwent retransplantation. Age over 40 years, increased lung allocation score, increased percentage decline in forced ventilatory capacity (FVC), and readmission to the intensive care unit each were associated with retransplantation (odds ratios, 2.26, 0.98, 0.99, and 2.27, respectively), Dr. J. Awori Hayanga reported at the annual meeting of the Society of Thoracic Surgeons.

The current findings could allow for better prediction of graft failure and the need for retransplantation, and could help guide immunosuppression protocols and donor selection, he said. This is important, because although the overall volume of retransplantation remains less than 5%, the number of such procedures is steadily increasing, with up to 100 now performed each year.

"Following the introduction of the lung allocation score, the waiting time decreased, and the volume, perhaps predictably, increased by almost 60% with this increased emphasis on clinical acuity. The relative paucity of donors nevertheless engenders a considerable amount of scrutiny," Dr. Hayanga said. "Contention exists between the utilitarian view, where allocation prioritizes recipients in most need, versus the egalitarian view that seeks to provide equal opportunity to all those in need," he explained.

While this ethical argument is "tempered somewhat by steadily improving outcomes," retransplantations still remain inferior to primary transplantations, carrying a 30% overall increased risk of death. Prior to this study, the risk factors for retransplantation were poorly characterized in the literature.

The study also showed that donor factors associated with retransplantation included smoking history and body mass index less than 18.5 kg/m² (OR, 1.47 and 1.68, respectively). One transplant-related factor – increased graft ischemic time – was also associated with retransplantation (OR, 0.91), said Dr. Hayanga of the University of Pittsburgh.

Lung transplantation is a well-established therapeutic option for end-stage lung disease, but long-term outcomes are largely determined by chronic allograft failure – a diagnosis which constitutes "the most justifiable, evidence-driven indication for retransplantation," he said. Survival among patients who undergo retransplantation for this indication have nearly equivalent survival to those with a first transplant, he noted.

Conversely, "there are multiple observations in the literature of the dismal outcomes observed following retransplantation for primary graft failure and airway complications," he noted.

"We seek now to build and validate a risk scoring model to help predict the risk for chronic graft failures and for retransplantation, to enrich the dialogue, to improve immunosuppressive and selection protocols, and ultimately to provide evidence-based prognostic data," he said.

This study was funded by the Ruben J. Williams Foundation. Dr. Hayanga reported having no other disclosures.

ORLANDO – Age and increased lung allocation score are among factors associated with risk of lung retransplantation, according to an analysis of data from the United Network for Organ Sharing.

Of 24,194 consecutive patients who underwent lung transplantation between 1987 and 2012 and who were included in the nationwide registry, 941 (3.9%) underwent retransplantation. Age over 40 years, increased lung allocation score, increased percentage decline in forced ventilatory capacity (FVC), and readmission to the intensive care unit each were associated with retransplantation (odds ratios, 2.26, 0.98, 0.99, and 2.27, respectively), Dr. J. Awori Hayanga reported at the annual meeting of the Society of Thoracic Surgeons.

The current findings could allow for better prediction of graft failure and the need for retransplantation, and could help guide immunosuppression protocols and donor selection, he said. This is important, because although the overall volume of retransplantation remains less than 5%, the number of such procedures is steadily increasing, with up to 100 now performed each year.

"Following the introduction of the lung allocation score, the waiting time decreased, and the volume, perhaps predictably, increased by almost 60% with this increased emphasis on clinical acuity. The relative paucity of donors nevertheless engenders a considerable amount of scrutiny," Dr. Hayanga said. "Contention exists between the utilitarian view, where allocation prioritizes recipients in most need, versus the egalitarian view that seeks to provide equal opportunity to all those in need," he explained.

While this ethical argument is "tempered somewhat by steadily improving outcomes," retransplantations still remain inferior to primary transplantations, carrying a 30% overall increased risk of death. Prior to this study, the risk factors for retransplantation were poorly characterized in the literature.

The study also showed that donor factors associated with retransplantation included smoking history and body mass index less than 18.5 kg/m² (OR, 1.47 and 1.68, respectively). One transplant-related factor – increased graft ischemic time – was also associated with retransplantation (OR, 0.91), said Dr. Hayanga of the University of Pittsburgh.

Lung transplantation is a well-established therapeutic option for end-stage lung disease, but long-term outcomes are largely determined by chronic allograft failure – a diagnosis which constitutes "the most justifiable, evidence-driven indication for retransplantation," he said. Survival among patients who undergo retransplantation for this indication have nearly equivalent survival to those with a first transplant, he noted.

Conversely, "there are multiple observations in the literature of the dismal outcomes observed following retransplantation for primary graft failure and airway complications," he noted.

"We seek now to build and validate a risk scoring model to help predict the risk for chronic graft failures and for retransplantation, to enrich the dialogue, to improve immunosuppressive and selection protocols, and ultimately to provide evidence-based prognostic data," he said.

This study was funded by the Ruben J. Williams Foundation. Dr. Hayanga reported having no other disclosures.

ORLANDO – Age and increased lung allocation score are among factors associated with risk of lung retransplantation, according to an analysis of data from the United Network for Organ Sharing.

Of 24,194 consecutive patients who underwent lung transplantation between 1987 and 2012 and who were included in the nationwide registry, 941 (3.9%) underwent retransplantation. Age over 40 years, increased lung allocation score, increased percentage decline in forced ventilatory capacity (FVC), and readmission to the intensive care unit each were associated with retransplantation (odds ratios, 2.26, 0.98, 0.99, and 2.27, respectively), Dr. J. Awori Hayanga reported at the annual meeting of the Society of Thoracic Surgeons.

The current findings could allow for better prediction of graft failure and the need for retransplantation, and could help guide immunosuppression protocols and donor selection, he said. This is important, because although the overall volume of retransplantation remains less than 5%, the number of such procedures is steadily increasing, with up to 100 now performed each year.

"Following the introduction of the lung allocation score, the waiting time decreased, and the volume, perhaps predictably, increased by almost 60% with this increased emphasis on clinical acuity. The relative paucity of donors nevertheless engenders a considerable amount of scrutiny," Dr. Hayanga said. "Contention exists between the utilitarian view, where allocation prioritizes recipients in most need, versus the egalitarian view that seeks to provide equal opportunity to all those in need," he explained.

While this ethical argument is "tempered somewhat by steadily improving outcomes," retransplantations still remain inferior to primary transplantations, carrying a 30% overall increased risk of death. Prior to this study, the risk factors for retransplantation were poorly characterized in the literature.

The study also showed that donor factors associated with retransplantation included smoking history and body mass index less than 18.5 kg/m² (OR, 1.47 and 1.68, respectively). One transplant-related factor – increased graft ischemic time – was also associated with retransplantation (OR, 0.91), said Dr. Hayanga of the University of Pittsburgh.

Lung transplantation is a well-established therapeutic option for end-stage lung disease, but long-term outcomes are largely determined by chronic allograft failure – a diagnosis which constitutes "the most justifiable, evidence-driven indication for retransplantation," he said. Survival among patients who undergo retransplantation for this indication have nearly equivalent survival to those with a first transplant, he noted.

Conversely, "there are multiple observations in the literature of the dismal outcomes observed following retransplantation for primary graft failure and airway complications," he noted.

"We seek now to build and validate a risk scoring model to help predict the risk for chronic graft failures and for retransplantation, to enrich the dialogue, to improve immunosuppressive and selection protocols, and ultimately to provide evidence-based prognostic data," he said.

This study was funded by the Ruben J. Williams Foundation. Dr. Hayanga reported having no other disclosures.

WASHINGTON – Medicare should cover telemedicine services regardless of geography, and physicians who use the technologies should be paid appropriately by all health insurers.

Those are among the goals of the Alliance for Connected Care, led by three formers leaders of the U.S. Senate.

Alicia Ault/Frontline Medical News

At a press briefing, former Senate Majority Leader Tom Daschle (D-S.D.), former Senate Majority Leader Trent Lott (R-Miss.), and former Sen. John Breaux (R-La.) said that they have begun meeting with legislators regarding the coalition’s agenda.

Geographic expansion of telemedicine under Medicare is a key goal; the program currently will pay in rural areas only. Appropriate and widespread reimbursement for providers, including physicians, is another goal. The alliance also want to see telemedicine, remote patient monitoring and other technology that helps deliver and coordinate care, reimbursed under new models of care like patient-centered medical homes and accountable care organizations.

Sen. Lott said that he and Sen. Breaux recently met with Sen. Ron Wyden (D-Ore.), who likely will be the next chairman of the Finance Committee (since Chairman Max Baucus [D-Mont.] left Congress to become U.S. ambassador to China), as well as with committee member John Thune (R-S.D.).

"Both of them are very interested and committed," to helping increase access to telemedicine, Sen. Lott said at a briefing with reporters on Feb. 12.

Rep. Gregg Harper (R-Miss.) noted that his bill to encourage telemedicine is likely to see some action in the House this spring.

The Telehealth Enhancement Act of 2013 was introduced in October and currently has 14 cosponsors. With Congress looking at alternative delivery and payment models, "the time is right, the time is really now to grant providers flexibility to improve telemedicine," he said.

Telemedicine holds the potential to improve patient outcomes, quality of care, and to "meet the demands of the aging population," said Rep. Harper, who sits on the House Energy and Commerce Committee. It can also save Medicare and Medicaid money.

The Alliance for Connected Careis a nonprofit organization that includes a half-dozen large and small health-related companies on its board of directors: Verizon, Walgreens, CVS/Caremark, WellPoint, HealthSpot, and Teladoc. Associate members include Welch Allyn, Cardinal Health, Care Innovations, Doctor on Demand, and MDLive.

Those companies are mostly interested in selling telemedicine platforms to physicians or insurers. For 3 years, WellPoint has been offering its subscribers access to online consultations through LiveHealth Online. So far, it has saved money; patients have given it high marks, said John F. Jesser, vice president of provider engagement strategy at LiveHealth Online.

The alliance also plans to talk to state and federal officials about creating standard definitions for telemedicine, creating security and fraud protections, and making it easier for physicians to use telemedicine across state lines. According to the group, 20 states and the District of Columbia currently require commercial insurers to cover telemedicine services. Forty-five states allow Medicaid to pay for telemedicine.

Medicare is the laggard, Sen. Daschle said.

"We must ensure that our regulatory environment appropriately balances the exciting advances in technology for patients, while still maintaining safeguards that allow innovation," he said.

Several physician organizations and patient advocacy groups have signed on as advisers to the alliance, including the American Academy of Family Physicians, the National Association of ACOs, the American Heart Association, and National Alliance on Mental Illness.

[email protected]

On Twitter @aliciaault

WASHINGTON – Medicare should cover telemedicine services regardless of geography, and physicians who use the technologies should be paid appropriately by all health insurers.

Those are among the goals of the Alliance for Connected Care, led by three formers leaders of the U.S. Senate.

Alicia Ault/Frontline Medical News

At a press briefing, former Senate Majority Leader Tom Daschle (D-S.D.), former Senate Majority Leader Trent Lott (R-Miss.), and former Sen. John Breaux (R-La.) said that they have begun meeting with legislators regarding the coalition’s agenda.

Geographic expansion of telemedicine under Medicare is a key goal; the program currently will pay in rural areas only. Appropriate and widespread reimbursement for providers, including physicians, is another goal. The alliance also want to see telemedicine, remote patient monitoring and other technology that helps deliver and coordinate care, reimbursed under new models of care like patient-centered medical homes and accountable care organizations.

Sen. Lott said that he and Sen. Breaux recently met with Sen. Ron Wyden (D-Ore.), who likely will be the next chairman of the Finance Committee (since Chairman Max Baucus [D-Mont.] left Congress to become U.S. ambassador to China), as well as with committee member John Thune (R-S.D.).

"Both of them are very interested and committed," to helping increase access to telemedicine, Sen. Lott said at a briefing with reporters on Feb. 12.

Rep. Gregg Harper (R-Miss.) noted that his bill to encourage telemedicine is likely to see some action in the House this spring.

The Telehealth Enhancement Act of 2013 was introduced in October and currently has 14 cosponsors. With Congress looking at alternative delivery and payment models, "the time is right, the time is really now to grant providers flexibility to improve telemedicine," he said.

Telemedicine holds the potential to improve patient outcomes, quality of care, and to "meet the demands of the aging population," said Rep. Harper, who sits on the House Energy and Commerce Committee. It can also save Medicare and Medicaid money.

The Alliance for Connected Careis a nonprofit organization that includes a half-dozen large and small health-related companies on its board of directors: Verizon, Walgreens, CVS/Caremark, WellPoint, HealthSpot, and Teladoc. Associate members include Welch Allyn, Cardinal Health, Care Innovations, Doctor on Demand, and MDLive.

Those companies are mostly interested in selling telemedicine platforms to physicians or insurers. For 3 years, WellPoint has been offering its subscribers access to online consultations through LiveHealth Online. So far, it has saved money; patients have given it high marks, said John F. Jesser, vice president of provider engagement strategy at LiveHealth Online.

The alliance also plans to talk to state and federal officials about creating standard definitions for telemedicine, creating security and fraud protections, and making it easier for physicians to use telemedicine across state lines. According to the group, 20 states and the District of Columbia currently require commercial insurers to cover telemedicine services. Forty-five states allow Medicaid to pay for telemedicine.

Medicare is the laggard, Sen. Daschle said.

"We must ensure that our regulatory environment appropriately balances the exciting advances in technology for patients, while still maintaining safeguards that allow innovation," he said.

Several physician organizations and patient advocacy groups have signed on as advisers to the alliance, including the American Academy of Family Physicians, the National Association of ACOs, the American Heart Association, and National Alliance on Mental Illness.

[email protected]

On Twitter @aliciaault

WASHINGTON – Medicare should cover telemedicine services regardless of geography, and physicians who use the technologies should be paid appropriately by all health insurers.

Those are among the goals of the Alliance for Connected Care, led by three formers leaders of the U.S. Senate.

Alicia Ault/Frontline Medical News

At a press briefing, former Senate Majority Leader Tom Daschle (D-S.D.), former Senate Majority Leader Trent Lott (R-Miss.), and former Sen. John Breaux (R-La.) said that they have begun meeting with legislators regarding the coalition’s agenda.

Geographic expansion of telemedicine under Medicare is a key goal; the program currently will pay in rural areas only. Appropriate and widespread reimbursement for providers, including physicians, is another goal. The alliance also want to see telemedicine, remote patient monitoring and other technology that helps deliver and coordinate care, reimbursed under new models of care like patient-centered medical homes and accountable care organizations.

Sen. Lott said that he and Sen. Breaux recently met with Sen. Ron Wyden (D-Ore.), who likely will be the next chairman of the Finance Committee (since Chairman Max Baucus [D-Mont.] left Congress to become U.S. ambassador to China), as well as with committee member John Thune (R-S.D.).

"Both of them are very interested and committed," to helping increase access to telemedicine, Sen. Lott said at a briefing with reporters on Feb. 12.

Rep. Gregg Harper (R-Miss.) noted that his bill to encourage telemedicine is likely to see some action in the House this spring.

The Telehealth Enhancement Act of 2013 was introduced in October and currently has 14 cosponsors. With Congress looking at alternative delivery and payment models, "the time is right, the time is really now to grant providers flexibility to improve telemedicine," he said.

Telemedicine holds the potential to improve patient outcomes, quality of care, and to "meet the demands of the aging population," said Rep. Harper, who sits on the House Energy and Commerce Committee. It can also save Medicare and Medicaid money.

The Alliance for Connected Careis a nonprofit organization that includes a half-dozen large and small health-related companies on its board of directors: Verizon, Walgreens, CVS/Caremark, WellPoint, HealthSpot, and Teladoc. Associate members include Welch Allyn, Cardinal Health, Care Innovations, Doctor on Demand, and MDLive.

Those companies are mostly interested in selling telemedicine platforms to physicians or insurers. For 3 years, WellPoint has been offering its subscribers access to online consultations through LiveHealth Online. So far, it has saved money; patients have given it high marks, said John F. Jesser, vice president of provider engagement strategy at LiveHealth Online.

The alliance also plans to talk to state and federal officials about creating standard definitions for telemedicine, creating security and fraud protections, and making it easier for physicians to use telemedicine across state lines. According to the group, 20 states and the District of Columbia currently require commercial insurers to cover telemedicine services. Forty-five states allow Medicaid to pay for telemedicine.

Medicare is the laggard, Sen. Daschle said.

"We must ensure that our regulatory environment appropriately balances the exciting advances in technology for patients, while still maintaining safeguards that allow innovation," he said.

Several physician organizations and patient advocacy groups have signed on as advisers to the alliance, including the American Academy of Family Physicians, the National Association of ACOs, the American Heart Association, and National Alliance on Mental Illness.

[email protected]

On Twitter @aliciaault

NAPLES, FLA. – Vitamin D deficiency is common in critically ill trauma patients and portends worse outcomes, a retrospective study suggests.

Among 200 trauma patients with available vitamin D levels, 26% were vitamin D deficient on ICU admission.

"These patients have a higher APACHE II score, have a longer ICU stay, and will likely be hospitalized greater than 2 weeks," Dr. Joseph Ibrahim reported at the annual scientific assembly of the Eastern Association for the Surgery of Trauma.

Long known to be essential for bone development and wound healing, recent studies have demonstrated that vitamin D deficiency is a significant predictor of 30- and 90-day all-cause mortality in critically ill patients, even after adjustment for such factors as age, Charlson/Deyo index, sepsis, and season (Crit. Care. Med. 2012;40:63-72). It also has been shown to significantly predict acute kidney injury in the critically ill (Crit. Care Med. 2012;40:3170-9).

For the current analysis, vitamin D levels were drawn upon ICU admission, at 72 hours, and every 7 days until hospital discharge in 200 of 234 consecutive adult trauma patients admitted to the ICU at the Level 1 Orlando Regional Medical Center during a 4-month period. Deficiency was defined as 25-hydroxyvitamin D 20 ng/mL or less. All patients received nutritional support using a standard protocol, but not vitamin D supplementation.

Median vitamin D ICU admission levels in the 51 vitamin D–deficient patients were significantly lower than for nondeficient patients (16 ng/mL vs. 28 ng/mL; P less than .001). Levels decreased a median of 4 ng/mL at 72 hours in both groups, but only the sufficient group returned to admission baseline levels at week 2, reported Dr. Ibrahim, a critical care surgeon with the medical center.

"This demonstrates that if we wish to obtain normal vitamin D levels in these patients, we will have to supplement them with much higher doses than what we are providing with standard enteral formulas," he said in an interview.

Patients with vitamin D deficiency spent more time than did nondeficient patients in the ICU (median 3 days vs. 2.7 days) and hospital (median 8.4 days vs. 7.1 days), but these trends did not reach statistical significance.

Significantly more deficient patients, however, remained in the hospital for at least 2 weeks (37% vs. 20%; P = .01).

The investigators were unable to show a difference in mortality between the deficient and nondeficient groups (16% vs. 12%; P = .51), possibly because the study was underpowered, he said.

Deficient and sufficient patients did not differ in age (median 48 years vs. 44 years), body mass index (26.2 kg/m² vs. 25.7 kg/m²), admission ionized calcium (1.06 mmol/L for both), or Injury Severity Score (14 vs. 13). Only APACHE II scores were significantly higher in deficient patients (20 vs. 15).

"It makes sense that with the significant difference in APACHE II score, one would expect to see a similar difference in mortality, but again we were unable to show this with this study," Dr. Ibrahim said.

Prehospital factors significantly associated with low vitamin D status were African American race, diabetes, and lack of vitamin D supplementation.

Vitamin D supplementation may be helpful in critically ill trauma patients during hospitalization, but more research is needed, Dr. Ibrahim said. The group is planning a supplementation study, looking at vitamin D dosing and frequency of testing.

"Our first goal was to demonstrate a significant incidence, which we did," he said. "It should be noted that the incidence was in a location with probably one of the highest amounts of sunshine in the country and that the findings may underestimate what one would find in other areas of the United States."

Dr. Oscar Guillamondegui, of Vanderbilt University Medical Center in Nashville, Tenn., who proctored the poster session, said he would expect vitamin D levels to be lower in acutely sick patients requiring ICU management because production of vitamin D–binding protein, a subprotein in the albumin family of proteins involved in vitamin D transport and storage, is decreased in high stress situations to allow for the increase in acute phase protein production.

"Although the data are intriguing, as a retrospective study, it is too early to suggest that supplementation is essential," he said. "I do believe this is great work and will stimulate several studies to prove the need for supplementation and for that, I commend Dr. Ibrahim and his group in their efforts."

Dr. Ibrahim and Dr. Guillamondegui reported having no financial disclosures.

[email protected]

NAPLES, FLA. – Vitamin D deficiency is common in critically ill trauma patients and portends worse outcomes, a retrospective study suggests.

Among 200 trauma patients with available vitamin D levels, 26% were vitamin D deficient on ICU admission.

"These patients have a higher APACHE II score, have a longer ICU stay, and will likely be hospitalized greater than 2 weeks," Dr. Joseph Ibrahim reported at the annual scientific assembly of the Eastern Association for the Surgery of Trauma.

Long known to be essential for bone development and wound healing, recent studies have demonstrated that vitamin D deficiency is a significant predictor of 30- and 90-day all-cause mortality in critically ill patients, even after adjustment for such factors as age, Charlson/Deyo index, sepsis, and season (Crit. Care. Med. 2012;40:63-72). It also has been shown to significantly predict acute kidney injury in the critically ill (Crit. Care Med. 2012;40:3170-9).

For the current analysis, vitamin D levels were drawn upon ICU admission, at 72 hours, and every 7 days until hospital discharge in 200 of 234 consecutive adult trauma patients admitted to the ICU at the Level 1 Orlando Regional Medical Center during a 4-month period. Deficiency was defined as 25-hydroxyvitamin D 20 ng/mL or less. All patients received nutritional support using a standard protocol, but not vitamin D supplementation.

Median vitamin D ICU admission levels in the 51 vitamin D–deficient patients were significantly lower than for nondeficient patients (16 ng/mL vs. 28 ng/mL; P less than .001). Levels decreased a median of 4 ng/mL at 72 hours in both groups, but only the sufficient group returned to admission baseline levels at week 2, reported Dr. Ibrahim, a critical care surgeon with the medical center.

"This demonstrates that if we wish to obtain normal vitamin D levels in these patients, we will have to supplement them with much higher doses than what we are providing with standard enteral formulas," he said in an interview.

Patients with vitamin D deficiency spent more time than did nondeficient patients in the ICU (median 3 days vs. 2.7 days) and hospital (median 8.4 days vs. 7.1 days), but these trends did not reach statistical significance.

Significantly more deficient patients, however, remained in the hospital for at least 2 weeks (37% vs. 20%; P = .01).

The investigators were unable to show a difference in mortality between the deficient and nondeficient groups (16% vs. 12%; P = .51), possibly because the study was underpowered, he said.

Deficient and sufficient patients did not differ in age (median 48 years vs. 44 years), body mass index (26.2 kg/m² vs. 25.7 kg/m²), admission ionized calcium (1.06 mmol/L for both), or Injury Severity Score (14 vs. 13). Only APACHE II scores were significantly higher in deficient patients (20 vs. 15).

"It makes sense that with the significant difference in APACHE II score, one would expect to see a similar difference in mortality, but again we were unable to show this with this study," Dr. Ibrahim said.

Prehospital factors significantly associated with low vitamin D status were African American race, diabetes, and lack of vitamin D supplementation.

Vitamin D supplementation may be helpful in critically ill trauma patients during hospitalization, but more research is needed, Dr. Ibrahim said. The group is planning a supplementation study, looking at vitamin D dosing and frequency of testing.

"Our first goal was to demonstrate a significant incidence, which we did," he said. "It should be noted that the incidence was in a location with probably one of the highest amounts of sunshine in the country and that the findings may underestimate what one would find in other areas of the United States."

Dr. Oscar Guillamondegui, of Vanderbilt University Medical Center in Nashville, Tenn., who proctored the poster session, said he would expect vitamin D levels to be lower in acutely sick patients requiring ICU management because production of vitamin D–binding protein, a subprotein in the albumin family of proteins involved in vitamin D transport and storage, is decreased in high stress situations to allow for the increase in acute phase protein production.

"Although the data are intriguing, as a retrospective study, it is too early to suggest that supplementation is essential," he said. "I do believe this is great work and will stimulate several studies to prove the need for supplementation and for that, I commend Dr. Ibrahim and his group in their efforts."

Dr. Ibrahim and Dr. Guillamondegui reported having no financial disclosures.

[email protected]

NAPLES, FLA. – Vitamin D deficiency is common in critically ill trauma patients and portends worse outcomes, a retrospective study suggests.

Among 200 trauma patients with available vitamin D levels, 26% were vitamin D deficient on ICU admission.

"These patients have a higher APACHE II score, have a longer ICU stay, and will likely be hospitalized greater than 2 weeks," Dr. Joseph Ibrahim reported at the annual scientific assembly of the Eastern Association for the Surgery of Trauma.

Long known to be essential for bone development and wound healing, recent studies have demonstrated that vitamin D deficiency is a significant predictor of 30- and 90-day all-cause mortality in critically ill patients, even after adjustment for such factors as age, Charlson/Deyo index, sepsis, and season (Crit. Care. Med. 2012;40:63-72). It also has been shown to significantly predict acute kidney injury in the critically ill (Crit. Care Med. 2012;40:3170-9).

For the current analysis, vitamin D levels were drawn upon ICU admission, at 72 hours, and every 7 days until hospital discharge in 200 of 234 consecutive adult trauma patients admitted to the ICU at the Level 1 Orlando Regional Medical Center during a 4-month period. Deficiency was defined as 25-hydroxyvitamin D 20 ng/mL or less. All patients received nutritional support using a standard protocol, but not vitamin D supplementation.

Median vitamin D ICU admission levels in the 51 vitamin D–deficient patients were significantly lower than for nondeficient patients (16 ng/mL vs. 28 ng/mL; P less than .001). Levels decreased a median of 4 ng/mL at 72 hours in both groups, but only the sufficient group returned to admission baseline levels at week 2, reported Dr. Ibrahim, a critical care surgeon with the medical center.

"This demonstrates that if we wish to obtain normal vitamin D levels in these patients, we will have to supplement them with much higher doses than what we are providing with standard enteral formulas," he said in an interview.

Patients with vitamin D deficiency spent more time than did nondeficient patients in the ICU (median 3 days vs. 2.7 days) and hospital (median 8.4 days vs. 7.1 days), but these trends did not reach statistical significance.

Significantly more deficient patients, however, remained in the hospital for at least 2 weeks (37% vs. 20%; P = .01).

The investigators were unable to show a difference in mortality between the deficient and nondeficient groups (16% vs. 12%; P = .51), possibly because the study was underpowered, he said.

Deficient and sufficient patients did not differ in age (median 48 years vs. 44 years), body mass index (26.2 kg/m² vs. 25.7 kg/m²), admission ionized calcium (1.06 mmol/L for both), or Injury Severity Score (14 vs. 13). Only APACHE II scores were significantly higher in deficient patients (20 vs. 15).

"It makes sense that with the significant difference in APACHE II score, one would expect to see a similar difference in mortality, but again we were unable to show this with this study," Dr. Ibrahim said.

Prehospital factors significantly associated with low vitamin D status were African American race, diabetes, and lack of vitamin D supplementation.

Vitamin D supplementation may be helpful in critically ill trauma patients during hospitalization, but more research is needed, Dr. Ibrahim said. The group is planning a supplementation study, looking at vitamin D dosing and frequency of testing.

"Our first goal was to demonstrate a significant incidence, which we did," he said. "It should be noted that the incidence was in a location with probably one of the highest amounts of sunshine in the country and that the findings may underestimate what one would find in other areas of the United States."

Dr. Oscar Guillamondegui, of Vanderbilt University Medical Center in Nashville, Tenn., who proctored the poster session, said he would expect vitamin D levels to be lower in acutely sick patients requiring ICU management because production of vitamin D–binding protein, a subprotein in the albumin family of proteins involved in vitamin D transport and storage, is decreased in high stress situations to allow for the increase in acute phase protein production.

"Although the data are intriguing, as a retrospective study, it is too early to suggest that supplementation is essential," he said. "I do believe this is great work and will stimulate several studies to prove the need for supplementation and for that, I commend Dr. Ibrahim and his group in their efforts."

Dr. Ibrahim and Dr. Guillamondegui reported having no financial disclosures.

[email protected]

ORLANDO – Survival following repeat lung transplantation is similar to survival following initial lung transplantation when performed at least 90 days after the initial transplant, according to a review of data from the United Network for Organ Sharing registry.

However, survival in those retransplanted within 90 days of the primary transplant is severely diminished, Asishana A. Osho, a fourth-year medical student at Duke University, Durham, N.C., reported at the annual meeting of the Society of Thoracic Surgeons.

The outcomes of 9,270 primary lung transplant cases and 456 retransplant cases performed since implementation of the lung allocation score (LAS) show that overall 5-year survival was significantly better in the primary transplant patients (hazard ratio, 1.69). However, after 1:1 propensity matching, 5-year survival was similar for 429 primary transplant and 429 retransplant patients (HR, 1.01), and between 392 primary transplant patients and 392 matched late (after 90 days) retransplant patients (HR, 1.23).

Conversely, 5-year survival was significantly reduced for 51 early (within 90 days) retransplant patients, compared with 51 matched primary transplant patients (HR, 1.38), Mr. Osho said.

Patients included in the study were participants in the UNOS registry. The median age of those in the primary transplant group was 58 years, compared with 62 years for the early retransplantation group and 47 for the late retransplantation group. The median LAS were 38.9, 88.3, and 45.8 for the groups, respectively.

Bilateral transplantation was performed in 66.5% of cases.

The findings provide new information about the effects of retransplantation timing and have potential implications for clinical decision making, Mr. Osho said.

The frequency of lung retransplantation has increased over the past several years, probably because of the implementation of the LAS, and this increase has also been accompanied by an increase in survival among those undergoing a repeat transplantation, as is apparent when comparing survival curves before and after 2005, he noted.

The current results, however, show that the survival is diminished with early retransplantation. Patients also generally did worse if they were treated in the ICU before transplant, if they had a single vs. double lung transplant, or if they received the transplant for primary graft dysfunction vs. for bronchiolitis obliterans.

The diminished survival among those undergoing early retransplantation may be related to the stress of having two major procedures in close proximity, Mr. Osho said.

"An additional consideration is that patients who do poorly shortly after the first transplant may have certain traits that predispose them to doing poorly with subsequent procedures," he said.

Though limited by the fact that only patients who ultimately received lungs were included, and by the retrospective design (a factor somewhat mitigated by the use of propensity matching), the findings identify factors, including admission status, type of treatment, and transplant diagnosis that clinicians should be cognizant of before performing retransplantation, and they suggest that the utility of early repeat transplantation requires further examination, he concluded.

Mr. Osho reporting having no disclosures.

ORLANDO – Survival following repeat lung transplantation is similar to survival following initial lung transplantation when performed at least 90 days after the initial transplant, according to a review of data from the United Network for Organ Sharing registry.

However, survival in those retransplanted within 90 days of the primary transplant is severely diminished, Asishana A. Osho, a fourth-year medical student at Duke University, Durham, N.C., reported at the annual meeting of the Society of Thoracic Surgeons.

The outcomes of 9,270 primary lung transplant cases and 456 retransplant cases performed since implementation of the lung allocation score (LAS) show that overall 5-year survival was significantly better in the primary transplant patients (hazard ratio, 1.69). However, after 1:1 propensity matching, 5-year survival was similar for 429 primary transplant and 429 retransplant patients (HR, 1.01), and between 392 primary transplant patients and 392 matched late (after 90 days) retransplant patients (HR, 1.23).

Conversely, 5-year survival was significantly reduced for 51 early (within 90 days) retransplant patients, compared with 51 matched primary transplant patients (HR, 1.38), Mr. Osho said.

Patients included in the study were participants in the UNOS registry. The median age of those in the primary transplant group was 58 years, compared with 62 years for the early retransplantation group and 47 for the late retransplantation group. The median LAS were 38.9, 88.3, and 45.8 for the groups, respectively.

Bilateral transplantation was performed in 66.5% of cases.

The findings provide new information about the effects of retransplantation timing and have potential implications for clinical decision making, Mr. Osho said.

The frequency of lung retransplantation has increased over the past several years, probably because of the implementation of the LAS, and this increase has also been accompanied by an increase in survival among those undergoing a repeat transplantation, as is apparent when comparing survival curves before and after 2005, he noted.

The current results, however, show that the survival is diminished with early retransplantation. Patients also generally did worse if they were treated in the ICU before transplant, if they had a single vs. double lung transplant, or if they received the transplant for primary graft dysfunction vs. for bronchiolitis obliterans.

The diminished survival among those undergoing early retransplantation may be related to the stress of having two major procedures in close proximity, Mr. Osho said.

"An additional consideration is that patients who do poorly shortly after the first transplant may have certain traits that predispose them to doing poorly with subsequent procedures," he said.

Though limited by the fact that only patients who ultimately received lungs were included, and by the retrospective design (a factor somewhat mitigated by the use of propensity matching), the findings identify factors, including admission status, type of treatment, and transplant diagnosis that clinicians should be cognizant of before performing retransplantation, and they suggest that the utility of early repeat transplantation requires further examination, he concluded.

Mr. Osho reporting having no disclosures.

ORLANDO – Survival following repeat lung transplantation is similar to survival following initial lung transplantation when performed at least 90 days after the initial transplant, according to a review of data from the United Network for Organ Sharing registry.

However, survival in those retransplanted within 90 days of the primary transplant is severely diminished, Asishana A. Osho, a fourth-year medical student at Duke University, Durham, N.C., reported at the annual meeting of the Society of Thoracic Surgeons.

The outcomes of 9,270 primary lung transplant cases and 456 retransplant cases performed since implementation of the lung allocation score (LAS) show that overall 5-year survival was significantly better in the primary transplant patients (hazard ratio, 1.69). However, after 1:1 propensity matching, 5-year survival was similar for 429 primary transplant and 429 retransplant patients (HR, 1.01), and between 392 primary transplant patients and 392 matched late (after 90 days) retransplant patients (HR, 1.23).

Conversely, 5-year survival was significantly reduced for 51 early (within 90 days) retransplant patients, compared with 51 matched primary transplant patients (HR, 1.38), Mr. Osho said.

Patients included in the study were participants in the UNOS registry. The median age of those in the primary transplant group was 58 years, compared with 62 years for the early retransplantation group and 47 for the late retransplantation group. The median LAS were 38.9, 88.3, and 45.8 for the groups, respectively.

Bilateral transplantation was performed in 66.5% of cases.

The findings provide new information about the effects of retransplantation timing and have potential implications for clinical decision making, Mr. Osho said.

The frequency of lung retransplantation has increased over the past several years, probably because of the implementation of the LAS, and this increase has also been accompanied by an increase in survival among those undergoing a repeat transplantation, as is apparent when comparing survival curves before and after 2005, he noted.

The current results, however, show that the survival is diminished with early retransplantation. Patients also generally did worse if they were treated in the ICU before transplant, if they had a single vs. double lung transplant, or if they received the transplant for primary graft dysfunction vs. for bronchiolitis obliterans.

The diminished survival among those undergoing early retransplantation may be related to the stress of having two major procedures in close proximity, Mr. Osho said.

"An additional consideration is that patients who do poorly shortly after the first transplant may have certain traits that predispose them to doing poorly with subsequent procedures," he said.

Though limited by the fact that only patients who ultimately received lungs were included, and by the retrospective design (a factor somewhat mitigated by the use of propensity matching), the findings identify factors, including admission status, type of treatment, and transplant diagnosis that clinicians should be cognizant of before performing retransplantation, and they suggest that the utility of early repeat transplantation requires further examination, he concluded.

Mr. Osho reporting having no disclosures.