Damian McNamara

Adolescents hospitalized for anorexia nervosa could benefit from a more-aggressive feeding strategy – one that contradicts the current "start low, go slow" approach to providing calories, according to a new study.

Administration of more than the conservative 1,200 calories/day initially could prevent weight loss that typically is seen in the first week in the hospital and could mean many patients will leave the hospital sooner, Andrea K. Garber, Ph.D., lead author of the study, said in an interview.

"It was really a known thing in clinical practice – that patients on this ‘start low and go slow’ approach would lose weight initially. It was just accepted as part of the course of recovery," said Dr. Garber, who is on the pediatrics faculty within the division of adolescent medicine at the University of California, San Francisco.

Fluids shifts are widely believed to cause this initial weight loss. "Our data support that it was related in part to fluid shifts. We also really believe, and were able to show, that it is due to underfeeding as well," Dr. Garber said. "That was a surprise."

Dr. Garber and her associates in the UCSF Pediatric Clinical Research Center studied 35 patients hospitalized for weight loss secondary to anorexia nervosa (J. Adolesc. Health 2011 [doi:10.1016/j.jadohealth.2011.06.011]).All except one of the participants were girls; the mean age was 16 years. The mean body mass index on admission was 16 kg/m² (range, 11-22 kg/m²).

Although a range of calories initially were prescribed, from 800-2,200 calories/day, 94% started on 1,400 calories or fewer per day. This approach approximated the current 1,200-calorie/day recommendations from the American Psychiatric Association (Am. J. Psychiatry 2006;163:4-54) and the American Dietetic Association (J. Am. Diet. Assoc. 2006;106:2073-82).

"A major finding of ours is that the recommendations in place are probably not working," Dr. Garber said.

Most participants, 29 of the 35 treated according to the more-conservative protocol, initially lost weight. Significant weight gain was not observed until day 8 of admission. A higher-calorie starting diet predicted an increase in percentage median BMI (50th percentile adjusted for age and gender) and shorter length of stay. For every 100-calorie increase at baseline, the rate of percentage median BMI increased by 0.02%, and length of time in the hospital decreased by a mean 0.9 days.

"It’s an interesting study because it challenges the current practices," said Dr. Michelle Marks, director of pediatric hospitalist medicine, Cleveland Clinic, said in an interview when asked to comment.

Since 2005, Cleveland Clinic protocol has been to start most patients at 1,200 calories and increase intake by 250 calories/day, based on weight gain. "I have often thought that it would be realistic to start most of these kids at a higher initial calorie [baseline]," Dr. Marks said.

Dr. Marks urged some caution as well. "Even though we may believe that we may use more calories at the beginning, it’s not clear at what level to start. So this paper shouldn’t have people saying ‘Oh, great. I can start at any calorie I want, and if I start at 2,000 calories, it’s okay.’ " She added that patients with lower initial body weights should be watched more closely.

The more-conservative protocol was a success in the study, the researchers noted, because no patient developed refeeding syndrome, considered a major reason for the "start low and go slow" strategy. Only 20% of participants required phosphorus supplementation, they added (low phosphorus is considered a hallmark of this syndrome, and patients were closely monitored for any downward trend in their levels).

Hospitalists "are the ones who will be taking care of these patients, so this [study] is really pertinent for hospitalists, especially," said Dr. Garber, who is also a registered dietitian. "They’re going to now have to make a decision about whether they will stick with the current recommendations ... or move to something more aggressive when there is not a lot of evidence to support what is the best approach or high-calorie diet to use.

"Some clinics have opted to be more conservative and stick with the recommendations, and other people are moving full steam ahead with more aggressive refeeding protocols," Dr. Garber said.

Some clinicians say practice cannot be changed based on a single study, Dr. Garber said. "That is very true. However, I will tell you, clinical practice is already changing." She added that Australian researchers have demonstrated that a 1,900 initial calories per day diet was safe (J. Adolesc. Health 2010; 46:577-82).

"This is a case where the clinical practice is moving on, and we are just catching up now with the evidence. Certainly, more evidence is needed ... to develop best practices," Dr. Garber said. "But people are doing high-calorie feedings in the U.S. and other countries."

Psychiatrists also can play an important role in this refeeding process, Dr. Garber said. "One of the questions ... is whether these diets will be tolerated psychiatrically. What is the psychiatric and psychological impact of refeeding with this high number of calories?" Not only is this an opportunity for future research, but an area where psychiatrists could offer significant support to patients hospitalized with anorexia.

"Studies have shown there is an enormous amount of anxiety associated with refeeding in the hospital," Dr. Garber said.

Dr. B. Timothy Walsh offered another perspective.

"Probably, the clinician who does not specialize in this area should recognize the potential medical complexities and have a low threshold for referring cases to specialist centers where there is greater awareness of the dangers of refeeding 'too slow' or too fast,' " Dr. Walsh, Ruane Professor of Pediatric Psychopharmacology in the department of psychiatry at the College of Physicians & Surgeons, Columbia University, said in an interview.

Dr. Garber and Dr. Marks said they had no relevant financial disclosures.

Adolescents hospitalized for anorexia nervosa could benefit from a more-aggressive feeding strategy – one that contradicts the current "start low, go slow" approach to providing calories, according to a new study.

Administration of more than the conservative 1,200 calories/day initially could prevent weight loss that typically is seen in the first week in the hospital and could mean many patients will leave the hospital sooner, Andrea K. Garber, Ph.D., lead author of the study, said in an interview.

"It was really a known thing in clinical practice – that patients on this ‘start low and go slow’ approach would lose weight initially. It was just accepted as part of the course of recovery," said Dr. Garber, who is on the pediatrics faculty within the division of adolescent medicine at the University of California, San Francisco.

Fluids shifts are widely believed to cause this initial weight loss. "Our data support that it was related in part to fluid shifts. We also really believe, and were able to show, that it is due to underfeeding as well," Dr. Garber said. "That was a surprise."

Dr. Garber and her associates in the UCSF Pediatric Clinical Research Center studied 35 patients hospitalized for weight loss secondary to anorexia nervosa (J. Adolesc. Health 2011 [doi:10.1016/j.jadohealth.2011.06.011]).All except one of the participants were girls; the mean age was 16 years. The mean body mass index on admission was 16 kg/m² (range, 11-22 kg/m²).

Although a range of calories initially were prescribed, from 800-2,200 calories/day, 94% started on 1,400 calories or fewer per day. This approach approximated the current 1,200-calorie/day recommendations from the American Psychiatric Association (Am. J. Psychiatry 2006;163:4-54) and the American Dietetic Association (J. Am. Diet. Assoc. 2006;106:2073-82).

"A major finding of ours is that the recommendations in place are probably not working," Dr. Garber said.

Most participants, 29 of the 35 treated according to the more-conservative protocol, initially lost weight. Significant weight gain was not observed until day 8 of admission. A higher-calorie starting diet predicted an increase in percentage median BMI (50th percentile adjusted for age and gender) and shorter length of stay. For every 100-calorie increase at baseline, the rate of percentage median BMI increased by 0.02%, and length of time in the hospital decreased by a mean 0.9 days.

"It’s an interesting study because it challenges the current practices," said Dr. Michelle Marks, director of pediatric hospitalist medicine, Cleveland Clinic, said in an interview when asked to comment.

Since 2005, Cleveland Clinic protocol has been to start most patients at 1,200 calories and increase intake by 250 calories/day, based on weight gain. "I have often thought that it would be realistic to start most of these kids at a higher initial calorie [baseline]," Dr. Marks said.

Dr. Marks urged some caution as well. "Even though we may believe that we may use more calories at the beginning, it’s not clear at what level to start. So this paper shouldn’t have people saying ‘Oh, great. I can start at any calorie I want, and if I start at 2,000 calories, it’s okay.’ " She added that patients with lower initial body weights should be watched more closely.

The more-conservative protocol was a success in the study, the researchers noted, because no patient developed refeeding syndrome, considered a major reason for the "start low and go slow" strategy. Only 20% of participants required phosphorus supplementation, they added (low phosphorus is considered a hallmark of this syndrome, and patients were closely monitored for any downward trend in their levels).

Hospitalists "are the ones who will be taking care of these patients, so this [study] is really pertinent for hospitalists, especially," said Dr. Garber, who is also a registered dietitian. "They’re going to now have to make a decision about whether they will stick with the current recommendations ... or move to something more aggressive when there is not a lot of evidence to support what is the best approach or high-calorie diet to use.

"Some clinics have opted to be more conservative and stick with the recommendations, and other people are moving full steam ahead with more aggressive refeeding protocols," Dr. Garber said.

Some clinicians say practice cannot be changed based on a single study, Dr. Garber said. "That is very true. However, I will tell you, clinical practice is already changing." She added that Australian researchers have demonstrated that a 1,900 initial calories per day diet was safe (J. Adolesc. Health 2010; 46:577-82).

"This is a case where the clinical practice is moving on, and we are just catching up now with the evidence. Certainly, more evidence is needed ... to develop best practices," Dr. Garber said. "But people are doing high-calorie feedings in the U.S. and other countries."

Psychiatrists also can play an important role in this refeeding process, Dr. Garber said. "One of the questions ... is whether these diets will be tolerated psychiatrically. What is the psychiatric and psychological impact of refeeding with this high number of calories?" Not only is this an opportunity for future research, but an area where psychiatrists could offer significant support to patients hospitalized with anorexia.

"Studies have shown there is an enormous amount of anxiety associated with refeeding in the hospital," Dr. Garber said.

Dr. B. Timothy Walsh offered another perspective.

"Probably, the clinician who does not specialize in this area should recognize the potential medical complexities and have a low threshold for referring cases to specialist centers where there is greater awareness of the dangers of refeeding 'too slow' or too fast,' " Dr. Walsh, Ruane Professor of Pediatric Psychopharmacology in the department of psychiatry at the College of Physicians & Surgeons, Columbia University, said in an interview.

Dr. Garber and Dr. Marks said they had no relevant financial disclosures.

Adolescents hospitalized for anorexia nervosa could benefit from a more-aggressive feeding strategy – one that contradicts the current "start low, go slow" approach to providing calories, according to a new study.

Administration of more than the conservative 1,200 calories/day initially could prevent weight loss that typically is seen in the first week in the hospital and could mean many patients will leave the hospital sooner, Andrea K. Garber, Ph.D., lead author of the study, said in an interview.

"It was really a known thing in clinical practice – that patients on this ‘start low and go slow’ approach would lose weight initially. It was just accepted as part of the course of recovery," said Dr. Garber, who is on the pediatrics faculty within the division of adolescent medicine at the University of California, San Francisco.

Fluids shifts are widely believed to cause this initial weight loss. "Our data support that it was related in part to fluid shifts. We also really believe, and were able to show, that it is due to underfeeding as well," Dr. Garber said. "That was a surprise."

Dr. Garber and her associates in the UCSF Pediatric Clinical Research Center studied 35 patients hospitalized for weight loss secondary to anorexia nervosa (J. Adolesc. Health 2011 [doi:10.1016/j.jadohealth.2011.06.011]).All except one of the participants were girls; the mean age was 16 years. The mean body mass index on admission was 16 kg/m² (range, 11-22 kg/m²).

Although a range of calories initially were prescribed, from 800-2,200 calories/day, 94% started on 1,400 calories or fewer per day. This approach approximated the current 1,200-calorie/day recommendations from the American Psychiatric Association (Am. J. Psychiatry 2006;163:4-54) and the American Dietetic Association (J. Am. Diet. Assoc. 2006;106:2073-82).

"A major finding of ours is that the recommendations in place are probably not working," Dr. Garber said.

Most participants, 29 of the 35 treated according to the more-conservative protocol, initially lost weight. Significant weight gain was not observed until day 8 of admission. A higher-calorie starting diet predicted an increase in percentage median BMI (50th percentile adjusted for age and gender) and shorter length of stay. For every 100-calorie increase at baseline, the rate of percentage median BMI increased by 0.02%, and length of time in the hospital decreased by a mean 0.9 days.

"It’s an interesting study because it challenges the current practices," said Dr. Michelle Marks, director of pediatric hospitalist medicine, Cleveland Clinic, said in an interview when asked to comment.

Since 2005, Cleveland Clinic protocol has been to start most patients at 1,200 calories and increase intake by 250 calories/day, based on weight gain. "I have often thought that it would be realistic to start most of these kids at a higher initial calorie [baseline]," Dr. Marks said.

Dr. Marks urged some caution as well. "Even though we may believe that we may use more calories at the beginning, it’s not clear at what level to start. So this paper shouldn’t have people saying ‘Oh, great. I can start at any calorie I want, and if I start at 2,000 calories, it’s okay.’ " She added that patients with lower initial body weights should be watched more closely.

The more-conservative protocol was a success in the study, the researchers noted, because no patient developed refeeding syndrome, considered a major reason for the "start low and go slow" strategy. Only 20% of participants required phosphorus supplementation, they added (low phosphorus is considered a hallmark of this syndrome, and patients were closely monitored for any downward trend in their levels).

Hospitalists "are the ones who will be taking care of these patients, so this [study] is really pertinent for hospitalists, especially," said Dr. Garber, who is also a registered dietitian. "They’re going to now have to make a decision about whether they will stick with the current recommendations ... or move to something more aggressive when there is not a lot of evidence to support what is the best approach or high-calorie diet to use.

"Some clinics have opted to be more conservative and stick with the recommendations, and other people are moving full steam ahead with more aggressive refeeding protocols," Dr. Garber said.

Some clinicians say practice cannot be changed based on a single study, Dr. Garber said. "That is very true. However, I will tell you, clinical practice is already changing." She added that Australian researchers have demonstrated that a 1,900 initial calories per day diet was safe (J. Adolesc. Health 2010; 46:577-82).

"This is a case where the clinical practice is moving on, and we are just catching up now with the evidence. Certainly, more evidence is needed ... to develop best practices," Dr. Garber said. "But people are doing high-calorie feedings in the U.S. and other countries."

Psychiatrists also can play an important role in this refeeding process, Dr. Garber said. "One of the questions ... is whether these diets will be tolerated psychiatrically. What is the psychiatric and psychological impact of refeeding with this high number of calories?" Not only is this an opportunity for future research, but an area where psychiatrists could offer significant support to patients hospitalized with anorexia.

"Studies have shown there is an enormous amount of anxiety associated with refeeding in the hospital," Dr. Garber said.

Dr. B. Timothy Walsh offered another perspective.

"Probably, the clinician who does not specialize in this area should recognize the potential medical complexities and have a low threshold for referring cases to specialist centers where there is greater awareness of the dangers of refeeding 'too slow' or too fast,' " Dr. Walsh, Ruane Professor of Pediatric Psychopharmacology in the department of psychiatry at the College of Physicians & Surgeons, Columbia University, said in an interview.

Dr. Garber and Dr. Marks said they had no relevant financial disclosures.

MIAMI BEACH – Think globally but track locally when it comes to antimicrobial resistance.

"We want to know what is going on nationally and worldwide in terms of resistance, but we really have to understand, and have down pat, what is going on in our own hospitals," said Aida E. Casiano-Colon, Ph.D., a microbiologist at a large regional laboratory in South Florida.

Awareness and collaboration among clinicians are particularly important when it comes to combating multidrug-resistant organisms (MDROs), Dr. Casiano-Colon said. "MDRO varies geographically and by health care setting. Larger hospitals usually have more resistance." Rates also vary by unit within a hospital, she said.

As clinical microbiology director at Integrated Regional Laboratories in Fort Lauderdale, Dr. Casiano-Colon has access to about 790,000 cultures each year from 13 hospitals and several nursing homes in South Florida, as well as from a national network of correctional facilities.

"We really have to understand, and have down pat, what is going on in our own hospitals."

"First the good news: The gram-positive organisms are actually showing a favorable trend. Antimicrobial resistance is very stable or improving," Dr. Casiano-Colon said at the Florida Antimicrobial Stewardship Symposium sponsored by the University of Miami.

In addition, the prevalence of methicillin-resistant Staphylococcus aureus (MRSA) "is actually starting to drop." MRSA prevalence was 62% in 2011 (based on approximately 42,000 S. aureus isolates from 12 South Florida hospitals). This represents a 7.5% drop since 2006. Put another way, there was a 22% decline in MRSA rates per 1,000 adjusted patient-days, from 4.5 in 2006 to 3.5 in 2011 (based on almost 25,000 isolates). Compulsive hand hygiene, use of active surveillance cultures, barrier precautions, and other interventions continue to decrease the MRSA rate, she said.

Annual rates of MRSA bacteremia also continue to steadily decrease. The 2011 rate of 2.9/10,000 adjusted patient-days reveals a 34% drop in the last 5 years. However, MRSA "is still a very significant pathogen. All the other MDROs that cause bacteremia pale in comparison in terms of the rate of bloodstream infections," Dr. Casiano-Colon said.

"We are not really seeing a lot of vancomycin-resistant S. aureus, which is also very good news," she added.

The bad news is "we continue to detect escalating resistance in gram-negative organisms overall, especially ESBL [extended-spectrum beta-lactamase] bacteremia, carbapenem-resistant enterics, and Acinetobacter."

For example, the rate of ESBL bloodstream infections jumped "a very alarming" 333% from 0.6/10,000 patient days in 2008 to 2.6/10,000 in 2010.

Rates of all ESBL infections (including respiratory and urinary tract infections) are also showing an alarming increase, to a rate of 1.2/1,000 adjusted patient-days from 0.48/10,000 in 2007, Dr. Casiano-Colon said.

Resistant strains of carbapenem-resistant Enterobacteriaceae are another growing concern. Rates increased from 0.007 in 2008 to 0.03 in 2011. "These organisms cause severe infections among hospital patients and residents of long-term care facilities," she said.

MIAMI BEACH – Think globally but track locally when it comes to antimicrobial resistance.

"We want to know what is going on nationally and worldwide in terms of resistance, but we really have to understand, and have down pat, what is going on in our own hospitals," said Aida E. Casiano-Colon, Ph.D., a microbiologist at a large regional laboratory in South Florida.

Awareness and collaboration among clinicians are particularly important when it comes to combating multidrug-resistant organisms (MDROs), Dr. Casiano-Colon said. "MDRO varies geographically and by health care setting. Larger hospitals usually have more resistance." Rates also vary by unit within a hospital, she said.

As clinical microbiology director at Integrated Regional Laboratories in Fort Lauderdale, Dr. Casiano-Colon has access to about 790,000 cultures each year from 13 hospitals and several nursing homes in South Florida, as well as from a national network of correctional facilities.

"We really have to understand, and have down pat, what is going on in our own hospitals."

"First the good news: The gram-positive organisms are actually showing a favorable trend. Antimicrobial resistance is very stable or improving," Dr. Casiano-Colon said at the Florida Antimicrobial Stewardship Symposium sponsored by the University of Miami.

In addition, the prevalence of methicillin-resistant Staphylococcus aureus (MRSA) "is actually starting to drop." MRSA prevalence was 62% in 2011 (based on approximately 42,000 S. aureus isolates from 12 South Florida hospitals). This represents a 7.5% drop since 2006. Put another way, there was a 22% decline in MRSA rates per 1,000 adjusted patient-days, from 4.5 in 2006 to 3.5 in 2011 (based on almost 25,000 isolates). Compulsive hand hygiene, use of active surveillance cultures, barrier precautions, and other interventions continue to decrease the MRSA rate, she said.

Annual rates of MRSA bacteremia also continue to steadily decrease. The 2011 rate of 2.9/10,000 adjusted patient-days reveals a 34% drop in the last 5 years. However, MRSA "is still a very significant pathogen. All the other MDROs that cause bacteremia pale in comparison in terms of the rate of bloodstream infections," Dr. Casiano-Colon said.

"We are not really seeing a lot of vancomycin-resistant S. aureus, which is also very good news," she added.

The bad news is "we continue to detect escalating resistance in gram-negative organisms overall, especially ESBL [extended-spectrum beta-lactamase] bacteremia, carbapenem-resistant enterics, and Acinetobacter."

For example, the rate of ESBL bloodstream infections jumped "a very alarming" 333% from 0.6/10,000 patient days in 2008 to 2.6/10,000 in 2010.

Rates of all ESBL infections (including respiratory and urinary tract infections) are also showing an alarming increase, to a rate of 1.2/1,000 adjusted patient-days from 0.48/10,000 in 2007, Dr. Casiano-Colon said.

Resistant strains of carbapenem-resistant Enterobacteriaceae are another growing concern. Rates increased from 0.007 in 2008 to 0.03 in 2011. "These organisms cause severe infections among hospital patients and residents of long-term care facilities," she said.

MIAMI BEACH – Think globally but track locally when it comes to antimicrobial resistance.

"We want to know what is going on nationally and worldwide in terms of resistance, but we really have to understand, and have down pat, what is going on in our own hospitals," said Aida E. Casiano-Colon, Ph.D., a microbiologist at a large regional laboratory in South Florida.

Awareness and collaboration among clinicians are particularly important when it comes to combating multidrug-resistant organisms (MDROs), Dr. Casiano-Colon said. "MDRO varies geographically and by health care setting. Larger hospitals usually have more resistance." Rates also vary by unit within a hospital, she said.

As clinical microbiology director at Integrated Regional Laboratories in Fort Lauderdale, Dr. Casiano-Colon has access to about 790,000 cultures each year from 13 hospitals and several nursing homes in South Florida, as well as from a national network of correctional facilities.

"We really have to understand, and have down pat, what is going on in our own hospitals."

"First the good news: The gram-positive organisms are actually showing a favorable trend. Antimicrobial resistance is very stable or improving," Dr. Casiano-Colon said at the Florida Antimicrobial Stewardship Symposium sponsored by the University of Miami.

In addition, the prevalence of methicillin-resistant Staphylococcus aureus (MRSA) "is actually starting to drop." MRSA prevalence was 62% in 2011 (based on approximately 42,000 S. aureus isolates from 12 South Florida hospitals). This represents a 7.5% drop since 2006. Put another way, there was a 22% decline in MRSA rates per 1,000 adjusted patient-days, from 4.5 in 2006 to 3.5 in 2011 (based on almost 25,000 isolates). Compulsive hand hygiene, use of active surveillance cultures, barrier precautions, and other interventions continue to decrease the MRSA rate, she said.

Annual rates of MRSA bacteremia also continue to steadily decrease. The 2011 rate of 2.9/10,000 adjusted patient-days reveals a 34% drop in the last 5 years. However, MRSA "is still a very significant pathogen. All the other MDROs that cause bacteremia pale in comparison in terms of the rate of bloodstream infections," Dr. Casiano-Colon said.

"We are not really seeing a lot of vancomycin-resistant S. aureus, which is also very good news," she added.

The bad news is "we continue to detect escalating resistance in gram-negative organisms overall, especially ESBL [extended-spectrum beta-lactamase] bacteremia, carbapenem-resistant enterics, and Acinetobacter."

For example, the rate of ESBL bloodstream infections jumped "a very alarming" 333% from 0.6/10,000 patient days in 2008 to 2.6/10,000 in 2010.

Rates of all ESBL infections (including respiratory and urinary tract infections) are also showing an alarming increase, to a rate of 1.2/1,000 adjusted patient-days from 0.48/10,000 in 2007, Dr. Casiano-Colon said.

Resistant strains of carbapenem-resistant Enterobacteriaceae are another growing concern. Rates increased from 0.007 in 2008 to 0.03 in 2011. "These organisms cause severe infections among hospital patients and residents of long-term care facilities," she said.

MIAMI BEACH – More than half of acute care hospitals in Florida feature a formal antimicrobial stewardship program, and a sizable minority plans to launch one in the next year, according to a survey.

Antimicrobial resistance "is one of the most serious problems globally. Studies from acute and long-term care facilities have shown 30%-50% of antimicrobial use is inappropriate," Dr. Lilian M. Abbo said at the Florida Antimicrobial Stewardship Symposium sponsored by the University of Miami.

Many hospitals already employ components of antimicrobial stewardship, such as formulary restrictions; requiring prescription preauthorizations; or post-prescribing reviews with feedback to the clinician. However, proponents point to better patient outcomes, lower resistance rates, and overall cost savings for hospitals through formal programs.

The positive outcomes demonstrated by the Florida survey could be applied nationwide, said Dr. Abbo, a clinical faculty member in the division of infectious diseases at the University of Miami Hospital.

The electronic survey in Florida revealed that 55% of 85 acute care facility respondents have a stewardship program and another 21% plan to join their ranks soon. "Of the 24% who said ‘no,’ 80% agreed a program would be useful," said Dr. Abbo, who is also the medical director of the Antimicrobial Stewardship Program at University of Miami Hospital/Jackson Memorial Medical Center.

Clostridium difficile, methicillin-resistant Staphylococcus aureus (MRSA), and multi-drug resistant gram-negative bacteria, in order, were the most troubling microbes reported. Specifically, when asked to identify their most challenging health care–associated infection, 33% of respondents cited C. difficile, 23% MRSA, and 19% the gram-negative bacteria.

So how are the facilities with formal stewardship programs combating this? The leading initiatives cited by 56 such hospitals including monitoring high-cost agents (52 hospitals or 93%), assessment of intravenous to oral conversions by 84%, and review of broad-spectrum agent use by 80%.

Specific agents under scrutiny through stewardship include linezolid (cited by 92% of respondents with a program), vancomycin (88%), and daptomycin (87%).

Outcomes associated with stewardship are one of the most difficult factors to measure, Dr. Abbo said. A total 70% of respondents with a program said they could demonstrate a decrease in drug purchasing costs, for example. Another 66% could show a reduction in antimicrobial resistance, and 66% a decrease in C. difficile infections. Other results show 64% can support lower antimicrobial consumption, 43% improved patient outcomes, 38% reduced length of stay, and 34% reduced adverse drug reactions associated with antibiotic use.

Stewardship programs that foster appropriate prescribing can save money. "That’s another important take-home message," Dr. Abbo said. "Cost savings are important. That is how you can negotiate with your CEO or CMO – that’s how you are going to save money for the hospital and more than pay for your salary."

In a practical move, the survey also examined barriers to implementation of stewardship programs. Of 76 responses, 66% cited personnel shortages, 64% cited time constraints, and 62% said funding is limited. Only 13% reported resistance from administration. "I was very impressed that most people do not feel their administrations are a barrier," Dr. Abbo said.

It takes a village to run an optimal stewardship program – another major theme from the results. "Stewardship cannot be done by one person alone," Dr. Abbo said. Efforts are multidisciplinary, with hospitalists involved in 23% of existing programs or those planned for the subsequent 12 months, the survey shows. Infectious disease physicians are involved in 55%, followed by clinical PharmDs (52%), infection control professionals (47%), and microbiologists (31%).

The majority of respondents, 62%, work at community hospitals. Another 10% each work at a city/county hospital or a nonuniversity teaching hospital. The remaining respondents hail from a university (adult or pediatric) hospital (6%), a community pediatric hospital (2%), a VA or military hospital (2%), or another acute care facility setting (8%).

A total 62% of facilities had between 100 and 500 beds. Only 11% had fewer than 100 beds, and 15% had more than 500 and up to 800 beds. The remaining 12% of facilities, the largest had more than 800 beds.

All 213 acute care facilities in the state were invited to participate in the survey, conducted from July to October 2011. Data are based on a 40% response rate.

A second survey was also e-mailed to nursing homes and skilled nursing facilities in the state to assess the scope of current and planned stewardship practices in those settings.

Dr. Abbo had no relevant financial disclosures. The survey was supported by a grant from the Florida Department of Health Bureau of Epidemiology.

MIAMI BEACH – More than half of acute care hospitals in Florida feature a formal antimicrobial stewardship program, and a sizable minority plans to launch one in the next year, according to a survey.

Antimicrobial resistance "is one of the most serious problems globally. Studies from acute and long-term care facilities have shown 30%-50% of antimicrobial use is inappropriate," Dr. Lilian M. Abbo said at the Florida Antimicrobial Stewardship Symposium sponsored by the University of Miami.

Many hospitals already employ components of antimicrobial stewardship, such as formulary restrictions; requiring prescription preauthorizations; or post-prescribing reviews with feedback to the clinician. However, proponents point to better patient outcomes, lower resistance rates, and overall cost savings for hospitals through formal programs.

The positive outcomes demonstrated by the Florida survey could be applied nationwide, said Dr. Abbo, a clinical faculty member in the division of infectious diseases at the University of Miami Hospital.

The electronic survey in Florida revealed that 55% of 85 acute care facility respondents have a stewardship program and another 21% plan to join their ranks soon. "Of the 24% who said ‘no,’ 80% agreed a program would be useful," said Dr. Abbo, who is also the medical director of the Antimicrobial Stewardship Program at University of Miami Hospital/Jackson Memorial Medical Center.

Clostridium difficile, methicillin-resistant Staphylococcus aureus (MRSA), and multi-drug resistant gram-negative bacteria, in order, were the most troubling microbes reported. Specifically, when asked to identify their most challenging health care–associated infection, 33% of respondents cited C. difficile, 23% MRSA, and 19% the gram-negative bacteria.

So how are the facilities with formal stewardship programs combating this? The leading initiatives cited by 56 such hospitals including monitoring high-cost agents (52 hospitals or 93%), assessment of intravenous to oral conversions by 84%, and review of broad-spectrum agent use by 80%.

Specific agents under scrutiny through stewardship include linezolid (cited by 92% of respondents with a program), vancomycin (88%), and daptomycin (87%).

Outcomes associated with stewardship are one of the most difficult factors to measure, Dr. Abbo said. A total 70% of respondents with a program said they could demonstrate a decrease in drug purchasing costs, for example. Another 66% could show a reduction in antimicrobial resistance, and 66% a decrease in C. difficile infections. Other results show 64% can support lower antimicrobial consumption, 43% improved patient outcomes, 38% reduced length of stay, and 34% reduced adverse drug reactions associated with antibiotic use.

Stewardship programs that foster appropriate prescribing can save money. "That’s another important take-home message," Dr. Abbo said. "Cost savings are important. That is how you can negotiate with your CEO or CMO – that’s how you are going to save money for the hospital and more than pay for your salary."

In a practical move, the survey also examined barriers to implementation of stewardship programs. Of 76 responses, 66% cited personnel shortages, 64% cited time constraints, and 62% said funding is limited. Only 13% reported resistance from administration. "I was very impressed that most people do not feel their administrations are a barrier," Dr. Abbo said.

It takes a village to run an optimal stewardship program – another major theme from the results. "Stewardship cannot be done by one person alone," Dr. Abbo said. Efforts are multidisciplinary, with hospitalists involved in 23% of existing programs or those planned for the subsequent 12 months, the survey shows. Infectious disease physicians are involved in 55%, followed by clinical PharmDs (52%), infection control professionals (47%), and microbiologists (31%).

The majority of respondents, 62%, work at community hospitals. Another 10% each work at a city/county hospital or a nonuniversity teaching hospital. The remaining respondents hail from a university (adult or pediatric) hospital (6%), a community pediatric hospital (2%), a VA or military hospital (2%), or another acute care facility setting (8%).

A total 62% of facilities had between 100 and 500 beds. Only 11% had fewer than 100 beds, and 15% had more than 500 and up to 800 beds. The remaining 12% of facilities, the largest had more than 800 beds.

All 213 acute care facilities in the state were invited to participate in the survey, conducted from July to October 2011. Data are based on a 40% response rate.

A second survey was also e-mailed to nursing homes and skilled nursing facilities in the state to assess the scope of current and planned stewardship practices in those settings.

Dr. Abbo had no relevant financial disclosures. The survey was supported by a grant from the Florida Department of Health Bureau of Epidemiology.

MIAMI BEACH – More than half of acute care hospitals in Florida feature a formal antimicrobial stewardship program, and a sizable minority plans to launch one in the next year, according to a survey.

Antimicrobial resistance "is one of the most serious problems globally. Studies from acute and long-term care facilities have shown 30%-50% of antimicrobial use is inappropriate," Dr. Lilian M. Abbo said at the Florida Antimicrobial Stewardship Symposium sponsored by the University of Miami.

Many hospitals already employ components of antimicrobial stewardship, such as formulary restrictions; requiring prescription preauthorizations; or post-prescribing reviews with feedback to the clinician. However, proponents point to better patient outcomes, lower resistance rates, and overall cost savings for hospitals through formal programs.

The positive outcomes demonstrated by the Florida survey could be applied nationwide, said Dr. Abbo, a clinical faculty member in the division of infectious diseases at the University of Miami Hospital.

The electronic survey in Florida revealed that 55% of 85 acute care facility respondents have a stewardship program and another 21% plan to join their ranks soon. "Of the 24% who said ‘no,’ 80% agreed a program would be useful," said Dr. Abbo, who is also the medical director of the Antimicrobial Stewardship Program at University of Miami Hospital/Jackson Memorial Medical Center.

Clostridium difficile, methicillin-resistant Staphylococcus aureus (MRSA), and multi-drug resistant gram-negative bacteria, in order, were the most troubling microbes reported. Specifically, when asked to identify their most challenging health care–associated infection, 33% of respondents cited C. difficile, 23% MRSA, and 19% the gram-negative bacteria.

So how are the facilities with formal stewardship programs combating this? The leading initiatives cited by 56 such hospitals including monitoring high-cost agents (52 hospitals or 93%), assessment of intravenous to oral conversions by 84%, and review of broad-spectrum agent use by 80%.

Specific agents under scrutiny through stewardship include linezolid (cited by 92% of respondents with a program), vancomycin (88%), and daptomycin (87%).

Outcomes associated with stewardship are one of the most difficult factors to measure, Dr. Abbo said. A total 70% of respondents with a program said they could demonstrate a decrease in drug purchasing costs, for example. Another 66% could show a reduction in antimicrobial resistance, and 66% a decrease in C. difficile infections. Other results show 64% can support lower antimicrobial consumption, 43% improved patient outcomes, 38% reduced length of stay, and 34% reduced adverse drug reactions associated with antibiotic use.

Stewardship programs that foster appropriate prescribing can save money. "That’s another important take-home message," Dr. Abbo said. "Cost savings are important. That is how you can negotiate with your CEO or CMO – that’s how you are going to save money for the hospital and more than pay for your salary."

In a practical move, the survey also examined barriers to implementation of stewardship programs. Of 76 responses, 66% cited personnel shortages, 64% cited time constraints, and 62% said funding is limited. Only 13% reported resistance from administration. "I was very impressed that most people do not feel their administrations are a barrier," Dr. Abbo said.

It takes a village to run an optimal stewardship program – another major theme from the results. "Stewardship cannot be done by one person alone," Dr. Abbo said. Efforts are multidisciplinary, with hospitalists involved in 23% of existing programs or those planned for the subsequent 12 months, the survey shows. Infectious disease physicians are involved in 55%, followed by clinical PharmDs (52%), infection control professionals (47%), and microbiologists (31%).

The majority of respondents, 62%, work at community hospitals. Another 10% each work at a city/county hospital or a nonuniversity teaching hospital. The remaining respondents hail from a university (adult or pediatric) hospital (6%), a community pediatric hospital (2%), a VA or military hospital (2%), or another acute care facility setting (8%).

A total 62% of facilities had between 100 and 500 beds. Only 11% had fewer than 100 beds, and 15% had more than 500 and up to 800 beds. The remaining 12% of facilities, the largest had more than 800 beds.

All 213 acute care facilities in the state were invited to participate in the survey, conducted from July to October 2011. Data are based on a 40% response rate.

A second survey was also e-mailed to nursing homes and skilled nursing facilities in the state to assess the scope of current and planned stewardship practices in those settings.

Dr. Abbo had no relevant financial disclosures. The survey was supported by a grant from the Florida Department of Health Bureau of Epidemiology.

MIAMI BEACH – In the 2 years since California mandated judicious antimicrobial use, more money has poured into antimicrobial stewardship programs to combat inappropriate use, increasing resistance, and the sometimes debilitating adverse effects of these agents.

It is unlikely that hospital administrators would have funded these initiatives to this extent, particularly during a time of constrained budgets, without the law, Dr. Kavita K. Trivedi said.

"California currently is the only state with legislation regarding antimicrobial use. We hope that other states will follow along, especially because we’ve had such a positive experience with our legislation," said Dr. Trivedi, public health medical officer for the California Department of Public Health in Richmond.

"We are seeing and entering now that postantibiotic era where we don’t have the right antibiotics out there to treat our patients."

Clinically speaking, the law could not have come at a more critical point, Dr. Trivedi said. "I personally hear about all the resistant organisms and infections we have in the State of California. And thus far, we have had about 15 infections where we had absolutely no antibiotics that we can treat these patients with. It’s very concerning."

Not only has inappropriate antimicrobial use caused the current problems, but "we don’t have any antibiotics coming down the line that will be able to help those 15 patients of mine in California," she said. There are only 15 or 16 antibiotics currently in development in the United States, and only 8 have any activity against gram-negative bacteria, where resistance patterns are particularly worrisome, she added.

"We are seeing and entering now that postantibiotic era where we don’t have the right antibiotics out there to treat our patients," Dr. Trivedi said at the symposium. "It’s very, very concerning."

The 425 general acute care hospitals in California had 2 years to comply with the law after Gov. Arnold Schwarzenegger signed Senate Bill 739 into law in January 2008. "In this very long Senate bill, there is one sentence that was snuck in at the last minute regarding antimicrobial use. I’m very happy that someone did this," Dr. Trivedi said. The law includes a requirement that "all general acute care hospitals develop a process for evaluating the judicious use of antibiotics, the results of which should be monitored jointly by appropriate representatives and committees involved in quality improvement activities."

"We, and by that I mean the California Department of Public Health, interpret this to mean each California acute care hospital should have an antimicrobial stewardship program," Dr. Trivedi said.

"If they do it appropriately, they are going to decrease health care costs, reduce resistance rates, and improve the number of resistant infections in patients, so overall it’s a ‘win-win.’ "

A meeting attendee questioned how the public health department can help hospitals develop effective programs and, at the same time, punish hospitals that do not comply. "Although this is punitive now, and we are citing hospitals for not having stewardship programs, it is really encouraging hospitals to do the right thing in terms of patient safety and quality. So we do believe in our legislation and are very proud of it," Dr. Trivedi said.

The director of the hospital medicine program at the University of Michigan, Ann Arbor, Dr. Scott A. Flanders, was not convinced about legislation. "I’m reluctant to say that states should mandate [these programs]," he asserted. More research is needed to define the most essential aspects of effective stewardship programs, he said when reached for comment.

"While I applaud efforts to improve antimicrobial use – it’s critically important and hospitals need to prioritize it – I don’t know that legislation is always the best way to do that," Dr. Flanders said. "Many hospitals are resource constrained and are struggling with numerous legislative and nationally imposed mandates. Adding yet another on top of it is a challenge."

Arizona and Minnesota are among other states considering legislation to bolster antimicrobial stewardship, Dr. Trivedi said, but the proposals so far are not as strict as the law in California.

Because of the legislation, California launched its Antimicrobial Stewardship Program Initiative in February 2010. To initially assess the status of stewardship statewide, the health department conducted a web-based survey from May 2010 to March 2011. Responses came from 220 acute care hospitals, for a response rate of 52%. Of these, 167 were community hospitals. Almost half of these community hospitals, 45%, had a stewardship program, and another 31% were planning such an initiative. "A good chunk of our community hospitals ... already had these programs, even before our initiative started to help them," Dr. Trivedi said.

Nearly 128 hospitals, or a quarter of those in the state, said the law influenced them to start a stewardship program, Dr. Trivedi said. "Even though our legislation is very nonspecific, and does not even mention the words ‘stewardship program,’ it really did help the hospital administrations focus on these initiatives and allocate the funding for these programs."

The next step for the health department is to compile and release antimicrobial susceptibility data for 2008, 2009, and 2010, Dr. Trivedi said.

Dr. Trivedi and Dr. Flanders said they had no relevant financial disclosures.

MIAMI BEACH – In the 2 years since California mandated judicious antimicrobial use, more money has poured into antimicrobial stewardship programs to combat inappropriate use, increasing resistance, and the sometimes debilitating adverse effects of these agents.

It is unlikely that hospital administrators would have funded these initiatives to this extent, particularly during a time of constrained budgets, without the law, Dr. Kavita K. Trivedi said.

"California currently is the only state with legislation regarding antimicrobial use. We hope that other states will follow along, especially because we’ve had such a positive experience with our legislation," said Dr. Trivedi, public health medical officer for the California Department of Public Health in Richmond.

"We are seeing and entering now that postantibiotic era where we don’t have the right antibiotics out there to treat our patients."

Clinically speaking, the law could not have come at a more critical point, Dr. Trivedi said. "I personally hear about all the resistant organisms and infections we have in the State of California. And thus far, we have had about 15 infections where we had absolutely no antibiotics that we can treat these patients with. It’s very concerning."

Not only has inappropriate antimicrobial use caused the current problems, but "we don’t have any antibiotics coming down the line that will be able to help those 15 patients of mine in California," she said. There are only 15 or 16 antibiotics currently in development in the United States, and only 8 have any activity against gram-negative bacteria, where resistance patterns are particularly worrisome, she added.

"We are seeing and entering now that postantibiotic era where we don’t have the right antibiotics out there to treat our patients," Dr. Trivedi said at the symposium. "It’s very, very concerning."

The 425 general acute care hospitals in California had 2 years to comply with the law after Gov. Arnold Schwarzenegger signed Senate Bill 739 into law in January 2008. "In this very long Senate bill, there is one sentence that was snuck in at the last minute regarding antimicrobial use. I’m very happy that someone did this," Dr. Trivedi said. The law includes a requirement that "all general acute care hospitals develop a process for evaluating the judicious use of antibiotics, the results of which should be monitored jointly by appropriate representatives and committees involved in quality improvement activities."

"We, and by that I mean the California Department of Public Health, interpret this to mean each California acute care hospital should have an antimicrobial stewardship program," Dr. Trivedi said.

"If they do it appropriately, they are going to decrease health care costs, reduce resistance rates, and improve the number of resistant infections in patients, so overall it’s a ‘win-win.’ "

A meeting attendee questioned how the public health department can help hospitals develop effective programs and, at the same time, punish hospitals that do not comply. "Although this is punitive now, and we are citing hospitals for not having stewardship programs, it is really encouraging hospitals to do the right thing in terms of patient safety and quality. So we do believe in our legislation and are very proud of it," Dr. Trivedi said.

The director of the hospital medicine program at the University of Michigan, Ann Arbor, Dr. Scott A. Flanders, was not convinced about legislation. "I’m reluctant to say that states should mandate [these programs]," he asserted. More research is needed to define the most essential aspects of effective stewardship programs, he said when reached for comment.

"While I applaud efforts to improve antimicrobial use – it’s critically important and hospitals need to prioritize it – I don’t know that legislation is always the best way to do that," Dr. Flanders said. "Many hospitals are resource constrained and are struggling with numerous legislative and nationally imposed mandates. Adding yet another on top of it is a challenge."

Arizona and Minnesota are among other states considering legislation to bolster antimicrobial stewardship, Dr. Trivedi said, but the proposals so far are not as strict as the law in California.

Because of the legislation, California launched its Antimicrobial Stewardship Program Initiative in February 2010. To initially assess the status of stewardship statewide, the health department conducted a web-based survey from May 2010 to March 2011. Responses came from 220 acute care hospitals, for a response rate of 52%. Of these, 167 were community hospitals. Almost half of these community hospitals, 45%, had a stewardship program, and another 31% were planning such an initiative. "A good chunk of our community hospitals ... already had these programs, even before our initiative started to help them," Dr. Trivedi said.

Nearly 128 hospitals, or a quarter of those in the state, said the law influenced them to start a stewardship program, Dr. Trivedi said. "Even though our legislation is very nonspecific, and does not even mention the words ‘stewardship program,’ it really did help the hospital administrations focus on these initiatives and allocate the funding for these programs."

The next step for the health department is to compile and release antimicrobial susceptibility data for 2008, 2009, and 2010, Dr. Trivedi said.

Dr. Trivedi and Dr. Flanders said they had no relevant financial disclosures.

MIAMI BEACH – In the 2 years since California mandated judicious antimicrobial use, more money has poured into antimicrobial stewardship programs to combat inappropriate use, increasing resistance, and the sometimes debilitating adverse effects of these agents.

It is unlikely that hospital administrators would have funded these initiatives to this extent, particularly during a time of constrained budgets, without the law, Dr. Kavita K. Trivedi said.

"California currently is the only state with legislation regarding antimicrobial use. We hope that other states will follow along, especially because we’ve had such a positive experience with our legislation," said Dr. Trivedi, public health medical officer for the California Department of Public Health in Richmond.

"We are seeing and entering now that postantibiotic era where we don’t have the right antibiotics out there to treat our patients."

Clinically speaking, the law could not have come at a more critical point, Dr. Trivedi said. "I personally hear about all the resistant organisms and infections we have in the State of California. And thus far, we have had about 15 infections where we had absolutely no antibiotics that we can treat these patients with. It’s very concerning."

Not only has inappropriate antimicrobial use caused the current problems, but "we don’t have any antibiotics coming down the line that will be able to help those 15 patients of mine in California," she said. There are only 15 or 16 antibiotics currently in development in the United States, and only 8 have any activity against gram-negative bacteria, where resistance patterns are particularly worrisome, she added.

"We are seeing and entering now that postantibiotic era where we don’t have the right antibiotics out there to treat our patients," Dr. Trivedi said at the symposium. "It’s very, very concerning."

The 425 general acute care hospitals in California had 2 years to comply with the law after Gov. Arnold Schwarzenegger signed Senate Bill 739 into law in January 2008. "In this very long Senate bill, there is one sentence that was snuck in at the last minute regarding antimicrobial use. I’m very happy that someone did this," Dr. Trivedi said. The law includes a requirement that "all general acute care hospitals develop a process for evaluating the judicious use of antibiotics, the results of which should be monitored jointly by appropriate representatives and committees involved in quality improvement activities."

"We, and by that I mean the California Department of Public Health, interpret this to mean each California acute care hospital should have an antimicrobial stewardship program," Dr. Trivedi said.

"If they do it appropriately, they are going to decrease health care costs, reduce resistance rates, and improve the number of resistant infections in patients, so overall it’s a ‘win-win.’ "

A meeting attendee questioned how the public health department can help hospitals develop effective programs and, at the same time, punish hospitals that do not comply. "Although this is punitive now, and we are citing hospitals for not having stewardship programs, it is really encouraging hospitals to do the right thing in terms of patient safety and quality. So we do believe in our legislation and are very proud of it," Dr. Trivedi said.

The director of the hospital medicine program at the University of Michigan, Ann Arbor, Dr. Scott A. Flanders, was not convinced about legislation. "I’m reluctant to say that states should mandate [these programs]," he asserted. More research is needed to define the most essential aspects of effective stewardship programs, he said when reached for comment.

"While I applaud efforts to improve antimicrobial use – it’s critically important and hospitals need to prioritize it – I don’t know that legislation is always the best way to do that," Dr. Flanders said. "Many hospitals are resource constrained and are struggling with numerous legislative and nationally imposed mandates. Adding yet another on top of it is a challenge."

Arizona and Minnesota are among other states considering legislation to bolster antimicrobial stewardship, Dr. Trivedi said, but the proposals so far are not as strict as the law in California.

Because of the legislation, California launched its Antimicrobial Stewardship Program Initiative in February 2010. To initially assess the status of stewardship statewide, the health department conducted a web-based survey from May 2010 to March 2011. Responses came from 220 acute care hospitals, for a response rate of 52%. Of these, 167 were community hospitals. Almost half of these community hospitals, 45%, had a stewardship program, and another 31% were planning such an initiative. "A good chunk of our community hospitals ... already had these programs, even before our initiative started to help them," Dr. Trivedi said.

Nearly 128 hospitals, or a quarter of those in the state, said the law influenced them to start a stewardship program, Dr. Trivedi said. "Even though our legislation is very nonspecific, and does not even mention the words ‘stewardship program,’ it really did help the hospital administrations focus on these initiatives and allocate the funding for these programs."

The next step for the health department is to compile and release antimicrobial susceptibility data for 2008, 2009, and 2010, Dr. Trivedi said.

Dr. Trivedi and Dr. Flanders said they had no relevant financial disclosures.

ORLANDO – Obesity significantly lowers a woman's chance of delivering a live birth after in vitro fertilization, according to a retrospective study of more than 4,500 women.

Up to a 68% lower chance for a live birth was the major finding when researchers compared overweight and obese women to those with a normal body mass index (BMI). Women with a BMI greater than 25 kg/m

The live birth rate declined as BMI increased, Dr. Stephanie Jones said. Compared with women with a normal BMI (18.50-24.99), the adjusted odds ratio (OR) for a live birth was 0.96 among overweight women (25-29.99); 0.63 for obesity class I (30-34.99); 0.39 for obesity class II (35-39.99); and 0.32 for those in obesity class III (BMI of 40 kg/m

The clinical message is to counsel patients that even “a modest amount of weight loss might improve IVF success rates,” Dr. Jones said at the meeting.

Dr. Jones and her associates examined outcomes after the first, fresh, autologous procedure for 4,609 women treated at Boston IVF in Brookline, Mass. from 2006 to 2010. Patients were aged 20-45 years.

A secondary outcome, the likelihood of implantation, was significantly different by BMI, compared with those with a normal BMI. Chances dropped for underweight women (BMI less than 18 kg/m

The likelihood of clinical pregnancy dropped only slightly for underweight women (adjusted OR, 0.98). However, it decreased significantly for overweight women (0.90) and for women in obesity class I (0.70), class II (0.41), and class III (0.43).

Interestingly, the miscarriage rate did not differ significantly according to maternal BMI, said Dr. Jones, a third-year resident in the department of obstetrics and gynecology, Beth Israel Deaconess Medical Center, Boston.

The normal-weight reference group included 2,605 patients with a BMI of 18.5-24.99 kg/m

In addition to its large sample size, the single institution design of the study is an advantage, Dr. Jones said. Previous researchers reported an association between increasing obesity and lower IVF success, but most of these studies were small, unadjusted, and focused on pregnancy rates.

“The live birth rate is the outcome most significant to our patients,” she said.

A systematic literature review found a decreased chance of IVF pregnancy (OR, 0.71) for overweight or obese women compared with normal weight women (Hum. Reprod. Update 2007;13:433-44). “But they only compared women in two groups – those with a BMI of 25 or less versus 25 plus,” Dr. Jones said.

In another study reported at the 2009 ASRM meeting, researchers found a lower clinical pregnancy rate and lower birth weights as maternal BMI increased (Hum. Reprod. 2011;26:245-52). This report was multicenter “and they did not necessarily control for differences in provider factors,” she said.

Dr. Jones and her associates also controlled for multiple potential confounders, including maternal age, paternal age, baseline follicle stimulating hormone levels, duration of stimulation, mean daily gonadotropin dose, peak estradiol, number of oocytes retrieved, use of intracytoplasmic sperm injection, embryo quality and number, transfer day, and number of embryos transferred.

ORLANDO – Obesity significantly lowers a woman's chance of delivering a live birth after in vitro fertilization, according to a retrospective study of more than 4,500 women.

Up to a 68% lower chance for a live birth was the major finding when researchers compared overweight and obese women to those with a normal body mass index (BMI). Women with a BMI greater than 25 kg/m

The live birth rate declined as BMI increased, Dr. Stephanie Jones said. Compared with women with a normal BMI (18.50-24.99), the adjusted odds ratio (OR) for a live birth was 0.96 among overweight women (25-29.99); 0.63 for obesity class I (30-34.99); 0.39 for obesity class II (35-39.99); and 0.32 for those in obesity class III (BMI of 40 kg/m

The clinical message is to counsel patients that even “a modest amount of weight loss might improve IVF success rates,” Dr. Jones said at the meeting.

Dr. Jones and her associates examined outcomes after the first, fresh, autologous procedure for 4,609 women treated at Boston IVF in Brookline, Mass. from 2006 to 2010. Patients were aged 20-45 years.

A secondary outcome, the likelihood of implantation, was significantly different by BMI, compared with those with a normal BMI. Chances dropped for underweight women (BMI less than 18 kg/m

The likelihood of clinical pregnancy dropped only slightly for underweight women (adjusted OR, 0.98). However, it decreased significantly for overweight women (0.90) and for women in obesity class I (0.70), class II (0.41), and class III (0.43).

Interestingly, the miscarriage rate did not differ significantly according to maternal BMI, said Dr. Jones, a third-year resident in the department of obstetrics and gynecology, Beth Israel Deaconess Medical Center, Boston.

The normal-weight reference group included 2,605 patients with a BMI of 18.5-24.99 kg/m

In addition to its large sample size, the single institution design of the study is an advantage, Dr. Jones said. Previous researchers reported an association between increasing obesity and lower IVF success, but most of these studies were small, unadjusted, and focused on pregnancy rates.

“The live birth rate is the outcome most significant to our patients,” she said.

A systematic literature review found a decreased chance of IVF pregnancy (OR, 0.71) for overweight or obese women compared with normal weight women (Hum. Reprod. Update 2007;13:433-44). “But they only compared women in two groups – those with a BMI of 25 or less versus 25 plus,” Dr. Jones said.

In another study reported at the 2009 ASRM meeting, researchers found a lower clinical pregnancy rate and lower birth weights as maternal BMI increased (Hum. Reprod. 2011;26:245-52). This report was multicenter “and they did not necessarily control for differences in provider factors,” she said.

Dr. Jones and her associates also controlled for multiple potential confounders, including maternal age, paternal age, baseline follicle stimulating hormone levels, duration of stimulation, mean daily gonadotropin dose, peak estradiol, number of oocytes retrieved, use of intracytoplasmic sperm injection, embryo quality and number, transfer day, and number of embryos transferred.

ORLANDO – Obesity significantly lowers a woman's chance of delivering a live birth after in vitro fertilization, according to a retrospective study of more than 4,500 women.

Up to a 68% lower chance for a live birth was the major finding when researchers compared overweight and obese women to those with a normal body mass index (BMI). Women with a BMI greater than 25 kg/m

The live birth rate declined as BMI increased, Dr. Stephanie Jones said. Compared with women with a normal BMI (18.50-24.99), the adjusted odds ratio (OR) for a live birth was 0.96 among overweight women (25-29.99); 0.63 for obesity class I (30-34.99); 0.39 for obesity class II (35-39.99); and 0.32 for those in obesity class III (BMI of 40 kg/m

The clinical message is to counsel patients that even “a modest amount of weight loss might improve IVF success rates,” Dr. Jones said at the meeting.

Dr. Jones and her associates examined outcomes after the first, fresh, autologous procedure for 4,609 women treated at Boston IVF in Brookline, Mass. from 2006 to 2010. Patients were aged 20-45 years.

A secondary outcome, the likelihood of implantation, was significantly different by BMI, compared with those with a normal BMI. Chances dropped for underweight women (BMI less than 18 kg/m

The likelihood of clinical pregnancy dropped only slightly for underweight women (adjusted OR, 0.98). However, it decreased significantly for overweight women (0.90) and for women in obesity class I (0.70), class II (0.41), and class III (0.43).

Interestingly, the miscarriage rate did not differ significantly according to maternal BMI, said Dr. Jones, a third-year resident in the department of obstetrics and gynecology, Beth Israel Deaconess Medical Center, Boston.

The normal-weight reference group included 2,605 patients with a BMI of 18.5-24.99 kg/m

In addition to its large sample size, the single institution design of the study is an advantage, Dr. Jones said. Previous researchers reported an association between increasing obesity and lower IVF success, but most of these studies were small, unadjusted, and focused on pregnancy rates.

“The live birth rate is the outcome most significant to our patients,” she said.

A systematic literature review found a decreased chance of IVF pregnancy (OR, 0.71) for overweight or obese women compared with normal weight women (Hum. Reprod. Update 2007;13:433-44). “But they only compared women in two groups – those with a BMI of 25 or less versus 25 plus,” Dr. Jones said.

In another study reported at the 2009 ASRM meeting, researchers found a lower clinical pregnancy rate and lower birth weights as maternal BMI increased (Hum. Reprod. 2011;26:245-52). This report was multicenter “and they did not necessarily control for differences in provider factors,” she said.

Dr. Jones and her associates also controlled for multiple potential confounders, including maternal age, paternal age, baseline follicle stimulating hormone levels, duration of stimulation, mean daily gonadotropin dose, peak estradiol, number of oocytes retrieved, use of intracytoplasmic sperm injection, embryo quality and number, transfer day, and number of embryos transferred.

ORLANDO – Good perioperative outcomes result when women undergo a total vaginal approach to hysterectomy in an outpatient setting, according to a case series of more than 1,000 such surgeries.

“Vaginal hysterectomy can be successfully adapted for outpatient surgery centers,” Dr. Mark A. Zakaria said. “In this select patient population, regardless of previous pelvic surgery or nulliparity, and even in cases with larger uteri, good perioperative outcomes have been achieved.”

Dr. Zakaria and his associates retrospectively reviewed 1,162 consecutive women who underwent hysterectomy from 2000 to 2010 by a single surgeon. A total of 1,071, or 92%, were total vaginal hysterectomies, and their outcomes were studied further. The current research is an update to a 2005 study of outcomes in the first 412 patients (J. Minim. Invasive Gynecol. 2005;12:494-501).

Approximately 600,000 hysterectomies are performed annually in the United States, according to the Centers for Disease Control and Prevention. At the time of the 2005 study, approximately two-thirds of hysterectomies were done through an open, abdominal incision, Dr. Zakaria said at the meeting. “Vaginal hysterectomy has been shown to be safely adapted as an outpatient procedure. Both the American College of Obstetrics and Gynecology and the AAGL support vaginal hysterectomy as a preferred, minimally invasive mode of hysterectomy.”

The current study supports a vaginal approach, Dr. Zakaria said, with its mean operative time of 40 minutes, mean estimated blood loss of 63 mL, and same-day discharge for 96% of patients.

Although many women in the series had concurrent procedures, researchers focused only on the hysterectomy portion of surgery, from incision of the mucosa to the close of the vaginal cuff, Dr. Zakaria said in response to a meeting attendee's question. Dr. Zakaria is a minimally invasive gynecologic surgery fellow at the University of South Florida, Tampa.

All women had hysterectomies for benign indications, including dysfunctional uterine bleeding, pelvic organ prolapse, fibroids, pelvic pain, and carcinoma-in-situ of the cervix.

Preoperative and postoperative care was standardized.

For example, all patients received preoperative counseling, pre-emptive analgesia, and deep vein thrombosis prophylaxis. In addition, they had active pain control during recovery and intensive postoperative surveillance, including daily telephone calls up to 7 days post surgery.

The researchers reviewed potential confounders including age, uterine weight, nulliparity, and prior pelvic surgery. Mean patient age was 47 years. The mean uterine weight was 230 g.

“Of note, 30% of these cases had greater than 250-g uteri, and 17 out of the 1,071 were greater than 1,000 g,” Dr. Zakaria said.

A total 193 women were nulliparous and 281 had prior pelvic surgery. Four patients were readmitted after surgery, for a rate of 0.4%.

All surgeries were performed by Dr. Barbara Levy, coauthor of the current research and lead investigator for the 2005 report. Dr. Levy is a gynecologist at St. Francis Hospital in Federal Way, Wash.

Prospective studies in the outpatient setting are needed to further compare minimally invasive hysterectomy approaches, Dr. Zakaria said.

ORLANDO – Good perioperative outcomes result when women undergo a total vaginal approach to hysterectomy in an outpatient setting, according to a case series of more than 1,000 such surgeries.

“Vaginal hysterectomy can be successfully adapted for outpatient surgery centers,” Dr. Mark A. Zakaria said. “In this select patient population, regardless of previous pelvic surgery or nulliparity, and even in cases with larger uteri, good perioperative outcomes have been achieved.”

Dr. Zakaria and his associates retrospectively reviewed 1,162 consecutive women who underwent hysterectomy from 2000 to 2010 by a single surgeon. A total of 1,071, or 92%, were total vaginal hysterectomies, and their outcomes were studied further. The current research is an update to a 2005 study of outcomes in the first 412 patients (J. Minim. Invasive Gynecol. 2005;12:494-501).

Approximately 600,000 hysterectomies are performed annually in the United States, according to the Centers for Disease Control and Prevention. At the time of the 2005 study, approximately two-thirds of hysterectomies were done through an open, abdominal incision, Dr. Zakaria said at the meeting. “Vaginal hysterectomy has been shown to be safely adapted as an outpatient procedure. Both the American College of Obstetrics and Gynecology and the AAGL support vaginal hysterectomy as a preferred, minimally invasive mode of hysterectomy.”

The current study supports a vaginal approach, Dr. Zakaria said, with its mean operative time of 40 minutes, mean estimated blood loss of 63 mL, and same-day discharge for 96% of patients.

Although many women in the series had concurrent procedures, researchers focused only on the hysterectomy portion of surgery, from incision of the mucosa to the close of the vaginal cuff, Dr. Zakaria said in response to a meeting attendee's question. Dr. Zakaria is a minimally invasive gynecologic surgery fellow at the University of South Florida, Tampa.

All women had hysterectomies for benign indications, including dysfunctional uterine bleeding, pelvic organ prolapse, fibroids, pelvic pain, and carcinoma-in-situ of the cervix.

Preoperative and postoperative care was standardized.

For example, all patients received preoperative counseling, pre-emptive analgesia, and deep vein thrombosis prophylaxis. In addition, they had active pain control during recovery and intensive postoperative surveillance, including daily telephone calls up to 7 days post surgery.

The researchers reviewed potential confounders including age, uterine weight, nulliparity, and prior pelvic surgery. Mean patient age was 47 years. The mean uterine weight was 230 g.

“Of note, 30% of these cases had greater than 250-g uteri, and 17 out of the 1,071 were greater than 1,000 g,” Dr. Zakaria said.

A total 193 women were nulliparous and 281 had prior pelvic surgery. Four patients were readmitted after surgery, for a rate of 0.4%.

All surgeries were performed by Dr. Barbara Levy, coauthor of the current research and lead investigator for the 2005 report. Dr. Levy is a gynecologist at St. Francis Hospital in Federal Way, Wash.

Prospective studies in the outpatient setting are needed to further compare minimally invasive hysterectomy approaches, Dr. Zakaria said.

ORLANDO – Good perioperative outcomes result when women undergo a total vaginal approach to hysterectomy in an outpatient setting, according to a case series of more than 1,000 such surgeries.

“Vaginal hysterectomy can be successfully adapted for outpatient surgery centers,” Dr. Mark A. Zakaria said. “In this select patient population, regardless of previous pelvic surgery or nulliparity, and even in cases with larger uteri, good perioperative outcomes have been achieved.”

Dr. Zakaria and his associates retrospectively reviewed 1,162 consecutive women who underwent hysterectomy from 2000 to 2010 by a single surgeon. A total of 1,071, or 92%, were total vaginal hysterectomies, and their outcomes were studied further. The current research is an update to a 2005 study of outcomes in the first 412 patients (J. Minim. Invasive Gynecol. 2005;12:494-501).

Approximately 600,000 hysterectomies are performed annually in the United States, according to the Centers for Disease Control and Prevention. At the time of the 2005 study, approximately two-thirds of hysterectomies were done through an open, abdominal incision, Dr. Zakaria said at the meeting. “Vaginal hysterectomy has been shown to be safely adapted as an outpatient procedure. Both the American College of Obstetrics and Gynecology and the AAGL support vaginal hysterectomy as a preferred, minimally invasive mode of hysterectomy.”

The current study supports a vaginal approach, Dr. Zakaria said, with its mean operative time of 40 minutes, mean estimated blood loss of 63 mL, and same-day discharge for 96% of patients.

Although many women in the series had concurrent procedures, researchers focused only on the hysterectomy portion of surgery, from incision of the mucosa to the close of the vaginal cuff, Dr. Zakaria said in response to a meeting attendee's question. Dr. Zakaria is a minimally invasive gynecologic surgery fellow at the University of South Florida, Tampa.

All women had hysterectomies for benign indications, including dysfunctional uterine bleeding, pelvic organ prolapse, fibroids, pelvic pain, and carcinoma-in-situ of the cervix.

Preoperative and postoperative care was standardized.

For example, all patients received preoperative counseling, pre-emptive analgesia, and deep vein thrombosis prophylaxis. In addition, they had active pain control during recovery and intensive postoperative surveillance, including daily telephone calls up to 7 days post surgery.

The researchers reviewed potential confounders including age, uterine weight, nulliparity, and prior pelvic surgery. Mean patient age was 47 years. The mean uterine weight was 230 g.

“Of note, 30% of these cases had greater than 250-g uteri, and 17 out of the 1,071 were greater than 1,000 g,” Dr. Zakaria said.

A total 193 women were nulliparous and 281 had prior pelvic surgery. Four patients were readmitted after surgery, for a rate of 0.4%.

All surgeries were performed by Dr. Barbara Levy, coauthor of the current research and lead investigator for the 2005 report. Dr. Levy is a gynecologist at St. Francis Hospital in Federal Way, Wash.

Prospective studies in the outpatient setting are needed to further compare minimally invasive hysterectomy approaches, Dr. Zakaria said.

HOLLYWOOD, FLA. – Researchers report a good correlation between hysteroscopy and histopathology in the diagnosis of endometrial cancer among women with postmenopausal bleeding.

An estimated 10%-15% of patients with postmenopausal bleeding have endometrial cancer. “In Brazil, this is the eighth most frequent tumor [type],” said Dr. Raquel P. Dibi, a gynecologist at Complexo Hospitalar Santa Casa de Porto Alegre, a teaching hospital in Porto Alegre, Rio Grande do Sul, Brazil.

Dr. Dibi and her associates compared hysteroscopy and biopsy histopathology findings for 507 patients with postmenopausal bleeding. Hysteroscopy identified 41 (8%) cases suggestive of endometrial cancer, and histology confirmed 30 of these (73%). Hysteroscopy for the diagnosis of endometrial cancer was associated with 94% sensitivity, 98% specificity, a 73% positive predictive value, and a 99.6% negative predictive value.

“A good correlation was observed between hysteroscopy and histological findings,” Dr. Dibi said at the meeting.

With hysteroscopy, the most common findings were endometrial polyps (40%) and atrophic endometrium (34%). With histopathology, almost half of reports came back designated “absent material” (47%); the most common findings also were endometrial polyps (17%) and atrophic endometrium (5%).

“Hysteroscopy has demonstrated efficacy for diagnosis of endometrial cancer, agreeing with studies published by other authors,” Dr. Dibi said.

Patients ranged in age from 43 to 85 years. The mean age at time of menopause was 48 years. The median time since menopause was 9 years in this study.

HOLLYWOOD, FLA. – Researchers report a good correlation between hysteroscopy and histopathology in the diagnosis of endometrial cancer among women with postmenopausal bleeding.

An estimated 10%-15% of patients with postmenopausal bleeding have endometrial cancer. “In Brazil, this is the eighth most frequent tumor [type],” said Dr. Raquel P. Dibi, a gynecologist at Complexo Hospitalar Santa Casa de Porto Alegre, a teaching hospital in Porto Alegre, Rio Grande do Sul, Brazil.

Dr. Dibi and her associates compared hysteroscopy and biopsy histopathology findings for 507 patients with postmenopausal bleeding. Hysteroscopy identified 41 (8%) cases suggestive of endometrial cancer, and histology confirmed 30 of these (73%). Hysteroscopy for the diagnosis of endometrial cancer was associated with 94% sensitivity, 98% specificity, a 73% positive predictive value, and a 99.6% negative predictive value.

“A good correlation was observed between hysteroscopy and histological findings,” Dr. Dibi said at the meeting.

With hysteroscopy, the most common findings were endometrial polyps (40%) and atrophic endometrium (34%). With histopathology, almost half of reports came back designated “absent material” (47%); the most common findings also were endometrial polyps (17%) and atrophic endometrium (5%).

“Hysteroscopy has demonstrated efficacy for diagnosis of endometrial cancer, agreeing with studies published by other authors,” Dr. Dibi said.

Patients ranged in age from 43 to 85 years. The mean age at time of menopause was 48 years. The median time since menopause was 9 years in this study.

HOLLYWOOD, FLA. – Researchers report a good correlation between hysteroscopy and histopathology in the diagnosis of endometrial cancer among women with postmenopausal bleeding.

An estimated 10%-15% of patients with postmenopausal bleeding have endometrial cancer. “In Brazil, this is the eighth most frequent tumor [type],” said Dr. Raquel P. Dibi, a gynecologist at Complexo Hospitalar Santa Casa de Porto Alegre, a teaching hospital in Porto Alegre, Rio Grande do Sul, Brazil.

Dr. Dibi and her associates compared hysteroscopy and biopsy histopathology findings for 507 patients with postmenopausal bleeding. Hysteroscopy identified 41 (8%) cases suggestive of endometrial cancer, and histology confirmed 30 of these (73%). Hysteroscopy for the diagnosis of endometrial cancer was associated with 94% sensitivity, 98% specificity, a 73% positive predictive value, and a 99.6% negative predictive value.

“A good correlation was observed between hysteroscopy and histological findings,” Dr. Dibi said at the meeting.

With hysteroscopy, the most common findings were endometrial polyps (40%) and atrophic endometrium (34%). With histopathology, almost half of reports came back designated “absent material” (47%); the most common findings also were endometrial polyps (17%) and atrophic endometrium (5%).

“Hysteroscopy has demonstrated efficacy for diagnosis of endometrial cancer, agreeing with studies published by other authors,” Dr. Dibi said.

Patients ranged in age from 43 to 85 years. The mean age at time of menopause was 48 years. The median time since menopause was 9 years in this study.

HOLLYWOOD, FLA. – Robotic-assisted hysterectomy takes significantly more operating room time and surgical time compared with a laparoscopic approach, according to the first randomized controlled trial to confirm what many already suspect about these two minimally invasive techniques.

Uterine weight, hospital length of stay, and rates of short- or long-term complications, in contrast, did not significantly differ between the 26 women randomized to robotic-assisted total laparoscopic hysterectomy and the 27 randomized to total laparoscopic hysterectomy. In addition, researchers found no significant differences between pain scores or the mean time for these women to return to activities.

“Robotic assistance results in longer OR times,” Dr. Marie Fidela Paraiso said at the meeting.

Operative time was the main outcome of the study. Mean time in the operating room was 246 minutes in the robotic group versus 172 minutes in the laparoscopic patients. Mean case time, or time from incision to closure of the hysterectomy, was 173 minutes in the robotic group versus 103 minutes in the laparoscopy group.

“There were no differences in intraoperative or postoperative complications between groups,” Dr. Paraiso said. Similarly, estimated blood loss and postoperative hematocrit findings did not differ significantly between groups. Follow-up was at 6 weeks and 6 months.

Although there were no differences in length of stay by surgical approach, patients whose surgeries lasted more than 185 minutes had a significantly longer hospital stay than did patients with shorter surgeries, said Dr. Paraiso, head of the Center for Urogynecology and Reconstructive Pelvic Surgery and staff physician in the department of obstetrics and gynecology at the Cleveland Clinic.

Dr. Paraiso and her colleagues also assessed functional status and quality of life using the Short Form −36 and pain using visual analog scales at baseline and postoperatively. “There were no differences in pain between groups on postoperative visual analog scales.”

She also assessed the economics of the robotic-assisted versus laparoscopic cases in the study, but the data were still being analyzed at press time.

The randomized clinical trial design and inclusion of hospital parameters were strengths of the study, Dr. Paraiso said. “There are currently no randomized controlled trials in the gynecologic literature comparing robotic versus conventional hysterectomy.”

Limitations included the small number of participants, a limited follow-up time, and a question about the generalizability of the findings to other institutions, she said.

The study included adult women who had hysterectomy for a benign indication and who desired laparoscopic management. Mean age was 45 years and mean body mass index was 31 kg/m

HOLLYWOOD, FLA. – Robotic-assisted hysterectomy takes significantly more operating room time and surgical time compared with a laparoscopic approach, according to the first randomized controlled trial to confirm what many already suspect about these two minimally invasive techniques.

Uterine weight, hospital length of stay, and rates of short- or long-term complications, in contrast, did not significantly differ between the 26 women randomized to robotic-assisted total laparoscopic hysterectomy and the 27 randomized to total laparoscopic hysterectomy. In addition, researchers found no significant differences between pain scores or the mean time for these women to return to activities.

“Robotic assistance results in longer OR times,” Dr. Marie Fidela Paraiso said at the meeting.

Operative time was the main outcome of the study. Mean time in the operating room was 246 minutes in the robotic group versus 172 minutes in the laparoscopic patients. Mean case time, or time from incision to closure of the hysterectomy, was 173 minutes in the robotic group versus 103 minutes in the laparoscopy group.

“There were no differences in intraoperative or postoperative complications between groups,” Dr. Paraiso said. Similarly, estimated blood loss and postoperative hematocrit findings did not differ significantly between groups. Follow-up was at 6 weeks and 6 months.

Although there were no differences in length of stay by surgical approach, patients whose surgeries lasted more than 185 minutes had a significantly longer hospital stay than did patients with shorter surgeries, said Dr. Paraiso, head of the Center for Urogynecology and Reconstructive Pelvic Surgery and staff physician in the department of obstetrics and gynecology at the Cleveland Clinic.

Dr. Paraiso and her colleagues also assessed functional status and quality of life using the Short Form −36 and pain using visual analog scales at baseline and postoperatively. “There were no differences in pain between groups on postoperative visual analog scales.”

She also assessed the economics of the robotic-assisted versus laparoscopic cases in the study, but the data were still being analyzed at press time.

The randomized clinical trial design and inclusion of hospital parameters were strengths of the study, Dr. Paraiso said. “There are currently no randomized controlled trials in the gynecologic literature comparing robotic versus conventional hysterectomy.”

Limitations included the small number of participants, a limited follow-up time, and a question about the generalizability of the findings to other institutions, she said.

The study included adult women who had hysterectomy for a benign indication and who desired laparoscopic management. Mean age was 45 years and mean body mass index was 31 kg/m

HOLLYWOOD, FLA. – Robotic-assisted hysterectomy takes significantly more operating room time and surgical time compared with a laparoscopic approach, according to the first randomized controlled trial to confirm what many already suspect about these two minimally invasive techniques.

Uterine weight, hospital length of stay, and rates of short- or long-term complications, in contrast, did not significantly differ between the 26 women randomized to robotic-assisted total laparoscopic hysterectomy and the 27 randomized to total laparoscopic hysterectomy. In addition, researchers found no significant differences between pain scores or the mean time for these women to return to activities.

“Robotic assistance results in longer OR times,” Dr. Marie Fidela Paraiso said at the meeting.

Operative time was the main outcome of the study. Mean time in the operating room was 246 minutes in the robotic group versus 172 minutes in the laparoscopic patients. Mean case time, or time from incision to closure of the hysterectomy, was 173 minutes in the robotic group versus 103 minutes in the laparoscopy group.

“There were no differences in intraoperative or postoperative complications between groups,” Dr. Paraiso said. Similarly, estimated blood loss and postoperative hematocrit findings did not differ significantly between groups. Follow-up was at 6 weeks and 6 months.

Although there were no differences in length of stay by surgical approach, patients whose surgeries lasted more than 185 minutes had a significantly longer hospital stay than did patients with shorter surgeries, said Dr. Paraiso, head of the Center for Urogynecology and Reconstructive Pelvic Surgery and staff physician in the department of obstetrics and gynecology at the Cleveland Clinic.

Dr. Paraiso and her colleagues also assessed functional status and quality of life using the Short Form −36 and pain using visual analog scales at baseline and postoperatively. “There were no differences in pain between groups on postoperative visual analog scales.”

She also assessed the economics of the robotic-assisted versus laparoscopic cases in the study, but the data were still being analyzed at press time.

The randomized clinical trial design and inclusion of hospital parameters were strengths of the study, Dr. Paraiso said. “There are currently no randomized controlled trials in the gynecologic literature comparing robotic versus conventional hysterectomy.”

Limitations included the small number of participants, a limited follow-up time, and a question about the generalizability of the findings to other institutions, she said.

The study included adult women who had hysterectomy for a benign indication and who desired laparoscopic management. Mean age was 45 years and mean body mass index was 31 kg/m

HOLLYWOOD, FLA. – Surgical outcomes of robotic-assisted hysterectomy did not differ significantly for women whether they were nonobese, obese, or morbidly obese, in a study of 442 women classified according to body mass index.

“Our findings reiterate the safety of robotic hysterectomy for the obese and morbidly obese patients,” Dr. Taryn Gallo said. “As minimally invasive surgeons, we know every day we are facing bigger and bigger patients. You can't underestimate the value of being able to offer these women a minimally invasive approach and sending them home the next day.”

Approximately 34% of U.S. women are obese with a body mass index (BMI) of 30 kg/m

Difficulty obtaining pneumoperitoneum secondary to preperitoneal fat, difficulty ventilating these women in steep Trendelenburg position, and difficulty gaining adequate exposure during surgery are among the challenges in this patient population, she added.

“In the gynecologic literature, few studies have addressed robotic surgery for the morbidly obese patient,” Dr. Gallo said. So she and her colleagues retrospectively studied women who underwent robotic-assisted hysterectomy over a 4-year period in a single surgeon teaching practice. Dr. Masoud Azodi, the senior author and surgeon in this study, is director of the minimally invasive gynecologic surgery (MIGS) fellowship program at Yale University, New Haven.

A total of 58% of the 442 women were obese or morbidly obese, said Dr. Gallo, a gynecologist in private practice in Sebastian, Fla. She was a minimally invasive gynecologic surgery fellow at Bridgeport Hospital/Yale New Haven Health System in Connecticut at the time of the study.

“All BMI groups had similar outcomes,” Dr. Gallo said. Median operative times, estimated blood loss, length of stay, and complication rates did not differ significantly among the nonobese women (BMI less than 30 kg/m

Median operative time for the entire cohort from skin incision to skin closure was 135 minutes. This included time for any concomitant procedures, such as lymphadenectomy or pelvic floor repair, she said. Median operative time by BMI group was similar: 141 minutes for the nonobese group, 135 minutes for the obese women, and 124 minutes for the morbidly obese.

Three patients, one in each BMI group, were converted to laparotomy, for an overall rate of 0.7%.

Median estimated blood loss overall and in each BMI group was 100 mL. Median length of hospital stay of 1 day, likewise, was the same overall and in each group.

The overall complication rate in the study was 12%. This figure includes a major complication rate of 4% (readmissions, reoperations) and a minor complication rate of 8%. “By BMI group, the complications – major, minor, or total – these did not differ,” Dr. Gallo said.

Urinary complications affected 11 women (2.6%), including 1% who had bladder injuries recognized and repaired intraoperatively and 1.6% who had ureteral injuries. Two women with ureteral injuries were repaired with stenting, and four others required subsequent ureteral reimplantation, she said.

Bowel injuries occurred in six patients. Four cases were recognized and repaired intraoperatively, and two women required reoperation and bowel resection.

The remainder of the complications in the study occurred less than 1% of the time. One patient, in the nonobese BMI group, had a vaginal cuff dehiscence, for an overall rate of 0.2% in the study.

Patient demographics were similar between groups. For example, the median age was 51 years in the nonobese, 55 years in the obese, and 54 years in the morbidly obese groups. Women underwent hysterectomy for benign and malignant indications, including early endometrial cancer, early cervical cancer, and occult ovarian cancer.

The retrospective design of the study is a limitation, Dr. Gallo said, and no absolute conclusions can be drawn. “Also, our study was not adequately powered. We would have required more than 4,300 patients to detect a difference in operative time between BMI groups with a power of 80%.”

She added, “Our study may not be generalizable to other surgeons or other institutions – this was a single surgeon with a high surgical volume and extensive experience in laparoscopic and robotic surgery.

“Despite these limitations, we believe our study offers clinically relevant information pertaining to the growing number of obese patients that will be faced by minimally invasive surgeons,” she said.

Assessment of costs associated with robotic-assisted hysterectomy was outside the scope of this study.

HOLLYWOOD, FLA. – Surgical outcomes of robotic-assisted hysterectomy did not differ significantly for women whether they were nonobese, obese, or morbidly obese, in a study of 442 women classified according to body mass index.

“Our findings reiterate the safety of robotic hysterectomy for the obese and morbidly obese patients,” Dr. Taryn Gallo said. “As minimally invasive surgeons, we know every day we are facing bigger and bigger patients. You can't underestimate the value of being able to offer these women a minimally invasive approach and sending them home the next day.”

Approximately 34% of U.S. women are obese with a body mass index (BMI) of 30 kg/m

Difficulty obtaining pneumoperitoneum secondary to preperitoneal fat, difficulty ventilating these women in steep Trendelenburg position, and difficulty gaining adequate exposure during surgery are among the challenges in this patient population, she added.

“In the gynecologic literature, few studies have addressed robotic surgery for the morbidly obese patient,” Dr. Gallo said. So she and her colleagues retrospectively studied women who underwent robotic-assisted hysterectomy over a 4-year period in a single surgeon teaching practice. Dr. Masoud Azodi, the senior author and surgeon in this study, is director of the minimally invasive gynecologic surgery (MIGS) fellowship program at Yale University, New Haven.

A total of 58% of the 442 women were obese or morbidly obese, said Dr. Gallo, a gynecologist in private practice in Sebastian, Fla. She was a minimally invasive gynecologic surgery fellow at Bridgeport Hospital/Yale New Haven Health System in Connecticut at the time of the study.

“All BMI groups had similar outcomes,” Dr. Gallo said. Median operative times, estimated blood loss, length of stay, and complication rates did not differ significantly among the nonobese women (BMI less than 30 kg/m

Median operative time for the entire cohort from skin incision to skin closure was 135 minutes. This included time for any concomitant procedures, such as lymphadenectomy or pelvic floor repair, she said. Median operative time by BMI group was similar: 141 minutes for the nonobese group, 135 minutes for the obese women, and 124 minutes for the morbidly obese.

Three patients, one in each BMI group, were converted to laparotomy, for an overall rate of 0.7%.

Median estimated blood loss overall and in each BMI group was 100 mL. Median length of hospital stay of 1 day, likewise, was the same overall and in each group.

The overall complication rate in the study was 12%. This figure includes a major complication rate of 4% (readmissions, reoperations) and a minor complication rate of 8%. “By BMI group, the complications – major, minor, or total – these did not differ,” Dr. Gallo said.

Urinary complications affected 11 women (2.6%), including 1% who had bladder injuries recognized and repaired intraoperatively and 1.6% who had ureteral injuries. Two women with ureteral injuries were repaired with stenting, and four others required subsequent ureteral reimplantation, she said.

Bowel injuries occurred in six patients. Four cases were recognized and repaired intraoperatively, and two women required reoperation and bowel resection.

The remainder of the complications in the study occurred less than 1% of the time. One patient, in the nonobese BMI group, had a vaginal cuff dehiscence, for an overall rate of 0.2% in the study.

Patient demographics were similar between groups. For example, the median age was 51 years in the nonobese, 55 years in the obese, and 54 years in the morbidly obese groups. Women underwent hysterectomy for benign and malignant indications, including early endometrial cancer, early cervical cancer, and occult ovarian cancer.

The retrospective design of the study is a limitation, Dr. Gallo said, and no absolute conclusions can be drawn. “Also, our study was not adequately powered. We would have required more than 4,300 patients to detect a difference in operative time between BMI groups with a power of 80%.”

She added, “Our study may not be generalizable to other surgeons or other institutions – this was a single surgeon with a high surgical volume and extensive experience in laparoscopic and robotic surgery.

“Despite these limitations, we believe our study offers clinically relevant information pertaining to the growing number of obese patients that will be faced by minimally invasive surgeons,” she said.

Assessment of costs associated with robotic-assisted hysterectomy was outside the scope of this study.

HOLLYWOOD, FLA. – Surgical outcomes of robotic-assisted hysterectomy did not differ significantly for women whether they were nonobese, obese, or morbidly obese, in a study of 442 women classified according to body mass index.

“Our findings reiterate the safety of robotic hysterectomy for the obese and morbidly obese patients,” Dr. Taryn Gallo said. “As minimally invasive surgeons, we know every day we are facing bigger and bigger patients. You can't underestimate the value of being able to offer these women a minimally invasive approach and sending them home the next day.”

Approximately 34% of U.S. women are obese with a body mass index (BMI) of 30 kg/m

Difficulty obtaining pneumoperitoneum secondary to preperitoneal fat, difficulty ventilating these women in steep Trendelenburg position, and difficulty gaining adequate exposure during surgery are among the challenges in this patient population, she added.

“In the gynecologic literature, few studies have addressed robotic surgery for the morbidly obese patient,” Dr. Gallo said. So she and her colleagues retrospectively studied women who underwent robotic-assisted hysterectomy over a 4-year period in a single surgeon teaching practice. Dr. Masoud Azodi, the senior author and surgeon in this study, is director of the minimally invasive gynecologic surgery (MIGS) fellowship program at Yale University, New Haven.

A total of 58% of the 442 women were obese or morbidly obese, said Dr. Gallo, a gynecologist in private practice in Sebastian, Fla. She was a minimally invasive gynecologic surgery fellow at Bridgeport Hospital/Yale New Haven Health System in Connecticut at the time of the study.

“All BMI groups had similar outcomes,” Dr. Gallo said. Median operative times, estimated blood loss, length of stay, and complication rates did not differ significantly among the nonobese women (BMI less than 30 kg/m

Median operative time for the entire cohort from skin incision to skin closure was 135 minutes. This included time for any concomitant procedures, such as lymphadenectomy or pelvic floor repair, she said. Median operative time by BMI group was similar: 141 minutes for the nonobese group, 135 minutes for the obese women, and 124 minutes for the morbidly obese.

Three patients, one in each BMI group, were converted to laparotomy, for an overall rate of 0.7%.

Median estimated blood loss overall and in each BMI group was 100 mL. Median length of hospital stay of 1 day, likewise, was the same overall and in each group.

The overall complication rate in the study was 12%. This figure includes a major complication rate of 4% (readmissions, reoperations) and a minor complication rate of 8%. “By BMI group, the complications – major, minor, or total – these did not differ,” Dr. Gallo said.

Urinary complications affected 11 women (2.6%), including 1% who had bladder injuries recognized and repaired intraoperatively and 1.6% who had ureteral injuries. Two women with ureteral injuries were repaired with stenting, and four others required subsequent ureteral reimplantation, she said.

Bowel injuries occurred in six patients. Four cases were recognized and repaired intraoperatively, and two women required reoperation and bowel resection.

The remainder of the complications in the study occurred less than 1% of the time. One patient, in the nonobese BMI group, had a vaginal cuff dehiscence, for an overall rate of 0.2% in the study.

Patient demographics were similar between groups. For example, the median age was 51 years in the nonobese, 55 years in the obese, and 54 years in the morbidly obese groups. Women underwent hysterectomy for benign and malignant indications, including early endometrial cancer, early cervical cancer, and occult ovarian cancer.

The retrospective design of the study is a limitation, Dr. Gallo said, and no absolute conclusions can be drawn. “Also, our study was not adequately powered. We would have required more than 4,300 patients to detect a difference in operative time between BMI groups with a power of 80%.”

She added, “Our study may not be generalizable to other surgeons or other institutions – this was a single surgeon with a high surgical volume and extensive experience in laparoscopic and robotic surgery.

“Despite these limitations, we believe our study offers clinically relevant information pertaining to the growing number of obese patients that will be faced by minimally invasive surgeons,” she said.

Assessment of costs associated with robotic-assisted hysterectomy was outside the scope of this study.

HOLLYWOOD, FLA.–Women who undergo hysterectomy via one of three surgical approaches experience similar outcomes, with one caveat, according to findings of a retrospective study.

The caveat is that the 94 women who underwent robotic-assisted laparoscopic hysterectomy experienced unique adverse events: four vaginal cuff infections and two vaginal cuff separations. These unfavorable outcomes were not experienced by the 97 women who had total abdominal hysterectomy or another 96 who underwent vaginal hysterectomy.

The cuff separations each occurred 2-3 weeks postoperatively and the women presented with vaginal bleeding. Neither case was associated with early postoperative sexual intercourse.

“Excluding our vaginal cuff complications, we believe robotic hysterectomy offers a safe alternative to the abdominal route,” Dr. Corey A. Wagner said at the meeting. Prevention of vaginal cuff complications “would reduce this major complication rate to the same level seen with vaginal hysterectomy [from 10% down to 3%].”

“At the initiation of our study, robotic hysterectomy had been directly compared with laparoscopic hysterectomy, and had been shown to allow for similar outcomes. However, the purpose of the robotic hysterectomy is not to replace the laparoscopic but rather to replace the abdominal group,” said Dr. Wagner, a gynecologist at St. Elizabeth Medical Center in Utica, N.Y.

So Dr. Wagner and his associates compared all three approaches. Determination of the safety of robotic hysterectomy as an alternative to the abdominal approach was the primary aim, said Dr. Wagner, who conducted the study while affiliated with St. John's Mercy Hospital, a community hospital in St. Louis, Mo.

The primary end point was major complications, which included readmission to the hospital, unexpected return to the operating room, or unanticipated transfusion. The rates for all major complications did not differ significantly (9.6% of the robotic group, 8.2% of the abdominal group, and 3.1% of the vaginal hysterectomy patients). Similar trends were seen for minor complications, Dr. Wagner said. In contrast, the differences in rates for any complication were significant (16% in the robotic, 14% in the abdominal, and 6% in the vaginal hysterectomy groups). Records were reviewed a minimum of 160 days post surgery.

Procedure time was longer in the robotic surgery group at a mean 168 minutes, compared with 99 minutes in the abdominal surgery patients and 69 minutes for the vaginal hysterectomy surgeries. Estimated blood loss was significantly lower in the robotic group at 101 mL, compared with 187 mL in the abdominal surgery group and 157 mL in the vaginal hysterectomy cohort.

Length of stay was a mean 1.1 days in the robotic cohort, 2.4 in the abdominal route patients, and 1.2 days among the vaginal surgery patients. Hospital stay was significantly longer in the abdominal surgery group, compared with the other two. Financial differences among the robotic, abdominal, and vaginal approaches to hysterectomy were not assessed in this study, Dr. Wagner said when contacted for additional information.

Further evaluation of vaginal cuff complications is warranted. Specifically, Dr. Wagner would like to determine the role, if any, of use of barbed sutures. Of the 28 cases that involved barbed sutures, 4 (14%) developed a cuff complication, compared with 2 of 63 (3%) cases that involved conventional sutures. Medical risk factors that patients bring with them to the operating room, the use of electrosurgery for colpotomies (unique to the robotic cohort), and the impact of robotic surgeon experience on complication rates are other areas of potential future study, he added.

Dr. Wagner said that he and his coauthors had no relevant financial disclosures.

HOLLYWOOD, FLA.–Women who undergo hysterectomy via one of three surgical approaches experience similar outcomes, with one caveat, according to findings of a retrospective study.

The caveat is that the 94 women who underwent robotic-assisted laparoscopic hysterectomy experienced unique adverse events: four vaginal cuff infections and two vaginal cuff separations. These unfavorable outcomes were not experienced by the 97 women who had total abdominal hysterectomy or another 96 who underwent vaginal hysterectomy.

The cuff separations each occurred 2-3 weeks postoperatively and the women presented with vaginal bleeding. Neither case was associated with early postoperative sexual intercourse.

“Excluding our vaginal cuff complications, we believe robotic hysterectomy offers a safe alternative to the abdominal route,” Dr. Corey A. Wagner said at the meeting. Prevention of vaginal cuff complications “would reduce this major complication rate to the same level seen with vaginal hysterectomy [from 10% down to 3%].”

“At the initiation of our study, robotic hysterectomy had been directly compared with laparoscopic hysterectomy, and had been shown to allow for similar outcomes. However, the purpose of the robotic hysterectomy is not to replace the laparoscopic but rather to replace the abdominal group,” said Dr. Wagner, a gynecologist at St. Elizabeth Medical Center in Utica, N.Y.

So Dr. Wagner and his associates compared all three approaches. Determination of the safety of robotic hysterectomy as an alternative to the abdominal approach was the primary aim, said Dr. Wagner, who conducted the study while affiliated with St. John's Mercy Hospital, a community hospital in St. Louis, Mo.

The primary end point was major complications, which included readmission to the hospital, unexpected return to the operating room, or unanticipated transfusion. The rates for all major complications did not differ significantly (9.6% of the robotic group, 8.2% of the abdominal group, and 3.1% of the vaginal hysterectomy patients). Similar trends were seen for minor complications, Dr. Wagner said. In contrast, the differences in rates for any complication were significant (16% in the robotic, 14% in the abdominal, and 6% in the vaginal hysterectomy groups). Records were reviewed a minimum of 160 days post surgery.

Procedure time was longer in the robotic surgery group at a mean 168 minutes, compared with 99 minutes in the abdominal surgery patients and 69 minutes for the vaginal hysterectomy surgeries. Estimated blood loss was significantly lower in the robotic group at 101 mL, compared with 187 mL in the abdominal surgery group and 157 mL in the vaginal hysterectomy cohort.

Length of stay was a mean 1.1 days in the robotic cohort, 2.4 in the abdominal route patients, and 1.2 days among the vaginal surgery patients. Hospital stay was significantly longer in the abdominal surgery group, compared with the other two. Financial differences among the robotic, abdominal, and vaginal approaches to hysterectomy were not assessed in this study, Dr. Wagner said when contacted for additional information.

Further evaluation of vaginal cuff complications is warranted. Specifically, Dr. Wagner would like to determine the role, if any, of use of barbed sutures. Of the 28 cases that involved barbed sutures, 4 (14%) developed a cuff complication, compared with 2 of 63 (3%) cases that involved conventional sutures. Medical risk factors that patients bring with them to the operating room, the use of electrosurgery for colpotomies (unique to the robotic cohort), and the impact of robotic surgeon experience on complication rates are other areas of potential future study, he added.

Dr. Wagner said that he and his coauthors had no relevant financial disclosures.

HOLLYWOOD, FLA.–Women who undergo hysterectomy via one of three surgical approaches experience similar outcomes, with one caveat, according to findings of a retrospective study.

The caveat is that the 94 women who underwent robotic-assisted laparoscopic hysterectomy experienced unique adverse events: four vaginal cuff infections and two vaginal cuff separations. These unfavorable outcomes were not experienced by the 97 women who had total abdominal hysterectomy or another 96 who underwent vaginal hysterectomy.

The cuff separations each occurred 2-3 weeks postoperatively and the women presented with vaginal bleeding. Neither case was associated with early postoperative sexual intercourse.

“Excluding our vaginal cuff complications, we believe robotic hysterectomy offers a safe alternative to the abdominal route,” Dr. Corey A. Wagner said at the meeting. Prevention of vaginal cuff complications “would reduce this major complication rate to the same level seen with vaginal hysterectomy [from 10% down to 3%].”

“At the initiation of our study, robotic hysterectomy had been directly compared with laparoscopic hysterectomy, and had been shown to allow for similar outcomes. However, the purpose of the robotic hysterectomy is not to replace the laparoscopic but rather to replace the abdominal group,” said Dr. Wagner, a gynecologist at St. Elizabeth Medical Center in Utica, N.Y.

So Dr. Wagner and his associates compared all three approaches. Determination of the safety of robotic hysterectomy as an alternative to the abdominal approach was the primary aim, said Dr. Wagner, who conducted the study while affiliated with St. John's Mercy Hospital, a community hospital in St. Louis, Mo.

The primary end point was major complications, which included readmission to the hospital, unexpected return to the operating room, or unanticipated transfusion. The rates for all major complications did not differ significantly (9.6% of the robotic group, 8.2% of the abdominal group, and 3.1% of the vaginal hysterectomy patients). Similar trends were seen for minor complications, Dr. Wagner said. In contrast, the differences in rates for any complication were significant (16% in the robotic, 14% in the abdominal, and 6% in the vaginal hysterectomy groups). Records were reviewed a minimum of 160 days post surgery.

Procedure time was longer in the robotic surgery group at a mean 168 minutes, compared with 99 minutes in the abdominal surgery patients and 69 minutes for the vaginal hysterectomy surgeries. Estimated blood loss was significantly lower in the robotic group at 101 mL, compared with 187 mL in the abdominal surgery group and 157 mL in the vaginal hysterectomy cohort.

Length of stay was a mean 1.1 days in the robotic cohort, 2.4 in the abdominal route patients, and 1.2 days among the vaginal surgery patients. Hospital stay was significantly longer in the abdominal surgery group, compared with the other two. Financial differences among the robotic, abdominal, and vaginal approaches to hysterectomy were not assessed in this study, Dr. Wagner said when contacted for additional information.

Further evaluation of vaginal cuff complications is warranted. Specifically, Dr. Wagner would like to determine the role, if any, of use of barbed sutures. Of the 28 cases that involved barbed sutures, 4 (14%) developed a cuff complication, compared with 2 of 63 (3%) cases that involved conventional sutures. Medical risk factors that patients bring with them to the operating room, the use of electrosurgery for colpotomies (unique to the robotic cohort), and the impact of robotic surgeon experience on complication rates are other areas of potential future study, he added.

Dr. Wagner said that he and his coauthors had no relevant financial disclosures.