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Many women have unprotected sex in year after bariatric surgery
More than 40% of reproductive-age women reported having unprotected sex in the year after undergoing bariatric surgery, despite recommendations to avoid pregnancy for at least a year, a new study finds. Another 4% of women reported trying to conceive in the 12 months after surgery.
“We were surprised to find such a large percentage of women were not using contraception, and we were also surprised to find so many were actively trying to conceive,” the study’s lead author Marie N. Menke, MD, MPH, of the University of Pittsburgh, said in an interview. “Reproductive-age women who are considering bariatric surgery should be counseled that they should plan to use contraceptives after surgery for about 12-18 months.”
Pregnancy isn’t recommended over that period mainly because of the risks to the fetus, Dr. Menke said. “These risks are different from obesity in general. We don’t know exactly why surgery causes these risks, but ideally, patients would be weight-stable prior to conception.”
In 2013, the American Association of Clinical Endocrinologists, the Obesity Society, and the American Society for Metabolic & Bariatric Surgery provided a Grade D recommendation for a 12-18 month delay in conception (Obesity [Silver Spring] 2013;21[suppl 1]:S1-27). A recent study provided more insight into the potential risks of pregnancy soon after weight-loss procedures. It reported that, compared with those who gave birth more than 4 years later, women who gave birth within 2 years of bariatric surgery had higher risks of premature birth, admission to neonatal intensive care units, and small-for-gestational-age infants (JAMA Surg. 2017 Feb 1;152[2]:1-8).
The current prospective cohort study included women who underwent bariatric surgery for the first time during 2005-2009 at 10 U.S. hospitals. The women, all aged 18-44 years, answered questions for as long as 7 years, until January 2015 (Obstet Gynecol. 2017 Oct 6. doi: 10.1097/AOG.0000000000002323).
The analysis included 710 women who provided conception data. The median body mass index of the women was 46.3 kg/m2. Most patients underwent Roux-en-Y gastric bypass (73%), followed by laparoscopic adjustable gastric banding (23%).
Researchers found that 4.3% of the women tried to conceive in the first year after surgery (95% confidence interval, 2.4-6.3), and 13.1% did so in the second year (95% CI, 9.3-17.0; P less than .001).
During the first year after surgery, 12.7% of women had no intercourse (95% CI, 9.4-16.0), 40.5% had only protected intercourse (95% CI, 35.6-45.4), and 41.5% (95% CI, 36.4-46.6) had unprotected intercourse while not trying to conceive.
Why are the unprotected sex numbers so high? “We wonder if some women simply feel that they cannot get pregnant,” Dr. Menke said. “Our group has previously reported that 42% of women who had attempted to conceive prior to bariatric surgery had a history of infertility. Some of these women went on to deliver a live birth, but many did not.”
The study reports that 183 of the 710 women did ultimately conceive and that the number may be as high as 237 because data were missing for 54 women who may have not wanted to report a nonlive birth. Of the women who reported conceiving, 68.9% had live births, 1.1% had stillbirths, 1.1% had ectopic pregnancies, 21.9% miscarried and 7.1% had abortions.
“We’d really like this research to be a reason to consider presurgical contraceptive counseling as one of the steps prior to bariatric surgery,” Dr. Menke said. “This may include a referral by the bariatric surgeon to a physician would who provide counseling, prescribe, or both.”
The study was funded by the National Institute of Diabetes and Digestive and Kidney Diseases. Dr. Menke reported having no relevant disclosures. Her coauthors reported financial relationships with pharmaceutical and medical device companies with products to treat metabolic diseases.
More than 40% of reproductive-age women reported having unprotected sex in the year after undergoing bariatric surgery, despite recommendations to avoid pregnancy for at least a year, a new study finds. Another 4% of women reported trying to conceive in the 12 months after surgery.
“We were surprised to find such a large percentage of women were not using contraception, and we were also surprised to find so many were actively trying to conceive,” the study’s lead author Marie N. Menke, MD, MPH, of the University of Pittsburgh, said in an interview. “Reproductive-age women who are considering bariatric surgery should be counseled that they should plan to use contraceptives after surgery for about 12-18 months.”
Pregnancy isn’t recommended over that period mainly because of the risks to the fetus, Dr. Menke said. “These risks are different from obesity in general. We don’t know exactly why surgery causes these risks, but ideally, patients would be weight-stable prior to conception.”
In 2013, the American Association of Clinical Endocrinologists, the Obesity Society, and the American Society for Metabolic & Bariatric Surgery provided a Grade D recommendation for a 12-18 month delay in conception (Obesity [Silver Spring] 2013;21[suppl 1]:S1-27). A recent study provided more insight into the potential risks of pregnancy soon after weight-loss procedures. It reported that, compared with those who gave birth more than 4 years later, women who gave birth within 2 years of bariatric surgery had higher risks of premature birth, admission to neonatal intensive care units, and small-for-gestational-age infants (JAMA Surg. 2017 Feb 1;152[2]:1-8).
The current prospective cohort study included women who underwent bariatric surgery for the first time during 2005-2009 at 10 U.S. hospitals. The women, all aged 18-44 years, answered questions for as long as 7 years, until January 2015 (Obstet Gynecol. 2017 Oct 6. doi: 10.1097/AOG.0000000000002323).
The analysis included 710 women who provided conception data. The median body mass index of the women was 46.3 kg/m2. Most patients underwent Roux-en-Y gastric bypass (73%), followed by laparoscopic adjustable gastric banding (23%).
Researchers found that 4.3% of the women tried to conceive in the first year after surgery (95% confidence interval, 2.4-6.3), and 13.1% did so in the second year (95% CI, 9.3-17.0; P less than .001).
During the first year after surgery, 12.7% of women had no intercourse (95% CI, 9.4-16.0), 40.5% had only protected intercourse (95% CI, 35.6-45.4), and 41.5% (95% CI, 36.4-46.6) had unprotected intercourse while not trying to conceive.
Why are the unprotected sex numbers so high? “We wonder if some women simply feel that they cannot get pregnant,” Dr. Menke said. “Our group has previously reported that 42% of women who had attempted to conceive prior to bariatric surgery had a history of infertility. Some of these women went on to deliver a live birth, but many did not.”
The study reports that 183 of the 710 women did ultimately conceive and that the number may be as high as 237 because data were missing for 54 women who may have not wanted to report a nonlive birth. Of the women who reported conceiving, 68.9% had live births, 1.1% had stillbirths, 1.1% had ectopic pregnancies, 21.9% miscarried and 7.1% had abortions.
“We’d really like this research to be a reason to consider presurgical contraceptive counseling as one of the steps prior to bariatric surgery,” Dr. Menke said. “This may include a referral by the bariatric surgeon to a physician would who provide counseling, prescribe, or both.”
The study was funded by the National Institute of Diabetes and Digestive and Kidney Diseases. Dr. Menke reported having no relevant disclosures. Her coauthors reported financial relationships with pharmaceutical and medical device companies with products to treat metabolic diseases.
More than 40% of reproductive-age women reported having unprotected sex in the year after undergoing bariatric surgery, despite recommendations to avoid pregnancy for at least a year, a new study finds. Another 4% of women reported trying to conceive in the 12 months after surgery.
“We were surprised to find such a large percentage of women were not using contraception, and we were also surprised to find so many were actively trying to conceive,” the study’s lead author Marie N. Menke, MD, MPH, of the University of Pittsburgh, said in an interview. “Reproductive-age women who are considering bariatric surgery should be counseled that they should plan to use contraceptives after surgery for about 12-18 months.”
Pregnancy isn’t recommended over that period mainly because of the risks to the fetus, Dr. Menke said. “These risks are different from obesity in general. We don’t know exactly why surgery causes these risks, but ideally, patients would be weight-stable prior to conception.”
In 2013, the American Association of Clinical Endocrinologists, the Obesity Society, and the American Society for Metabolic & Bariatric Surgery provided a Grade D recommendation for a 12-18 month delay in conception (Obesity [Silver Spring] 2013;21[suppl 1]:S1-27). A recent study provided more insight into the potential risks of pregnancy soon after weight-loss procedures. It reported that, compared with those who gave birth more than 4 years later, women who gave birth within 2 years of bariatric surgery had higher risks of premature birth, admission to neonatal intensive care units, and small-for-gestational-age infants (JAMA Surg. 2017 Feb 1;152[2]:1-8).
The current prospective cohort study included women who underwent bariatric surgery for the first time during 2005-2009 at 10 U.S. hospitals. The women, all aged 18-44 years, answered questions for as long as 7 years, until January 2015 (Obstet Gynecol. 2017 Oct 6. doi: 10.1097/AOG.0000000000002323).
The analysis included 710 women who provided conception data. The median body mass index of the women was 46.3 kg/m2. Most patients underwent Roux-en-Y gastric bypass (73%), followed by laparoscopic adjustable gastric banding (23%).
Researchers found that 4.3% of the women tried to conceive in the first year after surgery (95% confidence interval, 2.4-6.3), and 13.1% did so in the second year (95% CI, 9.3-17.0; P less than .001).
During the first year after surgery, 12.7% of women had no intercourse (95% CI, 9.4-16.0), 40.5% had only protected intercourse (95% CI, 35.6-45.4), and 41.5% (95% CI, 36.4-46.6) had unprotected intercourse while not trying to conceive.
Why are the unprotected sex numbers so high? “We wonder if some women simply feel that they cannot get pregnant,” Dr. Menke said. “Our group has previously reported that 42% of women who had attempted to conceive prior to bariatric surgery had a history of infertility. Some of these women went on to deliver a live birth, but many did not.”
The study reports that 183 of the 710 women did ultimately conceive and that the number may be as high as 237 because data were missing for 54 women who may have not wanted to report a nonlive birth. Of the women who reported conceiving, 68.9% had live births, 1.1% had stillbirths, 1.1% had ectopic pregnancies, 21.9% miscarried and 7.1% had abortions.
“We’d really like this research to be a reason to consider presurgical contraceptive counseling as one of the steps prior to bariatric surgery,” Dr. Menke said. “This may include a referral by the bariatric surgeon to a physician would who provide counseling, prescribe, or both.”
The study was funded by the National Institute of Diabetes and Digestive and Kidney Diseases. Dr. Menke reported having no relevant disclosures. Her coauthors reported financial relationships with pharmaceutical and medical device companies with products to treat metabolic diseases.
FROM OBSTETRICS & GYNECOLOGY
Key clinical point:
Major finding: In the first year after surgery, 4.3% of women surveyed tried to conceive (95% CI, 2.4-6.3), and another 41.5% had unprotected intercourse (95% CI, 36.4-46.6).
Data source: Prospective cohort study of 710 women, aged 18-44 years, who underwent bariatric surgery for the first time during 2005-2009 at 10 U.S. hospitals.
Disclosures: The study was funded by the National Institute of Diabetes and Digestive and Kidney Diseases. Dr. Menke reported having no relevant disclosures. Her coauthors reported financial relationships with pharmaceutical and medical device companies with products to treat metabolic diseases.
Study: EHR malpractice claims rising
Malpractice claims involving the use of electronic health records (EHRs) are on the rise, according to data from The Doctors Company.
Cases in which EHRs were a factor grew from 2 claims during 2007-2010 to 161 claims from 2011 to December 2016, according an analysis published Oct. 16 by The Doctors Company, a national medical malpractice insurer.
The majority of EHR-related claims during 2014-2016 stemmed from incidents in a doctor’s office or a hospital clinic (35%), while the second most common location was a patient’s room. Malpractice claims involving EHRs were most commonly alleged against ob.gyns, followed by family physicians, and orthopedists. Diagnosis errors and improper medication management were the top most frequent allegations associated with EHR claims.
The analysis shows that while digitization of medicine has improved patient safety, it also has a dark side – as evidenced by the emergence of new kinds of errors, said Robert M. Wachter, MD, a professor at the University of California, San Francisco, and a member of the board of governors for The Doctors Company.
“This study makes an important contribution by chronicling actual errors, such as wrong medications selected from an autopick list, and helps point the way to changes ranging from physician education to EHR software design,” Dr. Wachter said in a statement.
[email protected]
On Twitter @legal_med
Malpractice claims involving the use of electronic health records (EHRs) are on the rise, according to data from The Doctors Company.
Cases in which EHRs were a factor grew from 2 claims during 2007-2010 to 161 claims from 2011 to December 2016, according an analysis published Oct. 16 by The Doctors Company, a national medical malpractice insurer.
The majority of EHR-related claims during 2014-2016 stemmed from incidents in a doctor’s office or a hospital clinic (35%), while the second most common location was a patient’s room. Malpractice claims involving EHRs were most commonly alleged against ob.gyns, followed by family physicians, and orthopedists. Diagnosis errors and improper medication management were the top most frequent allegations associated with EHR claims.
The analysis shows that while digitization of medicine has improved patient safety, it also has a dark side – as evidenced by the emergence of new kinds of errors, said Robert M. Wachter, MD, a professor at the University of California, San Francisco, and a member of the board of governors for The Doctors Company.
“This study makes an important contribution by chronicling actual errors, such as wrong medications selected from an autopick list, and helps point the way to changes ranging from physician education to EHR software design,” Dr. Wachter said in a statement.
[email protected]
On Twitter @legal_med
Malpractice claims involving the use of electronic health records (EHRs) are on the rise, according to data from The Doctors Company.
Cases in which EHRs were a factor grew from 2 claims during 2007-2010 to 161 claims from 2011 to December 2016, according an analysis published Oct. 16 by The Doctors Company, a national medical malpractice insurer.
The majority of EHR-related claims during 2014-2016 stemmed from incidents in a doctor’s office or a hospital clinic (35%), while the second most common location was a patient’s room. Malpractice claims involving EHRs were most commonly alleged against ob.gyns, followed by family physicians, and orthopedists. Diagnosis errors and improper medication management were the top most frequent allegations associated with EHR claims.
The analysis shows that while digitization of medicine has improved patient safety, it also has a dark side – as evidenced by the emergence of new kinds of errors, said Robert M. Wachter, MD, a professor at the University of California, San Francisco, and a member of the board of governors for The Doctors Company.
“This study makes an important contribution by chronicling actual errors, such as wrong medications selected from an autopick list, and helps point the way to changes ranging from physician education to EHR software design,” Dr. Wachter said in a statement.
[email protected]
On Twitter @legal_med
Key clinical point:
Major finding: Cases in which EHRs were a factor grew from 2 claims during 2007-2010 to 161 claims from 2011 to December 2016
Data source: Review of 163 claims from 2007 to 2016 in The Doctors Company database.
Disclosures: The study was funded by The Doctors Company.
Use multimodal analgesia protocols after minimally invasive gynecologic surgery
Minimally invasive gynecologic surgeons can combat the opioid epidemic by devising creative, multimodal approaches to analgesia, according to the authors of an extensive narrative review.
Acetaminophen, NSAIDs, antiepileptics, and local anesthetic incision infiltration all significantly reduce postoperative pain, as does reducing laparoscopic trocar size to less than 10 mm and evacuating pneumoperitoneum at the end of a case, reported Marron Wong, MD, of Newton (Mass.)-Wellesley Hospital and her associates.
“In the midst of the opioid crisis currently affecting the United States, we believe that it is imperative for [minimally invasive gynecologic surgeons] to use these available tools,” Dr. Wong and her associates wrote in the Journal of Minimally Invasive Gynecology.
The experts reviewed studies identified through PubMed, EMBASE, and the Cochrane Database. They focused on randomized controlled trials and highlighted the role of multimodal approaches. “Reasonable evidence” supports the preemptive and postoperative use of NSAIDs and acetaminophen, as well as the preemptive use of gabapentin, pregabalin and dexamethasone, they concluded (J Minim Invasive Gynecol. 2017 Sep 27. doi: 10.1016/j.jmig.2017.09.016).
Preemptive liposomal bupivacaine also is promising, the reviewers said. In a randomized controlled trial, transverse abdominis plane (TAP) infiltration with liposomal bupivacaine was associated with significant and clinically meaningful reductions in pain, morphine use, and postoperative nausea and vomiting, compared with transverse abdominis plane infiltration with regular bupivacaine (Gynecol Oncol. 2015 Sep;138[3]:609-13).
“Local infiltration [also] has been shown to decrease pain as well as opioid intake,” the reviewers wrote. “Pre-closure infiltration has been shown to have more effect than pre-incisional dosing.” Bupivicaine has a longer duration of action (120-240 minutes) than lidocaine (30-60 minutes), which can be extended further by adding epinephrine, they noted.
The adverse effects of alpha-2 agonists (bradycardia and hypotension) and N-methyl-d-aspartate receptor antagonists (vivid dreams, hallucination, emergence confusion) limit their use, the reviewers found.
Another recent systematic review drew similar conclusions, recommending NSAIDs, acetaminophen, anti-epileptics, and dexamethasone for nonopioid pain management in benign minimally invasive hysterectomy (Am J Obstet Gynecol. 2017 Jun;216[6]:557-67). That review found no positive results for local anesthesia, suggesting that the benefits of local anesthesia are limited to minor procedures, Dr. Wong and her associates noted.
The authors reported having no financial disclosures.
Minimally invasive gynecologic surgeons can combat the opioid epidemic by devising creative, multimodal approaches to analgesia, according to the authors of an extensive narrative review.
Acetaminophen, NSAIDs, antiepileptics, and local anesthetic incision infiltration all significantly reduce postoperative pain, as does reducing laparoscopic trocar size to less than 10 mm and evacuating pneumoperitoneum at the end of a case, reported Marron Wong, MD, of Newton (Mass.)-Wellesley Hospital and her associates.
“In the midst of the opioid crisis currently affecting the United States, we believe that it is imperative for [minimally invasive gynecologic surgeons] to use these available tools,” Dr. Wong and her associates wrote in the Journal of Minimally Invasive Gynecology.
The experts reviewed studies identified through PubMed, EMBASE, and the Cochrane Database. They focused on randomized controlled trials and highlighted the role of multimodal approaches. “Reasonable evidence” supports the preemptive and postoperative use of NSAIDs and acetaminophen, as well as the preemptive use of gabapentin, pregabalin and dexamethasone, they concluded (J Minim Invasive Gynecol. 2017 Sep 27. doi: 10.1016/j.jmig.2017.09.016).
Preemptive liposomal bupivacaine also is promising, the reviewers said. In a randomized controlled trial, transverse abdominis plane (TAP) infiltration with liposomal bupivacaine was associated with significant and clinically meaningful reductions in pain, morphine use, and postoperative nausea and vomiting, compared with transverse abdominis plane infiltration with regular bupivacaine (Gynecol Oncol. 2015 Sep;138[3]:609-13).
“Local infiltration [also] has been shown to decrease pain as well as opioid intake,” the reviewers wrote. “Pre-closure infiltration has been shown to have more effect than pre-incisional dosing.” Bupivicaine has a longer duration of action (120-240 minutes) than lidocaine (30-60 minutes), which can be extended further by adding epinephrine, they noted.
The adverse effects of alpha-2 agonists (bradycardia and hypotension) and N-methyl-d-aspartate receptor antagonists (vivid dreams, hallucination, emergence confusion) limit their use, the reviewers found.
Another recent systematic review drew similar conclusions, recommending NSAIDs, acetaminophen, anti-epileptics, and dexamethasone for nonopioid pain management in benign minimally invasive hysterectomy (Am J Obstet Gynecol. 2017 Jun;216[6]:557-67). That review found no positive results for local anesthesia, suggesting that the benefits of local anesthesia are limited to minor procedures, Dr. Wong and her associates noted.
The authors reported having no financial disclosures.
Minimally invasive gynecologic surgeons can combat the opioid epidemic by devising creative, multimodal approaches to analgesia, according to the authors of an extensive narrative review.
Acetaminophen, NSAIDs, antiepileptics, and local anesthetic incision infiltration all significantly reduce postoperative pain, as does reducing laparoscopic trocar size to less than 10 mm and evacuating pneumoperitoneum at the end of a case, reported Marron Wong, MD, of Newton (Mass.)-Wellesley Hospital and her associates.
“In the midst of the opioid crisis currently affecting the United States, we believe that it is imperative for [minimally invasive gynecologic surgeons] to use these available tools,” Dr. Wong and her associates wrote in the Journal of Minimally Invasive Gynecology.
The experts reviewed studies identified through PubMed, EMBASE, and the Cochrane Database. They focused on randomized controlled trials and highlighted the role of multimodal approaches. “Reasonable evidence” supports the preemptive and postoperative use of NSAIDs and acetaminophen, as well as the preemptive use of gabapentin, pregabalin and dexamethasone, they concluded (J Minim Invasive Gynecol. 2017 Sep 27. doi: 10.1016/j.jmig.2017.09.016).
Preemptive liposomal bupivacaine also is promising, the reviewers said. In a randomized controlled trial, transverse abdominis plane (TAP) infiltration with liposomal bupivacaine was associated with significant and clinically meaningful reductions in pain, morphine use, and postoperative nausea and vomiting, compared with transverse abdominis plane infiltration with regular bupivacaine (Gynecol Oncol. 2015 Sep;138[3]:609-13).
“Local infiltration [also] has been shown to decrease pain as well as opioid intake,” the reviewers wrote. “Pre-closure infiltration has been shown to have more effect than pre-incisional dosing.” Bupivicaine has a longer duration of action (120-240 minutes) than lidocaine (30-60 minutes), which can be extended further by adding epinephrine, they noted.
The adverse effects of alpha-2 agonists (bradycardia and hypotension) and N-methyl-d-aspartate receptor antagonists (vivid dreams, hallucination, emergence confusion) limit their use, the reviewers found.
Another recent systematic review drew similar conclusions, recommending NSAIDs, acetaminophen, anti-epileptics, and dexamethasone for nonopioid pain management in benign minimally invasive hysterectomy (Am J Obstet Gynecol. 2017 Jun;216[6]:557-67). That review found no positive results for local anesthesia, suggesting that the benefits of local anesthesia are limited to minor procedures, Dr. Wong and her associates noted.
The authors reported having no financial disclosures.
FROM THE JOURNAL OF MINIMALLY INVASIVE GYNECOLOGY
Key clinical point:
Major finding: Medical options include acetaminophen, NSAIDs, antiepileptics, and local anesthetic incision infiltration. Surgical measures include reducing laparoscopic trocar size to less than 10 mm and evacuating pneumoperitoneum at the end of a case.
Data source: An extensive narrative review, primarily of randomized controlled trials.
Disclosures: The authors reported having no financial disclosures.
Early liver transplant good for patients with severe alcoholic hepatitis
Early liver transplantation was associated with good short-term survival in patients with severe alcoholic hepatitis, but a significant number of patients started consuming alcohol again, according to a study presented at the annual meeting of the American Association for the Study of Liver Diseases.
The study was a retrospective review of the ACCELERATE-AH trial, utilizing a cohort of 147 patients with severe AH who underwent liver transplant prior to a 6-month abstinence period and were discharged home after surgery, said Dr. Brian Lee of the University of California, San Francisco, and his colleagues. Patients also underwent a follow-up period with a median time of 1.6 years.
Pretransplant abstinence time was a median of 55 days, and 54% received steroids for alcoholic hepatitis before the surgery. A total of 141 patients were discharged home after surgery, and 132 survived past 3 months. Of the nine patients who died within 3 months of their liver transplant, eight had received steroid therapy, and five died from sepsis.
No deaths were reported between 3 months and 1 year post transplant, but nine deaths were reported after 1 year, seven of which were alcohol related. The probability of alcohol use after 1 year was 25% and was 34% after 3 years.
After adjustment, a lack of self-admission into a hospital was associated with alcohol usage post transplant, with a hazard ratio of 4.3. In multivariate analysis, any alcohol use post transplant was associated with death, with a hazard ratio of 3.9, Dr. Lee and his colleagues noted.
Dr. Lee, Dr. Mehta, Dr. Platt, Dr. Gurakar, Dr. Im, Dr. Han, Dr. Victor, Dr. Rinella, Dr. Maddur, Dr. Eswaran, Dr. Hause, Dr. Foley, Dr. Dodge, Dr. Li, and Dr. Terrault reported conflicts of interest.
Early liver transplantation was associated with good short-term survival in patients with severe alcoholic hepatitis, but a significant number of patients started consuming alcohol again, according to a study presented at the annual meeting of the American Association for the Study of Liver Diseases.
The study was a retrospective review of the ACCELERATE-AH trial, utilizing a cohort of 147 patients with severe AH who underwent liver transplant prior to a 6-month abstinence period and were discharged home after surgery, said Dr. Brian Lee of the University of California, San Francisco, and his colleagues. Patients also underwent a follow-up period with a median time of 1.6 years.
Pretransplant abstinence time was a median of 55 days, and 54% received steroids for alcoholic hepatitis before the surgery. A total of 141 patients were discharged home after surgery, and 132 survived past 3 months. Of the nine patients who died within 3 months of their liver transplant, eight had received steroid therapy, and five died from sepsis.
No deaths were reported between 3 months and 1 year post transplant, but nine deaths were reported after 1 year, seven of which were alcohol related. The probability of alcohol use after 1 year was 25% and was 34% after 3 years.
After adjustment, a lack of self-admission into a hospital was associated with alcohol usage post transplant, with a hazard ratio of 4.3. In multivariate analysis, any alcohol use post transplant was associated with death, with a hazard ratio of 3.9, Dr. Lee and his colleagues noted.
Dr. Lee, Dr. Mehta, Dr. Platt, Dr. Gurakar, Dr. Im, Dr. Han, Dr. Victor, Dr. Rinella, Dr. Maddur, Dr. Eswaran, Dr. Hause, Dr. Foley, Dr. Dodge, Dr. Li, and Dr. Terrault reported conflicts of interest.
Early liver transplantation was associated with good short-term survival in patients with severe alcoholic hepatitis, but a significant number of patients started consuming alcohol again, according to a study presented at the annual meeting of the American Association for the Study of Liver Diseases.
The study was a retrospective review of the ACCELERATE-AH trial, utilizing a cohort of 147 patients with severe AH who underwent liver transplant prior to a 6-month abstinence period and were discharged home after surgery, said Dr. Brian Lee of the University of California, San Francisco, and his colleagues. Patients also underwent a follow-up period with a median time of 1.6 years.
Pretransplant abstinence time was a median of 55 days, and 54% received steroids for alcoholic hepatitis before the surgery. A total of 141 patients were discharged home after surgery, and 132 survived past 3 months. Of the nine patients who died within 3 months of their liver transplant, eight had received steroid therapy, and five died from sepsis.
No deaths were reported between 3 months and 1 year post transplant, but nine deaths were reported after 1 year, seven of which were alcohol related. The probability of alcohol use after 1 year was 25% and was 34% after 3 years.
After adjustment, a lack of self-admission into a hospital was associated with alcohol usage post transplant, with a hazard ratio of 4.3. In multivariate analysis, any alcohol use post transplant was associated with death, with a hazard ratio of 3.9, Dr. Lee and his colleagues noted.
Dr. Lee, Dr. Mehta, Dr. Platt, Dr. Gurakar, Dr. Im, Dr. Han, Dr. Victor, Dr. Rinella, Dr. Maddur, Dr. Eswaran, Dr. Hause, Dr. Foley, Dr. Dodge, Dr. Li, and Dr. Terrault reported conflicts of interest.
FROM THE LIVER MEETING 2017
Key clinical point:
Major finding: The survival rate post transplant was 94% after 1 year.
Data source: A retrospective review from the ACCELERATE-AH trial of 147 alcoholic hepatitis patients who received liver transplants.
Disclosures: Dr. Lee, Dr. Mehta, Dr. Platt, Dr. Gurakar, Dr. Im, Dr. Han, Dr. Victor, Dr. Rinella, Dr. Maddur, Dr. Eswaran, Dr. Hause, Dr. Foley, Dr. Dodge, Dr. Li, and Dr. Terrault reported conflicts of interest.
Asians have highest rate of herbal dietary supplement DILI liver transplantations
There is a significant relationship between race/ethnicity and drug-induced liver disease requiring liver transplantation caused by herbal and dietary supplements (HDS), according to a study presented at the annual meeting of the American Association for the Study of Liver Diseases.
Asian people had significantly higher rates of HDS DILI that required transplant than did blacks, Hispanics, whites, and others (American Indian/Alaskan native, multiracial, and native Hawaii/Pacific Islander). White people had significantly lower rates of HDS DILI than did blacks, Hispanics, and others.
While the proportion of white people with HDS DILI requiring transplant was much lower than other races/ethnicities, the rate from 2005 to 2015 was significantly higher in this population than in 1995-2005, Dr. Kesar and his colleagues noted.
Dr. Odin is a member of Intercept Pharmaceuticals advisory committees or review panels and is an AASLD member. Dr. Ahmad is an AASLD member.
There is a significant relationship between race/ethnicity and drug-induced liver disease requiring liver transplantation caused by herbal and dietary supplements (HDS), according to a study presented at the annual meeting of the American Association for the Study of Liver Diseases.
Asian people had significantly higher rates of HDS DILI that required transplant than did blacks, Hispanics, whites, and others (American Indian/Alaskan native, multiracial, and native Hawaii/Pacific Islander). White people had significantly lower rates of HDS DILI than did blacks, Hispanics, and others.
While the proportion of white people with HDS DILI requiring transplant was much lower than other races/ethnicities, the rate from 2005 to 2015 was significantly higher in this population than in 1995-2005, Dr. Kesar and his colleagues noted.
Dr. Odin is a member of Intercept Pharmaceuticals advisory committees or review panels and is an AASLD member. Dr. Ahmad is an AASLD member.
There is a significant relationship between race/ethnicity and drug-induced liver disease requiring liver transplantation caused by herbal and dietary supplements (HDS), according to a study presented at the annual meeting of the American Association for the Study of Liver Diseases.
Asian people had significantly higher rates of HDS DILI that required transplant than did blacks, Hispanics, whites, and others (American Indian/Alaskan native, multiracial, and native Hawaii/Pacific Islander). White people had significantly lower rates of HDS DILI than did blacks, Hispanics, and others.
While the proportion of white people with HDS DILI requiring transplant was much lower than other races/ethnicities, the rate from 2005 to 2015 was significantly higher in this population than in 1995-2005, Dr. Kesar and his colleagues noted.
Dr. Odin is a member of Intercept Pharmaceuticals advisory committees or review panels and is an AASLD member. Dr. Ahmad is an AASLD member.
FROM THE LIVER MEETING 2017
Key clinical point:
Major finding: People of Asian descent were most likely to require transplantation because of drug-induced liver injury from herbal dietary supplements.
Data source: Retrospective data analysis of 645 patients from the Organ Procurement and Transplantation Network database.
Disclosures: Dr. Odin is a member of Intercept Pharmaceuticals advisory committees or review panels and is an AASLD member. Dr. Ahmad is an AASLD member.
VIDEO: Measuring, treating brain hypoxia looks promising for TBI
SAN DIEGO – It’s been possible for over 15 years for neurointensivists to measure the partial pressure of oxygen in the brain of patients following traumatic brain injury.
But the technology has not been widely adopted because there have been no high-quality data showing that it’s useful. As a result, in most hospitals, TBI treatment is guided mostly by intracranial pressure.
The evidence gap is being filled. In a recent phase 2 trial, there was a trend towards benefit when treatment was guided by both intracranial pressure and the brain oxygenation (Crit Care Med. 2017 Nov;45[11]:1907-14). The study was powered for nonfutility, not clinically meaningful change, but the National Institute of Neurological Disorders and Stroke has recently funded a 45-site, phase 3 trial that will definitively answer whether treatment protocols informed by both pressure and oxygen improve neurologic outcomes, said principal investigator Ramon Diaz-Arrastia, MD, PhD, a professor of neurology at the University of Pennsylvania, Philadelphia.
In an interview at the annual meeting of the American Neurological Association, he explained the work, and exactly how paying attention to brain oxygen levels changed treatment in the phase 2 study. It didn’t take anything unusual to maintain oxygen partial pressure above 20 mm Hg.
The video associated with this article is no longer available on this site. Please view all of our videos on the MDedge YouTube channel
SAN DIEGO – It’s been possible for over 15 years for neurointensivists to measure the partial pressure of oxygen in the brain of patients following traumatic brain injury.
But the technology has not been widely adopted because there have been no high-quality data showing that it’s useful. As a result, in most hospitals, TBI treatment is guided mostly by intracranial pressure.
The evidence gap is being filled. In a recent phase 2 trial, there was a trend towards benefit when treatment was guided by both intracranial pressure and the brain oxygenation (Crit Care Med. 2017 Nov;45[11]:1907-14). The study was powered for nonfutility, not clinically meaningful change, but the National Institute of Neurological Disorders and Stroke has recently funded a 45-site, phase 3 trial that will definitively answer whether treatment protocols informed by both pressure and oxygen improve neurologic outcomes, said principal investigator Ramon Diaz-Arrastia, MD, PhD, a professor of neurology at the University of Pennsylvania, Philadelphia.
In an interview at the annual meeting of the American Neurological Association, he explained the work, and exactly how paying attention to brain oxygen levels changed treatment in the phase 2 study. It didn’t take anything unusual to maintain oxygen partial pressure above 20 mm Hg.
The video associated with this article is no longer available on this site. Please view all of our videos on the MDedge YouTube channel
SAN DIEGO – It’s been possible for over 15 years for neurointensivists to measure the partial pressure of oxygen in the brain of patients following traumatic brain injury.
But the technology has not been widely adopted because there have been no high-quality data showing that it’s useful. As a result, in most hospitals, TBI treatment is guided mostly by intracranial pressure.
The evidence gap is being filled. In a recent phase 2 trial, there was a trend towards benefit when treatment was guided by both intracranial pressure and the brain oxygenation (Crit Care Med. 2017 Nov;45[11]:1907-14). The study was powered for nonfutility, not clinically meaningful change, but the National Institute of Neurological Disorders and Stroke has recently funded a 45-site, phase 3 trial that will definitively answer whether treatment protocols informed by both pressure and oxygen improve neurologic outcomes, said principal investigator Ramon Diaz-Arrastia, MD, PhD, a professor of neurology at the University of Pennsylvania, Philadelphia.
In an interview at the annual meeting of the American Neurological Association, he explained the work, and exactly how paying attention to brain oxygen levels changed treatment in the phase 2 study. It didn’t take anything unusual to maintain oxygen partial pressure above 20 mm Hg.
The video associated with this article is no longer available on this site. Please view all of our videos on the MDedge YouTube channel
AT ANA 2017
From the Washington Office: Lessons learned from a faithful reader – A tribute to Daniel M. Caruso, MD, FACS
One of the most difficult and unpleasant aspects of being middle-aged is beginning to experience the loss of friends and colleagues who have had a profound impact on one’s life. Those who have been, or continue to be, associated with the department of surgery of Maricopa Medical Center in Phoenix recently experienced such a loss with the passing of Daniel M. Caruso, MD, FACS, after a very determined and utterly courageous battle with cancer.
I first came to know Dan 9 years ago when Maricopa Medical Center’s need for a pediatric surgeon and my desire for a different practice situation in the Phoenix area converged, resulting in my becoming a member of his faculty. As my chairman and my friend, Dan had a significant positive impact on me, and though he was chronologically several years my junior, he taught and reinforced life lessons that I will forever carry forward. He was also a faithful reader of this column, and whenever I saw him in Arizona, he always had a kind word about my monthly efforts presented here.
Perhaps Dan’s most admirable trait was his loyalty. He was fiercely loyal to me, his other faculty, the staff of the Arizona Burn Center, and his resident trainees. In turn, he instilled in all around him a profound sense of loyalty to both himself and our department. Nothing exemplifies this better than the “leave no stone unturned” care he received from current faculty, hospital staff, and his former trainees over the last months of his life. In short, he was the leader of his pack.
Dan’s loyalty was not of the “fair weather” sort; it prevailed even in the face of potential adverse circumstances that promised to actually cause him more grief. Nor was his loyalty blind and without limits, as all who were ever in contentious conversation with him have likely been reminded, “I am Sicilian. Don’t put a gun to my head.” That said, his loyalty was, like everything else about him, appropriately measured and extraordinarily genuine, providing for all of us an example toward which to strive.
Being measured in all one’s responses to the adversity presented by others is another valuable lesson Dan taught me. I can only imagine the headaches, anxiety, and stress of being the chair of a department largely made up of “passionate” mid-career surgeons during tumultuous times of continuous change. Despite the fact that many of us frequently urged him to be more forceful, just say “no,” or otherwise flex his or our collective muscle, Dan was forever the calm voice in the storm, reacting in a measured way that was much more reminiscent of honey than vinegar. Dan provided indisputable evidence that your grandmother was correct when she told you that you will catch more flies that way.
Nowhere were these qualities more preeminently displayed than in the administration of the surgical residency program at Maricopa. As is common to most academically affiliated, community-based surgery programs, much of our collective identity as a department was cloaked in the residency program and our trainees. Being a product of the program himself, Dan was the consummate “keeper of the flame.” He was also a superb judge of character and surgical aptitude and the unsurpassed prophet of future success. He was a passionate advocate for those residents in whom he saw promise even when his view was aggressively challenged by others in the department who felt otherwise.
In the case of residents whose flaws in the form of either “expressions of youth” or academic performance caused some faculty to have a negative opinion, Dan remained singularly focused on what he saw as their future potential. He not only protected them, but also saw to it that they were provided every resource available to succeed. He ensured that all trainees who met his muster by working hard and taking excellent care of the patients were given every opportunity to succeed. When appropriate and necessary, his profound insight into others’ talents combined with his compassionate demeanor made him particularly well suited to make suggestions, to the very few, that they might be happier and more successful in a specialty other than surgery. In sum, he had an unsurpassed passion for training the next generation of surgeons, paying it forward into the future as he went.
Dan had both a profound sense of justice and a keen political sense about how and when to strategically best use his position and influence to ensure fairness of outcomes. Amongst his faculty, he was particularly adept at discerning whose talents were best suited to specific tasks and thus, whom he should assign to ensure the optimal outcome for the department, our trainees, and our patients. When once I met with him to express my profound concerns relative to how members of our department were being treated by a certain hospital committee, his response was to act swiftly to ensure that I was appointed to that committee. By doing so, he showed that he trusted my judgment to look out for the interests of our department whilst simultaneously resolving my own concerns. He also gently reinforced the valuable life lesson of not going to your boss only with a problem. Take along that potential solution as well.
As I look forward to Clinical Congress and seeing familiar faces from the “Copa,” past and present, I anticipate many firm handshakes and warm embraces as well as a few tears shed in shared grief. Plain and simple, Dan was the consummate critical care/burn surgeon, a passionate surgical educator, and overall, epitomized the phrase, “great guy.” Our world is a far better place because of his 53 years of labor in the fields of this life.
Somewhere, a red Ferrari with a Detroit Lions license plate is humming down a flat stretch of highway at a clearly excessive rate of speed with Bob Seger blasting from the stereo ...
Well done, my friend. Very well done.
Until next month …
Dr. Bailey is a pediatric surgeon and Medical Director, Advocacy, for the Division of Advocacy and Health Policy in the ACS offices in Washington, DC.
One of the most difficult and unpleasant aspects of being middle-aged is beginning to experience the loss of friends and colleagues who have had a profound impact on one’s life. Those who have been, or continue to be, associated with the department of surgery of Maricopa Medical Center in Phoenix recently experienced such a loss with the passing of Daniel M. Caruso, MD, FACS, after a very determined and utterly courageous battle with cancer.
I first came to know Dan 9 years ago when Maricopa Medical Center’s need for a pediatric surgeon and my desire for a different practice situation in the Phoenix area converged, resulting in my becoming a member of his faculty. As my chairman and my friend, Dan had a significant positive impact on me, and though he was chronologically several years my junior, he taught and reinforced life lessons that I will forever carry forward. He was also a faithful reader of this column, and whenever I saw him in Arizona, he always had a kind word about my monthly efforts presented here.
Perhaps Dan’s most admirable trait was his loyalty. He was fiercely loyal to me, his other faculty, the staff of the Arizona Burn Center, and his resident trainees. In turn, he instilled in all around him a profound sense of loyalty to both himself and our department. Nothing exemplifies this better than the “leave no stone unturned” care he received from current faculty, hospital staff, and his former trainees over the last months of his life. In short, he was the leader of his pack.
Dan’s loyalty was not of the “fair weather” sort; it prevailed even in the face of potential adverse circumstances that promised to actually cause him more grief. Nor was his loyalty blind and without limits, as all who were ever in contentious conversation with him have likely been reminded, “I am Sicilian. Don’t put a gun to my head.” That said, his loyalty was, like everything else about him, appropriately measured and extraordinarily genuine, providing for all of us an example toward which to strive.
Being measured in all one’s responses to the adversity presented by others is another valuable lesson Dan taught me. I can only imagine the headaches, anxiety, and stress of being the chair of a department largely made up of “passionate” mid-career surgeons during tumultuous times of continuous change. Despite the fact that many of us frequently urged him to be more forceful, just say “no,” or otherwise flex his or our collective muscle, Dan was forever the calm voice in the storm, reacting in a measured way that was much more reminiscent of honey than vinegar. Dan provided indisputable evidence that your grandmother was correct when she told you that you will catch more flies that way.
Nowhere were these qualities more preeminently displayed than in the administration of the surgical residency program at Maricopa. As is common to most academically affiliated, community-based surgery programs, much of our collective identity as a department was cloaked in the residency program and our trainees. Being a product of the program himself, Dan was the consummate “keeper of the flame.” He was also a superb judge of character and surgical aptitude and the unsurpassed prophet of future success. He was a passionate advocate for those residents in whom he saw promise even when his view was aggressively challenged by others in the department who felt otherwise.
In the case of residents whose flaws in the form of either “expressions of youth” or academic performance caused some faculty to have a negative opinion, Dan remained singularly focused on what he saw as their future potential. He not only protected them, but also saw to it that they were provided every resource available to succeed. He ensured that all trainees who met his muster by working hard and taking excellent care of the patients were given every opportunity to succeed. When appropriate and necessary, his profound insight into others’ talents combined with his compassionate demeanor made him particularly well suited to make suggestions, to the very few, that they might be happier and more successful in a specialty other than surgery. In sum, he had an unsurpassed passion for training the next generation of surgeons, paying it forward into the future as he went.
Dan had both a profound sense of justice and a keen political sense about how and when to strategically best use his position and influence to ensure fairness of outcomes. Amongst his faculty, he was particularly adept at discerning whose talents were best suited to specific tasks and thus, whom he should assign to ensure the optimal outcome for the department, our trainees, and our patients. When once I met with him to express my profound concerns relative to how members of our department were being treated by a certain hospital committee, his response was to act swiftly to ensure that I was appointed to that committee. By doing so, he showed that he trusted my judgment to look out for the interests of our department whilst simultaneously resolving my own concerns. He also gently reinforced the valuable life lesson of not going to your boss only with a problem. Take along that potential solution as well.
As I look forward to Clinical Congress and seeing familiar faces from the “Copa,” past and present, I anticipate many firm handshakes and warm embraces as well as a few tears shed in shared grief. Plain and simple, Dan was the consummate critical care/burn surgeon, a passionate surgical educator, and overall, epitomized the phrase, “great guy.” Our world is a far better place because of his 53 years of labor in the fields of this life.
Somewhere, a red Ferrari with a Detroit Lions license plate is humming down a flat stretch of highway at a clearly excessive rate of speed with Bob Seger blasting from the stereo ...
Well done, my friend. Very well done.
Until next month …
Dr. Bailey is a pediatric surgeon and Medical Director, Advocacy, for the Division of Advocacy and Health Policy in the ACS offices in Washington, DC.
One of the most difficult and unpleasant aspects of being middle-aged is beginning to experience the loss of friends and colleagues who have had a profound impact on one’s life. Those who have been, or continue to be, associated with the department of surgery of Maricopa Medical Center in Phoenix recently experienced such a loss with the passing of Daniel M. Caruso, MD, FACS, after a very determined and utterly courageous battle with cancer.
I first came to know Dan 9 years ago when Maricopa Medical Center’s need for a pediatric surgeon and my desire for a different practice situation in the Phoenix area converged, resulting in my becoming a member of his faculty. As my chairman and my friend, Dan had a significant positive impact on me, and though he was chronologically several years my junior, he taught and reinforced life lessons that I will forever carry forward. He was also a faithful reader of this column, and whenever I saw him in Arizona, he always had a kind word about my monthly efforts presented here.
Perhaps Dan’s most admirable trait was his loyalty. He was fiercely loyal to me, his other faculty, the staff of the Arizona Burn Center, and his resident trainees. In turn, he instilled in all around him a profound sense of loyalty to both himself and our department. Nothing exemplifies this better than the “leave no stone unturned” care he received from current faculty, hospital staff, and his former trainees over the last months of his life. In short, he was the leader of his pack.
Dan’s loyalty was not of the “fair weather” sort; it prevailed even in the face of potential adverse circumstances that promised to actually cause him more grief. Nor was his loyalty blind and without limits, as all who were ever in contentious conversation with him have likely been reminded, “I am Sicilian. Don’t put a gun to my head.” That said, his loyalty was, like everything else about him, appropriately measured and extraordinarily genuine, providing for all of us an example toward which to strive.
Being measured in all one’s responses to the adversity presented by others is another valuable lesson Dan taught me. I can only imagine the headaches, anxiety, and stress of being the chair of a department largely made up of “passionate” mid-career surgeons during tumultuous times of continuous change. Despite the fact that many of us frequently urged him to be more forceful, just say “no,” or otherwise flex his or our collective muscle, Dan was forever the calm voice in the storm, reacting in a measured way that was much more reminiscent of honey than vinegar. Dan provided indisputable evidence that your grandmother was correct when she told you that you will catch more flies that way.
Nowhere were these qualities more preeminently displayed than in the administration of the surgical residency program at Maricopa. As is common to most academically affiliated, community-based surgery programs, much of our collective identity as a department was cloaked in the residency program and our trainees. Being a product of the program himself, Dan was the consummate “keeper of the flame.” He was also a superb judge of character and surgical aptitude and the unsurpassed prophet of future success. He was a passionate advocate for those residents in whom he saw promise even when his view was aggressively challenged by others in the department who felt otherwise.
In the case of residents whose flaws in the form of either “expressions of youth” or academic performance caused some faculty to have a negative opinion, Dan remained singularly focused on what he saw as their future potential. He not only protected them, but also saw to it that they were provided every resource available to succeed. He ensured that all trainees who met his muster by working hard and taking excellent care of the patients were given every opportunity to succeed. When appropriate and necessary, his profound insight into others’ talents combined with his compassionate demeanor made him particularly well suited to make suggestions, to the very few, that they might be happier and more successful in a specialty other than surgery. In sum, he had an unsurpassed passion for training the next generation of surgeons, paying it forward into the future as he went.
Dan had both a profound sense of justice and a keen political sense about how and when to strategically best use his position and influence to ensure fairness of outcomes. Amongst his faculty, he was particularly adept at discerning whose talents were best suited to specific tasks and thus, whom he should assign to ensure the optimal outcome for the department, our trainees, and our patients. When once I met with him to express my profound concerns relative to how members of our department were being treated by a certain hospital committee, his response was to act swiftly to ensure that I was appointed to that committee. By doing so, he showed that he trusted my judgment to look out for the interests of our department whilst simultaneously resolving my own concerns. He also gently reinforced the valuable life lesson of not going to your boss only with a problem. Take along that potential solution as well.
As I look forward to Clinical Congress and seeing familiar faces from the “Copa,” past and present, I anticipate many firm handshakes and warm embraces as well as a few tears shed in shared grief. Plain and simple, Dan was the consummate critical care/burn surgeon, a passionate surgical educator, and overall, epitomized the phrase, “great guy.” Our world is a far better place because of his 53 years of labor in the fields of this life.
Somewhere, a red Ferrari with a Detroit Lions license plate is humming down a flat stretch of highway at a clearly excessive rate of speed with Bob Seger blasting from the stereo ...
Well done, my friend. Very well done.
Until next month …
Dr. Bailey is a pediatric surgeon and Medical Director, Advocacy, for the Division of Advocacy and Health Policy in the ACS offices in Washington, DC.
The opioid epidemic, surgeons, and palliative care
Recent public and professional attention to what is now called the opioid epidemic has obvious implications for surgery and palliative care. Because of the status of “epidemic,” there is a sense of urgency within the surgical and palliative care community to reevaluate the assessment and treatment of patients for whom opioid therapy is being considered.
Although the liberal use of opioids is a common stereotype of palliative care, the use of opioids in the palliative care setting is part of a complex assessment and treatment process. Opioid use in this setting is analogous to palliative surgery in the surgical palliative care setting: It is one tool, and it is most effective and safe when based on an assessment of the more general picture. A fundamental concept of palliative care, “total pain,” provides a basis for improved pain management that goes far beyond the use and dependency on opioid therapy. Dame Cicely Saunders, who was mentored by a surgeon and later became a Fellow of the Royal College of Surgeons, defined the concept of total pain as the suffering that encompasses all of a person’s physical, psychological, social, spiritual, and practical struggles (BMJ. 2005 Jul 23;331[7510]:238). Blake Cady, a preeminent surgeon and surgical educator, once wrote that the day-to-day decisions in surgery are best made in the context of a surgical philosophy of care (J Am Coll Surg. 2005 Feb;200[2]:285-90). This applies to all interventions. Total-pain assessment provides us the opportunity to identify nonphysical factors associated with pain that might not indicate opioid use or even contraindicate their use. Existential distress or spiritual pain in a delirious or underassessed patient can be indistinguishable from physical distress. Socioeconomic factors, such as an inability to pay for medical care, can present as pain.
Surgeons are uniquely positioned as “listening posts” in the overall campaign to curb opioid misuse. They can identify patients at risk for or diagnosed with substance use disorder so they can be managed or referred for specialist treatment appropriately.
Awareness of other dimensions of pain will enhance their efficacy in this role.
Opioid sparing is a key tactic in the strategy for controlling opioid use and minimizing opioid-induced side effects. Occasionally surgical or interventional radiologic procedures are useful for this purpose.
There are immediate, specific actions surgeons can take in order to constructively participate in opioid use reform:
- Expand your patient’s pain history to include nonphysical dimensions of pain and refer appropriately.
- Know your opioids; carry an opioid conversion table. Errors in opioid conversion can result in significant undertreatment of pain but can result in overdosage just as easily.
- Know your pharmacist. Pharmacists are valuable allies in safe opioid prescribing and monitoring practices.
- Be wary of “standardized” order sets that include opioids. There is no standard dose or standard patient as we are rapidly learning from genomics.
- Utilize your state’s patient drug-monitoring program – a new pain for clinicians, but some headaches are worth it. It clearly has already put the brakes on opioid prescribing.
Given the recent public and professional attention to the problems of opioid misuse, there is a long-overdue opportunity to reassess not only the indications and management of opioid therapy but also our more general approach to the management of pain. There is now an opportunity for surgeons to play a major role in improving opioid-prescribing practice. One potentially successful approach could be better assessment and management of pain through an awareness and application of palliative care principles. Like all encounters with uncertainty, the best way out of the current opioid dilemma is the way through: Surgeons should not abandon opioids but – in conjunction with nurses, palliative care practitioners, pharmacists, and pain and anesthesia specialists – reinvent their role in the war on suffering.
Dr. Dunn is the medical director of the palliative care consultation service at the University of Pittsburgh Medical Center Hamot in Erie, Pa., and vice chair of the ACS Committee on Surgical Palliative Care.
Recent public and professional attention to what is now called the opioid epidemic has obvious implications for surgery and palliative care. Because of the status of “epidemic,” there is a sense of urgency within the surgical and palliative care community to reevaluate the assessment and treatment of patients for whom opioid therapy is being considered.
Although the liberal use of opioids is a common stereotype of palliative care, the use of opioids in the palliative care setting is part of a complex assessment and treatment process. Opioid use in this setting is analogous to palliative surgery in the surgical palliative care setting: It is one tool, and it is most effective and safe when based on an assessment of the more general picture. A fundamental concept of palliative care, “total pain,” provides a basis for improved pain management that goes far beyond the use and dependency on opioid therapy. Dame Cicely Saunders, who was mentored by a surgeon and later became a Fellow of the Royal College of Surgeons, defined the concept of total pain as the suffering that encompasses all of a person’s physical, psychological, social, spiritual, and practical struggles (BMJ. 2005 Jul 23;331[7510]:238). Blake Cady, a preeminent surgeon and surgical educator, once wrote that the day-to-day decisions in surgery are best made in the context of a surgical philosophy of care (J Am Coll Surg. 2005 Feb;200[2]:285-90). This applies to all interventions. Total-pain assessment provides us the opportunity to identify nonphysical factors associated with pain that might not indicate opioid use or even contraindicate their use. Existential distress or spiritual pain in a delirious or underassessed patient can be indistinguishable from physical distress. Socioeconomic factors, such as an inability to pay for medical care, can present as pain.
Surgeons are uniquely positioned as “listening posts” in the overall campaign to curb opioid misuse. They can identify patients at risk for or diagnosed with substance use disorder so they can be managed or referred for specialist treatment appropriately.
Awareness of other dimensions of pain will enhance their efficacy in this role.
Opioid sparing is a key tactic in the strategy for controlling opioid use and minimizing opioid-induced side effects. Occasionally surgical or interventional radiologic procedures are useful for this purpose.
There are immediate, specific actions surgeons can take in order to constructively participate in opioid use reform:
- Expand your patient’s pain history to include nonphysical dimensions of pain and refer appropriately.
- Know your opioids; carry an opioid conversion table. Errors in opioid conversion can result in significant undertreatment of pain but can result in overdosage just as easily.
- Know your pharmacist. Pharmacists are valuable allies in safe opioid prescribing and monitoring practices.
- Be wary of “standardized” order sets that include opioids. There is no standard dose or standard patient as we are rapidly learning from genomics.
- Utilize your state’s patient drug-monitoring program – a new pain for clinicians, but some headaches are worth it. It clearly has already put the brakes on opioid prescribing.
Given the recent public and professional attention to the problems of opioid misuse, there is a long-overdue opportunity to reassess not only the indications and management of opioid therapy but also our more general approach to the management of pain. There is now an opportunity for surgeons to play a major role in improving opioid-prescribing practice. One potentially successful approach could be better assessment and management of pain through an awareness and application of palliative care principles. Like all encounters with uncertainty, the best way out of the current opioid dilemma is the way through: Surgeons should not abandon opioids but – in conjunction with nurses, palliative care practitioners, pharmacists, and pain and anesthesia specialists – reinvent their role in the war on suffering.
Dr. Dunn is the medical director of the palliative care consultation service at the University of Pittsburgh Medical Center Hamot in Erie, Pa., and vice chair of the ACS Committee on Surgical Palliative Care.
Recent public and professional attention to what is now called the opioid epidemic has obvious implications for surgery and palliative care. Because of the status of “epidemic,” there is a sense of urgency within the surgical and palliative care community to reevaluate the assessment and treatment of patients for whom opioid therapy is being considered.
Although the liberal use of opioids is a common stereotype of palliative care, the use of opioids in the palliative care setting is part of a complex assessment and treatment process. Opioid use in this setting is analogous to palliative surgery in the surgical palliative care setting: It is one tool, and it is most effective and safe when based on an assessment of the more general picture. A fundamental concept of palliative care, “total pain,” provides a basis for improved pain management that goes far beyond the use and dependency on opioid therapy. Dame Cicely Saunders, who was mentored by a surgeon and later became a Fellow of the Royal College of Surgeons, defined the concept of total pain as the suffering that encompasses all of a person’s physical, psychological, social, spiritual, and practical struggles (BMJ. 2005 Jul 23;331[7510]:238). Blake Cady, a preeminent surgeon and surgical educator, once wrote that the day-to-day decisions in surgery are best made in the context of a surgical philosophy of care (J Am Coll Surg. 2005 Feb;200[2]:285-90). This applies to all interventions. Total-pain assessment provides us the opportunity to identify nonphysical factors associated with pain that might not indicate opioid use or even contraindicate their use. Existential distress or spiritual pain in a delirious or underassessed patient can be indistinguishable from physical distress. Socioeconomic factors, such as an inability to pay for medical care, can present as pain.
Surgeons are uniquely positioned as “listening posts” in the overall campaign to curb opioid misuse. They can identify patients at risk for or diagnosed with substance use disorder so they can be managed or referred for specialist treatment appropriately.
Awareness of other dimensions of pain will enhance their efficacy in this role.
Opioid sparing is a key tactic in the strategy for controlling opioid use and minimizing opioid-induced side effects. Occasionally surgical or interventional radiologic procedures are useful for this purpose.
There are immediate, specific actions surgeons can take in order to constructively participate in opioid use reform:
- Expand your patient’s pain history to include nonphysical dimensions of pain and refer appropriately.
- Know your opioids; carry an opioid conversion table. Errors in opioid conversion can result in significant undertreatment of pain but can result in overdosage just as easily.
- Know your pharmacist. Pharmacists are valuable allies in safe opioid prescribing and monitoring practices.
- Be wary of “standardized” order sets that include opioids. There is no standard dose or standard patient as we are rapidly learning from genomics.
- Utilize your state’s patient drug-monitoring program – a new pain for clinicians, but some headaches are worth it. It clearly has already put the brakes on opioid prescribing.
Given the recent public and professional attention to the problems of opioid misuse, there is a long-overdue opportunity to reassess not only the indications and management of opioid therapy but also our more general approach to the management of pain. There is now an opportunity for surgeons to play a major role in improving opioid-prescribing practice. One potentially successful approach could be better assessment and management of pain through an awareness and application of palliative care principles. Like all encounters with uncertainty, the best way out of the current opioid dilemma is the way through: Surgeons should not abandon opioids but – in conjunction with nurses, palliative care practitioners, pharmacists, and pain and anesthesia specialists – reinvent their role in the war on suffering.
Dr. Dunn is the medical director of the palliative care consultation service at the University of Pittsburgh Medical Center Hamot in Erie, Pa., and vice chair of the ACS Committee on Surgical Palliative Care.
Inaugural ACS Quality and Safety Conference: Achieving quality across the continuum of care
Approximately 1,900 individuals who contribute to hospital quality improvement (QI) programs attended the inaugural American College of Surgeons (ACS) Quality and Safety Conference, July 21−24 at the New York Hilton Midtown, NY. The rapid growth of ACS Quality Programs in recent years prompted the expansion of the College’s Annual National Surgical Quality Improvement Program (ACS NSQIP®) Conference to include a more comprehensive look at not only ACS NSQIP Adult and Pediatric, but also the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP®), the Children’s Surgery Verification (CSV) Quality Improvement Program, and the Surgeon Specific Registry (SSR).
In addition to providing details about the work of the aforementioned ACS Quality Programs, the conference also covered included discussion of the new ACS quality manual, the reconstructed SSR, and programs for improving surgical recovery and outcomes for geriatric surgery patients. The quality manual, Optimal Resources for Surgical Quality and Safety, was provided to all conference attendees and is intended to serve as a resource for surgical leaders seeking to improve patient care in their institutions, departments, and practices.
David B. Hoyt, ACS Executive Director, spoke about the SSR, explaining how it will be part of of the “registry of the future,” allowing users to eventually incorporate relevant data across individual ACS Quality Programs. Also discussed were the Agency for Healthcare Research and Quality Safety Program for Improving Surgical Care and Recovery and the Coalition for Quality in Geriatric Surgery, supported by the John A. Hartford Foundation—programs that seek to set standards and improve outcomes in surgical patients.
The Keynote Address was provided by Blake Haxton, JD, who lost both of his legs to necrotizing fasciitis. Mr. Haxton described his journey from going to the local hospital’s emergency department with debilitating swelling and redness in his right leg to reclaiming his identity, and how he learned that “essential worth is intrinsic and unearned.”
Speakers at the conference addressed a number of hot issues in health care, including health policy, opioid abuse, patient-reported outcomes (PROs), and disparities in care.
A topic of considerable interest was how important culture change is for any sustained QI effort. For any QI effort to succeed it has to evolve in a culture that accepts change, acknowledges shortcomings, uses data to find strengths and weaknesses, and demonstrates resilience. Two cultural changes that surgical teams have experienced in recent years include a greater emphasis on process improvement and checklists.
To read a more detailed account of the topics covered at the conference, read the October Bulletin at URL TO COME. The 2018 ACS Quality and Safety Conference will be held July 21–24 in Orlando, FL.
Approximately 1,900 individuals who contribute to hospital quality improvement (QI) programs attended the inaugural American College of Surgeons (ACS) Quality and Safety Conference, July 21−24 at the New York Hilton Midtown, NY. The rapid growth of ACS Quality Programs in recent years prompted the expansion of the College’s Annual National Surgical Quality Improvement Program (ACS NSQIP®) Conference to include a more comprehensive look at not only ACS NSQIP Adult and Pediatric, but also the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP®), the Children’s Surgery Verification (CSV) Quality Improvement Program, and the Surgeon Specific Registry (SSR).
In addition to providing details about the work of the aforementioned ACS Quality Programs, the conference also covered included discussion of the new ACS quality manual, the reconstructed SSR, and programs for improving surgical recovery and outcomes for geriatric surgery patients. The quality manual, Optimal Resources for Surgical Quality and Safety, was provided to all conference attendees and is intended to serve as a resource for surgical leaders seeking to improve patient care in their institutions, departments, and practices.
David B. Hoyt, ACS Executive Director, spoke about the SSR, explaining how it will be part of of the “registry of the future,” allowing users to eventually incorporate relevant data across individual ACS Quality Programs. Also discussed were the Agency for Healthcare Research and Quality Safety Program for Improving Surgical Care and Recovery and the Coalition for Quality in Geriatric Surgery, supported by the John A. Hartford Foundation—programs that seek to set standards and improve outcomes in surgical patients.
The Keynote Address was provided by Blake Haxton, JD, who lost both of his legs to necrotizing fasciitis. Mr. Haxton described his journey from going to the local hospital’s emergency department with debilitating swelling and redness in his right leg to reclaiming his identity, and how he learned that “essential worth is intrinsic and unearned.”
Speakers at the conference addressed a number of hot issues in health care, including health policy, opioid abuse, patient-reported outcomes (PROs), and disparities in care.
A topic of considerable interest was how important culture change is for any sustained QI effort. For any QI effort to succeed it has to evolve in a culture that accepts change, acknowledges shortcomings, uses data to find strengths and weaknesses, and demonstrates resilience. Two cultural changes that surgical teams have experienced in recent years include a greater emphasis on process improvement and checklists.
To read a more detailed account of the topics covered at the conference, read the October Bulletin at URL TO COME. The 2018 ACS Quality and Safety Conference will be held July 21–24 in Orlando, FL.
Approximately 1,900 individuals who contribute to hospital quality improvement (QI) programs attended the inaugural American College of Surgeons (ACS) Quality and Safety Conference, July 21−24 at the New York Hilton Midtown, NY. The rapid growth of ACS Quality Programs in recent years prompted the expansion of the College’s Annual National Surgical Quality Improvement Program (ACS NSQIP®) Conference to include a more comprehensive look at not only ACS NSQIP Adult and Pediatric, but also the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP®), the Children’s Surgery Verification (CSV) Quality Improvement Program, and the Surgeon Specific Registry (SSR).
In addition to providing details about the work of the aforementioned ACS Quality Programs, the conference also covered included discussion of the new ACS quality manual, the reconstructed SSR, and programs for improving surgical recovery and outcomes for geriatric surgery patients. The quality manual, Optimal Resources for Surgical Quality and Safety, was provided to all conference attendees and is intended to serve as a resource for surgical leaders seeking to improve patient care in their institutions, departments, and practices.
David B. Hoyt, ACS Executive Director, spoke about the SSR, explaining how it will be part of of the “registry of the future,” allowing users to eventually incorporate relevant data across individual ACS Quality Programs. Also discussed were the Agency for Healthcare Research and Quality Safety Program for Improving Surgical Care and Recovery and the Coalition for Quality in Geriatric Surgery, supported by the John A. Hartford Foundation—programs that seek to set standards and improve outcomes in surgical patients.
The Keynote Address was provided by Blake Haxton, JD, who lost both of his legs to necrotizing fasciitis. Mr. Haxton described his journey from going to the local hospital’s emergency department with debilitating swelling and redness in his right leg to reclaiming his identity, and how he learned that “essential worth is intrinsic and unearned.”
Speakers at the conference addressed a number of hot issues in health care, including health policy, opioid abuse, patient-reported outcomes (PROs), and disparities in care.
A topic of considerable interest was how important culture change is for any sustained QI effort. For any QI effort to succeed it has to evolve in a culture that accepts change, acknowledges shortcomings, uses data to find strengths and weaknesses, and demonstrates resilience. Two cultural changes that surgical teams have experienced in recent years include a greater emphasis on process improvement and checklists.
To read a more detailed account of the topics covered at the conference, read the October Bulletin at URL TO COME. The 2018 ACS Quality and Safety Conference will be held July 21–24 in Orlando, FL.
Apply for three ACS scholarships by November
The American College of Surgeons (ACS) is offering the following three scholarships for 2018 and 2019., each with a November due date.
2018 Faculty Research Fellowships
The American College of Surgeons is offering two-year faculty research fellowships, through the generosity of Fellows, Chapters, and friends of the College, to surgeons entering academic careers in surgery or a surgical specialty. The fellowship is to assist a surgeon in establishing their research program under mentorship, with the goal of transitioning to becoming an independent investigator. Applicants should have demonstrated their potential to work as independent investigators. The fellowship award is $40,000 per year for each of two years, to support the research.
Applications are due by November 1, 2017, and decisions will be made in February 2018.Read the applications requirements and apply at facs.org/member-services/scholarships/research/acsfaculty. Contact the Scholarships Administrator at [email protected] with questions.
ACS/ASBrS International Scholarship 2018
The ACS and the American Society of Breast Surgeons (ASBrS) is offering this scholarship, which will be awarded to surgeons specifically working in countries other than the U.S. and Canada to improve the quality of breast cancer surgical services. Preference will be given to applicants from developing nations. The scholarship, in the amount of $5,000, provides the scholar with an opportunity to attend the annual meeting of the ASBrS and to visit the National Accreditation Program for Breast Centers headquarters in Chicago, IL, to learn about the standards for a breast cancer program/database and the importance of multidisciplinary breast cancer care. The awardee will receive gratis registration to the annual meeting of the ASBrS and to one available postgraduate course at the meeting. Assistance will be provided to obtain preferential housing in an economical hotel in the ASBrS meeting city. Hotel and travel expenses will be the responsibility of the awardee, to be funded from the scholarship award.
Applications are due by November 15, 2017. All applicants will be notified of the selection committee’s decision in January 2018. Read the application requirements and apply at facs.org/member-services/scholarships/international/acsasbrs-intl. Contact the International Liaison at [email protected] with questions.
2019 Traveling Fellowships
The International Relations Committee of the ACS announces the availability of a traveling fellowship in the amount of $10,000 each to Australia and New Zealand (ANZ), one to Germany, and one to Japan. They are intended to encourage international exchange of information concerning surgical science, practice, and education and to establish professional and academic collaborations and friendships. The Traveling Fellows are required to spend a minimum of two to three weeks in the country that they visit. The dates and locations are as follows:
Royal Australasian College of Surgeons, Bangkok, Thailand (May 6–10, 2019)
Germany Society of Surgery, Munich (March 26–29, 2019)
Japan Surgical Society, Osaka (April 18–20, 2019)
The closing date for receipt of completed applications for all three destinations is November 15, 2017. Applicants will be notified by March 2018. Read the application requirements and apply at facs.org/member-services/scholarships/traveling. Contact the International Liaison at [email protected] with any questions.
The American College of Surgeons (ACS) is offering the following three scholarships for 2018 and 2019., each with a November due date.
2018 Faculty Research Fellowships
The American College of Surgeons is offering two-year faculty research fellowships, through the generosity of Fellows, Chapters, and friends of the College, to surgeons entering academic careers in surgery or a surgical specialty. The fellowship is to assist a surgeon in establishing their research program under mentorship, with the goal of transitioning to becoming an independent investigator. Applicants should have demonstrated their potential to work as independent investigators. The fellowship award is $40,000 per year for each of two years, to support the research.
Applications are due by November 1, 2017, and decisions will be made in February 2018.Read the applications requirements and apply at facs.org/member-services/scholarships/research/acsfaculty. Contact the Scholarships Administrator at [email protected] with questions.
ACS/ASBrS International Scholarship 2018
The ACS and the American Society of Breast Surgeons (ASBrS) is offering this scholarship, which will be awarded to surgeons specifically working in countries other than the U.S. and Canada to improve the quality of breast cancer surgical services. Preference will be given to applicants from developing nations. The scholarship, in the amount of $5,000, provides the scholar with an opportunity to attend the annual meeting of the ASBrS and to visit the National Accreditation Program for Breast Centers headquarters in Chicago, IL, to learn about the standards for a breast cancer program/database and the importance of multidisciplinary breast cancer care. The awardee will receive gratis registration to the annual meeting of the ASBrS and to one available postgraduate course at the meeting. Assistance will be provided to obtain preferential housing in an economical hotel in the ASBrS meeting city. Hotel and travel expenses will be the responsibility of the awardee, to be funded from the scholarship award.
Applications are due by November 15, 2017. All applicants will be notified of the selection committee’s decision in January 2018. Read the application requirements and apply at facs.org/member-services/scholarships/international/acsasbrs-intl. Contact the International Liaison at [email protected] with questions.
2019 Traveling Fellowships
The International Relations Committee of the ACS announces the availability of a traveling fellowship in the amount of $10,000 each to Australia and New Zealand (ANZ), one to Germany, and one to Japan. They are intended to encourage international exchange of information concerning surgical science, practice, and education and to establish professional and academic collaborations and friendships. The Traveling Fellows are required to spend a minimum of two to three weeks in the country that they visit. The dates and locations are as follows:
Royal Australasian College of Surgeons, Bangkok, Thailand (May 6–10, 2019)
Germany Society of Surgery, Munich (March 26–29, 2019)
Japan Surgical Society, Osaka (April 18–20, 2019)
The closing date for receipt of completed applications for all three destinations is November 15, 2017. Applicants will be notified by March 2018. Read the application requirements and apply at facs.org/member-services/scholarships/traveling. Contact the International Liaison at [email protected] with any questions.
The American College of Surgeons (ACS) is offering the following three scholarships for 2018 and 2019., each with a November due date.
2018 Faculty Research Fellowships
The American College of Surgeons is offering two-year faculty research fellowships, through the generosity of Fellows, Chapters, and friends of the College, to surgeons entering academic careers in surgery or a surgical specialty. The fellowship is to assist a surgeon in establishing their research program under mentorship, with the goal of transitioning to becoming an independent investigator. Applicants should have demonstrated their potential to work as independent investigators. The fellowship award is $40,000 per year for each of two years, to support the research.
Applications are due by November 1, 2017, and decisions will be made in February 2018.Read the applications requirements and apply at facs.org/member-services/scholarships/research/acsfaculty. Contact the Scholarships Administrator at [email protected] with questions.
ACS/ASBrS International Scholarship 2018
The ACS and the American Society of Breast Surgeons (ASBrS) is offering this scholarship, which will be awarded to surgeons specifically working in countries other than the U.S. and Canada to improve the quality of breast cancer surgical services. Preference will be given to applicants from developing nations. The scholarship, in the amount of $5,000, provides the scholar with an opportunity to attend the annual meeting of the ASBrS and to visit the National Accreditation Program for Breast Centers headquarters in Chicago, IL, to learn about the standards for a breast cancer program/database and the importance of multidisciplinary breast cancer care. The awardee will receive gratis registration to the annual meeting of the ASBrS and to one available postgraduate course at the meeting. Assistance will be provided to obtain preferential housing in an economical hotel in the ASBrS meeting city. Hotel and travel expenses will be the responsibility of the awardee, to be funded from the scholarship award.
Applications are due by November 15, 2017. All applicants will be notified of the selection committee’s decision in January 2018. Read the application requirements and apply at facs.org/member-services/scholarships/international/acsasbrs-intl. Contact the International Liaison at [email protected] with questions.
2019 Traveling Fellowships
The International Relations Committee of the ACS announces the availability of a traveling fellowship in the amount of $10,000 each to Australia and New Zealand (ANZ), one to Germany, and one to Japan. They are intended to encourage international exchange of information concerning surgical science, practice, and education and to establish professional and academic collaborations and friendships. The Traveling Fellows are required to spend a minimum of two to three weeks in the country that they visit. The dates and locations are as follows:
Royal Australasian College of Surgeons, Bangkok, Thailand (May 6–10, 2019)
Germany Society of Surgery, Munich (March 26–29, 2019)
Japan Surgical Society, Osaka (April 18–20, 2019)
The closing date for receipt of completed applications for all three destinations is November 15, 2017. Applicants will be notified by March 2018. Read the application requirements and apply at facs.org/member-services/scholarships/traveling. Contact the International Liaison at [email protected] with any questions.