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Status asthmaticus risk upped fourfold with IV labetalol for preeclampsia
DALLAS – A maternal death occurred at Columbia University Medical Center after a patient with asthma was given intravenous labetalol, prompting a study that found an elevated risk of status asthmaticus associated with intravenous (IV) labetalol administration but not with the uterotonic carboprost.
“Overall, 71.4% of status asthmaticus cases occurred among women receiving IV labetalol,” said Whitney A. Booker, MD, speaking about the findings at the meeting sponsored by the Society for Maternal-Fetal Medicine.
The risk of status asthmaticus didn’t reach statistical significance when women with asthma who experienced postpartum hemorrhage were given carboprost, compared with other uterotonics (3.1 vs. 1.0 per 1,000 patients; P = .56).
“Some regularly used medications in obstetrics can trigger bronchospasm,” said Dr. Booker; the American College of Obstetricians and Gynecologists lists both carboprost and labetalol as contraindicated for use in patients with asthma because of the potential for bronchospasm with each medication.
However, she said, data on the actual risk of bronchospasm when these medications are used in obstetric patients is limited.
The retrospective cohort study constructed by Dr. Booker and her colleagues at Columbia University Medical Center’s department of obstetrics and gynecology tapped 10 years’ worth of data from a large inpatient drug utilization database.
Dr. Booker, a maternal-fetal medicine fellow, said that patients were included if they were admitted for delivery and had a diagnosis of preeclampsia or postpartum hemorrhage. Of the 5.7 million hospitalizations from 2006 to 2015, 2.5% were for postpartum hemorrhage, and 4.2% for preeclampsia.
Of the patients with hemorrhage, 5,633 had a prior history of asthma, as did 12,486 of the patients with preeclampsia. In both groups, a little more than a third of patients were younger than 25 years, and about a quarter were black. Half were on Medicaid, and most were in urban areas and cared for in a teaching hospital.
The first outcome that Dr. Booker and her colleagues looked at was how practice patterns for postpartum hemorrhage varied according to whether patients had asthma; to do so, they looked at receipt of carboprost, misoprostol, and methylergonovine. A similar analysis was performed for the second outcome addressing patients with preeclampsia, in which investigators examined the use of both IV and oral labetalol, hydralazine, and nifedipine. For this and the hemorrhage outcome, the investigators performed multivariable analysis, with receipt of carboprost and IV labetalol as the outcomes of interest.
Finally, the investigators assessed the risk of status asthmaticus by comparing receipt of either carboprost (for postpartum hemorrhage) or IV labetalol (for preeclampsia) with receipt of the other medications to treat these conditions.
They found that overall, 11.4% of patients with asthma and 18% of patients without asthma received carboprost to treat postpartum hemorrhage, which makes for an adjusted risk model of 0.68 (95% confidence interval, 0.62-0.74) for receipt of carboprost for patients with asthma versus those without.
However, the pattern was different for IV labetalol: 18.5% of patients with asthma and preeclampsia received labetalol, compared with 16.7% of those without asthma. After statistical adjustment, patients with asthma had a risk ratio of 0.93 (95% CI, 0.90-0.97) for receiving IV labetalol for preeclampsia.
The analysis showed that pregnant patients with asthma were less likely to be given carboprost than labetalol, although the actual risk of status asthmaticus was higher when patients with asthma received labetalol than when they received carboprost.
“Given similar theoretical risks, obstetric providers currently administer carboprost differently than labetalol. ... Obstetricians should proceed with caution prior to giving labetalol to patients with underlying asthma,” said Dr. Booker.
During the discussion after the presentation, one attendee suggested that a next step might be to examine claims databases in conjunction with the findings of Dr. Booker’s current work in order to see whether there’s an association between asthma medication prescription fills – a surrogate for disease severity – and the risk of bronchospasm. Dr. Booker agreed that this might be a promising line of inquiry.
Dr. Booker and her colleagues reported that they had no conflicts of interest. The study was supported by the Eunice Kennedy Shriver National Institute of Child Health and Human Development.
SOURCE: Booker W et al. Am J Obstet Gynecol. 2018 Jan;218:S51.
I teach my residents and fellows the “rule of thirds”: One-third of asthma patients get worse during pregnancy; one-third get better; one-third stay the same.” Asthma during pregnancy remains a challenging problem, with physicians striving to treat two complicated patients (mother and child) safely and effectively. We learn now that the use of labetalol, a beta-blocker, to treat preeclampsia in pregnant asthma patients may be associated with an increased incidence of status asthmaticus. Until we learn more about these occurrences, we should use great caution in treating pregnant asthma patients with labetalol and other beta-blockers
I teach my residents and fellows the “rule of thirds”: One-third of asthma patients get worse during pregnancy; one-third get better; one-third stay the same.” Asthma during pregnancy remains a challenging problem, with physicians striving to treat two complicated patients (mother and child) safely and effectively. We learn now that the use of labetalol, a beta-blocker, to treat preeclampsia in pregnant asthma patients may be associated with an increased incidence of status asthmaticus. Until we learn more about these occurrences, we should use great caution in treating pregnant asthma patients with labetalol and other beta-blockers
I teach my residents and fellows the “rule of thirds”: One-third of asthma patients get worse during pregnancy; one-third get better; one-third stay the same.” Asthma during pregnancy remains a challenging problem, with physicians striving to treat two complicated patients (mother and child) safely and effectively. We learn now that the use of labetalol, a beta-blocker, to treat preeclampsia in pregnant asthma patients may be associated with an increased incidence of status asthmaticus. Until we learn more about these occurrences, we should use great caution in treating pregnant asthma patients with labetalol and other beta-blockers
DALLAS – A maternal death occurred at Columbia University Medical Center after a patient with asthma was given intravenous labetalol, prompting a study that found an elevated risk of status asthmaticus associated with intravenous (IV) labetalol administration but not with the uterotonic carboprost.
“Overall, 71.4% of status asthmaticus cases occurred among women receiving IV labetalol,” said Whitney A. Booker, MD, speaking about the findings at the meeting sponsored by the Society for Maternal-Fetal Medicine.
The risk of status asthmaticus didn’t reach statistical significance when women with asthma who experienced postpartum hemorrhage were given carboprost, compared with other uterotonics (3.1 vs. 1.0 per 1,000 patients; P = .56).
“Some regularly used medications in obstetrics can trigger bronchospasm,” said Dr. Booker; the American College of Obstetricians and Gynecologists lists both carboprost and labetalol as contraindicated for use in patients with asthma because of the potential for bronchospasm with each medication.
However, she said, data on the actual risk of bronchospasm when these medications are used in obstetric patients is limited.
The retrospective cohort study constructed by Dr. Booker and her colleagues at Columbia University Medical Center’s department of obstetrics and gynecology tapped 10 years’ worth of data from a large inpatient drug utilization database.
Dr. Booker, a maternal-fetal medicine fellow, said that patients were included if they were admitted for delivery and had a diagnosis of preeclampsia or postpartum hemorrhage. Of the 5.7 million hospitalizations from 2006 to 2015, 2.5% were for postpartum hemorrhage, and 4.2% for preeclampsia.
Of the patients with hemorrhage, 5,633 had a prior history of asthma, as did 12,486 of the patients with preeclampsia. In both groups, a little more than a third of patients were younger than 25 years, and about a quarter were black. Half were on Medicaid, and most were in urban areas and cared for in a teaching hospital.
The first outcome that Dr. Booker and her colleagues looked at was how practice patterns for postpartum hemorrhage varied according to whether patients had asthma; to do so, they looked at receipt of carboprost, misoprostol, and methylergonovine. A similar analysis was performed for the second outcome addressing patients with preeclampsia, in which investigators examined the use of both IV and oral labetalol, hydralazine, and nifedipine. For this and the hemorrhage outcome, the investigators performed multivariable analysis, with receipt of carboprost and IV labetalol as the outcomes of interest.
Finally, the investigators assessed the risk of status asthmaticus by comparing receipt of either carboprost (for postpartum hemorrhage) or IV labetalol (for preeclampsia) with receipt of the other medications to treat these conditions.
They found that overall, 11.4% of patients with asthma and 18% of patients without asthma received carboprost to treat postpartum hemorrhage, which makes for an adjusted risk model of 0.68 (95% confidence interval, 0.62-0.74) for receipt of carboprost for patients with asthma versus those without.
However, the pattern was different for IV labetalol: 18.5% of patients with asthma and preeclampsia received labetalol, compared with 16.7% of those without asthma. After statistical adjustment, patients with asthma had a risk ratio of 0.93 (95% CI, 0.90-0.97) for receiving IV labetalol for preeclampsia.
The analysis showed that pregnant patients with asthma were less likely to be given carboprost than labetalol, although the actual risk of status asthmaticus was higher when patients with asthma received labetalol than when they received carboprost.
“Given similar theoretical risks, obstetric providers currently administer carboprost differently than labetalol. ... Obstetricians should proceed with caution prior to giving labetalol to patients with underlying asthma,” said Dr. Booker.
During the discussion after the presentation, one attendee suggested that a next step might be to examine claims databases in conjunction with the findings of Dr. Booker’s current work in order to see whether there’s an association between asthma medication prescription fills – a surrogate for disease severity – and the risk of bronchospasm. Dr. Booker agreed that this might be a promising line of inquiry.
Dr. Booker and her colleagues reported that they had no conflicts of interest. The study was supported by the Eunice Kennedy Shriver National Institute of Child Health and Human Development.
SOURCE: Booker W et al. Am J Obstet Gynecol. 2018 Jan;218:S51.
DALLAS – A maternal death occurred at Columbia University Medical Center after a patient with asthma was given intravenous labetalol, prompting a study that found an elevated risk of status asthmaticus associated with intravenous (IV) labetalol administration but not with the uterotonic carboprost.
“Overall, 71.4% of status asthmaticus cases occurred among women receiving IV labetalol,” said Whitney A. Booker, MD, speaking about the findings at the meeting sponsored by the Society for Maternal-Fetal Medicine.
The risk of status asthmaticus didn’t reach statistical significance when women with asthma who experienced postpartum hemorrhage were given carboprost, compared with other uterotonics (3.1 vs. 1.0 per 1,000 patients; P = .56).
“Some regularly used medications in obstetrics can trigger bronchospasm,” said Dr. Booker; the American College of Obstetricians and Gynecologists lists both carboprost and labetalol as contraindicated for use in patients with asthma because of the potential for bronchospasm with each medication.
However, she said, data on the actual risk of bronchospasm when these medications are used in obstetric patients is limited.
The retrospective cohort study constructed by Dr. Booker and her colleagues at Columbia University Medical Center’s department of obstetrics and gynecology tapped 10 years’ worth of data from a large inpatient drug utilization database.
Dr. Booker, a maternal-fetal medicine fellow, said that patients were included if they were admitted for delivery and had a diagnosis of preeclampsia or postpartum hemorrhage. Of the 5.7 million hospitalizations from 2006 to 2015, 2.5% were for postpartum hemorrhage, and 4.2% for preeclampsia.
Of the patients with hemorrhage, 5,633 had a prior history of asthma, as did 12,486 of the patients with preeclampsia. In both groups, a little more than a third of patients were younger than 25 years, and about a quarter were black. Half were on Medicaid, and most were in urban areas and cared for in a teaching hospital.
The first outcome that Dr. Booker and her colleagues looked at was how practice patterns for postpartum hemorrhage varied according to whether patients had asthma; to do so, they looked at receipt of carboprost, misoprostol, and methylergonovine. A similar analysis was performed for the second outcome addressing patients with preeclampsia, in which investigators examined the use of both IV and oral labetalol, hydralazine, and nifedipine. For this and the hemorrhage outcome, the investigators performed multivariable analysis, with receipt of carboprost and IV labetalol as the outcomes of interest.
Finally, the investigators assessed the risk of status asthmaticus by comparing receipt of either carboprost (for postpartum hemorrhage) or IV labetalol (for preeclampsia) with receipt of the other medications to treat these conditions.
They found that overall, 11.4% of patients with asthma and 18% of patients without asthma received carboprost to treat postpartum hemorrhage, which makes for an adjusted risk model of 0.68 (95% confidence interval, 0.62-0.74) for receipt of carboprost for patients with asthma versus those without.
However, the pattern was different for IV labetalol: 18.5% of patients with asthma and preeclampsia received labetalol, compared with 16.7% of those without asthma. After statistical adjustment, patients with asthma had a risk ratio of 0.93 (95% CI, 0.90-0.97) for receiving IV labetalol for preeclampsia.
The analysis showed that pregnant patients with asthma were less likely to be given carboprost than labetalol, although the actual risk of status asthmaticus was higher when patients with asthma received labetalol than when they received carboprost.
“Given similar theoretical risks, obstetric providers currently administer carboprost differently than labetalol. ... Obstetricians should proceed with caution prior to giving labetalol to patients with underlying asthma,” said Dr. Booker.
During the discussion after the presentation, one attendee suggested that a next step might be to examine claims databases in conjunction with the findings of Dr. Booker’s current work in order to see whether there’s an association between asthma medication prescription fills – a surrogate for disease severity – and the risk of bronchospasm. Dr. Booker agreed that this might be a promising line of inquiry.
Dr. Booker and her colleagues reported that they had no conflicts of interest. The study was supported by the Eunice Kennedy Shriver National Institute of Child Health and Human Development.
SOURCE: Booker W et al. Am J Obstet Gynecol. 2018 Jan;218:S51.
REPORTING FROM THE PREGNANCY MEETING
Key clinical point: IV labetalol receipt meant a fourfold increase in risk of status asthmaticus for women with preeclampsia and asthma.
Major finding: Status asthmaticus occurred in 6.5 per 1,000 patients given IV labetalol, and 1.7 per 1,000 given a different antihypertensive.
Study details: Retrospective review of 10 years’ data from a national inpatient database, which gathered data on 18,149 women with asthma and either preeclampsia or postpartum hemorrhage.
Disclosures: The study was sponsored by the Eunice Kennedy Shriver National Institute of Child Health and Human Development. The study authors had no conflicts of interest.
Source: Booker W et al. Am J Obstet Gynecol. 2018 Jan;218:S51.
Cerclage plus progesterone for preventing preterm births
DALLAS – Placing a cerclage conferred additional benefit over vaginal progesterone alone for women with extreme short cervixes and singleton pregnancies, in a recent study. Those who received rescue cerclage in addition to vaginal progesterone had a 92% overall reduction in spontaneous preterm birth rates, and infants had fewer neonatal ICU admissions and neonatal complications.
The single-center retrospective cohort study of 75 women with cervical length less than 10 cm who were receiving vaginal progesterone was presented by Christopher Enakpene, MD, at the meeting sponsored by the Society for Maternal-Fetal Medicine.
Women who received rescue cerclage in addition to progesterone delivered at a mean 34.3 weeks gestational age, compared with 27.5 weeks for those receiving progesterone alone (P less than .001).
There were 13 neonatal ICU admissions for infants born to the 36 patients in the cerclage group, compared with 23 for the 39 women receiving progesterone alone (P = .009). And there were seven perinatal or neonatal deaths among the group who did not receive cerclage; no deaths occurred in the cerclage group.
“Premature cervical ripening plays a significant role in spontaneous preterm birth,” said Dr. Enakpene. “And studies have shown that, the shorter the cervix, the higher the risk of spontaneous preterm birth.”
Preterm birth, said Dr. Enakpene, is the top cause of neonatal morbidity and mortality both in the United States and worldwide; it is associated with 70% of neonatal deaths and half of all neurodevelopmental delay, he said.
At the University of Illinois at Chicago, where Dr. Enakpene is a maternal-fetal medicine fellow in the department of obstetrics and gynecology, all pregnant women are screened for cervical length by transvaginal ultrasound during their second trimester.
If screening reveals cervical length of less than 20 mm, the patient receives vaginal progesterone, “the current standard of care in singleton pregnancy with incidental short cervix,” said Dr. Enakpene. Vaginal progesterone can reduce the risk of spontaneous preterm birth by about half, he said.
At his facility, women with a short cervix then receive serial cervical length assessments every week or 2 until 24 weeks’ gestation, to identify women whose cervixes continue to shorten. For these women, it’s usually physician preference that determines whether cerclage is placed to reinforce the progressively shortening cervix, said Dr. Enakpene.
There had been previous retrospective work showing that cerclage was more effective at preventing spontaneous preterm birth than was doing nothing when a woman with a singleton pregnancy had a short cervix. However, Dr. Enakpene said that vaginal progesterone alone had not been compared with continuing progesterone and adding a cerclage.
During the study period, 310 women with cervical length of less than 20 mm were placed on progesterone. These women were included in the study cohort if, over the course of at least two cervical length measurements, their cervix shortened to less than 10 mm while they were on vaginal progesterone. They could not have indications that delivery was imminent when the 10 mm threshold was met, said Dr. Enakpene.
Women with known intrauterine fetal death, an undesired pregnancy, or any sign of intra-amniotic infection or fetal anomalies were excluded from the study.
A total of 75 women met final inclusion criteria, and received cerclage (n = 36), or not (n = 39) according to physician judgment. Demographic and pregnancy-specific characteristics were generally similar between the two groups.
In their statistical analysis, Dr. Enakpene and his colleagues used Kaplan-Meier survival analysis to look at pregnancy latency over time for women who did – or didn’t – receive a cerclage. There were significantly fewer spontaneous preterm births before 24, 28, and 34 weeks gestational age in the cerclage group (P less than .001 for all).
Dr. Enakpene acknowledged the study’s limitations, including its retrospective nature, the small sample size, and the fact that cerclage placement was done by the preference of the attending physician. However, this study was the first to examine rescue cerclage as add-on to vaginal progesterone, he said, adding, “Following this study, we are designing a prospective randomized interventional study to address this important topic.”
Dr. Enakpene reported that he had no conflicts of interest, and reported no outside sources of funding.
SOURCE: Enakpene C et al. Am J Obstet Gynecol. 2018 Jan;218:S72-S73.
DALLAS – Placing a cerclage conferred additional benefit over vaginal progesterone alone for women with extreme short cervixes and singleton pregnancies, in a recent study. Those who received rescue cerclage in addition to vaginal progesterone had a 92% overall reduction in spontaneous preterm birth rates, and infants had fewer neonatal ICU admissions and neonatal complications.
The single-center retrospective cohort study of 75 women with cervical length less than 10 cm who were receiving vaginal progesterone was presented by Christopher Enakpene, MD, at the meeting sponsored by the Society for Maternal-Fetal Medicine.
Women who received rescue cerclage in addition to progesterone delivered at a mean 34.3 weeks gestational age, compared with 27.5 weeks for those receiving progesterone alone (P less than .001).
There were 13 neonatal ICU admissions for infants born to the 36 patients in the cerclage group, compared with 23 for the 39 women receiving progesterone alone (P = .009). And there were seven perinatal or neonatal deaths among the group who did not receive cerclage; no deaths occurred in the cerclage group.
“Premature cervical ripening plays a significant role in spontaneous preterm birth,” said Dr. Enakpene. “And studies have shown that, the shorter the cervix, the higher the risk of spontaneous preterm birth.”
Preterm birth, said Dr. Enakpene, is the top cause of neonatal morbidity and mortality both in the United States and worldwide; it is associated with 70% of neonatal deaths and half of all neurodevelopmental delay, he said.
At the University of Illinois at Chicago, where Dr. Enakpene is a maternal-fetal medicine fellow in the department of obstetrics and gynecology, all pregnant women are screened for cervical length by transvaginal ultrasound during their second trimester.
If screening reveals cervical length of less than 20 mm, the patient receives vaginal progesterone, “the current standard of care in singleton pregnancy with incidental short cervix,” said Dr. Enakpene. Vaginal progesterone can reduce the risk of spontaneous preterm birth by about half, he said.
At his facility, women with a short cervix then receive serial cervical length assessments every week or 2 until 24 weeks’ gestation, to identify women whose cervixes continue to shorten. For these women, it’s usually physician preference that determines whether cerclage is placed to reinforce the progressively shortening cervix, said Dr. Enakpene.
There had been previous retrospective work showing that cerclage was more effective at preventing spontaneous preterm birth than was doing nothing when a woman with a singleton pregnancy had a short cervix. However, Dr. Enakpene said that vaginal progesterone alone had not been compared with continuing progesterone and adding a cerclage.
During the study period, 310 women with cervical length of less than 20 mm were placed on progesterone. These women were included in the study cohort if, over the course of at least two cervical length measurements, their cervix shortened to less than 10 mm while they were on vaginal progesterone. They could not have indications that delivery was imminent when the 10 mm threshold was met, said Dr. Enakpene.
Women with known intrauterine fetal death, an undesired pregnancy, or any sign of intra-amniotic infection or fetal anomalies were excluded from the study.
A total of 75 women met final inclusion criteria, and received cerclage (n = 36), or not (n = 39) according to physician judgment. Demographic and pregnancy-specific characteristics were generally similar between the two groups.
In their statistical analysis, Dr. Enakpene and his colleagues used Kaplan-Meier survival analysis to look at pregnancy latency over time for women who did – or didn’t – receive a cerclage. There were significantly fewer spontaneous preterm births before 24, 28, and 34 weeks gestational age in the cerclage group (P less than .001 for all).
Dr. Enakpene acknowledged the study’s limitations, including its retrospective nature, the small sample size, and the fact that cerclage placement was done by the preference of the attending physician. However, this study was the first to examine rescue cerclage as add-on to vaginal progesterone, he said, adding, “Following this study, we are designing a prospective randomized interventional study to address this important topic.”
Dr. Enakpene reported that he had no conflicts of interest, and reported no outside sources of funding.
SOURCE: Enakpene C et al. Am J Obstet Gynecol. 2018 Jan;218:S72-S73.
DALLAS – Placing a cerclage conferred additional benefit over vaginal progesterone alone for women with extreme short cervixes and singleton pregnancies, in a recent study. Those who received rescue cerclage in addition to vaginal progesterone had a 92% overall reduction in spontaneous preterm birth rates, and infants had fewer neonatal ICU admissions and neonatal complications.
The single-center retrospective cohort study of 75 women with cervical length less than 10 cm who were receiving vaginal progesterone was presented by Christopher Enakpene, MD, at the meeting sponsored by the Society for Maternal-Fetal Medicine.
Women who received rescue cerclage in addition to progesterone delivered at a mean 34.3 weeks gestational age, compared with 27.5 weeks for those receiving progesterone alone (P less than .001).
There were 13 neonatal ICU admissions for infants born to the 36 patients in the cerclage group, compared with 23 for the 39 women receiving progesterone alone (P = .009). And there were seven perinatal or neonatal deaths among the group who did not receive cerclage; no deaths occurred in the cerclage group.
“Premature cervical ripening plays a significant role in spontaneous preterm birth,” said Dr. Enakpene. “And studies have shown that, the shorter the cervix, the higher the risk of spontaneous preterm birth.”
Preterm birth, said Dr. Enakpene, is the top cause of neonatal morbidity and mortality both in the United States and worldwide; it is associated with 70% of neonatal deaths and half of all neurodevelopmental delay, he said.
At the University of Illinois at Chicago, where Dr. Enakpene is a maternal-fetal medicine fellow in the department of obstetrics and gynecology, all pregnant women are screened for cervical length by transvaginal ultrasound during their second trimester.
If screening reveals cervical length of less than 20 mm, the patient receives vaginal progesterone, “the current standard of care in singleton pregnancy with incidental short cervix,” said Dr. Enakpene. Vaginal progesterone can reduce the risk of spontaneous preterm birth by about half, he said.
At his facility, women with a short cervix then receive serial cervical length assessments every week or 2 until 24 weeks’ gestation, to identify women whose cervixes continue to shorten. For these women, it’s usually physician preference that determines whether cerclage is placed to reinforce the progressively shortening cervix, said Dr. Enakpene.
There had been previous retrospective work showing that cerclage was more effective at preventing spontaneous preterm birth than was doing nothing when a woman with a singleton pregnancy had a short cervix. However, Dr. Enakpene said that vaginal progesterone alone had not been compared with continuing progesterone and adding a cerclage.
During the study period, 310 women with cervical length of less than 20 mm were placed on progesterone. These women were included in the study cohort if, over the course of at least two cervical length measurements, their cervix shortened to less than 10 mm while they were on vaginal progesterone. They could not have indications that delivery was imminent when the 10 mm threshold was met, said Dr. Enakpene.
Women with known intrauterine fetal death, an undesired pregnancy, or any sign of intra-amniotic infection or fetal anomalies were excluded from the study.
A total of 75 women met final inclusion criteria, and received cerclage (n = 36), or not (n = 39) according to physician judgment. Demographic and pregnancy-specific characteristics were generally similar between the two groups.
In their statistical analysis, Dr. Enakpene and his colleagues used Kaplan-Meier survival analysis to look at pregnancy latency over time for women who did – or didn’t – receive a cerclage. There were significantly fewer spontaneous preterm births before 24, 28, and 34 weeks gestational age in the cerclage group (P less than .001 for all).
Dr. Enakpene acknowledged the study’s limitations, including its retrospective nature, the small sample size, and the fact that cerclage placement was done by the preference of the attending physician. However, this study was the first to examine rescue cerclage as add-on to vaginal progesterone, he said, adding, “Following this study, we are designing a prospective randomized interventional study to address this important topic.”
Dr. Enakpene reported that he had no conflicts of interest, and reported no outside sources of funding.
SOURCE: Enakpene C et al. Am J Obstet Gynecol. 2018 Jan;218:S72-S73.
REPORTING FROM THE PREGNANCY MEETING
Key clinical point: Women receiving rescue cerclage plus progesterone had fewer spontaneous preterm births.
Major finding: Those who also received cerclage delivered at 34.3 weeks gestational age, compared with 27.5 weeks for those on progesterone alone (P less than .001).
Study details: Retrospective cohort study of 75 women with singleton pregnancies and very short cervixes.
Disclosures: Dr. Enakpene reported no outside sources of funding and had no conflicts of interest.
Source: Enakpene C et al. Am J Obstet Gynecol. 2018 Jan;218:S72-S73.
Reported penicillin allergies hike inpatient costs
Total inpatient costs for patients who report being allergic to penicillin are much higher than for those who don’t report an allergy, according to a recent systematic review and meta-analysis.
The review, which eventually included 30 articles, found that total inpatient costs ranged from an average $1,145-$4,254 higher per patient with a reported penicillin allergy compared to nonallergic patients, said T. Joseph Mattingly, PharmD, and his associates. Outpatient prescription costs were also estimated to be steeper, running $14-$93 higher per patient who reported a penicillin allergy.
Although 10%-20% of patients report a penicillin allergy, “[a] majority of patients who report PCN [penicillin] allergy are not truly allergic upon confirmatory testing,” Dr. Mattingly and his colleagues wrote.
This overreporting of penicillin allergies is a problem for the patient and the health care system because “reported antibiotic allergies have been associated with suboptimal antibiotic therapy, increased antimicrobial resistance, increased length of stay, increased antibiotic-related adverse events, increased rates of C. difficile infection, intensive care unit (ICU) admission, death, as well as increased treatment cost,” said Dr. Mattingly and his coauthors.
Health care providers often “tend to take reported allergies at face value,” said coauthor Anne Fulton, suggesting that primary care practices can help by considering skin testing for those patients who carry a label of penicillin allergy, but don’t have a documented confirmatory test. The cost for a commonly used skin test for penicillin allergy runs about $200, said Ms. Fulton, a doctoral candidate at the University of Maryland, Baltimore, in an interview.
When conducting the meta-analysis, Dr. Mattingly and his coauthors converted all figures to 2017 U.S. dollars, using Consumer Price Index figures to adjust for inflation. This yields conservative estimates for cost, as drug and health care prices have far outstripped the general rate of inflation during the period in which the studies occurred, Ms. Fulton acknowledged.
The investigators highlighted the need for ongoing study in this area. “To our knowledge, there are no evaluations of long-term outpatient outcomes related to the effects of PCN allergy and the potential impact of delabeling patients who do not have a true allergy,” they wrote.
Ms. Fulton agreed, noting that the studies covered in the meta-analysis were primarily focused on short-term outcomes, though there are many potential long-term benefits to delabeling patients who are not truly penicillin allergic.
For the patient, this includes the opportunity to receive optimal antimicrobial therapy, as well as potential savings in copays and other out-of-pocket expenses for outpatient medications, she said.
As antimicrobial resistance becomes an ever more pressing problem, there are more opportunities for targeted therapy if inappropriate allergy labeling is addressed, Ms. Fulton added.
Further study should use “cost-effectiveness analysis methods that include societal and health sector perspectives capturing immediate and future outcomes and costs to evaluate the use of skin-testing procedures in either inpatient or outpatient settings,” the investigators wrote.
The study was supported by ALK, the manufacturer of Pre-Pen, a commercially available penicillin allergy skin test.
SOURCE: Mattingly TJ et al. J Allergy Clin Immunol Pract. 2018 Jan 31. doi: 10.1016/j.jaip.2017.12.033.
Total inpatient costs for patients who report being allergic to penicillin are much higher than for those who don’t report an allergy, according to a recent systematic review and meta-analysis.
The review, which eventually included 30 articles, found that total inpatient costs ranged from an average $1,145-$4,254 higher per patient with a reported penicillin allergy compared to nonallergic patients, said T. Joseph Mattingly, PharmD, and his associates. Outpatient prescription costs were also estimated to be steeper, running $14-$93 higher per patient who reported a penicillin allergy.
Although 10%-20% of patients report a penicillin allergy, “[a] majority of patients who report PCN [penicillin] allergy are not truly allergic upon confirmatory testing,” Dr. Mattingly and his colleagues wrote.
This overreporting of penicillin allergies is a problem for the patient and the health care system because “reported antibiotic allergies have been associated with suboptimal antibiotic therapy, increased antimicrobial resistance, increased length of stay, increased antibiotic-related adverse events, increased rates of C. difficile infection, intensive care unit (ICU) admission, death, as well as increased treatment cost,” said Dr. Mattingly and his coauthors.
Health care providers often “tend to take reported allergies at face value,” said coauthor Anne Fulton, suggesting that primary care practices can help by considering skin testing for those patients who carry a label of penicillin allergy, but don’t have a documented confirmatory test. The cost for a commonly used skin test for penicillin allergy runs about $200, said Ms. Fulton, a doctoral candidate at the University of Maryland, Baltimore, in an interview.
When conducting the meta-analysis, Dr. Mattingly and his coauthors converted all figures to 2017 U.S. dollars, using Consumer Price Index figures to adjust for inflation. This yields conservative estimates for cost, as drug and health care prices have far outstripped the general rate of inflation during the period in which the studies occurred, Ms. Fulton acknowledged.
The investigators highlighted the need for ongoing study in this area. “To our knowledge, there are no evaluations of long-term outpatient outcomes related to the effects of PCN allergy and the potential impact of delabeling patients who do not have a true allergy,” they wrote.
Ms. Fulton agreed, noting that the studies covered in the meta-analysis were primarily focused on short-term outcomes, though there are many potential long-term benefits to delabeling patients who are not truly penicillin allergic.
For the patient, this includes the opportunity to receive optimal antimicrobial therapy, as well as potential savings in copays and other out-of-pocket expenses for outpatient medications, she said.
As antimicrobial resistance becomes an ever more pressing problem, there are more opportunities for targeted therapy if inappropriate allergy labeling is addressed, Ms. Fulton added.
Further study should use “cost-effectiveness analysis methods that include societal and health sector perspectives capturing immediate and future outcomes and costs to evaluate the use of skin-testing procedures in either inpatient or outpatient settings,” the investigators wrote.
The study was supported by ALK, the manufacturer of Pre-Pen, a commercially available penicillin allergy skin test.
SOURCE: Mattingly TJ et al. J Allergy Clin Immunol Pract. 2018 Jan 31. doi: 10.1016/j.jaip.2017.12.033.
Total inpatient costs for patients who report being allergic to penicillin are much higher than for those who don’t report an allergy, according to a recent systematic review and meta-analysis.
The review, which eventually included 30 articles, found that total inpatient costs ranged from an average $1,145-$4,254 higher per patient with a reported penicillin allergy compared to nonallergic patients, said T. Joseph Mattingly, PharmD, and his associates. Outpatient prescription costs were also estimated to be steeper, running $14-$93 higher per patient who reported a penicillin allergy.
Although 10%-20% of patients report a penicillin allergy, “[a] majority of patients who report PCN [penicillin] allergy are not truly allergic upon confirmatory testing,” Dr. Mattingly and his colleagues wrote.
This overreporting of penicillin allergies is a problem for the patient and the health care system because “reported antibiotic allergies have been associated with suboptimal antibiotic therapy, increased antimicrobial resistance, increased length of stay, increased antibiotic-related adverse events, increased rates of C. difficile infection, intensive care unit (ICU) admission, death, as well as increased treatment cost,” said Dr. Mattingly and his coauthors.
Health care providers often “tend to take reported allergies at face value,” said coauthor Anne Fulton, suggesting that primary care practices can help by considering skin testing for those patients who carry a label of penicillin allergy, but don’t have a documented confirmatory test. The cost for a commonly used skin test for penicillin allergy runs about $200, said Ms. Fulton, a doctoral candidate at the University of Maryland, Baltimore, in an interview.
When conducting the meta-analysis, Dr. Mattingly and his coauthors converted all figures to 2017 U.S. dollars, using Consumer Price Index figures to adjust for inflation. This yields conservative estimates for cost, as drug and health care prices have far outstripped the general rate of inflation during the period in which the studies occurred, Ms. Fulton acknowledged.
The investigators highlighted the need for ongoing study in this area. “To our knowledge, there are no evaluations of long-term outpatient outcomes related to the effects of PCN allergy and the potential impact of delabeling patients who do not have a true allergy,” they wrote.
Ms. Fulton agreed, noting that the studies covered in the meta-analysis were primarily focused on short-term outcomes, though there are many potential long-term benefits to delabeling patients who are not truly penicillin allergic.
For the patient, this includes the opportunity to receive optimal antimicrobial therapy, as well as potential savings in copays and other out-of-pocket expenses for outpatient medications, she said.
As antimicrobial resistance becomes an ever more pressing problem, there are more opportunities for targeted therapy if inappropriate allergy labeling is addressed, Ms. Fulton added.
Further study should use “cost-effectiveness analysis methods that include societal and health sector perspectives capturing immediate and future outcomes and costs to evaluate the use of skin-testing procedures in either inpatient or outpatient settings,” the investigators wrote.
The study was supported by ALK, the manufacturer of Pre-Pen, a commercially available penicillin allergy skin test.
SOURCE: Mattingly TJ et al. J Allergy Clin Immunol Pract. 2018 Jan 31. doi: 10.1016/j.jaip.2017.12.033.
FROM JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY: IN PRACTICE
Key clinical point: Inpatient costs were $1,145 – $4,254 higher for those reporting penicillin allergy.
Major finding: Though most studies addressed inpatient admissions, outpatient costs were also significantly higher.
Study details: Systematic review and meta-analysis of 30 articles addressing reported penicillin allergy.
Disclosures: The study was sponsored by ALK.
Source: Mattingly TJ et al. J Allergy Clin Immunol Pract. 2018 Jan 31. doi: 10.1016/j.jaip.2017.12.033.
Barbed sutures shorten cesarean closure time, reduce blood loss
DALLAS – Using knotless barbed sutures to close the uterine incision after cesarean delivery reduced operating time and blood loss, according to a recent randomized controlled study.
“On average, knotless barbed sutures were 1 minute and 43 seconds faster,” said David Peleg, MD, discussing the study results at the meeting sponsored by the Society for Maternal-Fetal Medicine. Average uterine closure time with knotless barbed sutures was 3 minutes and 37 seconds; with smooth sutures, average closure time was 5 minutes and 20 seconds (103-second difference; 95% confidence interval, 67.69-138.47 seconds; P less than .001).
Barbed sutures, in contrast, are usually made of monofilament with barbs created by the addition of tiny diagonal cuts made just partway through the suture material. When the suture is pulled through with the angle of the barbs, it pulls smoothly, but pulling back against the barb angle causes the barbs to protrude and catch against tissue, preventing slippage and eliminating the need for knots.
The fact that the monofilament has been partially cut to create the barbs can also reduce tensile strength, but some of the other disadvantages of smooth sutures are avoided, said Dr. Peleg.
The suture material used for the study was bidirectional, with the barbs running in opposite directions from the midline and a needle swaged onto each end; other barbed suture systems have an integral loop at one end of a unidirectionally barbed length of suture material that is used to anchor the first suture. The brand used was Stratafix.
The prospective study was necessarily unblinded, and compared the knotless barbed sutures with smooth sutures using polyglactin 910 braided material (Vicryl) for use during closure of the uterine incision during cesarean section procedures.
Patients were eligible if they were having an elective cesarean section after at least 38 weeks’ gestation, or if they were having a cesarean for the usual obstetric indications after laboring. Women with previous cesareans who failed a trial of labor were eligible.
The primary outcome was the length of time to close the uterine incision, measured from the start of suturing until hemostasis was achieved; the time included hemostatic suturing.
After a small pilot study that established a baseline suturing time with polyglactin 910 sutures of 6 minutes (standard deviation, 2 minutes and 10 seconds), Dr. Peleg and his collaborators determined that they would need to enroll at least 34 women per study arm to detect a decrease of 25% in suture time – to 4.5 minutes – with barbed sutures.
“The decrease in closure time is not linear,” said Dr. Peleg, so they increased their sample size by 50%, to 51 patients in each group, to ensure statistical significance of the results.
One of the challenges of a surgical randomized controlled trial is ensuring uniform technique; for this study, all patients had epidural or spinal anesthesia and antibiotics before opening. Surgeon clinical judgment was used to determine whether a Pfannenstiel or low transverse incision was made. In either case, there was no closure of the parietal peritoneum or the rectus muscles, and subcutaneous closure was used if tissues were greater than 2 cm in depth. Subcuticular stitches were used if possible.
Looking at secondary outcomes, there was a trend toward shorter total operative time with barbed sutures that didn’t reach statistical significance (20.1 min for barbed sutures vs. 23.1 for conventional, P = .062). However, fewer hemostatic sutures were required when barbed sutures were used: Extra sutures were used in 16 of the barbed group vs. 41 who had conventional sutures (P less than .001). Those receiving barbed sutures also had significantly less blood loss and estimated total blood loss during uterine closure than the conventional suture group (P = .005 and P = .002, respectively).
No study patients experienced serious postoperative complications; there were no infections, hematomas, or other wound complications, said Dr. Peleg of Bar-Ilan University, Zefat, Israel.
On the pro side for wider implementation of the use of barbed sutures for uterine closure stand the quicker closure and better hemostasis, along with the theoretical benefits of having no knots. Additionally, said Dr. Peleg, “there’s a gentle learning curve – it’s relatively easy to get used to the technique” of using barbed sutures. And, he said, “surgeons find them satisfying to use.”
However, he acknowledged the extra expense of barbed suture material – depending on the location and supplier, he estimated the cost could run from 7- to 20-fold for the barbed sutures, which he said cost $23.50 apiece. Also, he said, though the results were statistically significant, “Are they clinically significant? Does a difference in closure time of one minute 43 seconds, and a decrease in blood loss of 47 milliliters matter?”
Other considerations, he said, will require longer-term study. Polydioxanone, used for the barbed sutures, has a longer absorption time – a factor with unknown clinical implications in this application. Other longer-term outcomes, such as vaginal birth after cesarean success rates, rates of uterine rupture, the thickness of the uterine scar, and rates of adhesions and placenta accreta, will need to be tracked for years.
The authors reported no conflicts of interest and specifically reported that they had no relevant consulting or research agreements with suture manufacturers or marketers.
SOURCE: Peleg D et al. The Pregnancy Meeting Abstract 32.
DALLAS – Using knotless barbed sutures to close the uterine incision after cesarean delivery reduced operating time and blood loss, according to a recent randomized controlled study.
“On average, knotless barbed sutures were 1 minute and 43 seconds faster,” said David Peleg, MD, discussing the study results at the meeting sponsored by the Society for Maternal-Fetal Medicine. Average uterine closure time with knotless barbed sutures was 3 minutes and 37 seconds; with smooth sutures, average closure time was 5 minutes and 20 seconds (103-second difference; 95% confidence interval, 67.69-138.47 seconds; P less than .001).
Barbed sutures, in contrast, are usually made of monofilament with barbs created by the addition of tiny diagonal cuts made just partway through the suture material. When the suture is pulled through with the angle of the barbs, it pulls smoothly, but pulling back against the barb angle causes the barbs to protrude and catch against tissue, preventing slippage and eliminating the need for knots.
The fact that the monofilament has been partially cut to create the barbs can also reduce tensile strength, but some of the other disadvantages of smooth sutures are avoided, said Dr. Peleg.
The suture material used for the study was bidirectional, with the barbs running in opposite directions from the midline and a needle swaged onto each end; other barbed suture systems have an integral loop at one end of a unidirectionally barbed length of suture material that is used to anchor the first suture. The brand used was Stratafix.
The prospective study was necessarily unblinded, and compared the knotless barbed sutures with smooth sutures using polyglactin 910 braided material (Vicryl) for use during closure of the uterine incision during cesarean section procedures.
Patients were eligible if they were having an elective cesarean section after at least 38 weeks’ gestation, or if they were having a cesarean for the usual obstetric indications after laboring. Women with previous cesareans who failed a trial of labor were eligible.
The primary outcome was the length of time to close the uterine incision, measured from the start of suturing until hemostasis was achieved; the time included hemostatic suturing.
After a small pilot study that established a baseline suturing time with polyglactin 910 sutures of 6 minutes (standard deviation, 2 minutes and 10 seconds), Dr. Peleg and his collaborators determined that they would need to enroll at least 34 women per study arm to detect a decrease of 25% in suture time – to 4.5 minutes – with barbed sutures.
“The decrease in closure time is not linear,” said Dr. Peleg, so they increased their sample size by 50%, to 51 patients in each group, to ensure statistical significance of the results.
One of the challenges of a surgical randomized controlled trial is ensuring uniform technique; for this study, all patients had epidural or spinal anesthesia and antibiotics before opening. Surgeon clinical judgment was used to determine whether a Pfannenstiel or low transverse incision was made. In either case, there was no closure of the parietal peritoneum or the rectus muscles, and subcutaneous closure was used if tissues were greater than 2 cm in depth. Subcuticular stitches were used if possible.
Looking at secondary outcomes, there was a trend toward shorter total operative time with barbed sutures that didn’t reach statistical significance (20.1 min for barbed sutures vs. 23.1 for conventional, P = .062). However, fewer hemostatic sutures were required when barbed sutures were used: Extra sutures were used in 16 of the barbed group vs. 41 who had conventional sutures (P less than .001). Those receiving barbed sutures also had significantly less blood loss and estimated total blood loss during uterine closure than the conventional suture group (P = .005 and P = .002, respectively).
No study patients experienced serious postoperative complications; there were no infections, hematomas, or other wound complications, said Dr. Peleg of Bar-Ilan University, Zefat, Israel.
On the pro side for wider implementation of the use of barbed sutures for uterine closure stand the quicker closure and better hemostasis, along with the theoretical benefits of having no knots. Additionally, said Dr. Peleg, “there’s a gentle learning curve – it’s relatively easy to get used to the technique” of using barbed sutures. And, he said, “surgeons find them satisfying to use.”
However, he acknowledged the extra expense of barbed suture material – depending on the location and supplier, he estimated the cost could run from 7- to 20-fold for the barbed sutures, which he said cost $23.50 apiece. Also, he said, though the results were statistically significant, “Are they clinically significant? Does a difference in closure time of one minute 43 seconds, and a decrease in blood loss of 47 milliliters matter?”
Other considerations, he said, will require longer-term study. Polydioxanone, used for the barbed sutures, has a longer absorption time – a factor with unknown clinical implications in this application. Other longer-term outcomes, such as vaginal birth after cesarean success rates, rates of uterine rupture, the thickness of the uterine scar, and rates of adhesions and placenta accreta, will need to be tracked for years.
The authors reported no conflicts of interest and specifically reported that they had no relevant consulting or research agreements with suture manufacturers or marketers.
SOURCE: Peleg D et al. The Pregnancy Meeting Abstract 32.
DALLAS – Using knotless barbed sutures to close the uterine incision after cesarean delivery reduced operating time and blood loss, according to a recent randomized controlled study.
“On average, knotless barbed sutures were 1 minute and 43 seconds faster,” said David Peleg, MD, discussing the study results at the meeting sponsored by the Society for Maternal-Fetal Medicine. Average uterine closure time with knotless barbed sutures was 3 minutes and 37 seconds; with smooth sutures, average closure time was 5 minutes and 20 seconds (103-second difference; 95% confidence interval, 67.69-138.47 seconds; P less than .001).
Barbed sutures, in contrast, are usually made of monofilament with barbs created by the addition of tiny diagonal cuts made just partway through the suture material. When the suture is pulled through with the angle of the barbs, it pulls smoothly, but pulling back against the barb angle causes the barbs to protrude and catch against tissue, preventing slippage and eliminating the need for knots.
The fact that the monofilament has been partially cut to create the barbs can also reduce tensile strength, but some of the other disadvantages of smooth sutures are avoided, said Dr. Peleg.
The suture material used for the study was bidirectional, with the barbs running in opposite directions from the midline and a needle swaged onto each end; other barbed suture systems have an integral loop at one end of a unidirectionally barbed length of suture material that is used to anchor the first suture. The brand used was Stratafix.
The prospective study was necessarily unblinded, and compared the knotless barbed sutures with smooth sutures using polyglactin 910 braided material (Vicryl) for use during closure of the uterine incision during cesarean section procedures.
Patients were eligible if they were having an elective cesarean section after at least 38 weeks’ gestation, or if they were having a cesarean for the usual obstetric indications after laboring. Women with previous cesareans who failed a trial of labor were eligible.
The primary outcome was the length of time to close the uterine incision, measured from the start of suturing until hemostasis was achieved; the time included hemostatic suturing.
After a small pilot study that established a baseline suturing time with polyglactin 910 sutures of 6 minutes (standard deviation, 2 minutes and 10 seconds), Dr. Peleg and his collaborators determined that they would need to enroll at least 34 women per study arm to detect a decrease of 25% in suture time – to 4.5 minutes – with barbed sutures.
“The decrease in closure time is not linear,” said Dr. Peleg, so they increased their sample size by 50%, to 51 patients in each group, to ensure statistical significance of the results.
One of the challenges of a surgical randomized controlled trial is ensuring uniform technique; for this study, all patients had epidural or spinal anesthesia and antibiotics before opening. Surgeon clinical judgment was used to determine whether a Pfannenstiel or low transverse incision was made. In either case, there was no closure of the parietal peritoneum or the rectus muscles, and subcutaneous closure was used if tissues were greater than 2 cm in depth. Subcuticular stitches were used if possible.
Looking at secondary outcomes, there was a trend toward shorter total operative time with barbed sutures that didn’t reach statistical significance (20.1 min for barbed sutures vs. 23.1 for conventional, P = .062). However, fewer hemostatic sutures were required when barbed sutures were used: Extra sutures were used in 16 of the barbed group vs. 41 who had conventional sutures (P less than .001). Those receiving barbed sutures also had significantly less blood loss and estimated total blood loss during uterine closure than the conventional suture group (P = .005 and P = .002, respectively).
No study patients experienced serious postoperative complications; there were no infections, hematomas, or other wound complications, said Dr. Peleg of Bar-Ilan University, Zefat, Israel.
On the pro side for wider implementation of the use of barbed sutures for uterine closure stand the quicker closure and better hemostasis, along with the theoretical benefits of having no knots. Additionally, said Dr. Peleg, “there’s a gentle learning curve – it’s relatively easy to get used to the technique” of using barbed sutures. And, he said, “surgeons find them satisfying to use.”
However, he acknowledged the extra expense of barbed suture material – depending on the location and supplier, he estimated the cost could run from 7- to 20-fold for the barbed sutures, which he said cost $23.50 apiece. Also, he said, though the results were statistically significant, “Are they clinically significant? Does a difference in closure time of one minute 43 seconds, and a decrease in blood loss of 47 milliliters matter?”
Other considerations, he said, will require longer-term study. Polydioxanone, used for the barbed sutures, has a longer absorption time – a factor with unknown clinical implications in this application. Other longer-term outcomes, such as vaginal birth after cesarean success rates, rates of uterine rupture, the thickness of the uterine scar, and rates of adhesions and placenta accreta, will need to be tracked for years.
The authors reported no conflicts of interest and specifically reported that they had no relevant consulting or research agreements with suture manufacturers or marketers.
SOURCE: Peleg D et al. The Pregnancy Meeting Abstract 32.
REPORTING FROM THE PREGNANCY MEETING
Key clinical point: Closure time and blood loss were less with barbed sutures closing the uterine incision.
Major finding: Average uterine incision closure time was 3:37 minutes with knotless barbed sutures and 5:20 minutes with conventional smooth sutures.
Study details: Randomized controlled trial of 102 women undergoing cesarean section.
Disclosures: The study had no external sources of funding, and the study authors reported no relevant outside support.
Source: Peleg D et al. The Pregnancy Meeting Abstract 32.
Placental transfusion volume unaffected by oxytocin timing
DALLAS – Timing of maternal oxytocin administration did not affect total placental transfusion volume accomplished via delayed umbilical cord clamping, according to a recent randomized, controlled trial.
Of 144 infants born to women who consented to randomization, those whose mothers received intravenous oxytocin within 15 seconds of delivery (n = 70) gained a mean 86 g (standard deviation, 48; 95% confidence interval, 74-97) in the 3 minutes after delivery, before umbilical cord clamping. Infants whose mothers received oxytocin when the umbilical cord was clamped 3 minutes after delivery (n = 74) gained 87 g (SD, 50; 95% CI, 75-98; P for difference between groups = .92). The findings were presented during an abstract session at the meeting sponsored by the Society for Maternal-Fetal Medicine.
It had not previously been known whether immediate oxytocin administration enhanced or diminished placental transfusion volume, said Daniela Satragno, MD, the study’s first author.
The investigators had hypothesized that immediate oxytocin administration would increase the volume of placental transfusion, said Dr. Satragno, of Argentina’s Foundation for Maternal and Child Health. However, their study didn’t bear this out. “When umbilical cord clamping is delayed for 3 minutes, infants receive a clinically significant placental transfusion which is not modified by the administration of IV oxytocin immediately after birth,” wrote Dr. Satragno and her coauthors in the abstract accompanying the presentation.
The study in the American Journal of Obstetrics & Gynecology included healthy term infants born via vaginal delivery; Dr. Satragno said that consent was obtained from mothers in early labor, and that study recruiters did not approach women who were in more advanced stages of labor because of ethical concerns. Women with high-risk pregnancies and those with known fetal anomalies were excluded, as were any who required forceps deliveries, neonatal resuscitation, and those whose deliveries involved a short umbilical cord or a nuchal cord.
In order to estimate the volume of placental transfusion, all infants were weighed on a 1-g precision scale placed at the level of the vagina both immediately after birth and after the umbilical cord was clamped at 3 minutes after delivery. All participating mothers received 10 IU of oxytocin, with the timing varying by intervention arm. A figure of 1.05 g/cc of blood was used to calculate transfusion volume, with change in infant weight used as a proxy for transfusion volume.
Hematocrit levels were also similar between the two groups: infants whose mothers received immediate oxytocin had a mean hematocrit of 57% (SD, 5), while those whose mothers had delayed oxytocin administration had a mean hematocrit of 56.8% (SD, 6).
Dr. Satragno and her collaborators also looked at a number of other secondary outcome measures, including incidence of jaundice and polycythemia in the infant, and maternal postpartum hemorrhage. There were no such adverse events that reached the level of clinical relevance among any of the mothers or infants in the study population, she said.
A larger study had been planned, said Dr. Satragno, but the data safety monitoring board recommended stopping the study for futility after the prespecified interim analysis of data from 144 patients – just 25% of the originally planned sample size.
In response to an audience question, Dr. Satragno acknowledged that blinding was not feasible with their study design, but that she did not think that this affected physician management in the first few minutes postpartum. She noted that delayed cord clamping has been an area of active research at her institution, and protocols are well established.
“Based on the available data, a recalculation of the sample size for a difference of 20% in the volume of placental transfusion would result in a trial of an unrealistically large magnitude,” said Dr. Satragno.
The study was funded by the Foundation for Maternal and Child Health. The authors reported no conflicts of interest.
SOURCE: Satragno D et al. Am J Obstet Gynecol. 2018 Jan;218:S26.
DALLAS – Timing of maternal oxytocin administration did not affect total placental transfusion volume accomplished via delayed umbilical cord clamping, according to a recent randomized, controlled trial.
Of 144 infants born to women who consented to randomization, those whose mothers received intravenous oxytocin within 15 seconds of delivery (n = 70) gained a mean 86 g (standard deviation, 48; 95% confidence interval, 74-97) in the 3 minutes after delivery, before umbilical cord clamping. Infants whose mothers received oxytocin when the umbilical cord was clamped 3 minutes after delivery (n = 74) gained 87 g (SD, 50; 95% CI, 75-98; P for difference between groups = .92). The findings were presented during an abstract session at the meeting sponsored by the Society for Maternal-Fetal Medicine.
It had not previously been known whether immediate oxytocin administration enhanced or diminished placental transfusion volume, said Daniela Satragno, MD, the study’s first author.
The investigators had hypothesized that immediate oxytocin administration would increase the volume of placental transfusion, said Dr. Satragno, of Argentina’s Foundation for Maternal and Child Health. However, their study didn’t bear this out. “When umbilical cord clamping is delayed for 3 minutes, infants receive a clinically significant placental transfusion which is not modified by the administration of IV oxytocin immediately after birth,” wrote Dr. Satragno and her coauthors in the abstract accompanying the presentation.
The study in the American Journal of Obstetrics & Gynecology included healthy term infants born via vaginal delivery; Dr. Satragno said that consent was obtained from mothers in early labor, and that study recruiters did not approach women who were in more advanced stages of labor because of ethical concerns. Women with high-risk pregnancies and those with known fetal anomalies were excluded, as were any who required forceps deliveries, neonatal resuscitation, and those whose deliveries involved a short umbilical cord or a nuchal cord.
In order to estimate the volume of placental transfusion, all infants were weighed on a 1-g precision scale placed at the level of the vagina both immediately after birth and after the umbilical cord was clamped at 3 minutes after delivery. All participating mothers received 10 IU of oxytocin, with the timing varying by intervention arm. A figure of 1.05 g/cc of blood was used to calculate transfusion volume, with change in infant weight used as a proxy for transfusion volume.
Hematocrit levels were also similar between the two groups: infants whose mothers received immediate oxytocin had a mean hematocrit of 57% (SD, 5), while those whose mothers had delayed oxytocin administration had a mean hematocrit of 56.8% (SD, 6).
Dr. Satragno and her collaborators also looked at a number of other secondary outcome measures, including incidence of jaundice and polycythemia in the infant, and maternal postpartum hemorrhage. There were no such adverse events that reached the level of clinical relevance among any of the mothers or infants in the study population, she said.
A larger study had been planned, said Dr. Satragno, but the data safety monitoring board recommended stopping the study for futility after the prespecified interim analysis of data from 144 patients – just 25% of the originally planned sample size.
In response to an audience question, Dr. Satragno acknowledged that blinding was not feasible with their study design, but that she did not think that this affected physician management in the first few minutes postpartum. She noted that delayed cord clamping has been an area of active research at her institution, and protocols are well established.
“Based on the available data, a recalculation of the sample size for a difference of 20% in the volume of placental transfusion would result in a trial of an unrealistically large magnitude,” said Dr. Satragno.
The study was funded by the Foundation for Maternal and Child Health. The authors reported no conflicts of interest.
SOURCE: Satragno D et al. Am J Obstet Gynecol. 2018 Jan;218:S26.
DALLAS – Timing of maternal oxytocin administration did not affect total placental transfusion volume accomplished via delayed umbilical cord clamping, according to a recent randomized, controlled trial.
Of 144 infants born to women who consented to randomization, those whose mothers received intravenous oxytocin within 15 seconds of delivery (n = 70) gained a mean 86 g (standard deviation, 48; 95% confidence interval, 74-97) in the 3 minutes after delivery, before umbilical cord clamping. Infants whose mothers received oxytocin when the umbilical cord was clamped 3 minutes after delivery (n = 74) gained 87 g (SD, 50; 95% CI, 75-98; P for difference between groups = .92). The findings were presented during an abstract session at the meeting sponsored by the Society for Maternal-Fetal Medicine.
It had not previously been known whether immediate oxytocin administration enhanced or diminished placental transfusion volume, said Daniela Satragno, MD, the study’s first author.
The investigators had hypothesized that immediate oxytocin administration would increase the volume of placental transfusion, said Dr. Satragno, of Argentina’s Foundation for Maternal and Child Health. However, their study didn’t bear this out. “When umbilical cord clamping is delayed for 3 minutes, infants receive a clinically significant placental transfusion which is not modified by the administration of IV oxytocin immediately after birth,” wrote Dr. Satragno and her coauthors in the abstract accompanying the presentation.
The study in the American Journal of Obstetrics & Gynecology included healthy term infants born via vaginal delivery; Dr. Satragno said that consent was obtained from mothers in early labor, and that study recruiters did not approach women who were in more advanced stages of labor because of ethical concerns. Women with high-risk pregnancies and those with known fetal anomalies were excluded, as were any who required forceps deliveries, neonatal resuscitation, and those whose deliveries involved a short umbilical cord or a nuchal cord.
In order to estimate the volume of placental transfusion, all infants were weighed on a 1-g precision scale placed at the level of the vagina both immediately after birth and after the umbilical cord was clamped at 3 minutes after delivery. All participating mothers received 10 IU of oxytocin, with the timing varying by intervention arm. A figure of 1.05 g/cc of blood was used to calculate transfusion volume, with change in infant weight used as a proxy for transfusion volume.
Hematocrit levels were also similar between the two groups: infants whose mothers received immediate oxytocin had a mean hematocrit of 57% (SD, 5), while those whose mothers had delayed oxytocin administration had a mean hematocrit of 56.8% (SD, 6).
Dr. Satragno and her collaborators also looked at a number of other secondary outcome measures, including incidence of jaundice and polycythemia in the infant, and maternal postpartum hemorrhage. There were no such adverse events that reached the level of clinical relevance among any of the mothers or infants in the study population, she said.
A larger study had been planned, said Dr. Satragno, but the data safety monitoring board recommended stopping the study for futility after the prespecified interim analysis of data from 144 patients – just 25% of the originally planned sample size.
In response to an audience question, Dr. Satragno acknowledged that blinding was not feasible with their study design, but that she did not think that this affected physician management in the first few minutes postpartum. She noted that delayed cord clamping has been an area of active research at her institution, and protocols are well established.
“Based on the available data, a recalculation of the sample size for a difference of 20% in the volume of placental transfusion would result in a trial of an unrealistically large magnitude,” said Dr. Satragno.
The study was funded by the Foundation for Maternal and Child Health. The authors reported no conflicts of interest.
SOURCE: Satragno D et al. Am J Obstet Gynecol. 2018 Jan;218:S26.
REPORTING FROM THE PREGNANCY MEETING
Key clinical point: The timing of oxytocin administration didn’t affect placental transfusion volume with delayed cord clamping.
Major finding: Placental transfusion volume was 86 g with immediate and 87 g with delayed oxytocin administration (P = .92), with infant weight used as proxy.
Study details: Randomized controlled trial of 144 healthy term infants delivered vaginally after uncomplicated pregnancy.
Disclosures: The study was sponsored by the Foundation for Maternal and Child Health, where Dr. Satragno is employed.
Source: Satragno D et al. Am J Obstet Gynecol. 2018 Jan;218:S26.
'This has to change': Surgeon pain, disability on the rise
The evidence has been accumulating for decades: Practicing surgery can exact a toll on surgeons’ physical well-being in ways that can shorten careers and contribute to professional dissatisfaction.
“Ergonomists have described the surgeon’s work environment and working conditions as equal to, if not at times harsher than, those of certain industrial workers,” wrote Sherise Epstein, MPH, and the coauthors of the systematic review and meta-analysis of studies addressing the issue. Ms. Epstein, currently a 4th-year medical student at the University of California, San Diego, and her team found a high prevalence of work-related musculoskeletal disorders and pain among surgeons and interventionalists, with pooled prevalence estimates for pain among these physicians ranging from 35% to 60% of all respondents. Cervical spine disease, rotator cuff pathology, and degenerative lumbar spine disease were each reported by nearly one in five respondents in the pooled analyses, with increasing prevalence over the duration of the study period (JAMA Surg. 2017 Dec 27. doi:10.1001/jamasurg.2017.49).
These findings, called “worrisome” by the study’s authors, come at a time when the demand for surgeons and interventionalists is expected soon to outstrip supply, and point to a major stressor for a profession already plagued by high rates of burnout and depression.
The results of the study are in line with previous work that finds a high – and increasing – rate of pain and disability among at-risk physicians, who endure long work hours, awkward positioning, and few opportunities for breaks.
The study also suggested a possible linkage between work-related pain and other factors, such as burnout and depression, that lead to attrition in the surgical profession.
Adrian Park, MD, FACS, a general surgeon who has long studied the issue of work-related musculoskeletal disorders (MSDs) among surgeons and interventionalists, was not surprised by the study’s findings. “This just goes to further the narrative, which is a consistent one: These aren’t just sporadic instances of individual surgeons having a tough time; this is an increasingly broadly recognized problem. ... These are the consequences of surgeons simply getting up and going to work each week,” Dr. Park said in an interview.
To take a long view of the published data on work-related injury and pain for at-risk physicians, Ms. Epstein and her collaborators identified 126 articles reporting physician work-related MSDs that met quality standards; the studies spanned 1974 to 2016, and 23 countries were represented.
A total of 21 articles were eventually included in the meta-analysis, which included responses from 5,828 physicians. Most of the respondents were male (78.5%), with a mean age of 46 years and a mean 12.8 years in practice. The mean number of hours spent in procedures per week was 14.4.
Sixteen cross-sectional studies included in the meta-analysis examined injury prevalence, with 14 studies eventually meeting eligibility criteria for quantitative synthesis. A total of 4,245 physicians were included in this portion of the analysis; 1,232 were orthopedic surgeons, 1,118 were interventional cardiologists, and 582 were general surgeons (a variety of other subspecialties made up the remainder).
The career prevalence of degenerative lumbar spine disease was estimated at 19%, with prevalence increasing over time in a series of surveys of interventional cardiologists, said Ms. Epstein and her colleagues. Among this group, the prevalence climbed from 6.5% in 1997 to 24.7% in 2015, an increase in prevalence of over 18%, they said. The investigators’ estimate of lumbar spine disease prevalence from their own data also showed an increase, to 21%, for studies published within the past decade.
Rotator cuff pathology during the study period was estimated at 18% overall, and carpal tunnel syndrome at 9% overall; carpal tunnel syndrome also appears to be increasing in prevalence, estimated at 12% within the last decade.
Musculoskeletal pain that was judged to be work related was common, as reported in 18 cross-sectional studies. Taken together, the studies used a total of five validated tools that measured both pain prevalence and related disability. Twelve of the studies met criteria for inclusion in the quantitative synthesis.
Neck, back, and shoulder pain were all common in this group of surgeons and interventionalists. Neck pain had a 60% estimated 12-month prevalence, and shoulder pain was almost as common, with a 52% prevalence; back pain was reported for about half (49%) of respondents.
Just 10 of the included studies addressed disability burden, said Ms. Epstein and her colleagues. Overall, 12% of physicians responding in this subset of studies reported that they required work modification, leave of absence, or early retirement because of work-related MSDs.
In a separate arm of the analysis, Ms. Epstein and her collaborators looked at studies that discussed ergonomic assessments and interventions, using a qualitative approach. A total of 101 studies, 50 of them in the United States, were included. None of the studies, they said, “included long-term surveillance for work-related MSDs”; rather, they focused on short-term outcomes and, in some cases, on real-time electromyographic data.
Of the 101 studies looking at ergonomics, about a third (n = 38) looked primarily at ergonomically designed devices or technology, while another third (n = 37) focused on educational or behavioral interventions and modifications. These were the studies included in the investigators’ analysis.
A lack of awareness of ergonomic recommendations on the part of the surgeons themselves was identified in several studies. Several specialties, publishing in a total of eight countries, have put forward “at least one article describing a need for ergonomics education during medical training.” And, said the investigators, “A few studies have found that ergonomics education during medical training appears feasible, accepted, and effective at changing behaviors and reducing symptoms.”
In addition to the usual limitations inherent to the meta-analysis research design (selection bias, self-reported data, small samples of individual studies), the study was limited by the elusive nature of the topic. Work-related pain and disability among surgeons remains underreported and underestimated, according to both Dr. Park and the study investigators. Further research is needed, and the investigators wrote: “Ultimately, this work should be integrated with research on preventing surgeon burnout and attrition given shared risk factors.”
Micro breaks can help
What’s the solution? Dr. Park says that some fixes are low tech, and can be put in place immediately. He and his team implemented a series of brief breaks, taken every half hour during a procedure, that they dubbed “targeted stretching micro breaks.” These are 45- to 50-second breaks during which a series of exercise physiologist–designed brief stretches are undertaken that do not require breaking scrub.
In a study of 66 surgeons and operating room staff, Dr. Park, chair of the department of surgery at Anne Arundel Medical Center, Annapolis, Md., and his collaborators found that surgeons reported less pain and fatigue, and improved mental focus, when they took micro breaks during a procedure. When surgeons took micro breaks, operative time was no longer than when they didn’t take the breaks (Ann Surg. 2017 Feb;265[2]:340-6).
“We do this all the time in our operating room now,” said Dr. Park. “And it makes a difference in terms of pain, in terms of alertness, in terms of stamina. And it costs nothing.”
Major redesign of tools and workspace
Other targets for technological improvement include offering better-designed handles for laparoscopic instruments. “We’ve had one size fits all forever. Why has it taken us so long to recognize that there’s not one size of surgical hand?” asked Dr. Park. He made the point that the influx of women – whose hands are smaller on average than men’s – into the surgical professions makes this a particularly pressing issue.
“The high-tech piece is going to be a better understanding of the operative work flow,” said Dr. Park, calling for “a meaningful revisiting of the surgeon-device interface and the surgeon-patient interface.”
A fundamental redesign of the operating room will eventually be in order, he said, contrasting the surgeon’s environments with that of an airline pilot. In the cockpit, the pilot sees a “heads-up” display of a limited amount of data, with an eye to controlling the cognitive workload for the operator. By contrast, said Dr. Park, in the OR, there are “lights flashing, and things pinging,” and pieces of equipment don’t “talk” to each other, presenting sometimes overwhelming sensory input that just potentiates the stress of the environment. Operating room design, he said, should move toward an ergonomically improved and stimulus-controlled environment.
As the leader of the surgical team, and as a physician whose foremost concern is the patient on the table, the surgeon may inadvertently have fallen into a role where his or her well-being is neglected.
Dr. Park suggested that, in the surgical profession, “it has never felt safe or appropriate to talk about ourselves.” But for the good of the profession, and ultimately for patient care, “this has to change.”
Ms. Epstein and her coauthors reported no conflicts of interest. .
We rarely think of surgeons as athletes and certainly we sometimes don’t look like athletes, but surgery is a performance sport that includes strength and grace. Many surgeons are also very active outside the OR. So, not only OR activity but all the other activities are stacked upon our bodies. Posture, strength training, and ergonomics need to be part of our training just as it would for a pitcher for the Kansas City Royals. You wouldn’t expect the pitcher’s arm to last long without coaching and training physically. That player’s career would be shortened. Why would we expect surgeons to be different? Our game is 90% mental, but the other half is physical (with respect to Yogi Berra).
We rarely think of surgeons as athletes and certainly we sometimes don’t look like athletes, but surgery is a performance sport that includes strength and grace. Many surgeons are also very active outside the OR. So, not only OR activity but all the other activities are stacked upon our bodies. Posture, strength training, and ergonomics need to be part of our training just as it would for a pitcher for the Kansas City Royals. You wouldn’t expect the pitcher’s arm to last long without coaching and training physically. That player’s career would be shortened. Why would we expect surgeons to be different? Our game is 90% mental, but the other half is physical (with respect to Yogi Berra).
We rarely think of surgeons as athletes and certainly we sometimes don’t look like athletes, but surgery is a performance sport that includes strength and grace. Many surgeons are also very active outside the OR. So, not only OR activity but all the other activities are stacked upon our bodies. Posture, strength training, and ergonomics need to be part of our training just as it would for a pitcher for the Kansas City Royals. You wouldn’t expect the pitcher’s arm to last long without coaching and training physically. That player’s career would be shortened. Why would we expect surgeons to be different? Our game is 90% mental, but the other half is physical (with respect to Yogi Berra).
The evidence has been accumulating for decades: Practicing surgery can exact a toll on surgeons’ physical well-being in ways that can shorten careers and contribute to professional dissatisfaction.
“Ergonomists have described the surgeon’s work environment and working conditions as equal to, if not at times harsher than, those of certain industrial workers,” wrote Sherise Epstein, MPH, and the coauthors of the systematic review and meta-analysis of studies addressing the issue. Ms. Epstein, currently a 4th-year medical student at the University of California, San Diego, and her team found a high prevalence of work-related musculoskeletal disorders and pain among surgeons and interventionalists, with pooled prevalence estimates for pain among these physicians ranging from 35% to 60% of all respondents. Cervical spine disease, rotator cuff pathology, and degenerative lumbar spine disease were each reported by nearly one in five respondents in the pooled analyses, with increasing prevalence over the duration of the study period (JAMA Surg. 2017 Dec 27. doi:10.1001/jamasurg.2017.49).
These findings, called “worrisome” by the study’s authors, come at a time when the demand for surgeons and interventionalists is expected soon to outstrip supply, and point to a major stressor for a profession already plagued by high rates of burnout and depression.
The results of the study are in line with previous work that finds a high – and increasing – rate of pain and disability among at-risk physicians, who endure long work hours, awkward positioning, and few opportunities for breaks.
The study also suggested a possible linkage between work-related pain and other factors, such as burnout and depression, that lead to attrition in the surgical profession.
Adrian Park, MD, FACS, a general surgeon who has long studied the issue of work-related musculoskeletal disorders (MSDs) among surgeons and interventionalists, was not surprised by the study’s findings. “This just goes to further the narrative, which is a consistent one: These aren’t just sporadic instances of individual surgeons having a tough time; this is an increasingly broadly recognized problem. ... These are the consequences of surgeons simply getting up and going to work each week,” Dr. Park said in an interview.
To take a long view of the published data on work-related injury and pain for at-risk physicians, Ms. Epstein and her collaborators identified 126 articles reporting physician work-related MSDs that met quality standards; the studies spanned 1974 to 2016, and 23 countries were represented.
A total of 21 articles were eventually included in the meta-analysis, which included responses from 5,828 physicians. Most of the respondents were male (78.5%), with a mean age of 46 years and a mean 12.8 years in practice. The mean number of hours spent in procedures per week was 14.4.
Sixteen cross-sectional studies included in the meta-analysis examined injury prevalence, with 14 studies eventually meeting eligibility criteria for quantitative synthesis. A total of 4,245 physicians were included in this portion of the analysis; 1,232 were orthopedic surgeons, 1,118 were interventional cardiologists, and 582 were general surgeons (a variety of other subspecialties made up the remainder).
The career prevalence of degenerative lumbar spine disease was estimated at 19%, with prevalence increasing over time in a series of surveys of interventional cardiologists, said Ms. Epstein and her colleagues. Among this group, the prevalence climbed from 6.5% in 1997 to 24.7% in 2015, an increase in prevalence of over 18%, they said. The investigators’ estimate of lumbar spine disease prevalence from their own data also showed an increase, to 21%, for studies published within the past decade.
Rotator cuff pathology during the study period was estimated at 18% overall, and carpal tunnel syndrome at 9% overall; carpal tunnel syndrome also appears to be increasing in prevalence, estimated at 12% within the last decade.
Musculoskeletal pain that was judged to be work related was common, as reported in 18 cross-sectional studies. Taken together, the studies used a total of five validated tools that measured both pain prevalence and related disability. Twelve of the studies met criteria for inclusion in the quantitative synthesis.
Neck, back, and shoulder pain were all common in this group of surgeons and interventionalists. Neck pain had a 60% estimated 12-month prevalence, and shoulder pain was almost as common, with a 52% prevalence; back pain was reported for about half (49%) of respondents.
Just 10 of the included studies addressed disability burden, said Ms. Epstein and her colleagues. Overall, 12% of physicians responding in this subset of studies reported that they required work modification, leave of absence, or early retirement because of work-related MSDs.
In a separate arm of the analysis, Ms. Epstein and her collaborators looked at studies that discussed ergonomic assessments and interventions, using a qualitative approach. A total of 101 studies, 50 of them in the United States, were included. None of the studies, they said, “included long-term surveillance for work-related MSDs”; rather, they focused on short-term outcomes and, in some cases, on real-time electromyographic data.
Of the 101 studies looking at ergonomics, about a third (n = 38) looked primarily at ergonomically designed devices or technology, while another third (n = 37) focused on educational or behavioral interventions and modifications. These were the studies included in the investigators’ analysis.
A lack of awareness of ergonomic recommendations on the part of the surgeons themselves was identified in several studies. Several specialties, publishing in a total of eight countries, have put forward “at least one article describing a need for ergonomics education during medical training.” And, said the investigators, “A few studies have found that ergonomics education during medical training appears feasible, accepted, and effective at changing behaviors and reducing symptoms.”
In addition to the usual limitations inherent to the meta-analysis research design (selection bias, self-reported data, small samples of individual studies), the study was limited by the elusive nature of the topic. Work-related pain and disability among surgeons remains underreported and underestimated, according to both Dr. Park and the study investigators. Further research is needed, and the investigators wrote: “Ultimately, this work should be integrated with research on preventing surgeon burnout and attrition given shared risk factors.”
Micro breaks can help
What’s the solution? Dr. Park says that some fixes are low tech, and can be put in place immediately. He and his team implemented a series of brief breaks, taken every half hour during a procedure, that they dubbed “targeted stretching micro breaks.” These are 45- to 50-second breaks during which a series of exercise physiologist–designed brief stretches are undertaken that do not require breaking scrub.
In a study of 66 surgeons and operating room staff, Dr. Park, chair of the department of surgery at Anne Arundel Medical Center, Annapolis, Md., and his collaborators found that surgeons reported less pain and fatigue, and improved mental focus, when they took micro breaks during a procedure. When surgeons took micro breaks, operative time was no longer than when they didn’t take the breaks (Ann Surg. 2017 Feb;265[2]:340-6).
“We do this all the time in our operating room now,” said Dr. Park. “And it makes a difference in terms of pain, in terms of alertness, in terms of stamina. And it costs nothing.”
Major redesign of tools and workspace
Other targets for technological improvement include offering better-designed handles for laparoscopic instruments. “We’ve had one size fits all forever. Why has it taken us so long to recognize that there’s not one size of surgical hand?” asked Dr. Park. He made the point that the influx of women – whose hands are smaller on average than men’s – into the surgical professions makes this a particularly pressing issue.
“The high-tech piece is going to be a better understanding of the operative work flow,” said Dr. Park, calling for “a meaningful revisiting of the surgeon-device interface and the surgeon-patient interface.”
A fundamental redesign of the operating room will eventually be in order, he said, contrasting the surgeon’s environments with that of an airline pilot. In the cockpit, the pilot sees a “heads-up” display of a limited amount of data, with an eye to controlling the cognitive workload for the operator. By contrast, said Dr. Park, in the OR, there are “lights flashing, and things pinging,” and pieces of equipment don’t “talk” to each other, presenting sometimes overwhelming sensory input that just potentiates the stress of the environment. Operating room design, he said, should move toward an ergonomically improved and stimulus-controlled environment.
As the leader of the surgical team, and as a physician whose foremost concern is the patient on the table, the surgeon may inadvertently have fallen into a role where his or her well-being is neglected.
Dr. Park suggested that, in the surgical profession, “it has never felt safe or appropriate to talk about ourselves.” But for the good of the profession, and ultimately for patient care, “this has to change.”
Ms. Epstein and her coauthors reported no conflicts of interest. .
The evidence has been accumulating for decades: Practicing surgery can exact a toll on surgeons’ physical well-being in ways that can shorten careers and contribute to professional dissatisfaction.
“Ergonomists have described the surgeon’s work environment and working conditions as equal to, if not at times harsher than, those of certain industrial workers,” wrote Sherise Epstein, MPH, and the coauthors of the systematic review and meta-analysis of studies addressing the issue. Ms. Epstein, currently a 4th-year medical student at the University of California, San Diego, and her team found a high prevalence of work-related musculoskeletal disorders and pain among surgeons and interventionalists, with pooled prevalence estimates for pain among these physicians ranging from 35% to 60% of all respondents. Cervical spine disease, rotator cuff pathology, and degenerative lumbar spine disease were each reported by nearly one in five respondents in the pooled analyses, with increasing prevalence over the duration of the study period (JAMA Surg. 2017 Dec 27. doi:10.1001/jamasurg.2017.49).
These findings, called “worrisome” by the study’s authors, come at a time when the demand for surgeons and interventionalists is expected soon to outstrip supply, and point to a major stressor for a profession already plagued by high rates of burnout and depression.
The results of the study are in line with previous work that finds a high – and increasing – rate of pain and disability among at-risk physicians, who endure long work hours, awkward positioning, and few opportunities for breaks.
The study also suggested a possible linkage between work-related pain and other factors, such as burnout and depression, that lead to attrition in the surgical profession.
Adrian Park, MD, FACS, a general surgeon who has long studied the issue of work-related musculoskeletal disorders (MSDs) among surgeons and interventionalists, was not surprised by the study’s findings. “This just goes to further the narrative, which is a consistent one: These aren’t just sporadic instances of individual surgeons having a tough time; this is an increasingly broadly recognized problem. ... These are the consequences of surgeons simply getting up and going to work each week,” Dr. Park said in an interview.
To take a long view of the published data on work-related injury and pain for at-risk physicians, Ms. Epstein and her collaborators identified 126 articles reporting physician work-related MSDs that met quality standards; the studies spanned 1974 to 2016, and 23 countries were represented.
A total of 21 articles were eventually included in the meta-analysis, which included responses from 5,828 physicians. Most of the respondents were male (78.5%), with a mean age of 46 years and a mean 12.8 years in practice. The mean number of hours spent in procedures per week was 14.4.
Sixteen cross-sectional studies included in the meta-analysis examined injury prevalence, with 14 studies eventually meeting eligibility criteria for quantitative synthesis. A total of 4,245 physicians were included in this portion of the analysis; 1,232 were orthopedic surgeons, 1,118 were interventional cardiologists, and 582 were general surgeons (a variety of other subspecialties made up the remainder).
The career prevalence of degenerative lumbar spine disease was estimated at 19%, with prevalence increasing over time in a series of surveys of interventional cardiologists, said Ms. Epstein and her colleagues. Among this group, the prevalence climbed from 6.5% in 1997 to 24.7% in 2015, an increase in prevalence of over 18%, they said. The investigators’ estimate of lumbar spine disease prevalence from their own data also showed an increase, to 21%, for studies published within the past decade.
Rotator cuff pathology during the study period was estimated at 18% overall, and carpal tunnel syndrome at 9% overall; carpal tunnel syndrome also appears to be increasing in prevalence, estimated at 12% within the last decade.
Musculoskeletal pain that was judged to be work related was common, as reported in 18 cross-sectional studies. Taken together, the studies used a total of five validated tools that measured both pain prevalence and related disability. Twelve of the studies met criteria for inclusion in the quantitative synthesis.
Neck, back, and shoulder pain were all common in this group of surgeons and interventionalists. Neck pain had a 60% estimated 12-month prevalence, and shoulder pain was almost as common, with a 52% prevalence; back pain was reported for about half (49%) of respondents.
Just 10 of the included studies addressed disability burden, said Ms. Epstein and her colleagues. Overall, 12% of physicians responding in this subset of studies reported that they required work modification, leave of absence, or early retirement because of work-related MSDs.
In a separate arm of the analysis, Ms. Epstein and her collaborators looked at studies that discussed ergonomic assessments and interventions, using a qualitative approach. A total of 101 studies, 50 of them in the United States, were included. None of the studies, they said, “included long-term surveillance for work-related MSDs”; rather, they focused on short-term outcomes and, in some cases, on real-time electromyographic data.
Of the 101 studies looking at ergonomics, about a third (n = 38) looked primarily at ergonomically designed devices or technology, while another third (n = 37) focused on educational or behavioral interventions and modifications. These were the studies included in the investigators’ analysis.
A lack of awareness of ergonomic recommendations on the part of the surgeons themselves was identified in several studies. Several specialties, publishing in a total of eight countries, have put forward “at least one article describing a need for ergonomics education during medical training.” And, said the investigators, “A few studies have found that ergonomics education during medical training appears feasible, accepted, and effective at changing behaviors and reducing symptoms.”
In addition to the usual limitations inherent to the meta-analysis research design (selection bias, self-reported data, small samples of individual studies), the study was limited by the elusive nature of the topic. Work-related pain and disability among surgeons remains underreported and underestimated, according to both Dr. Park and the study investigators. Further research is needed, and the investigators wrote: “Ultimately, this work should be integrated with research on preventing surgeon burnout and attrition given shared risk factors.”
Micro breaks can help
What’s the solution? Dr. Park says that some fixes are low tech, and can be put in place immediately. He and his team implemented a series of brief breaks, taken every half hour during a procedure, that they dubbed “targeted stretching micro breaks.” These are 45- to 50-second breaks during which a series of exercise physiologist–designed brief stretches are undertaken that do not require breaking scrub.
In a study of 66 surgeons and operating room staff, Dr. Park, chair of the department of surgery at Anne Arundel Medical Center, Annapolis, Md., and his collaborators found that surgeons reported less pain and fatigue, and improved mental focus, when they took micro breaks during a procedure. When surgeons took micro breaks, operative time was no longer than when they didn’t take the breaks (Ann Surg. 2017 Feb;265[2]:340-6).
“We do this all the time in our operating room now,” said Dr. Park. “And it makes a difference in terms of pain, in terms of alertness, in terms of stamina. And it costs nothing.”
Major redesign of tools and workspace
Other targets for technological improvement include offering better-designed handles for laparoscopic instruments. “We’ve had one size fits all forever. Why has it taken us so long to recognize that there’s not one size of surgical hand?” asked Dr. Park. He made the point that the influx of women – whose hands are smaller on average than men’s – into the surgical professions makes this a particularly pressing issue.
“The high-tech piece is going to be a better understanding of the operative work flow,” said Dr. Park, calling for “a meaningful revisiting of the surgeon-device interface and the surgeon-patient interface.”
A fundamental redesign of the operating room will eventually be in order, he said, contrasting the surgeon’s environments with that of an airline pilot. In the cockpit, the pilot sees a “heads-up” display of a limited amount of data, with an eye to controlling the cognitive workload for the operator. By contrast, said Dr. Park, in the OR, there are “lights flashing, and things pinging,” and pieces of equipment don’t “talk” to each other, presenting sometimes overwhelming sensory input that just potentiates the stress of the environment. Operating room design, he said, should move toward an ergonomically improved and stimulus-controlled environment.
As the leader of the surgical team, and as a physician whose foremost concern is the patient on the table, the surgeon may inadvertently have fallen into a role where his or her well-being is neglected.
Dr. Park suggested that, in the surgical profession, “it has never felt safe or appropriate to talk about ourselves.” But for the good of the profession, and ultimately for patient care, “this has to change.”
Ms. Epstein and her coauthors reported no conflicts of interest. .
Maternal short cervix and twins? Consider a pessary
DALLAS – Though cervical pessaries didn’t significantly reduce the rate of births before 34 weeks’ gestation when compared to vaginal progesterone for women with short cervixes and twin pregnancies, neonatal outcomes were improved with pessary use, according to the first randomized controlled trial that directly compared the two therapies.
Of 148 women who received pessaries, 24 (16.2%) delivered before 34 weeks’ gestation, compared with 33 of 149 women (22.1%) who received vaginal progesterone (relative risk 0.73, 95% confidence interval, 0.46-1.18; P = .24). Women who received pessaries were slightly more likely to carry their twin gestations to at least 37 weeks (79/148 versus 91/149; P = .05).
Certain perinatal outcomes were also better among the pessary group. The study measured a composite poor perinatal outcome of neonatal intensive care unit (NICU) admission, intraventricular hemorrhage, respiratory distress syndrome, necrotizing enterocolitis, and neonatal sepsis. This composite poor outcome occurred in 18.6% of the pessary group, compared with 26.5% of the progesterone group (P = .02). Neonatal admissions were more common in the progesterone than in the pessary group (22.1% vs. 13.2%, P = .01)
The odds of having a baby with birth weight less than 2,500 g was also higher for those receiving progesterone, with 22.1% of the progesterone group and 13.2% of the pessary group delivering infants in this range (P less than .001).
Previous work has shown that vaginal progesterone was efficacious when compared with placebo in preventing preterm births for women who have a twin gestation and a short cervix, according to Vinh Dang, MD, the study’s first author. Similarly, he said, studies have shown that placement of a cervical pessary also reduces preterm births in the scenario of twin gestation and a short cervix.
“No randomized controlled trial has directly compared cervical pessary versus vaginal progesterone for the prevention of preterm birth” in this population, Dr. Dang said during a presentation at the Pregnancy Meeting, sponsored by the Society for Maternal-Fetal Medicine.
Accordingly, he and his colleagues at My Duc Hospital in Ho Chi Minh City, Vietnam, conducted a comparative effectiveness trial to provide a head-to-head comparison of the use of cervical pessaries versus vaginal progesterone for women with twin gestations and short cervixes.
The investigators conducted a single-center, randomized controlled trial, enrolling women with either monochorionic or dichorionic twin pregnancies at between 16 and 22 weeks of gestation, with a cervix length of less than 38 mm, as assessed by two trained ultrasonographers.
At My Duc Hospital, 28.4% of women with twin pregnancies and cervical length less than 38 mm delivered earlier than 34 weeks. This meant that in order to detect a 14% reduction in preterm birth, the study would need to include 290 women for sufficient statistical power, Dr. Dang said.
Patients (n = 300) were randomized 1:1 to receive vaginal progesterone, begun on the day of enrollment, or cervical pessary placed within 1 week of study enrollment. Two patients in the pessary arm and one in the progesterone arm were lost to follow-up.
Patients were permitted to receive other therapies; 14 women in the pessary arm also received antibiotics and 1 received progesterone. In the progesterone group, 12 received antibiotics, and 4 patients were cotreated with cervical cerclage.
The study excluded women under 18 years of age, and those with a prior history of cervical surgery or cervical cerclage. Major known complications in the current pregnancy, such as twin-to-twin transfusion syndrome, major congenital anomaly, fetal demise, and any symptoms of labor or late miscarriage were also grounds for exclusion.
Patient characteristics were similar between groups. The average age was 32 years. Most of the patients (83%-90%) were nulliparous, and more than 90% of the pregnancies were the result of assisted reproduction.
In addition to the primary outcome measure of preterm birth earlier than 34 weeks, the investigators tracked a number of obstetric and neonatal outcomes as secondary endpoints.
For the obstetric measures, Dr. Dang and his colleagues recorded deliveries that occurred before 28, 32, and 27 weeks’ gestation, whether labor was induced and if tocolytics or corticosteroids were used, mode of delivery, and proportion of live births. The number of days of admission for preterm labor, presence of chorioamnionitis, and occurrence of other maternal morbidity were also measured.
Dr. Dang and his colleagues also tracked birth weight, congenital anomalies, and 1- and 5-minute Apgar scores.
A prespecified subgroup analysis of women with even shorter cervixes – less than 28 mm – showed a significant reduction in preterm birth before 34 weeks in addition to the significant improvement in neonatal outcomes.
One author reported being a consultant for ObsEva, Merck, and Guerbet. The other authors had no disclosures.
SOURCE: Dang V et al. The Pregnancy Meeting Abstract LB03
DALLAS – Though cervical pessaries didn’t significantly reduce the rate of births before 34 weeks’ gestation when compared to vaginal progesterone for women with short cervixes and twin pregnancies, neonatal outcomes were improved with pessary use, according to the first randomized controlled trial that directly compared the two therapies.
Of 148 women who received pessaries, 24 (16.2%) delivered before 34 weeks’ gestation, compared with 33 of 149 women (22.1%) who received vaginal progesterone (relative risk 0.73, 95% confidence interval, 0.46-1.18; P = .24). Women who received pessaries were slightly more likely to carry their twin gestations to at least 37 weeks (79/148 versus 91/149; P = .05).
Certain perinatal outcomes were also better among the pessary group. The study measured a composite poor perinatal outcome of neonatal intensive care unit (NICU) admission, intraventricular hemorrhage, respiratory distress syndrome, necrotizing enterocolitis, and neonatal sepsis. This composite poor outcome occurred in 18.6% of the pessary group, compared with 26.5% of the progesterone group (P = .02). Neonatal admissions were more common in the progesterone than in the pessary group (22.1% vs. 13.2%, P = .01)
The odds of having a baby with birth weight less than 2,500 g was also higher for those receiving progesterone, with 22.1% of the progesterone group and 13.2% of the pessary group delivering infants in this range (P less than .001).
Previous work has shown that vaginal progesterone was efficacious when compared with placebo in preventing preterm births for women who have a twin gestation and a short cervix, according to Vinh Dang, MD, the study’s first author. Similarly, he said, studies have shown that placement of a cervical pessary also reduces preterm births in the scenario of twin gestation and a short cervix.
“No randomized controlled trial has directly compared cervical pessary versus vaginal progesterone for the prevention of preterm birth” in this population, Dr. Dang said during a presentation at the Pregnancy Meeting, sponsored by the Society for Maternal-Fetal Medicine.
Accordingly, he and his colleagues at My Duc Hospital in Ho Chi Minh City, Vietnam, conducted a comparative effectiveness trial to provide a head-to-head comparison of the use of cervical pessaries versus vaginal progesterone for women with twin gestations and short cervixes.
The investigators conducted a single-center, randomized controlled trial, enrolling women with either monochorionic or dichorionic twin pregnancies at between 16 and 22 weeks of gestation, with a cervix length of less than 38 mm, as assessed by two trained ultrasonographers.
At My Duc Hospital, 28.4% of women with twin pregnancies and cervical length less than 38 mm delivered earlier than 34 weeks. This meant that in order to detect a 14% reduction in preterm birth, the study would need to include 290 women for sufficient statistical power, Dr. Dang said.
Patients (n = 300) were randomized 1:1 to receive vaginal progesterone, begun on the day of enrollment, or cervical pessary placed within 1 week of study enrollment. Two patients in the pessary arm and one in the progesterone arm were lost to follow-up.
Patients were permitted to receive other therapies; 14 women in the pessary arm also received antibiotics and 1 received progesterone. In the progesterone group, 12 received antibiotics, and 4 patients were cotreated with cervical cerclage.
The study excluded women under 18 years of age, and those with a prior history of cervical surgery or cervical cerclage. Major known complications in the current pregnancy, such as twin-to-twin transfusion syndrome, major congenital anomaly, fetal demise, and any symptoms of labor or late miscarriage were also grounds for exclusion.
Patient characteristics were similar between groups. The average age was 32 years. Most of the patients (83%-90%) were nulliparous, and more than 90% of the pregnancies were the result of assisted reproduction.
In addition to the primary outcome measure of preterm birth earlier than 34 weeks, the investigators tracked a number of obstetric and neonatal outcomes as secondary endpoints.
For the obstetric measures, Dr. Dang and his colleagues recorded deliveries that occurred before 28, 32, and 27 weeks’ gestation, whether labor was induced and if tocolytics or corticosteroids were used, mode of delivery, and proportion of live births. The number of days of admission for preterm labor, presence of chorioamnionitis, and occurrence of other maternal morbidity were also measured.
Dr. Dang and his colleagues also tracked birth weight, congenital anomalies, and 1- and 5-minute Apgar scores.
A prespecified subgroup analysis of women with even shorter cervixes – less than 28 mm – showed a significant reduction in preterm birth before 34 weeks in addition to the significant improvement in neonatal outcomes.
One author reported being a consultant for ObsEva, Merck, and Guerbet. The other authors had no disclosures.
SOURCE: Dang V et al. The Pregnancy Meeting Abstract LB03
DALLAS – Though cervical pessaries didn’t significantly reduce the rate of births before 34 weeks’ gestation when compared to vaginal progesterone for women with short cervixes and twin pregnancies, neonatal outcomes were improved with pessary use, according to the first randomized controlled trial that directly compared the two therapies.
Of 148 women who received pessaries, 24 (16.2%) delivered before 34 weeks’ gestation, compared with 33 of 149 women (22.1%) who received vaginal progesterone (relative risk 0.73, 95% confidence interval, 0.46-1.18; P = .24). Women who received pessaries were slightly more likely to carry their twin gestations to at least 37 weeks (79/148 versus 91/149; P = .05).
Certain perinatal outcomes were also better among the pessary group. The study measured a composite poor perinatal outcome of neonatal intensive care unit (NICU) admission, intraventricular hemorrhage, respiratory distress syndrome, necrotizing enterocolitis, and neonatal sepsis. This composite poor outcome occurred in 18.6% of the pessary group, compared with 26.5% of the progesterone group (P = .02). Neonatal admissions were more common in the progesterone than in the pessary group (22.1% vs. 13.2%, P = .01)
The odds of having a baby with birth weight less than 2,500 g was also higher for those receiving progesterone, with 22.1% of the progesterone group and 13.2% of the pessary group delivering infants in this range (P less than .001).
Previous work has shown that vaginal progesterone was efficacious when compared with placebo in preventing preterm births for women who have a twin gestation and a short cervix, according to Vinh Dang, MD, the study’s first author. Similarly, he said, studies have shown that placement of a cervical pessary also reduces preterm births in the scenario of twin gestation and a short cervix.
“No randomized controlled trial has directly compared cervical pessary versus vaginal progesterone for the prevention of preterm birth” in this population, Dr. Dang said during a presentation at the Pregnancy Meeting, sponsored by the Society for Maternal-Fetal Medicine.
Accordingly, he and his colleagues at My Duc Hospital in Ho Chi Minh City, Vietnam, conducted a comparative effectiveness trial to provide a head-to-head comparison of the use of cervical pessaries versus vaginal progesterone for women with twin gestations and short cervixes.
The investigators conducted a single-center, randomized controlled trial, enrolling women with either monochorionic or dichorionic twin pregnancies at between 16 and 22 weeks of gestation, with a cervix length of less than 38 mm, as assessed by two trained ultrasonographers.
At My Duc Hospital, 28.4% of women with twin pregnancies and cervical length less than 38 mm delivered earlier than 34 weeks. This meant that in order to detect a 14% reduction in preterm birth, the study would need to include 290 women for sufficient statistical power, Dr. Dang said.
Patients (n = 300) were randomized 1:1 to receive vaginal progesterone, begun on the day of enrollment, or cervical pessary placed within 1 week of study enrollment. Two patients in the pessary arm and one in the progesterone arm were lost to follow-up.
Patients were permitted to receive other therapies; 14 women in the pessary arm also received antibiotics and 1 received progesterone. In the progesterone group, 12 received antibiotics, and 4 patients were cotreated with cervical cerclage.
The study excluded women under 18 years of age, and those with a prior history of cervical surgery or cervical cerclage. Major known complications in the current pregnancy, such as twin-to-twin transfusion syndrome, major congenital anomaly, fetal demise, and any symptoms of labor or late miscarriage were also grounds for exclusion.
Patient characteristics were similar between groups. The average age was 32 years. Most of the patients (83%-90%) were nulliparous, and more than 90% of the pregnancies were the result of assisted reproduction.
In addition to the primary outcome measure of preterm birth earlier than 34 weeks, the investigators tracked a number of obstetric and neonatal outcomes as secondary endpoints.
For the obstetric measures, Dr. Dang and his colleagues recorded deliveries that occurred before 28, 32, and 27 weeks’ gestation, whether labor was induced and if tocolytics or corticosteroids were used, mode of delivery, and proportion of live births. The number of days of admission for preterm labor, presence of chorioamnionitis, and occurrence of other maternal morbidity were also measured.
Dr. Dang and his colleagues also tracked birth weight, congenital anomalies, and 1- and 5-minute Apgar scores.
A prespecified subgroup analysis of women with even shorter cervixes – less than 28 mm – showed a significant reduction in preterm birth before 34 weeks in addition to the significant improvement in neonatal outcomes.
One author reported being a consultant for ObsEva, Merck, and Guerbet. The other authors had no disclosures.
SOURCE: Dang V et al. The Pregnancy Meeting Abstract LB03
REPORTING FROM THE PREGNANCY MEETING
Key clinical point:
Major finding: Poor neonatal outcome occurred in 18.6% of those receiving pessary, compared with 26.5% of those receiving vaginal progesterone (P = .02).
Study details: Randomized controlled trial of cervical pessary versus vaginal progesterone for women with twin gestation and cervical length less than 38 mm.
Disclosures: One author reported funding from Obseva, Merck, and Guerbet. The other authors reported no conflicts of interest.
Source: Dang V et al. The Pregnancy Meeting Abstract LB03.
Persistent opioid use a risk after surgery in teens and young adults
For a subset of opioid-naive adolescents and young adults who received perioperative opioid scripts, those prescriptions were filled for months after the surgery, raising concerns about long-term risk for substance use disorder.
To get an idea of the teen opioid problem, from 1997 to 2012 for adolescents aged 15-19 years, the incidence of hospitalizations for opioid poisonings per 100,000 teens increased from 3.69 to 10.17, an increase of 176%, according to a study in JAMA Pediatrics (2016;170[12]:1195-201). Adolescents are at a three to five time higher risk for serious medical outcomes when hospitalized with opioid poisoning, such as life-threatening symptoms or death, compared with younger children, according to a study reporting prescription drug exposures among children (Pediatrics. 2017;139[4]:e20163382).
These figures are concerning in part because “a significant association between medical use of prescription opioids alone in adolescence and subsequent nonmedical use of prescription opioids was observed at age 35 years” in a national longitudinal study reported in the journal Pain (2016 Oct;157[10]:2173-8), said Calista M. Harbaugh, MD, of the University of Michigan, Ann Arbor, and her study coauthors.
The study in Pediatrics, which drew from a large national insurance claims database, found some patient characteristics had independent associations with increased risk of persistent opioid use. These included being female or older, as well as having a prior history of substance use disorder, chronic pain, or filling an opioid prescription preoperatively.
Dr. Harbaugh and her collaborators used a large national research database to select opioid-naive patients aged 13-21 years who received 1 of 13 surgical procedures. A total of 88,637 opioid-naive surgical patients were included in the study, with 110,432 control nonsurgical patients. The control group consisted of 3% of the database’s nonsurgical patients who met age and opioid-naivete criteria. Patients in both groups also had to have continuous insurance for the prior 12 months, not have had an opioid prescription filled within the prior year, and not have received any subsequent surgical procedures during the study period.
To be able to compare medication use among patients receiving different types of opioids, the opioid component of all prescriptions was converted to milligrams, and then used to calculate oral morphine equivalents (OMEs) for each prescription.
Although the most common procedures were tonsillectomy and/or adenoidectomy (35.9% of patients), arthroscopic knee repair (25.3%), and appendectomy, (18.6%), these were not the procedures that were most associated with persistent opioid use.
Overall, 7.1% of patients had an initial daily dosage greater than 100 OMEs for their first postoperative prescription. These high opioid doses were likely to be seen in patients undergoing three procedures known to have considerable postoperative pain: pectus repair, posterior arthrodesis, and supracondylar fracture fixation. However, patients undergoing these procedures weren’t more likely to have persistent opioid use than other surgical patients in the study, the researchers said.
Rather, cholecystectomy and colectomy had the highest risk for persistent opioid use, with adjusted odds ratios of 1.13 and 2.33, respectively. Dr. Harbaugh and her collaborators, in discussing the study’s findings, noted that these two conditions involve high levels of preoperative inflammation and are characterized by visceral pain. This scenario, they said, may set these patients up for visceral and central sensitization and present an increased risk for chronic pain.
Dr. Harbaugh and her colleagues called for preoperative screening for risk factors for persistent opioid use, so that at-risk patients can receive closer monitoring and attention. “We are not suggesting that … pain should be underappreciated or undertreated,” or that at-risk patients should not be prescribed opioids.
The investigators said that their work “points toward the multifactorial etiology of postoperative pain and its complex nature in both the short and long term.” They called for more work to “elucidate the mechanism that underlies new persistent opioid use after certain procedures,” as well as more efforts to better understand how best to use multimodal pharmacologic and nonpharmacologic pain control measures in the adolescent and young adult population.
The study was funded by the Michigan Department of Health and Human Services. Dr. Harbaugh reported that she had no relevant financial disclosures. Some of the other investigators received grants from various agencies.
SOURCE: Harbaugh CM et al. Pediatrics 2018 Jan 1;141(1):e20172439
For a subset of opioid-naive adolescents and young adults who received perioperative opioid scripts, those prescriptions were filled for months after the surgery, raising concerns about long-term risk for substance use disorder.
To get an idea of the teen opioid problem, from 1997 to 2012 for adolescents aged 15-19 years, the incidence of hospitalizations for opioid poisonings per 100,000 teens increased from 3.69 to 10.17, an increase of 176%, according to a study in JAMA Pediatrics (2016;170[12]:1195-201). Adolescents are at a three to five time higher risk for serious medical outcomes when hospitalized with opioid poisoning, such as life-threatening symptoms or death, compared with younger children, according to a study reporting prescription drug exposures among children (Pediatrics. 2017;139[4]:e20163382).
These figures are concerning in part because “a significant association between medical use of prescription opioids alone in adolescence and subsequent nonmedical use of prescription opioids was observed at age 35 years” in a national longitudinal study reported in the journal Pain (2016 Oct;157[10]:2173-8), said Calista M. Harbaugh, MD, of the University of Michigan, Ann Arbor, and her study coauthors.
The study in Pediatrics, which drew from a large national insurance claims database, found some patient characteristics had independent associations with increased risk of persistent opioid use. These included being female or older, as well as having a prior history of substance use disorder, chronic pain, or filling an opioid prescription preoperatively.
Dr. Harbaugh and her collaborators used a large national research database to select opioid-naive patients aged 13-21 years who received 1 of 13 surgical procedures. A total of 88,637 opioid-naive surgical patients were included in the study, with 110,432 control nonsurgical patients. The control group consisted of 3% of the database’s nonsurgical patients who met age and opioid-naivete criteria. Patients in both groups also had to have continuous insurance for the prior 12 months, not have had an opioid prescription filled within the prior year, and not have received any subsequent surgical procedures during the study period.
To be able to compare medication use among patients receiving different types of opioids, the opioid component of all prescriptions was converted to milligrams, and then used to calculate oral morphine equivalents (OMEs) for each prescription.
Although the most common procedures were tonsillectomy and/or adenoidectomy (35.9% of patients), arthroscopic knee repair (25.3%), and appendectomy, (18.6%), these were not the procedures that were most associated with persistent opioid use.
Overall, 7.1% of patients had an initial daily dosage greater than 100 OMEs for their first postoperative prescription. These high opioid doses were likely to be seen in patients undergoing three procedures known to have considerable postoperative pain: pectus repair, posterior arthrodesis, and supracondylar fracture fixation. However, patients undergoing these procedures weren’t more likely to have persistent opioid use than other surgical patients in the study, the researchers said.
Rather, cholecystectomy and colectomy had the highest risk for persistent opioid use, with adjusted odds ratios of 1.13 and 2.33, respectively. Dr. Harbaugh and her collaborators, in discussing the study’s findings, noted that these two conditions involve high levels of preoperative inflammation and are characterized by visceral pain. This scenario, they said, may set these patients up for visceral and central sensitization and present an increased risk for chronic pain.
Dr. Harbaugh and her colleagues called for preoperative screening for risk factors for persistent opioid use, so that at-risk patients can receive closer monitoring and attention. “We are not suggesting that … pain should be underappreciated or undertreated,” or that at-risk patients should not be prescribed opioids.
The investigators said that their work “points toward the multifactorial etiology of postoperative pain and its complex nature in both the short and long term.” They called for more work to “elucidate the mechanism that underlies new persistent opioid use after certain procedures,” as well as more efforts to better understand how best to use multimodal pharmacologic and nonpharmacologic pain control measures in the adolescent and young adult population.
The study was funded by the Michigan Department of Health and Human Services. Dr. Harbaugh reported that she had no relevant financial disclosures. Some of the other investigators received grants from various agencies.
SOURCE: Harbaugh CM et al. Pediatrics 2018 Jan 1;141(1):e20172439
For a subset of opioid-naive adolescents and young adults who received perioperative opioid scripts, those prescriptions were filled for months after the surgery, raising concerns about long-term risk for substance use disorder.
To get an idea of the teen opioid problem, from 1997 to 2012 for adolescents aged 15-19 years, the incidence of hospitalizations for opioid poisonings per 100,000 teens increased from 3.69 to 10.17, an increase of 176%, according to a study in JAMA Pediatrics (2016;170[12]:1195-201). Adolescents are at a three to five time higher risk for serious medical outcomes when hospitalized with opioid poisoning, such as life-threatening symptoms or death, compared with younger children, according to a study reporting prescription drug exposures among children (Pediatrics. 2017;139[4]:e20163382).
These figures are concerning in part because “a significant association between medical use of prescription opioids alone in adolescence and subsequent nonmedical use of prescription opioids was observed at age 35 years” in a national longitudinal study reported in the journal Pain (2016 Oct;157[10]:2173-8), said Calista M. Harbaugh, MD, of the University of Michigan, Ann Arbor, and her study coauthors.
The study in Pediatrics, which drew from a large national insurance claims database, found some patient characteristics had independent associations with increased risk of persistent opioid use. These included being female or older, as well as having a prior history of substance use disorder, chronic pain, or filling an opioid prescription preoperatively.
Dr. Harbaugh and her collaborators used a large national research database to select opioid-naive patients aged 13-21 years who received 1 of 13 surgical procedures. A total of 88,637 opioid-naive surgical patients were included in the study, with 110,432 control nonsurgical patients. The control group consisted of 3% of the database’s nonsurgical patients who met age and opioid-naivete criteria. Patients in both groups also had to have continuous insurance for the prior 12 months, not have had an opioid prescription filled within the prior year, and not have received any subsequent surgical procedures during the study period.
To be able to compare medication use among patients receiving different types of opioids, the opioid component of all prescriptions was converted to milligrams, and then used to calculate oral morphine equivalents (OMEs) for each prescription.
Although the most common procedures were tonsillectomy and/or adenoidectomy (35.9% of patients), arthroscopic knee repair (25.3%), and appendectomy, (18.6%), these were not the procedures that were most associated with persistent opioid use.
Overall, 7.1% of patients had an initial daily dosage greater than 100 OMEs for their first postoperative prescription. These high opioid doses were likely to be seen in patients undergoing three procedures known to have considerable postoperative pain: pectus repair, posterior arthrodesis, and supracondylar fracture fixation. However, patients undergoing these procedures weren’t more likely to have persistent opioid use than other surgical patients in the study, the researchers said.
Rather, cholecystectomy and colectomy had the highest risk for persistent opioid use, with adjusted odds ratios of 1.13 and 2.33, respectively. Dr. Harbaugh and her collaborators, in discussing the study’s findings, noted that these two conditions involve high levels of preoperative inflammation and are characterized by visceral pain. This scenario, they said, may set these patients up for visceral and central sensitization and present an increased risk for chronic pain.
Dr. Harbaugh and her colleagues called for preoperative screening for risk factors for persistent opioid use, so that at-risk patients can receive closer monitoring and attention. “We are not suggesting that … pain should be underappreciated or undertreated,” or that at-risk patients should not be prescribed opioids.
The investigators said that their work “points toward the multifactorial etiology of postoperative pain and its complex nature in both the short and long term.” They called for more work to “elucidate the mechanism that underlies new persistent opioid use after certain procedures,” as well as more efforts to better understand how best to use multimodal pharmacologic and nonpharmacologic pain control measures in the adolescent and young adult population.
The study was funded by the Michigan Department of Health and Human Services. Dr. Harbaugh reported that she had no relevant financial disclosures. Some of the other investigators received grants from various agencies.
SOURCE: Harbaugh CM et al. Pediatrics 2018 Jan 1;141(1):e20172439
FROM PEDIATRICS
Key clinical point: Especially for females, older teens, and young adults, there’s a risk for persistent postsurgical opioid use.
Major finding: Opioid use persisted for 4.8% of patients undergoing surgery, compared with 0.1% of patients who did not have surgery.
Study details: Retrospective review of claims database including 88,637 adolescent and young adult patients undergoing surgery, and 110,432 controls who did not have surgery.
Disclosures: The study was funded by the Michigan Department of Health and Human Services. Dr. Harbaugh reported that she had no conflicts of interest. Some of the other investigators received grants from various agencies.
Source: Harbaugh CM et al. Pediatrics. 2018 Jan 1;141(1):e20172439
Social media, apps aid adolescents, young adults with cancer
The first time Dave Fuehrer was diagnosed with testicular cancer, he was knocked back. The twenty-something competitive bodybuilder, a recent New York State champion, was unprepared for his journey from wellness to disease, and then through treatments and their sequelae.
However, it was the second diagnosis of primary testicular cancer that really got to him, he said. This time, he was a recently married young professional who was working on starting a family. The second round of cancer took parenthood away from him and left him “feeling even more lost and ashamed” than the first diagnosis, he said in an interview. He felt isolated, alone, and very different from most of the other cancer patients he saw.
Now, Mr. Fuehrer and partners, all of whom have been affected by cancer, have developed a web-based mobile application they call Stupid Cancer. The app is designed to connect adolescents and young adults who have cancer, or are cancer survivors, with each other and with resources and information.
When users set up their profiles on the app, they indicate their status as person with cancer or family member/supporter, as well as their geographic region, age, and type and stage of cancer. Then, users can connect with each other in private one-on-one chats or in chat rooms. Users are anonymous.
The Stupid Cancer app, said Mr. Fuehrer, was a natural extension of the nonprofit of the same name – an event-based organization designed to serve the needs for information and connection with others that are in many ways unique to adolescents and young adults.
Mr. Fuehrer, who has a professional background in the pharmaceutical industry, said that he sorely missed that connection during his cancer journeys and saw a big unmet need. “I was the only guy my age in a roomful of men in their 60s and 70s at my urologist’s office,” said Mr. Fuehrer. “Nobody looked like me.”
But even within the adolescent and young adult community, the lived experience of cancer can be much different for a younger patient. “I feel like I missed out on part of my childhood,” said Dane Koomen. When he was diagnosed with advanced Burkitt lymphoma nearly 10 years ago, “Myspace was the only social media out there, and as an 11 year old, I wasn’t exactly going to be hanging out there,” he said.
If Twitter, Snapchat, or Instagram had been available when he was going through cancer treatment, said Mr. Koomen, he could have stayed in better touch with his friends as they finished 6th grade and prepared for the transition to junior high school. “There are experiences I missed – field trips I didn’t go on, parties I missed,” and even vicarious involvement through social media would have been better than the isolation he felt, he said.
He thinks social media could also have helped his friends understand his experience: “If I’d had Snapchat, then they could see what I’m going through, and it would have been easier for people to understand what’s going on,” he said.
Through social media with broader reach, like Twitter or Instagram, he could have found encouragement and hope from inspiring stories of other cancer patients who were completing treatment and reaching the cancer-free status he was hoping for, he said. And he also would have enjoyed telling his story to a wider audience, and gaining strength from others’ well wishes, on Twitter.
Ilia Buhtoiarov, MD, a pediatric oncologist at Cleveland Clinic Children’s Hospital, Ohio, said that he sees different groups using social media platforms in a variety of ways for support and information sharing.
Parents, he said in an interview, are big Facebook users. Beginning with the early, uncertain days after a cancer diagnosis, parents can share a lot of information “in a structured fashion,” through one post. “They can target the post to a number of people – so everyone hears exactly what you want to say,” he said. For parents and other caregivers, this strategy is efficient when time and energy are limited.
Facebook is also useful, he said, for marshaling resources, such as finding help with rides or after-school care for other children and for such things as letting friends know when the patient is feeling well enough to see others.
For young cancer patients, Dr. Buhtoiarov said, a platform like Instagram or Snapchat affords “the opportunity to start a conversation” with peers. “The barriers are lifted quite naturally,” he said, and he sees how “the likes, smiles, and emojis provide support” for the person with cancer as peers follow along with the cancer journey.
Like an increasing number of pediatric oncology programs nationwide, Cleveland Clinic Children’s Hospital has services tailored for adolescents and young adults with cancer, who may “fall through the cracks” between pediatric and adult oncology services. Dr. Buhtoiarov said that among his peers, Twitter is used extensively to keep apprised of clinical trial opportunities and to link to new research in the field. This is especially important for those caring for an age group that’s been identified as significantly underrepresented in clinical trials and for whom cancer survival rates are persistently flat.
Oncologists also need to help patients and families navigate the reams of sometimes unreliable information they’ll find on the Internet, said Dr. Buhtoiarov. Though professionals can connect with each other to help patients find an expert close to home, or to consider enrollment in a clinical trial, patients need to know that “this information should always be discussed with experts,” he said.
The need for support and interaction continues into cancer survivorship. Both Mr. Fuehrer and Mr. Koomen said that it’s hard for those who haven’t lived through life-threatening diagnoses and traumatic, protracted treatments to understand how the experiences stay with you. Mr. Fuehrer has to gear himself up for a trip to the dentist, where the bright lights, reclining posture, and sights, sounds, and smells trigger unwelcome memories of old trauma.
And Mr. Koomen said that given the opportunity, he wouldn’t rewrite his history to have lived a cancer-free life because the experiences he went through shaped so much of who he is today. Still, he feels different from many of his young adult peers and has enjoyed connecting with fellow young survivors through the Stupid Cancer app.
Also, Mr. Koomen, now a college student in Rochester, N.Y., who’s contemplating writing a book about his experiences, said that a smartphone might have helped him keep a lost link to his past: He wishes he had more pictures of his time in the hospital. “I wish I could remember more about my favorite nurses. I have some great memories with them.”
The American Society of Clinical Oncology maintains a list of resources for teens with cancer and those supporting them, as well as a general information page for teens diagnosed with cancer.
Dr. Buhtoiarov reported no relevant conflicts of interests. Mr. Fuehrer is the chief executive officer of Gryt Health , the developer of the Stupid Cancer app. Mr. Koomen reported no relevant conflicts of interest.
The first time Dave Fuehrer was diagnosed with testicular cancer, he was knocked back. The twenty-something competitive bodybuilder, a recent New York State champion, was unprepared for his journey from wellness to disease, and then through treatments and their sequelae.
However, it was the second diagnosis of primary testicular cancer that really got to him, he said. This time, he was a recently married young professional who was working on starting a family. The second round of cancer took parenthood away from him and left him “feeling even more lost and ashamed” than the first diagnosis, he said in an interview. He felt isolated, alone, and very different from most of the other cancer patients he saw.
Now, Mr. Fuehrer and partners, all of whom have been affected by cancer, have developed a web-based mobile application they call Stupid Cancer. The app is designed to connect adolescents and young adults who have cancer, or are cancer survivors, with each other and with resources and information.
When users set up their profiles on the app, they indicate their status as person with cancer or family member/supporter, as well as their geographic region, age, and type and stage of cancer. Then, users can connect with each other in private one-on-one chats or in chat rooms. Users are anonymous.
The Stupid Cancer app, said Mr. Fuehrer, was a natural extension of the nonprofit of the same name – an event-based organization designed to serve the needs for information and connection with others that are in many ways unique to adolescents and young adults.
Mr. Fuehrer, who has a professional background in the pharmaceutical industry, said that he sorely missed that connection during his cancer journeys and saw a big unmet need. “I was the only guy my age in a roomful of men in their 60s and 70s at my urologist’s office,” said Mr. Fuehrer. “Nobody looked like me.”
But even within the adolescent and young adult community, the lived experience of cancer can be much different for a younger patient. “I feel like I missed out on part of my childhood,” said Dane Koomen. When he was diagnosed with advanced Burkitt lymphoma nearly 10 years ago, “Myspace was the only social media out there, and as an 11 year old, I wasn’t exactly going to be hanging out there,” he said.
If Twitter, Snapchat, or Instagram had been available when he was going through cancer treatment, said Mr. Koomen, he could have stayed in better touch with his friends as they finished 6th grade and prepared for the transition to junior high school. “There are experiences I missed – field trips I didn’t go on, parties I missed,” and even vicarious involvement through social media would have been better than the isolation he felt, he said.
He thinks social media could also have helped his friends understand his experience: “If I’d had Snapchat, then they could see what I’m going through, and it would have been easier for people to understand what’s going on,” he said.
Through social media with broader reach, like Twitter or Instagram, he could have found encouragement and hope from inspiring stories of other cancer patients who were completing treatment and reaching the cancer-free status he was hoping for, he said. And he also would have enjoyed telling his story to a wider audience, and gaining strength from others’ well wishes, on Twitter.
Ilia Buhtoiarov, MD, a pediatric oncologist at Cleveland Clinic Children’s Hospital, Ohio, said that he sees different groups using social media platforms in a variety of ways for support and information sharing.
Parents, he said in an interview, are big Facebook users. Beginning with the early, uncertain days after a cancer diagnosis, parents can share a lot of information “in a structured fashion,” through one post. “They can target the post to a number of people – so everyone hears exactly what you want to say,” he said. For parents and other caregivers, this strategy is efficient when time and energy are limited.
Facebook is also useful, he said, for marshaling resources, such as finding help with rides or after-school care for other children and for such things as letting friends know when the patient is feeling well enough to see others.
For young cancer patients, Dr. Buhtoiarov said, a platform like Instagram or Snapchat affords “the opportunity to start a conversation” with peers. “The barriers are lifted quite naturally,” he said, and he sees how “the likes, smiles, and emojis provide support” for the person with cancer as peers follow along with the cancer journey.
Like an increasing number of pediatric oncology programs nationwide, Cleveland Clinic Children’s Hospital has services tailored for adolescents and young adults with cancer, who may “fall through the cracks” between pediatric and adult oncology services. Dr. Buhtoiarov said that among his peers, Twitter is used extensively to keep apprised of clinical trial opportunities and to link to new research in the field. This is especially important for those caring for an age group that’s been identified as significantly underrepresented in clinical trials and for whom cancer survival rates are persistently flat.
Oncologists also need to help patients and families navigate the reams of sometimes unreliable information they’ll find on the Internet, said Dr. Buhtoiarov. Though professionals can connect with each other to help patients find an expert close to home, or to consider enrollment in a clinical trial, patients need to know that “this information should always be discussed with experts,” he said.
The need for support and interaction continues into cancer survivorship. Both Mr. Fuehrer and Mr. Koomen said that it’s hard for those who haven’t lived through life-threatening diagnoses and traumatic, protracted treatments to understand how the experiences stay with you. Mr. Fuehrer has to gear himself up for a trip to the dentist, where the bright lights, reclining posture, and sights, sounds, and smells trigger unwelcome memories of old trauma.
And Mr. Koomen said that given the opportunity, he wouldn’t rewrite his history to have lived a cancer-free life because the experiences he went through shaped so much of who he is today. Still, he feels different from many of his young adult peers and has enjoyed connecting with fellow young survivors through the Stupid Cancer app.
Also, Mr. Koomen, now a college student in Rochester, N.Y., who’s contemplating writing a book about his experiences, said that a smartphone might have helped him keep a lost link to his past: He wishes he had more pictures of his time in the hospital. “I wish I could remember more about my favorite nurses. I have some great memories with them.”
The American Society of Clinical Oncology maintains a list of resources for teens with cancer and those supporting them, as well as a general information page for teens diagnosed with cancer.
Dr. Buhtoiarov reported no relevant conflicts of interests. Mr. Fuehrer is the chief executive officer of Gryt Health , the developer of the Stupid Cancer app. Mr. Koomen reported no relevant conflicts of interest.
The first time Dave Fuehrer was diagnosed with testicular cancer, he was knocked back. The twenty-something competitive bodybuilder, a recent New York State champion, was unprepared for his journey from wellness to disease, and then through treatments and their sequelae.
However, it was the second diagnosis of primary testicular cancer that really got to him, he said. This time, he was a recently married young professional who was working on starting a family. The second round of cancer took parenthood away from him and left him “feeling even more lost and ashamed” than the first diagnosis, he said in an interview. He felt isolated, alone, and very different from most of the other cancer patients he saw.
Now, Mr. Fuehrer and partners, all of whom have been affected by cancer, have developed a web-based mobile application they call Stupid Cancer. The app is designed to connect adolescents and young adults who have cancer, or are cancer survivors, with each other and with resources and information.
When users set up their profiles on the app, they indicate their status as person with cancer or family member/supporter, as well as their geographic region, age, and type and stage of cancer. Then, users can connect with each other in private one-on-one chats or in chat rooms. Users are anonymous.
The Stupid Cancer app, said Mr. Fuehrer, was a natural extension of the nonprofit of the same name – an event-based organization designed to serve the needs for information and connection with others that are in many ways unique to adolescents and young adults.
Mr. Fuehrer, who has a professional background in the pharmaceutical industry, said that he sorely missed that connection during his cancer journeys and saw a big unmet need. “I was the only guy my age in a roomful of men in their 60s and 70s at my urologist’s office,” said Mr. Fuehrer. “Nobody looked like me.”
But even within the adolescent and young adult community, the lived experience of cancer can be much different for a younger patient. “I feel like I missed out on part of my childhood,” said Dane Koomen. When he was diagnosed with advanced Burkitt lymphoma nearly 10 years ago, “Myspace was the only social media out there, and as an 11 year old, I wasn’t exactly going to be hanging out there,” he said.
If Twitter, Snapchat, or Instagram had been available when he was going through cancer treatment, said Mr. Koomen, he could have stayed in better touch with his friends as they finished 6th grade and prepared for the transition to junior high school. “There are experiences I missed – field trips I didn’t go on, parties I missed,” and even vicarious involvement through social media would have been better than the isolation he felt, he said.
He thinks social media could also have helped his friends understand his experience: “If I’d had Snapchat, then they could see what I’m going through, and it would have been easier for people to understand what’s going on,” he said.
Through social media with broader reach, like Twitter or Instagram, he could have found encouragement and hope from inspiring stories of other cancer patients who were completing treatment and reaching the cancer-free status he was hoping for, he said. And he also would have enjoyed telling his story to a wider audience, and gaining strength from others’ well wishes, on Twitter.
Ilia Buhtoiarov, MD, a pediatric oncologist at Cleveland Clinic Children’s Hospital, Ohio, said that he sees different groups using social media platforms in a variety of ways for support and information sharing.
Parents, he said in an interview, are big Facebook users. Beginning with the early, uncertain days after a cancer diagnosis, parents can share a lot of information “in a structured fashion,” through one post. “They can target the post to a number of people – so everyone hears exactly what you want to say,” he said. For parents and other caregivers, this strategy is efficient when time and energy are limited.
Facebook is also useful, he said, for marshaling resources, such as finding help with rides or after-school care for other children and for such things as letting friends know when the patient is feeling well enough to see others.
For young cancer patients, Dr. Buhtoiarov said, a platform like Instagram or Snapchat affords “the opportunity to start a conversation” with peers. “The barriers are lifted quite naturally,” he said, and he sees how “the likes, smiles, and emojis provide support” for the person with cancer as peers follow along with the cancer journey.
Like an increasing number of pediatric oncology programs nationwide, Cleveland Clinic Children’s Hospital has services tailored for adolescents and young adults with cancer, who may “fall through the cracks” between pediatric and adult oncology services. Dr. Buhtoiarov said that among his peers, Twitter is used extensively to keep apprised of clinical trial opportunities and to link to new research in the field. This is especially important for those caring for an age group that’s been identified as significantly underrepresented in clinical trials and for whom cancer survival rates are persistently flat.
Oncologists also need to help patients and families navigate the reams of sometimes unreliable information they’ll find on the Internet, said Dr. Buhtoiarov. Though professionals can connect with each other to help patients find an expert close to home, or to consider enrollment in a clinical trial, patients need to know that “this information should always be discussed with experts,” he said.
The need for support and interaction continues into cancer survivorship. Both Mr. Fuehrer and Mr. Koomen said that it’s hard for those who haven’t lived through life-threatening diagnoses and traumatic, protracted treatments to understand how the experiences stay with you. Mr. Fuehrer has to gear himself up for a trip to the dentist, where the bright lights, reclining posture, and sights, sounds, and smells trigger unwelcome memories of old trauma.
And Mr. Koomen said that given the opportunity, he wouldn’t rewrite his history to have lived a cancer-free life because the experiences he went through shaped so much of who he is today. Still, he feels different from many of his young adult peers and has enjoyed connecting with fellow young survivors through the Stupid Cancer app.
Also, Mr. Koomen, now a college student in Rochester, N.Y., who’s contemplating writing a book about his experiences, said that a smartphone might have helped him keep a lost link to his past: He wishes he had more pictures of his time in the hospital. “I wish I could remember more about my favorite nurses. I have some great memories with them.”
The American Society of Clinical Oncology maintains a list of resources for teens with cancer and those supporting them, as well as a general information page for teens diagnosed with cancer.
Dr. Buhtoiarov reported no relevant conflicts of interests. Mr. Fuehrer is the chief executive officer of Gryt Health , the developer of the Stupid Cancer app. Mr. Koomen reported no relevant conflicts of interest.
Earlier treatment but shorter survival: The rurality paradox in cancer
MONTREAL – Does rurality matter in cancer treatment? According to lessons from a Scottish study, the answer may be yes, but in unexpected ways.
Patients who lived further away from a cancer treatment center were more likely to be treated within the 62 days postreferral window that the Scottish government has set as a target. Compared with those living within 15 minutes of a cancer center, the adjusted odds ratio for patients living at least an hour away to receive timely treatment was 1.42 (95% confidence interval, 1.25-1.61). For those living on remote islands, the aOR was 1.32 (95% CI, 1.09-1.59).
Dr. Murchie, speaking at the annual meeting of the North American Primary Care Research Group, shared results of an updated study that looked at the cancer population in Northeast Scotland to see how living farther from a cancer center might be associated with time to diagnosis and treatment of cancer and with 1-year survival rates.
A “seminal” work that set the background for this study, said Dr. Murchie, was the 2002 publication tracking the relationship between rural residence status and cancer survival (Br J Cancer. 2002;87[6]:585-90). Findings from that study showed that as the distance from the patient’s residence to a cancer center increased, so did the risk that the cancer wasn’t diagnosed before death. Survival, especially for prostate and lung cancer, was found to decrease with increasing distance, said Dr. Murchie.
“This study has been widely replicated in the global literature, but the mechanisms have never been satisfactorily explained,” he said.
For the present study, the primary outcome measure was whether patients achieved treatment within 62 days of referral, the target set by the Scottish government, said Dr. Murchie.
Secondary outcomes included secondary care delay – whether treatment was begun within 31 days of diagnosis – and survival at 1 year after presentation or referral by a general practitioner.
A total of 12,339 patients were included; 74% were older than 60 years. Patients were relatively affluent, with 59% in the two least-deprived quintiles according to Scottish government classification. Dr. Murchie said that this is in keeping with the geographic-socioeconomic status distribution in Scotland. Females made up 56% of the population, and 35% were classified as rural dwelling.
Nearly a third of patients (n = 3,722; 30.6%) had breast cancer. Colorectal cancer was the next most common diagnosis (n = 2,775; 22.5%), followed by prostate cancer, lung cancer, upper gastrointestinal cancer, melanoma, and cervical cancer. Most patients (n = 8,537; 62%) had a Charlson Comorbidity Index score of 0.
Dr. Murchie used the Northeast and Aberdeen Scottish Cancer and Residence Cohort (NASCAR) data gathered during 2007-2014; the cohort’s data came from a variety of sources, including the region’s cancer care pathway database. National cancer registries, morbidity records, and other nationally maintained demographic databases were also used for the NASCAR dataset.
Those building the NASCAR cohort were able to link all of the data from disparate datasets and still keep investigators blinded to patient identity via a “safe harvest” technique that created pseudonyms to harmonize the datasets.
Using patient postal codes, a geographical information systems approach was used to determine traveling time to a cancer center. Travel time, Dr. Murchie pointed out, is a better measure than straight-line distance of true accessibility for rural-dwelling patients.
In discussion, Dr. Murchie said that the correlation between longer distance and shorter time to treatment held even when he and his colleagues controlled for “the most obvious explanation – that disease was more advanced on diagnosis among remoter people.” But, he said, “This does not translate into better survival. Why?”
Hypotheses, said Dr. Murchie, include the many small and large barriers to care that rural-dwelling individuals face. They must find a way to their GP, or place a phone call, and that physician must weigh the risk of a serious complication against the burden to the patient – and that patient’s family – of travel from a remote location to a cancer center.
Dr. Murchie encouraged international collaboration and replication of his work so that cancer researchers and primary care practitioners can reach a better understanding of the unique challenges in treating rural cancer patients.
Dr. Murchie reported that he had no relevant disclosures.
SOURCE: Murchie P. NAPCRG 2017 Abstract CR15.
MONTREAL – Does rurality matter in cancer treatment? According to lessons from a Scottish study, the answer may be yes, but in unexpected ways.
Patients who lived further away from a cancer treatment center were more likely to be treated within the 62 days postreferral window that the Scottish government has set as a target. Compared with those living within 15 minutes of a cancer center, the adjusted odds ratio for patients living at least an hour away to receive timely treatment was 1.42 (95% confidence interval, 1.25-1.61). For those living on remote islands, the aOR was 1.32 (95% CI, 1.09-1.59).
Dr. Murchie, speaking at the annual meeting of the North American Primary Care Research Group, shared results of an updated study that looked at the cancer population in Northeast Scotland to see how living farther from a cancer center might be associated with time to diagnosis and treatment of cancer and with 1-year survival rates.
A “seminal” work that set the background for this study, said Dr. Murchie, was the 2002 publication tracking the relationship between rural residence status and cancer survival (Br J Cancer. 2002;87[6]:585-90). Findings from that study showed that as the distance from the patient’s residence to a cancer center increased, so did the risk that the cancer wasn’t diagnosed before death. Survival, especially for prostate and lung cancer, was found to decrease with increasing distance, said Dr. Murchie.
“This study has been widely replicated in the global literature, but the mechanisms have never been satisfactorily explained,” he said.
For the present study, the primary outcome measure was whether patients achieved treatment within 62 days of referral, the target set by the Scottish government, said Dr. Murchie.
Secondary outcomes included secondary care delay – whether treatment was begun within 31 days of diagnosis – and survival at 1 year after presentation or referral by a general practitioner.
A total of 12,339 patients were included; 74% were older than 60 years. Patients were relatively affluent, with 59% in the two least-deprived quintiles according to Scottish government classification. Dr. Murchie said that this is in keeping with the geographic-socioeconomic status distribution in Scotland. Females made up 56% of the population, and 35% were classified as rural dwelling.
Nearly a third of patients (n = 3,722; 30.6%) had breast cancer. Colorectal cancer was the next most common diagnosis (n = 2,775; 22.5%), followed by prostate cancer, lung cancer, upper gastrointestinal cancer, melanoma, and cervical cancer. Most patients (n = 8,537; 62%) had a Charlson Comorbidity Index score of 0.
Dr. Murchie used the Northeast and Aberdeen Scottish Cancer and Residence Cohort (NASCAR) data gathered during 2007-2014; the cohort’s data came from a variety of sources, including the region’s cancer care pathway database. National cancer registries, morbidity records, and other nationally maintained demographic databases were also used for the NASCAR dataset.
Those building the NASCAR cohort were able to link all of the data from disparate datasets and still keep investigators blinded to patient identity via a “safe harvest” technique that created pseudonyms to harmonize the datasets.
Using patient postal codes, a geographical information systems approach was used to determine traveling time to a cancer center. Travel time, Dr. Murchie pointed out, is a better measure than straight-line distance of true accessibility for rural-dwelling patients.
In discussion, Dr. Murchie said that the correlation between longer distance and shorter time to treatment held even when he and his colleagues controlled for “the most obvious explanation – that disease was more advanced on diagnosis among remoter people.” But, he said, “This does not translate into better survival. Why?”
Hypotheses, said Dr. Murchie, include the many small and large barriers to care that rural-dwelling individuals face. They must find a way to their GP, or place a phone call, and that physician must weigh the risk of a serious complication against the burden to the patient – and that patient’s family – of travel from a remote location to a cancer center.
Dr. Murchie encouraged international collaboration and replication of his work so that cancer researchers and primary care practitioners can reach a better understanding of the unique challenges in treating rural cancer patients.
Dr. Murchie reported that he had no relevant disclosures.
SOURCE: Murchie P. NAPCRG 2017 Abstract CR15.
MONTREAL – Does rurality matter in cancer treatment? According to lessons from a Scottish study, the answer may be yes, but in unexpected ways.
Patients who lived further away from a cancer treatment center were more likely to be treated within the 62 days postreferral window that the Scottish government has set as a target. Compared with those living within 15 minutes of a cancer center, the adjusted odds ratio for patients living at least an hour away to receive timely treatment was 1.42 (95% confidence interval, 1.25-1.61). For those living on remote islands, the aOR was 1.32 (95% CI, 1.09-1.59).
Dr. Murchie, speaking at the annual meeting of the North American Primary Care Research Group, shared results of an updated study that looked at the cancer population in Northeast Scotland to see how living farther from a cancer center might be associated with time to diagnosis and treatment of cancer and with 1-year survival rates.
A “seminal” work that set the background for this study, said Dr. Murchie, was the 2002 publication tracking the relationship between rural residence status and cancer survival (Br J Cancer. 2002;87[6]:585-90). Findings from that study showed that as the distance from the patient’s residence to a cancer center increased, so did the risk that the cancer wasn’t diagnosed before death. Survival, especially for prostate and lung cancer, was found to decrease with increasing distance, said Dr. Murchie.
“This study has been widely replicated in the global literature, but the mechanisms have never been satisfactorily explained,” he said.
For the present study, the primary outcome measure was whether patients achieved treatment within 62 days of referral, the target set by the Scottish government, said Dr. Murchie.
Secondary outcomes included secondary care delay – whether treatment was begun within 31 days of diagnosis – and survival at 1 year after presentation or referral by a general practitioner.
A total of 12,339 patients were included; 74% were older than 60 years. Patients were relatively affluent, with 59% in the two least-deprived quintiles according to Scottish government classification. Dr. Murchie said that this is in keeping with the geographic-socioeconomic status distribution in Scotland. Females made up 56% of the population, and 35% were classified as rural dwelling.
Nearly a third of patients (n = 3,722; 30.6%) had breast cancer. Colorectal cancer was the next most common diagnosis (n = 2,775; 22.5%), followed by prostate cancer, lung cancer, upper gastrointestinal cancer, melanoma, and cervical cancer. Most patients (n = 8,537; 62%) had a Charlson Comorbidity Index score of 0.
Dr. Murchie used the Northeast and Aberdeen Scottish Cancer and Residence Cohort (NASCAR) data gathered during 2007-2014; the cohort’s data came from a variety of sources, including the region’s cancer care pathway database. National cancer registries, morbidity records, and other nationally maintained demographic databases were also used for the NASCAR dataset.
Those building the NASCAR cohort were able to link all of the data from disparate datasets and still keep investigators blinded to patient identity via a “safe harvest” technique that created pseudonyms to harmonize the datasets.
Using patient postal codes, a geographical information systems approach was used to determine traveling time to a cancer center. Travel time, Dr. Murchie pointed out, is a better measure than straight-line distance of true accessibility for rural-dwelling patients.
In discussion, Dr. Murchie said that the correlation between longer distance and shorter time to treatment held even when he and his colleagues controlled for “the most obvious explanation – that disease was more advanced on diagnosis among remoter people.” But, he said, “This does not translate into better survival. Why?”
Hypotheses, said Dr. Murchie, include the many small and large barriers to care that rural-dwelling individuals face. They must find a way to their GP, or place a phone call, and that physician must weigh the risk of a serious complication against the burden to the patient – and that patient’s family – of travel from a remote location to a cancer center.
Dr. Murchie encouraged international collaboration and replication of his work so that cancer researchers and primary care practitioners can reach a better understanding of the unique challenges in treating rural cancer patients.
Dr. Murchie reported that he had no relevant disclosures.
SOURCE: Murchie P. NAPCRG 2017 Abstract CR15.
REPORTING FROM NAPCRG 2017
Key clinical point: Rural Scottish cancer patients were treated earlier but had shorter survival.
Major finding: Rural patients had an odds ratio of 1.42 for prompt treatment after a cancer diagnosis.
Study details: Study of 12,339 rural and urban patients with cancer living in Scotland.
Disclosures: Dr. Murchie reported no conflicts of interest.
Source: Murchie P. NAPCRG 2017 Abstract CR15.