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Growing old with HIV: What’s likely, and how can physicians help?
Individuals infected with HIV require early intervention with safe and effective antiretroviral therapy beyond the standard care required for successful aging. The long-term residual inflammation associated with fully suppressive ART must also be addressed, according to a review in the International Journal of Infectious Diseases.
The review was prompted by the increasing number of aging persons with HIV in the population, due to the advent of life-protecting drug treatments.
Gerome V. Escota, MD, and his colleagues at Washington University, St. Louis, assessed the factors faced by the normally aging population and then added an assessment of the path to successful aging given the unique aspects of the HIV infected population (Int J Infect Dis. 2018; 66:56-64).
For example, in San Francisco, 58% of the people with HIV were over 50 years of age by 2014, according to the authors, and those numbers will continue to increase. Such patients will not only be suffering the effects of the normal aging process, but also the potential burden of long-term antiretroviral drug use on their systems.
In addition, even the use of highly-effective antiretroviral therapy does not completely eliminate the inflammatory markers among HIV-infected individuals, and such markers have been associated with increased risk of cardiovascular and other problems. Of particular concern: “It remains unknown whether age-associated inflammation will aggravate residual HIV-associated inflammation in these patients over time,” the authors wrote.
Exacerbated comorbidities that may be a risk among the aging population infected with HIV include cardiovascular disease, osteoporosis, malignancies, chronic liver and kidney disease, and HIV-related neurocognitive disease.
The review was not sponsored and the authors reported that they had no disclosures.
SOURCE: Escota, J V et al. Int J Infect Dis. 2018;66:56-64.
Individuals infected with HIV require early intervention with safe and effective antiretroviral therapy beyond the standard care required for successful aging. The long-term residual inflammation associated with fully suppressive ART must also be addressed, according to a review in the International Journal of Infectious Diseases.
The review was prompted by the increasing number of aging persons with HIV in the population, due to the advent of life-protecting drug treatments.
Gerome V. Escota, MD, and his colleagues at Washington University, St. Louis, assessed the factors faced by the normally aging population and then added an assessment of the path to successful aging given the unique aspects of the HIV infected population (Int J Infect Dis. 2018; 66:56-64).
For example, in San Francisco, 58% of the people with HIV were over 50 years of age by 2014, according to the authors, and those numbers will continue to increase. Such patients will not only be suffering the effects of the normal aging process, but also the potential burden of long-term antiretroviral drug use on their systems.
In addition, even the use of highly-effective antiretroviral therapy does not completely eliminate the inflammatory markers among HIV-infected individuals, and such markers have been associated with increased risk of cardiovascular and other problems. Of particular concern: “It remains unknown whether age-associated inflammation will aggravate residual HIV-associated inflammation in these patients over time,” the authors wrote.
Exacerbated comorbidities that may be a risk among the aging population infected with HIV include cardiovascular disease, osteoporosis, malignancies, chronic liver and kidney disease, and HIV-related neurocognitive disease.
The review was not sponsored and the authors reported that they had no disclosures.
SOURCE: Escota, J V et al. Int J Infect Dis. 2018;66:56-64.
Individuals infected with HIV require early intervention with safe and effective antiretroviral therapy beyond the standard care required for successful aging. The long-term residual inflammation associated with fully suppressive ART must also be addressed, according to a review in the International Journal of Infectious Diseases.
The review was prompted by the increasing number of aging persons with HIV in the population, due to the advent of life-protecting drug treatments.
Gerome V. Escota, MD, and his colleagues at Washington University, St. Louis, assessed the factors faced by the normally aging population and then added an assessment of the path to successful aging given the unique aspects of the HIV infected population (Int J Infect Dis. 2018; 66:56-64).
For example, in San Francisco, 58% of the people with HIV were over 50 years of age by 2014, according to the authors, and those numbers will continue to increase. Such patients will not only be suffering the effects of the normal aging process, but also the potential burden of long-term antiretroviral drug use on their systems.
In addition, even the use of highly-effective antiretroviral therapy does not completely eliminate the inflammatory markers among HIV-infected individuals, and such markers have been associated with increased risk of cardiovascular and other problems. Of particular concern: “It remains unknown whether age-associated inflammation will aggravate residual HIV-associated inflammation in these patients over time,” the authors wrote.
Exacerbated comorbidities that may be a risk among the aging population infected with HIV include cardiovascular disease, osteoporosis, malignancies, chronic liver and kidney disease, and HIV-related neurocognitive disease.
The review was not sponsored and the authors reported that they had no disclosures.
SOURCE: Escota, J V et al. Int J Infect Dis. 2018;66:56-64.
FROM INTERNATIONAL JOURNAL OF INFECTIOUS DISEASES
Key clinical point: Significant medical monitoring and intervention may be required to enable successful aging in the HIV-infected population.
Major finding: Aggressive use of antiretroviral therapy, primary prevention, and early diagnosis and treatment of comorbidities are key.
Study details: Literature review.
Disclosures: The review was not sponsored and the authors reported that they had no disclosures.
Source: Escota, J V et al. Int J Infect Dis. 2018;66:56-64.
FDA approves complete combo tablet for HIV
The Food and Drug Administration announced that it has approved Symfi Lo tablets, a fixed-dose combination product containing efavirenz (400 mg), lamivudine (300 mg), and tenofovir disoproxil fumarate (300 mg, equivalent to 245 mg of tenofovir disoproxil). The tablets are indicated as a complete regimen for treating HIV-1 in adults and in pediatric patients weighing at least 35 kg.
The recommended dose is one tablet taken daily by mouth on an empty stomach, preferably at bedtime, as that may improve the tolerability of nervous system symptoms, according to an email release by the FDA Office of Health and Constituent Affairs.
The most common adverse reactions (in more than 5% of patients taking Symfi Lo) were rash and dizziness. The warnings and precautions contained in the label are: lactic acidosis/severe hepatomegaly with steatosis; new-onset or worsening renal impairment; and serious psychiatric symptoms, such as severe depression and suicidal ideation.
The FDA approval was primarily based upon the results of two randomized trials: Study 903 and Encore-1.
SOURCE: FDA email release and full label with prescribing information.
The Food and Drug Administration announced that it has approved Symfi Lo tablets, a fixed-dose combination product containing efavirenz (400 mg), lamivudine (300 mg), and tenofovir disoproxil fumarate (300 mg, equivalent to 245 mg of tenofovir disoproxil). The tablets are indicated as a complete regimen for treating HIV-1 in adults and in pediatric patients weighing at least 35 kg.
The recommended dose is one tablet taken daily by mouth on an empty stomach, preferably at bedtime, as that may improve the tolerability of nervous system symptoms, according to an email release by the FDA Office of Health and Constituent Affairs.
The most common adverse reactions (in more than 5% of patients taking Symfi Lo) were rash and dizziness. The warnings and precautions contained in the label are: lactic acidosis/severe hepatomegaly with steatosis; new-onset or worsening renal impairment; and serious psychiatric symptoms, such as severe depression and suicidal ideation.
The FDA approval was primarily based upon the results of two randomized trials: Study 903 and Encore-1.
SOURCE: FDA email release and full label with prescribing information.
The Food and Drug Administration announced that it has approved Symfi Lo tablets, a fixed-dose combination product containing efavirenz (400 mg), lamivudine (300 mg), and tenofovir disoproxil fumarate (300 mg, equivalent to 245 mg of tenofovir disoproxil). The tablets are indicated as a complete regimen for treating HIV-1 in adults and in pediatric patients weighing at least 35 kg.
The recommended dose is one tablet taken daily by mouth on an empty stomach, preferably at bedtime, as that may improve the tolerability of nervous system symptoms, according to an email release by the FDA Office of Health and Constituent Affairs.
The most common adverse reactions (in more than 5% of patients taking Symfi Lo) were rash and dizziness. The warnings and precautions contained in the label are: lactic acidosis/severe hepatomegaly with steatosis; new-onset or worsening renal impairment; and serious psychiatric symptoms, such as severe depression and suicidal ideation.
The FDA approval was primarily based upon the results of two randomized trials: Study 903 and Encore-1.
SOURCE: FDA email release and full label with prescribing information.
HCV screening, care inadequate for young adults who use opioids nonmedically
Younger adults aged 18-23 years who used opioids nonmedically were less likely to receive hepatitis C virus screening than their older peers aged 24-29 years, according to results from the Rhode Island Young Adults Prescription Drug Study (RAPIDS). Overall, those young adults screening positive for HCV received what the researchers deemed was inadequate follow-up, education, and care.
The study was carried out between January 2015 and February 2016 and assessed the self-reported HCV screening, confirmatory testing, and care experience of 196 young adults (aged between 18-29 years) who used opioids nonmedically, according to Ayorinde I. Soipe, MD, Rhode Island Hospital, Providence, and his colleagues.
Among the total of 154 participants who reported being screened, 18 (11.7%) reported a positive test result. Of those who tested positive, only 72% received a follow-up confirmatory blood test, 67% received referral for specialty HCV care, 50% received education about living with HCV, and 56% were given education about how not to transmit HCV to someone else.
A significantly higher proportion of the older participants reported being screened (90%) vs. 60% of the younger participants (P less than .001).
Multivariate analysis showed that age, history of injected drug use, and a history of ever being hospitalized for a psychiatric illness or depression were all significantly associated with HCV screening.
Self-reported barriers to screening and testing included health insurance status, discrimination experienced from the health care community, comorbid psychiatric illness, including depression, and access to drug addiction services.
“This study demonstrates the need to not only screen at-risk patients, but to also ensure adequate follow-up after referral to care. Establishing comprehensive integrated care programs that incorporate peer support, counselors, case managers, and educators is recommended to improve follow-up care,” the researchers concluded.
The authors reported that they had no disclosures. The study was sponsored by an National Institutes of Health grant.
SOURCE: Soipe AI et al. J Adolescent Health 2018;62:114-7.
Younger adults aged 18-23 years who used opioids nonmedically were less likely to receive hepatitis C virus screening than their older peers aged 24-29 years, according to results from the Rhode Island Young Adults Prescription Drug Study (RAPIDS). Overall, those young adults screening positive for HCV received what the researchers deemed was inadequate follow-up, education, and care.
The study was carried out between January 2015 and February 2016 and assessed the self-reported HCV screening, confirmatory testing, and care experience of 196 young adults (aged between 18-29 years) who used opioids nonmedically, according to Ayorinde I. Soipe, MD, Rhode Island Hospital, Providence, and his colleagues.
Among the total of 154 participants who reported being screened, 18 (11.7%) reported a positive test result. Of those who tested positive, only 72% received a follow-up confirmatory blood test, 67% received referral for specialty HCV care, 50% received education about living with HCV, and 56% were given education about how not to transmit HCV to someone else.
A significantly higher proportion of the older participants reported being screened (90%) vs. 60% of the younger participants (P less than .001).
Multivariate analysis showed that age, history of injected drug use, and a history of ever being hospitalized for a psychiatric illness or depression were all significantly associated with HCV screening.
Self-reported barriers to screening and testing included health insurance status, discrimination experienced from the health care community, comorbid psychiatric illness, including depression, and access to drug addiction services.
“This study demonstrates the need to not only screen at-risk patients, but to also ensure adequate follow-up after referral to care. Establishing comprehensive integrated care programs that incorporate peer support, counselors, case managers, and educators is recommended to improve follow-up care,” the researchers concluded.
The authors reported that they had no disclosures. The study was sponsored by an National Institutes of Health grant.
SOURCE: Soipe AI et al. J Adolescent Health 2018;62:114-7.
Younger adults aged 18-23 years who used opioids nonmedically were less likely to receive hepatitis C virus screening than their older peers aged 24-29 years, according to results from the Rhode Island Young Adults Prescription Drug Study (RAPIDS). Overall, those young adults screening positive for HCV received what the researchers deemed was inadequate follow-up, education, and care.
The study was carried out between January 2015 and February 2016 and assessed the self-reported HCV screening, confirmatory testing, and care experience of 196 young adults (aged between 18-29 years) who used opioids nonmedically, according to Ayorinde I. Soipe, MD, Rhode Island Hospital, Providence, and his colleagues.
Among the total of 154 participants who reported being screened, 18 (11.7%) reported a positive test result. Of those who tested positive, only 72% received a follow-up confirmatory blood test, 67% received referral for specialty HCV care, 50% received education about living with HCV, and 56% were given education about how not to transmit HCV to someone else.
A significantly higher proportion of the older participants reported being screened (90%) vs. 60% of the younger participants (P less than .001).
Multivariate analysis showed that age, history of injected drug use, and a history of ever being hospitalized for a psychiatric illness or depression were all significantly associated with HCV screening.
Self-reported barriers to screening and testing included health insurance status, discrimination experienced from the health care community, comorbid psychiatric illness, including depression, and access to drug addiction services.
“This study demonstrates the need to not only screen at-risk patients, but to also ensure adequate follow-up after referral to care. Establishing comprehensive integrated care programs that incorporate peer support, counselors, case managers, and educators is recommended to improve follow-up care,” the researchers concluded.
The authors reported that they had no disclosures. The study was sponsored by an National Institutes of Health grant.
SOURCE: Soipe AI et al. J Adolescent Health 2018;62:114-7.
FROM THE JOURNAL OF ADOLESCENT HEALTH
Key clinical point: Young adults who used nonmedical opioids received less HCV screening and treatment than older drug users.
Major finding: Nearly a third of young adults with a positive HCV screening were not referred to care.
Study details: Self-reported interview data from 196 participants in the Rhode Island Young Adults Prescription Drug Study.
Disclosures: The authors reported that they had no disclosures. The study was sponsored by a National Institutes of Health grant.
Source: Soipe AI et al. J Adolescent Health 2018;62:114-7.
Sleeve gastrectomy studied as an option for obese HIV-infected patients
according to the results of a small prospective trial conducted from 2009 to 2015 at a single institution in France.
Ten patients were followed before and after sleeve gastrectomy. Eight were women and half were of African origin. The median patient age was 48.5 years, and the median time since HIV infection was 7.5 years. Patients had a median body mass index of 48.5 kg/m2 at the time of their procedure, according to Guillaume Pourcher, MD, PhD, of Paris-Sud University and his colleagues.
The median postoperative weight loss was 43 kg, while the median percentage of excess weight loss was 82.5% at the latest follow-up. In addition, all comorbidities were resolved with weight loss. With regard to HIV status, there was no significant modification of the CD4 cell count in the patients before and after surgery. Importantly, the pharmacokinetics of the patients’ antiretroviral drugs remained “adequate and efficacious,” according to Dr. Pourcher and his colleagues.
“For HIV-infected patients,we need to choose a safe procedure, with no disruption of intestinal continuity, without implanted foreign material, resulting in less malabsorption, and with long-term weight loss efficacy,” the authors stated.
Taking this into account, optimal management of HIV-infected patients with morbid obesity may include classical surgical procedures such as sleeve gastrectomy as with non-HIV obese patients, as long as close drug monitoring and immunovirologic follow-up are maintained, they suggested.
Sleeve gastrectomy “appears to be a good therapeutic option in morbidly obese HIV-infected patients, because it avoids malabsorption and possible modification of antiretroviral drug absorption,” the researchers concluded.
The authors reported that they had no commercial conflicts of interest relative to their study.
SOURCE: Pourcher G et al. Surgery for Obesity and Related Diseases. 2017;13:1990-6.
according to the results of a small prospective trial conducted from 2009 to 2015 at a single institution in France.
Ten patients were followed before and after sleeve gastrectomy. Eight were women and half were of African origin. The median patient age was 48.5 years, and the median time since HIV infection was 7.5 years. Patients had a median body mass index of 48.5 kg/m2 at the time of their procedure, according to Guillaume Pourcher, MD, PhD, of Paris-Sud University and his colleagues.
The median postoperative weight loss was 43 kg, while the median percentage of excess weight loss was 82.5% at the latest follow-up. In addition, all comorbidities were resolved with weight loss. With regard to HIV status, there was no significant modification of the CD4 cell count in the patients before and after surgery. Importantly, the pharmacokinetics of the patients’ antiretroviral drugs remained “adequate and efficacious,” according to Dr. Pourcher and his colleagues.
“For HIV-infected patients,we need to choose a safe procedure, with no disruption of intestinal continuity, without implanted foreign material, resulting in less malabsorption, and with long-term weight loss efficacy,” the authors stated.
Taking this into account, optimal management of HIV-infected patients with morbid obesity may include classical surgical procedures such as sleeve gastrectomy as with non-HIV obese patients, as long as close drug monitoring and immunovirologic follow-up are maintained, they suggested.
Sleeve gastrectomy “appears to be a good therapeutic option in morbidly obese HIV-infected patients, because it avoids malabsorption and possible modification of antiretroviral drug absorption,” the researchers concluded.
The authors reported that they had no commercial conflicts of interest relative to their study.
SOURCE: Pourcher G et al. Surgery for Obesity and Related Diseases. 2017;13:1990-6.
according to the results of a small prospective trial conducted from 2009 to 2015 at a single institution in France.
Ten patients were followed before and after sleeve gastrectomy. Eight were women and half were of African origin. The median patient age was 48.5 years, and the median time since HIV infection was 7.5 years. Patients had a median body mass index of 48.5 kg/m2 at the time of their procedure, according to Guillaume Pourcher, MD, PhD, of Paris-Sud University and his colleagues.
The median postoperative weight loss was 43 kg, while the median percentage of excess weight loss was 82.5% at the latest follow-up. In addition, all comorbidities were resolved with weight loss. With regard to HIV status, there was no significant modification of the CD4 cell count in the patients before and after surgery. Importantly, the pharmacokinetics of the patients’ antiretroviral drugs remained “adequate and efficacious,” according to Dr. Pourcher and his colleagues.
“For HIV-infected patients,we need to choose a safe procedure, with no disruption of intestinal continuity, without implanted foreign material, resulting in less malabsorption, and with long-term weight loss efficacy,” the authors stated.
Taking this into account, optimal management of HIV-infected patients with morbid obesity may include classical surgical procedures such as sleeve gastrectomy as with non-HIV obese patients, as long as close drug monitoring and immunovirologic follow-up are maintained, they suggested.
Sleeve gastrectomy “appears to be a good therapeutic option in morbidly obese HIV-infected patients, because it avoids malabsorption and possible modification of antiretroviral drug absorption,” the researchers concluded.
The authors reported that they had no commercial conflicts of interest relative to their study.
SOURCE: Pourcher G et al. Surgery for Obesity and Related Diseases. 2017;13:1990-6.
FROM SURGERY FOR OBESITY AND RELATED DISEASES
Key clinical point: HIV-infected patients lost weight after sleeve gastrectomy and maintained their viral status.
Major finding: Median postoperative weight loss was 43 kg and median percentage of excess weight loss was 82.5%.
Study details: Ten HIV-infected patients were prospectively followed before and after sleeve gastrectomy.
Disclosures: The authors reported that they had no commercial conflicts of interest relative to their study.
Source: Pourcher G et al. Surg Obes Relat Dis. 2017;13:1990-6.
Slowed growth in prescription drug spending driven by HCV drugs
National health spending amounted to $3.3 trillion or $10,348/person, a 4.3% increase in 2016, according to the Centers for Medicare & Medicaid Services. This was a slower rate of growth than the 5.8% growth in 2015 because of slower insurance enrollment and declines in spending for services and retail prescription drugs.
The growth in spending on prescription drugs in 2016 declined significantly – 1.3% in 2016 vs. 8.9% in 2015. Strong growth in spending for drugs used to treat hepatitis C contributed to high overall spending growth in 2014 and 2015, which changed in 2016. Prescription drug spending in 2016 grew more slowly partially because spending for drugs used to treat hepatitis C decreased, as fewer patients received treatment and net prices for these drugs declined, the report stated.
"The 2016 rate of prescription drug spending growth is more in line with the lower average annual growth during the period 2010–13 of 1.2 percent—a rate that was driven by the shift to more consumption of generic drugs, which was partly influenced by the loss of patent protection of major brand-name drugs," the authors noted.
National health spending amounted to $3.3 trillion or $10,348/person, a 4.3% increase in 2016, according to the Centers for Medicare & Medicaid Services. This was a slower rate of growth than the 5.8% growth in 2015 because of slower insurance enrollment and declines in spending for services and retail prescription drugs.
The growth in spending on prescription drugs in 2016 declined significantly – 1.3% in 2016 vs. 8.9% in 2015. Strong growth in spending for drugs used to treat hepatitis C contributed to high overall spending growth in 2014 and 2015, which changed in 2016. Prescription drug spending in 2016 grew more slowly partially because spending for drugs used to treat hepatitis C decreased, as fewer patients received treatment and net prices for these drugs declined, the report stated.
"The 2016 rate of prescription drug spending growth is more in line with the lower average annual growth during the period 2010–13 of 1.2 percent—a rate that was driven by the shift to more consumption of generic drugs, which was partly influenced by the loss of patent protection of major brand-name drugs," the authors noted.
National health spending amounted to $3.3 trillion or $10,348/person, a 4.3% increase in 2016, according to the Centers for Medicare & Medicaid Services. This was a slower rate of growth than the 5.8% growth in 2015 because of slower insurance enrollment and declines in spending for services and retail prescription drugs.
The growth in spending on prescription drugs in 2016 declined significantly – 1.3% in 2016 vs. 8.9% in 2015. Strong growth in spending for drugs used to treat hepatitis C contributed to high overall spending growth in 2014 and 2015, which changed in 2016. Prescription drug spending in 2016 grew more slowly partially because spending for drugs used to treat hepatitis C decreased, as fewer patients received treatment and net prices for these drugs declined, the report stated.
"The 2016 rate of prescription drug spending growth is more in line with the lower average annual growth during the period 2010–13 of 1.2 percent—a rate that was driven by the shift to more consumption of generic drugs, which was partly influenced by the loss of patent protection of major brand-name drugs," the authors noted.
Predicting MDR Gram-negative infection mortality risk
Source control, defined as location and elimination of the source of the infection, was critical for patient survival in the case of multidrug resistant bacterial infection, according to the results of a case-control study of 62 critically ill surgical patients who were assessed between 2011 and 2014.
Researchers examined the characteristics of infected patients surviving to hospital discharge compared with those of nonsurvivors to look for predictive factors. Demographically, patients had an overall mean age of 62 years; 30.6% were women; 69.4% were white. The first culture obtained during a surgical ICU admission that grew a carbapenem-resistant Enterobacteriaceae (CRE), MDR Pseudomonas aeruginosa, or MDR Acinetobacter spp. was defined as the index culture.
“In this study, 33.9% [21/62] of critically ill surgical patients with a culture positive for MDR Gram-negative bacteria died prior to hospital discharge,” according to Andrew S. Jarrell, PharmD, of the Johns Hopkins Hospital, Baltimore, and his colleagues.
With multivariate logistic regression, achievement of source control was the only variable associated with decreased in-hospital mortality (odds ratio 0.04, 95% confidence interval, 0.003-0.52); P = .01).
“Source control status was predictive of in-hospital mortality after controlling for other factors. Specifically, the odds of in-hospital mortality were 97% lower when source control was achieved as compared to when source control was not achieved,” the authors stated (J Crit Care. 2018;43:321-6).
Scenarios in which source control was not applicable (pneumonia and urinary tract infection) were also similarly distributed between survivors and nonsurvivors, they reported.
Other than source control, the only significant risk factors for mortality, as seen in univariate analysis, all occurred prior to index culture. They were: vasopressor use (46.3% of survivors, vs. 76.2% of nonsurvivors, P = .03); mechanical ventilation (63.4% vs. 100%, P = .001); and median ICU length of stay (10 days vs. 18 days, P = .001).
“Achievement of source control stands out as a critical factor for patient survival. Clinicians should take this, along with prior ICU LOS, vasopressor use, and mechanical ventilation status, into consideration when evaluating patient prognosis,” Dr. Jarrell and his colleagues concluded.
The authors reported that they had no conflicts or source of funding.
Source: Jarrell, A.S., et al. J Crit Care. 2018;43:321-6.
Source control, defined as location and elimination of the source of the infection, was critical for patient survival in the case of multidrug resistant bacterial infection, according to the results of a case-control study of 62 critically ill surgical patients who were assessed between 2011 and 2014.
Researchers examined the characteristics of infected patients surviving to hospital discharge compared with those of nonsurvivors to look for predictive factors. Demographically, patients had an overall mean age of 62 years; 30.6% were women; 69.4% were white. The first culture obtained during a surgical ICU admission that grew a carbapenem-resistant Enterobacteriaceae (CRE), MDR Pseudomonas aeruginosa, or MDR Acinetobacter spp. was defined as the index culture.
“In this study, 33.9% [21/62] of critically ill surgical patients with a culture positive for MDR Gram-negative bacteria died prior to hospital discharge,” according to Andrew S. Jarrell, PharmD, of the Johns Hopkins Hospital, Baltimore, and his colleagues.
With multivariate logistic regression, achievement of source control was the only variable associated with decreased in-hospital mortality (odds ratio 0.04, 95% confidence interval, 0.003-0.52); P = .01).
“Source control status was predictive of in-hospital mortality after controlling for other factors. Specifically, the odds of in-hospital mortality were 97% lower when source control was achieved as compared to when source control was not achieved,” the authors stated (J Crit Care. 2018;43:321-6).
Scenarios in which source control was not applicable (pneumonia and urinary tract infection) were also similarly distributed between survivors and nonsurvivors, they reported.
Other than source control, the only significant risk factors for mortality, as seen in univariate analysis, all occurred prior to index culture. They were: vasopressor use (46.3% of survivors, vs. 76.2% of nonsurvivors, P = .03); mechanical ventilation (63.4% vs. 100%, P = .001); and median ICU length of stay (10 days vs. 18 days, P = .001).
“Achievement of source control stands out as a critical factor for patient survival. Clinicians should take this, along with prior ICU LOS, vasopressor use, and mechanical ventilation status, into consideration when evaluating patient prognosis,” Dr. Jarrell and his colleagues concluded.
The authors reported that they had no conflicts or source of funding.
Source: Jarrell, A.S., et al. J Crit Care. 2018;43:321-6.
Source control, defined as location and elimination of the source of the infection, was critical for patient survival in the case of multidrug resistant bacterial infection, according to the results of a case-control study of 62 critically ill surgical patients who were assessed between 2011 and 2014.
Researchers examined the characteristics of infected patients surviving to hospital discharge compared with those of nonsurvivors to look for predictive factors. Demographically, patients had an overall mean age of 62 years; 30.6% were women; 69.4% were white. The first culture obtained during a surgical ICU admission that grew a carbapenem-resistant Enterobacteriaceae (CRE), MDR Pseudomonas aeruginosa, or MDR Acinetobacter spp. was defined as the index culture.
“In this study, 33.9% [21/62] of critically ill surgical patients with a culture positive for MDR Gram-negative bacteria died prior to hospital discharge,” according to Andrew S. Jarrell, PharmD, of the Johns Hopkins Hospital, Baltimore, and his colleagues.
With multivariate logistic regression, achievement of source control was the only variable associated with decreased in-hospital mortality (odds ratio 0.04, 95% confidence interval, 0.003-0.52); P = .01).
“Source control status was predictive of in-hospital mortality after controlling for other factors. Specifically, the odds of in-hospital mortality were 97% lower when source control was achieved as compared to when source control was not achieved,” the authors stated (J Crit Care. 2018;43:321-6).
Scenarios in which source control was not applicable (pneumonia and urinary tract infection) were also similarly distributed between survivors and nonsurvivors, they reported.
Other than source control, the only significant risk factors for mortality, as seen in univariate analysis, all occurred prior to index culture. They were: vasopressor use (46.3% of survivors, vs. 76.2% of nonsurvivors, P = .03); mechanical ventilation (63.4% vs. 100%, P = .001); and median ICU length of stay (10 days vs. 18 days, P = .001).
“Achievement of source control stands out as a critical factor for patient survival. Clinicians should take this, along with prior ICU LOS, vasopressor use, and mechanical ventilation status, into consideration when evaluating patient prognosis,” Dr. Jarrell and his colleagues concluded.
The authors reported that they had no conflicts or source of funding.
Source: Jarrell, A.S., et al. J Crit Care. 2018;43:321-6.
FROM THE JOURNAL OF CRITICAL CARE
Key clinical point: Source control was the most important predictor of MDR Gram-negative infection mortality in hospitalized patients.
Major finding: The odds of in-hospital mortality were 97% lower when source control was achieved.
Study details: Case-control study of 62 critically ill surgical patients from 2011 to 2014 who had an MDR infection.
Disclosures: The authors reported that they had no conflicts or source of funding.
Source: Jarrell, A.S., et al. J Crit Care. 2018;43:321-6.
PPIs, certain antibiotics increase risk of hospital onset C. difficile infection
The use of proton pump inhibitors increased the odds of a patient having hospital-onset Clostridium difficile infection (HO CDI) as did the use of third- and fourth-generation cephalosporins, carbapenems, and piperacillin/tazobactam, according to the results of a retrospective database study of more than 1 million patients at 150 U.S. hospitals.
PPIs increased the odds of HO CDI by 44% (P less than .001), whereas the use of H2 antagonists increased the odds ratio for HO CDI to a lesser, but still significant, extent (13% increase, P less than .001), according to the report published online in Clinical Infectious Diseases.
Overall, the odds of HO CDI were significantly higher in patients taking carbapenems, third- and fourth-generation cephalosporins, metronidazole, and piperacillin/tazobactam, as well as patients on multiple antibiotics. However, treatment with tetracyclines, macrolides, or clindamycin significantly reduced the odds of HO CDI.
The combination of PPIs with fluoroquinolones, third-generation cephalosporins, fourth-generation cephalosporins, clindamycin, or carbapenems did not significantly alter the odds of HO CDI, which was in contrast with a previous meta-analysis (Am J Gastroenterol. 2012;107[7]:1011-9).
In addition to the drug associations, the odds of a patient having HO CDI increased by 0.5% for each year in age. The odds of CDI in women was 1.2 times as likely as in men, and admission from a long-term care facility, the presence of the comorbidities of diabetes, Crohn’s disease or ulcerative colitis, as well as days in the ICU and antibiotic days of therapy all significantly increased the odds of a patient having HO CDI. (Clin Infect Dis. 2017 Dec. 20. doi: 10.1093/cid/cix1112).
“The results support the need for stewardship practices around both high-risk antibiotics and medications that alter gastric acid regulation. Furthermore, the impact of deprescribing acid suppression therapy coupled with antibiotic stewardship could greatly reduce the incidence of HO CDI,” the researchers concluded.
The authors reported that they had no conflicts or funding source for this work.
SOURCE: Watson, T. et al. Clin Infect Dis. 2017 Dec. 20. doi: 10.1093/cid/cix1112.
The use of proton pump inhibitors increased the odds of a patient having hospital-onset Clostridium difficile infection (HO CDI) as did the use of third- and fourth-generation cephalosporins, carbapenems, and piperacillin/tazobactam, according to the results of a retrospective database study of more than 1 million patients at 150 U.S. hospitals.
PPIs increased the odds of HO CDI by 44% (P less than .001), whereas the use of H2 antagonists increased the odds ratio for HO CDI to a lesser, but still significant, extent (13% increase, P less than .001), according to the report published online in Clinical Infectious Diseases.
Overall, the odds of HO CDI were significantly higher in patients taking carbapenems, third- and fourth-generation cephalosporins, metronidazole, and piperacillin/tazobactam, as well as patients on multiple antibiotics. However, treatment with tetracyclines, macrolides, or clindamycin significantly reduced the odds of HO CDI.
The combination of PPIs with fluoroquinolones, third-generation cephalosporins, fourth-generation cephalosporins, clindamycin, or carbapenems did not significantly alter the odds of HO CDI, which was in contrast with a previous meta-analysis (Am J Gastroenterol. 2012;107[7]:1011-9).
In addition to the drug associations, the odds of a patient having HO CDI increased by 0.5% for each year in age. The odds of CDI in women was 1.2 times as likely as in men, and admission from a long-term care facility, the presence of the comorbidities of diabetes, Crohn’s disease or ulcerative colitis, as well as days in the ICU and antibiotic days of therapy all significantly increased the odds of a patient having HO CDI. (Clin Infect Dis. 2017 Dec. 20. doi: 10.1093/cid/cix1112).
“The results support the need for stewardship practices around both high-risk antibiotics and medications that alter gastric acid regulation. Furthermore, the impact of deprescribing acid suppression therapy coupled with antibiotic stewardship could greatly reduce the incidence of HO CDI,” the researchers concluded.
The authors reported that they had no conflicts or funding source for this work.
SOURCE: Watson, T. et al. Clin Infect Dis. 2017 Dec. 20. doi: 10.1093/cid/cix1112.
The use of proton pump inhibitors increased the odds of a patient having hospital-onset Clostridium difficile infection (HO CDI) as did the use of third- and fourth-generation cephalosporins, carbapenems, and piperacillin/tazobactam, according to the results of a retrospective database study of more than 1 million patients at 150 U.S. hospitals.
PPIs increased the odds of HO CDI by 44% (P less than .001), whereas the use of H2 antagonists increased the odds ratio for HO CDI to a lesser, but still significant, extent (13% increase, P less than .001), according to the report published online in Clinical Infectious Diseases.
Overall, the odds of HO CDI were significantly higher in patients taking carbapenems, third- and fourth-generation cephalosporins, metronidazole, and piperacillin/tazobactam, as well as patients on multiple antibiotics. However, treatment with tetracyclines, macrolides, or clindamycin significantly reduced the odds of HO CDI.
The combination of PPIs with fluoroquinolones, third-generation cephalosporins, fourth-generation cephalosporins, clindamycin, or carbapenems did not significantly alter the odds of HO CDI, which was in contrast with a previous meta-analysis (Am J Gastroenterol. 2012;107[7]:1011-9).
In addition to the drug associations, the odds of a patient having HO CDI increased by 0.5% for each year in age. The odds of CDI in women was 1.2 times as likely as in men, and admission from a long-term care facility, the presence of the comorbidities of diabetes, Crohn’s disease or ulcerative colitis, as well as days in the ICU and antibiotic days of therapy all significantly increased the odds of a patient having HO CDI. (Clin Infect Dis. 2017 Dec. 20. doi: 10.1093/cid/cix1112).
“The results support the need for stewardship practices around both high-risk antibiotics and medications that alter gastric acid regulation. Furthermore, the impact of deprescribing acid suppression therapy coupled with antibiotic stewardship could greatly reduce the incidence of HO CDI,” the researchers concluded.
The authors reported that they had no conflicts or funding source for this work.
SOURCE: Watson, T. et al. Clin Infect Dis. 2017 Dec. 20. doi: 10.1093/cid/cix1112.
FROM CLINICAL INFECTIOUS DISEASES
Key clinical point: Proper stewardship of PPIs, antibiotics might lower risk of hospital-onset C. difficile infection.
Major finding: Patients taking PPIs had a 44% increased risk of developing hospital-onset C. difficile infection.
Study details: Retrospective database study of more than 1 million patients at 150 U.S. hospitals.
Disclosures: The authors reported that they had no conflicts or funding source for this work.
Source: Watson, T. et al. Clin Infect Dis. 2017 Dec. 20. doi: 10.1093/cid/cix1112.
Gastrointestinal complications are a key risk factor for death after AEF repair
Aortoenteric fistulas (AEFs) are an uncommon but lethal form of aortic graft infection with morbidity and mortality rates reported in the literature to range from 14% to 75%. Over a 20-year period, researchers found that nearly half of their patients undergoing repair of their aortoenteric fistulas died within 60 days. The presence of gastrointestinal complications increased the risk of mortality more than threefold, according to the results of a single-center retrospective review of consecutive AEF repairs.
The researchers assessed 50 patients who presented with AEF and had repair during 1995-2014. Sixty percent of the patients were men, and the overall median age was 70 years. The median follow-up for the entire cohort was 14 months. The duodenum was the most common location of the enteric defect, found in 80% of the infections. Overall, 23 patients (46%) died by day 60, according to the report published in the July Journal of the American College of Surgeons.
Univariate analysis showed that advanced age, chronic renal insufficiency, any complications, and GI complications in particular (occurring in 26% of patients) were all associated with an increase in overall mortality (P less than .05). But upon multivariate analysis, gastrointestinal complications (hazard ratio, 3.23; P = .015) and advanced age (HR, 1.07; P = .01) were the only independent predictors of mortality, Atish Chopra, MD, of the division of vascular surgery, Oregon Health & Science University, Portland, and his colleagues wrote.
The institution changed operative procedures in 2007, based upon an earlier assessment of the importance of GI complications performed by the researchers, with greater emphasis placed on ensuring a viable GI reconstruction, and early intervention for mesenteric ischemia. In addition, they surmised that, after 2007, there was improved adherence to achieving wide debridement of nonviable and infected tissue, and to creating a tension-free anastomosis to healthy tissue edges while optimizing nutritional, medical, and antibiotic therapy, according to the researchers.
“When comparing the patients undergoing repair before 2007 with those compared after 2007 [38 and 12 AEF patients, respectively], we found that in-hospitality mortality decreased from 37% to 8% (P = .08), 60-day mortality decreased from 53% to 8% (P less than .01), and mortality at last follow-up decreased from 55% to 17% (P = .02). Dr. Chopra and his colleagues also found that mortality after GI complications decreased from 90% for those operated on before 2007 to 33% in those operated on after 2007 (P = .01).
“Methods to decrease and improvement management of GI complications may prove most effective at improving mortality rates for this lethal pathology,” the researchers concluded.
The authors reported that they had nothing to disclose.
SOURCE: Chopra A et al. J Am Coll Surg 2017 Jul;225(1):9-18.
While secondary aortoenteric fistulas fortunately are a rare occurrence after open aortic repair (less than 1%), the reported results of treatment are disappointing (up to 75% mortality). The authors have demonstrated significant improvement in overall mortality in their series by paying more attention to the GI component of the procedure and postoperative management of the patient.
When we published our institutions experience with AEFs from 1991 to 2004, the study included 29 patients with one-third of patients presenting in shock. Extra-anatomic repair was performed in 86% (68% single stage). Mortality was 24%, with shock, blood transfusions, and suprarenal clamping associated with a worse outcome. Our 5-year survival was 61% and freedom from recurrent infection or amputation was 86% and 88% respectively. While our experience favors an extra-anatomic reconstruction, there has been increased utilization of in-situ repair in recent years. The current authors have extensive experience with the Neoaortoiliac System (NAIS) procedure and have had minimal complications associated with the extensive vein harvest necessary for NAIS; however, this is not universal. Wound complications, compartment syndrome, and chronic venous insufficiency are not uncommon complications. Improved results using cryopreserved aortoiliac allografts (CAA) were reported by The Vascular Low-Frequency Disease Consortium. In a 2014 publication on 220 patients receiving CAA for aortic reconstruction for aortic graft infection, freedom from graft-related complications, graft explant, and limb loss was 80%, 88%, and 97%, respectively, at 5 years. This compares favorably with extra-anatomic reconstruction and other techniques. In suprarenal reconstructions, allografts have been favored since the natural branches can be used to simplify multiple vessel reconstruction. In cases of low-grade infection (Staphylococcus epidermidis), excellent results have been demonstrated with wide debridement, in-situ replacement with rifampin-bonded grafts and omental coverage.
AEF can also occur after endovascular abdominal aortic aneurysm (AAA) repair and a management strategy for removing the endograft should be considered in the planning of these cases. The authors describe their technique, which involves constraining the endograft using an umbilical tape. Another technique that I prefer uses a 20-cc syringe with the tip cut off. The endograft is constrained by advancing the syringe proximally over the endograft. The syringe collapses the device and can be used to constrain the proximal fixation stents of a suprarenal graft, simplifying removal of the stent graft. Infected EVAR will likely become more common as an etiology as we continue to expand EVAR utilization for AAA repair. Another Low-Frequency Consortium paper reviewed the treatment and outcome of EVAR infection. In that report of 206 infected EVAR (endovascular aneurysm repair) and TEVAR (thoracic endovascular aortic repair) patients, 90% had in situ replacement with a 30-day mortality of 11% and morbidity of 35%.
As in previous reports on AEF, the authors highlight the importance of high clinical suspicion in making an expeditious diagnosis. Many imaging modalities can be used, but often operative exploration is required for a definitive diagnosis. Complete graft excision and wide debridement are critical to minimize the risk of recurrent infection. Optimal revascularization techniques should be determined by the experience of the operator, current experience demonstrating nearly equivalent outcomes with extra-anatomic and in situ replacement. Careful GI reconstruction and post-operative nutrition, culture-specific antibiotics, and ICU care are likely more important than the mode of reconstruction. Lifelong surveillance to detect recurrent infections also is recommended.
Murray L. Shames, MD , is professor of surgery and radiology and chief of the division of vascular surgery at the University of South Florida, Tampa, and director of the Tampa General Hospital aortic program.
While secondary aortoenteric fistulas fortunately are a rare occurrence after open aortic repair (less than 1%), the reported results of treatment are disappointing (up to 75% mortality). The authors have demonstrated significant improvement in overall mortality in their series by paying more attention to the GI component of the procedure and postoperative management of the patient.
When we published our institutions experience with AEFs from 1991 to 2004, the study included 29 patients with one-third of patients presenting in shock. Extra-anatomic repair was performed in 86% (68% single stage). Mortality was 24%, with shock, blood transfusions, and suprarenal clamping associated with a worse outcome. Our 5-year survival was 61% and freedom from recurrent infection or amputation was 86% and 88% respectively. While our experience favors an extra-anatomic reconstruction, there has been increased utilization of in-situ repair in recent years. The current authors have extensive experience with the Neoaortoiliac System (NAIS) procedure and have had minimal complications associated with the extensive vein harvest necessary for NAIS; however, this is not universal. Wound complications, compartment syndrome, and chronic venous insufficiency are not uncommon complications. Improved results using cryopreserved aortoiliac allografts (CAA) were reported by The Vascular Low-Frequency Disease Consortium. In a 2014 publication on 220 patients receiving CAA for aortic reconstruction for aortic graft infection, freedom from graft-related complications, graft explant, and limb loss was 80%, 88%, and 97%, respectively, at 5 years. This compares favorably with extra-anatomic reconstruction and other techniques. In suprarenal reconstructions, allografts have been favored since the natural branches can be used to simplify multiple vessel reconstruction. In cases of low-grade infection (Staphylococcus epidermidis), excellent results have been demonstrated with wide debridement, in-situ replacement with rifampin-bonded grafts and omental coverage.
AEF can also occur after endovascular abdominal aortic aneurysm (AAA) repair and a management strategy for removing the endograft should be considered in the planning of these cases. The authors describe their technique, which involves constraining the endograft using an umbilical tape. Another technique that I prefer uses a 20-cc syringe with the tip cut off. The endograft is constrained by advancing the syringe proximally over the endograft. The syringe collapses the device and can be used to constrain the proximal fixation stents of a suprarenal graft, simplifying removal of the stent graft. Infected EVAR will likely become more common as an etiology as we continue to expand EVAR utilization for AAA repair. Another Low-Frequency Consortium paper reviewed the treatment and outcome of EVAR infection. In that report of 206 infected EVAR (endovascular aneurysm repair) and TEVAR (thoracic endovascular aortic repair) patients, 90% had in situ replacement with a 30-day mortality of 11% and morbidity of 35%.
As in previous reports on AEF, the authors highlight the importance of high clinical suspicion in making an expeditious diagnosis. Many imaging modalities can be used, but often operative exploration is required for a definitive diagnosis. Complete graft excision and wide debridement are critical to minimize the risk of recurrent infection. Optimal revascularization techniques should be determined by the experience of the operator, current experience demonstrating nearly equivalent outcomes with extra-anatomic and in situ replacement. Careful GI reconstruction and post-operative nutrition, culture-specific antibiotics, and ICU care are likely more important than the mode of reconstruction. Lifelong surveillance to detect recurrent infections also is recommended.
Murray L. Shames, MD , is professor of surgery and radiology and chief of the division of vascular surgery at the University of South Florida, Tampa, and director of the Tampa General Hospital aortic program.
While secondary aortoenteric fistulas fortunately are a rare occurrence after open aortic repair (less than 1%), the reported results of treatment are disappointing (up to 75% mortality). The authors have demonstrated significant improvement in overall mortality in their series by paying more attention to the GI component of the procedure and postoperative management of the patient.
When we published our institutions experience with AEFs from 1991 to 2004, the study included 29 patients with one-third of patients presenting in shock. Extra-anatomic repair was performed in 86% (68% single stage). Mortality was 24%, with shock, blood transfusions, and suprarenal clamping associated with a worse outcome. Our 5-year survival was 61% and freedom from recurrent infection or amputation was 86% and 88% respectively. While our experience favors an extra-anatomic reconstruction, there has been increased utilization of in-situ repair in recent years. The current authors have extensive experience with the Neoaortoiliac System (NAIS) procedure and have had minimal complications associated with the extensive vein harvest necessary for NAIS; however, this is not universal. Wound complications, compartment syndrome, and chronic venous insufficiency are not uncommon complications. Improved results using cryopreserved aortoiliac allografts (CAA) were reported by The Vascular Low-Frequency Disease Consortium. In a 2014 publication on 220 patients receiving CAA for aortic reconstruction for aortic graft infection, freedom from graft-related complications, graft explant, and limb loss was 80%, 88%, and 97%, respectively, at 5 years. This compares favorably with extra-anatomic reconstruction and other techniques. In suprarenal reconstructions, allografts have been favored since the natural branches can be used to simplify multiple vessel reconstruction. In cases of low-grade infection (Staphylococcus epidermidis), excellent results have been demonstrated with wide debridement, in-situ replacement with rifampin-bonded grafts and omental coverage.
AEF can also occur after endovascular abdominal aortic aneurysm (AAA) repair and a management strategy for removing the endograft should be considered in the planning of these cases. The authors describe their technique, which involves constraining the endograft using an umbilical tape. Another technique that I prefer uses a 20-cc syringe with the tip cut off. The endograft is constrained by advancing the syringe proximally over the endograft. The syringe collapses the device and can be used to constrain the proximal fixation stents of a suprarenal graft, simplifying removal of the stent graft. Infected EVAR will likely become more common as an etiology as we continue to expand EVAR utilization for AAA repair. Another Low-Frequency Consortium paper reviewed the treatment and outcome of EVAR infection. In that report of 206 infected EVAR (endovascular aneurysm repair) and TEVAR (thoracic endovascular aortic repair) patients, 90% had in situ replacement with a 30-day mortality of 11% and morbidity of 35%.
As in previous reports on AEF, the authors highlight the importance of high clinical suspicion in making an expeditious diagnosis. Many imaging modalities can be used, but often operative exploration is required for a definitive diagnosis. Complete graft excision and wide debridement are critical to minimize the risk of recurrent infection. Optimal revascularization techniques should be determined by the experience of the operator, current experience demonstrating nearly equivalent outcomes with extra-anatomic and in situ replacement. Careful GI reconstruction and post-operative nutrition, culture-specific antibiotics, and ICU care are likely more important than the mode of reconstruction. Lifelong surveillance to detect recurrent infections also is recommended.
Murray L. Shames, MD , is professor of surgery and radiology and chief of the division of vascular surgery at the University of South Florida, Tampa, and director of the Tampa General Hospital aortic program.
Aortoenteric fistulas (AEFs) are an uncommon but lethal form of aortic graft infection with morbidity and mortality rates reported in the literature to range from 14% to 75%. Over a 20-year period, researchers found that nearly half of their patients undergoing repair of their aortoenteric fistulas died within 60 days. The presence of gastrointestinal complications increased the risk of mortality more than threefold, according to the results of a single-center retrospective review of consecutive AEF repairs.
The researchers assessed 50 patients who presented with AEF and had repair during 1995-2014. Sixty percent of the patients were men, and the overall median age was 70 years. The median follow-up for the entire cohort was 14 months. The duodenum was the most common location of the enteric defect, found in 80% of the infections. Overall, 23 patients (46%) died by day 60, according to the report published in the July Journal of the American College of Surgeons.
Univariate analysis showed that advanced age, chronic renal insufficiency, any complications, and GI complications in particular (occurring in 26% of patients) were all associated with an increase in overall mortality (P less than .05). But upon multivariate analysis, gastrointestinal complications (hazard ratio, 3.23; P = .015) and advanced age (HR, 1.07; P = .01) were the only independent predictors of mortality, Atish Chopra, MD, of the division of vascular surgery, Oregon Health & Science University, Portland, and his colleagues wrote.
The institution changed operative procedures in 2007, based upon an earlier assessment of the importance of GI complications performed by the researchers, with greater emphasis placed on ensuring a viable GI reconstruction, and early intervention for mesenteric ischemia. In addition, they surmised that, after 2007, there was improved adherence to achieving wide debridement of nonviable and infected tissue, and to creating a tension-free anastomosis to healthy tissue edges while optimizing nutritional, medical, and antibiotic therapy, according to the researchers.
“When comparing the patients undergoing repair before 2007 with those compared after 2007 [38 and 12 AEF patients, respectively], we found that in-hospitality mortality decreased from 37% to 8% (P = .08), 60-day mortality decreased from 53% to 8% (P less than .01), and mortality at last follow-up decreased from 55% to 17% (P = .02). Dr. Chopra and his colleagues also found that mortality after GI complications decreased from 90% for those operated on before 2007 to 33% in those operated on after 2007 (P = .01).
“Methods to decrease and improvement management of GI complications may prove most effective at improving mortality rates for this lethal pathology,” the researchers concluded.
The authors reported that they had nothing to disclose.
SOURCE: Chopra A et al. J Am Coll Surg 2017 Jul;225(1):9-18.
Aortoenteric fistulas (AEFs) are an uncommon but lethal form of aortic graft infection with morbidity and mortality rates reported in the literature to range from 14% to 75%. Over a 20-year period, researchers found that nearly half of their patients undergoing repair of their aortoenteric fistulas died within 60 days. The presence of gastrointestinal complications increased the risk of mortality more than threefold, according to the results of a single-center retrospective review of consecutive AEF repairs.
The researchers assessed 50 patients who presented with AEF and had repair during 1995-2014. Sixty percent of the patients were men, and the overall median age was 70 years. The median follow-up for the entire cohort was 14 months. The duodenum was the most common location of the enteric defect, found in 80% of the infections. Overall, 23 patients (46%) died by day 60, according to the report published in the July Journal of the American College of Surgeons.
Univariate analysis showed that advanced age, chronic renal insufficiency, any complications, and GI complications in particular (occurring in 26% of patients) were all associated with an increase in overall mortality (P less than .05). But upon multivariate analysis, gastrointestinal complications (hazard ratio, 3.23; P = .015) and advanced age (HR, 1.07; P = .01) were the only independent predictors of mortality, Atish Chopra, MD, of the division of vascular surgery, Oregon Health & Science University, Portland, and his colleagues wrote.
The institution changed operative procedures in 2007, based upon an earlier assessment of the importance of GI complications performed by the researchers, with greater emphasis placed on ensuring a viable GI reconstruction, and early intervention for mesenteric ischemia. In addition, they surmised that, after 2007, there was improved adherence to achieving wide debridement of nonviable and infected tissue, and to creating a tension-free anastomosis to healthy tissue edges while optimizing nutritional, medical, and antibiotic therapy, according to the researchers.
“When comparing the patients undergoing repair before 2007 with those compared after 2007 [38 and 12 AEF patients, respectively], we found that in-hospitality mortality decreased from 37% to 8% (P = .08), 60-day mortality decreased from 53% to 8% (P less than .01), and mortality at last follow-up decreased from 55% to 17% (P = .02). Dr. Chopra and his colleagues also found that mortality after GI complications decreased from 90% for those operated on before 2007 to 33% in those operated on after 2007 (P = .01).
“Methods to decrease and improvement management of GI complications may prove most effective at improving mortality rates for this lethal pathology,” the researchers concluded.
The authors reported that they had nothing to disclose.
SOURCE: Chopra A et al. J Am Coll Surg 2017 Jul;225(1):9-18.
FROM THE JOURNAL OF THE AMERICAN COLLEGE OF SURGEONS
Key clinical point: Nearly half of patients undergoing aortoenteric fistula repair died within 60 days.
Major finding: The presence of gastrointestinal complications increased the risk of mortality for AEF repair more than threefold.
Study details: A single center, retrospective review of 50 consecutive patients with AEF repairs during 1995-2014.
Disclosures: The authors reported that they had nothing to disclose.
Source: Chopra A et al. J Am Coll Surg. 2017 Jul;225:9-18.
Major venous injury tied to adverse events in aortic reconstruction
Although uncommon, major venous injury during surgery for aortic reconstruction can result in massive blood loss resulting in increased morbidity and mortality, according to the results of a retrospective review conducted by Sachinder S. Hans, MD, and colleagues, and reported online in the Annals of Vascular Surgery.
Of 945 patients undergoing major aortic reconstruction, 723 (76.5%) underwent open abdominal aortic aneurysm (AAA) repair/iliac aneurysm repair; 222 patients (23.5%) underwent aortofemoral grafting (AFG). The number of units of packed red blood cells transfused, location of injured vessel, type of repair, postoperative morbidity, and mortality were collected in a vascular registry on a continuous basis. All patients identified with iliac vein/inferior vena cava/femoral vein injury had follow-up noninvasive venous examination of the lower extremities.
A total of 17 of 945 patients (1.9%) suffered 18 major venous injuries during aortic reconstruction according to Dr. Hans and his colleagues at St. John Macomb Hospital, Warren, Mich. These injuries comprised four inferior vena cava injuries, 10 iliac vein injuries, and four left renal vein injuries (Ann Vasc Surg. 2017. doi: 10.1016/j.avsg.2017.08.004).
Overall, 16 of the 18 injuries occurred during open AAA repair (7 for ruptured AAA, and 9 for intact). Two of the patients with venous injury died (11.8%), one from uncontrolled bleeding from a tear in the right iliac during repair of a ruptured AAA, and the second from disseminated intravascular complication following repair of ruptured AAA. The remaining two major venous injuries occurred during redo AFG (1 out of 6 total) and primary AFG (1 out of 216 total).
The following risk factors were also observed: The majority of the patients experiencing major venous injury were men (83%; P = .002), and the presence of periarterial inflammation (P = .006) and associated iliac aneurysm (P = .05) were significantly associated with major venous injury among the AAA patients.
The researchers suggested the following tips to lessen the likelihood of major venous injury: “Prevention of major venous injury is not always possible; however, keeping dissection plane close to arterial wall, avoiding passage of vessel loops or tapes around the neck of the aorta and iliac bifurcation, particularly in patients with surrounding inflammation and ligating venous tributaries crossing the aorta as they are joining the inferior vena cava may help reduce incidence of such injuries.”
They also suggested that surgeons should be cognizant of the serious complication that major venous injury was for patients undergoing aortic reconstruction, and to be aware that “the incidence of such injury is higher during the repair of ruptured AAA and redo aortofemoral grafting.”
The authors received no study funding and reported that they had no conflicts.
Although uncommon, major venous injury during surgery for aortic reconstruction can result in massive blood loss resulting in increased morbidity and mortality, according to the results of a retrospective review conducted by Sachinder S. Hans, MD, and colleagues, and reported online in the Annals of Vascular Surgery.
Of 945 patients undergoing major aortic reconstruction, 723 (76.5%) underwent open abdominal aortic aneurysm (AAA) repair/iliac aneurysm repair; 222 patients (23.5%) underwent aortofemoral grafting (AFG). The number of units of packed red blood cells transfused, location of injured vessel, type of repair, postoperative morbidity, and mortality were collected in a vascular registry on a continuous basis. All patients identified with iliac vein/inferior vena cava/femoral vein injury had follow-up noninvasive venous examination of the lower extremities.
A total of 17 of 945 patients (1.9%) suffered 18 major venous injuries during aortic reconstruction according to Dr. Hans and his colleagues at St. John Macomb Hospital, Warren, Mich. These injuries comprised four inferior vena cava injuries, 10 iliac vein injuries, and four left renal vein injuries (Ann Vasc Surg. 2017. doi: 10.1016/j.avsg.2017.08.004).
Overall, 16 of the 18 injuries occurred during open AAA repair (7 for ruptured AAA, and 9 for intact). Two of the patients with venous injury died (11.8%), one from uncontrolled bleeding from a tear in the right iliac during repair of a ruptured AAA, and the second from disseminated intravascular complication following repair of ruptured AAA. The remaining two major venous injuries occurred during redo AFG (1 out of 6 total) and primary AFG (1 out of 216 total).
The following risk factors were also observed: The majority of the patients experiencing major venous injury were men (83%; P = .002), and the presence of periarterial inflammation (P = .006) and associated iliac aneurysm (P = .05) were significantly associated with major venous injury among the AAA patients.
The researchers suggested the following tips to lessen the likelihood of major venous injury: “Prevention of major venous injury is not always possible; however, keeping dissection plane close to arterial wall, avoiding passage of vessel loops or tapes around the neck of the aorta and iliac bifurcation, particularly in patients with surrounding inflammation and ligating venous tributaries crossing the aorta as they are joining the inferior vena cava may help reduce incidence of such injuries.”
They also suggested that surgeons should be cognizant of the serious complication that major venous injury was for patients undergoing aortic reconstruction, and to be aware that “the incidence of such injury is higher during the repair of ruptured AAA and redo aortofemoral grafting.”
The authors received no study funding and reported that they had no conflicts.
Although uncommon, major venous injury during surgery for aortic reconstruction can result in massive blood loss resulting in increased morbidity and mortality, according to the results of a retrospective review conducted by Sachinder S. Hans, MD, and colleagues, and reported online in the Annals of Vascular Surgery.
Of 945 patients undergoing major aortic reconstruction, 723 (76.5%) underwent open abdominal aortic aneurysm (AAA) repair/iliac aneurysm repair; 222 patients (23.5%) underwent aortofemoral grafting (AFG). The number of units of packed red blood cells transfused, location of injured vessel, type of repair, postoperative morbidity, and mortality were collected in a vascular registry on a continuous basis. All patients identified with iliac vein/inferior vena cava/femoral vein injury had follow-up noninvasive venous examination of the lower extremities.
A total of 17 of 945 patients (1.9%) suffered 18 major venous injuries during aortic reconstruction according to Dr. Hans and his colleagues at St. John Macomb Hospital, Warren, Mich. These injuries comprised four inferior vena cava injuries, 10 iliac vein injuries, and four left renal vein injuries (Ann Vasc Surg. 2017. doi: 10.1016/j.avsg.2017.08.004).
Overall, 16 of the 18 injuries occurred during open AAA repair (7 for ruptured AAA, and 9 for intact). Two of the patients with venous injury died (11.8%), one from uncontrolled bleeding from a tear in the right iliac during repair of a ruptured AAA, and the second from disseminated intravascular complication following repair of ruptured AAA. The remaining two major venous injuries occurred during redo AFG (1 out of 6 total) and primary AFG (1 out of 216 total).
The following risk factors were also observed: The majority of the patients experiencing major venous injury were men (83%; P = .002), and the presence of periarterial inflammation (P = .006) and associated iliac aneurysm (P = .05) were significantly associated with major venous injury among the AAA patients.
The researchers suggested the following tips to lessen the likelihood of major venous injury: “Prevention of major venous injury is not always possible; however, keeping dissection plane close to arterial wall, avoiding passage of vessel loops or tapes around the neck of the aorta and iliac bifurcation, particularly in patients with surrounding inflammation and ligating venous tributaries crossing the aorta as they are joining the inferior vena cava may help reduce incidence of such injuries.”
They also suggested that surgeons should be cognizant of the serious complication that major venous injury was for patients undergoing aortic reconstruction, and to be aware that “the incidence of such injury is higher during the repair of ruptured AAA and redo aortofemoral grafting.”
The authors received no study funding and reported that they had no conflicts.
FROM THE ANNALS OF VASCULAR SURGERY
Key clinical point:
Major finding: A total of 17/945 patients suffered major venous injuries during aortic reconstruction.
Data source: A retrospective review of 945 patients undergoing aortic reconstruction at two sites.
Disclosures: The authors received no study funding and reported that they had no conflicts.
Pancreatic surgery: Similar outcomes with primary anastomosis, allografts
Pancreatic tumor involvement with the superior mesenteric vein/portal vein (SMV/PV) is common and requires exploration and resection, which has now become an integral part of routine surgical treatment. The short-term outcome of SMV/PV reconstruction with interposed cold-stored cadaveric venous allografts was found to be comparable to that of reconstruction with primary end-to-end anastomosis, according to the results of a study performed by Dyre Kleive, MD, and his colleagues.
In order to assess the optimal method of reconstructing the portal vein during pancreatic surgery, Dr. Kleive and his colleagues performed a retrospective review of all patients undergoing pancreatic surgery with venous resection and reconstruction at a single center between January 2006 and December 2015.
A total of 857 patients underwent open pancreatic surgery during the study period, of whom 171 (20%) had vascular resection and reconstruction. The study population comprised 42 patients treated with cold-stored interposition cadaveric allografts for reconstruction and 71 patients who had primary end-to-end anastomosis instead. Patients with other forms of reconstruction were excluded, according to an online report in the Journal of Vascular Surgery: Venous and Lymphatic Disorders (2017. doi: 10.1016/j.jvsv.2017.09.003).
Early failure at the reconstruction site was defined as the presence of thrombosis or no flow or low flow within the first 30 days after surgery.
Patients in the allograft group had statistically significantly longer mean operative times, more intraoperative bleeding, more frequent use of neoadjuvant therapy, and a longer length of tumor-vein involvement than the anastomosis group.
However, there was no statistically significant difference in the number of patients with major complications (42.9% for allografts vs. 36.6% for anastomosis) or early failure at the reconstruction site (9.5% for allografts vs. 8.5% for anastomosis) between the two groups, Dr Kleive and his colleagues reported.
The proportion of patients with grade C stenosis at last available imaging scan was significantly higher in the allograft group (26/42 [61.9%] vs. 13 of 66 [19.7%] for the anastomosis group; P less than .01). A subgroup analysis of 10 patients in the allograft group showed the presence of donor-specific antibodies in all patients. This could indicate that graft rejection was a contributing factor to the statistically higher development of severe stenosis in allograft vs. anastomosis patients, the authors suggested.
“This study shows that the short-term outcome of SMV/PV reconstruction with interposed cold-stored cadaveric venous allografts is comparable to that of reconstruction with primary end-to-end anastomosis,” the researchers concluded.
Dr. Kleive and his colleagues reported that they had no conflicts of interest.
Pancreatic tumor involvement with the superior mesenteric vein/portal vein (SMV/PV) is common and requires exploration and resection, which has now become an integral part of routine surgical treatment. The short-term outcome of SMV/PV reconstruction with interposed cold-stored cadaveric venous allografts was found to be comparable to that of reconstruction with primary end-to-end anastomosis, according to the results of a study performed by Dyre Kleive, MD, and his colleagues.
In order to assess the optimal method of reconstructing the portal vein during pancreatic surgery, Dr. Kleive and his colleagues performed a retrospective review of all patients undergoing pancreatic surgery with venous resection and reconstruction at a single center between January 2006 and December 2015.
A total of 857 patients underwent open pancreatic surgery during the study period, of whom 171 (20%) had vascular resection and reconstruction. The study population comprised 42 patients treated with cold-stored interposition cadaveric allografts for reconstruction and 71 patients who had primary end-to-end anastomosis instead. Patients with other forms of reconstruction were excluded, according to an online report in the Journal of Vascular Surgery: Venous and Lymphatic Disorders (2017. doi: 10.1016/j.jvsv.2017.09.003).
Early failure at the reconstruction site was defined as the presence of thrombosis or no flow or low flow within the first 30 days after surgery.
Patients in the allograft group had statistically significantly longer mean operative times, more intraoperative bleeding, more frequent use of neoadjuvant therapy, and a longer length of tumor-vein involvement than the anastomosis group.
However, there was no statistically significant difference in the number of patients with major complications (42.9% for allografts vs. 36.6% for anastomosis) or early failure at the reconstruction site (9.5% for allografts vs. 8.5% for anastomosis) between the two groups, Dr Kleive and his colleagues reported.
The proportion of patients with grade C stenosis at last available imaging scan was significantly higher in the allograft group (26/42 [61.9%] vs. 13 of 66 [19.7%] for the anastomosis group; P less than .01). A subgroup analysis of 10 patients in the allograft group showed the presence of donor-specific antibodies in all patients. This could indicate that graft rejection was a contributing factor to the statistically higher development of severe stenosis in allograft vs. anastomosis patients, the authors suggested.
“This study shows that the short-term outcome of SMV/PV reconstruction with interposed cold-stored cadaveric venous allografts is comparable to that of reconstruction with primary end-to-end anastomosis,” the researchers concluded.
Dr. Kleive and his colleagues reported that they had no conflicts of interest.
Pancreatic tumor involvement with the superior mesenteric vein/portal vein (SMV/PV) is common and requires exploration and resection, which has now become an integral part of routine surgical treatment. The short-term outcome of SMV/PV reconstruction with interposed cold-stored cadaveric venous allografts was found to be comparable to that of reconstruction with primary end-to-end anastomosis, according to the results of a study performed by Dyre Kleive, MD, and his colleagues.
In order to assess the optimal method of reconstructing the portal vein during pancreatic surgery, Dr. Kleive and his colleagues performed a retrospective review of all patients undergoing pancreatic surgery with venous resection and reconstruction at a single center between January 2006 and December 2015.
A total of 857 patients underwent open pancreatic surgery during the study period, of whom 171 (20%) had vascular resection and reconstruction. The study population comprised 42 patients treated with cold-stored interposition cadaveric allografts for reconstruction and 71 patients who had primary end-to-end anastomosis instead. Patients with other forms of reconstruction were excluded, according to an online report in the Journal of Vascular Surgery: Venous and Lymphatic Disorders (2017. doi: 10.1016/j.jvsv.2017.09.003).
Early failure at the reconstruction site was defined as the presence of thrombosis or no flow or low flow within the first 30 days after surgery.
Patients in the allograft group had statistically significantly longer mean operative times, more intraoperative bleeding, more frequent use of neoadjuvant therapy, and a longer length of tumor-vein involvement than the anastomosis group.
However, there was no statistically significant difference in the number of patients with major complications (42.9% for allografts vs. 36.6% for anastomosis) or early failure at the reconstruction site (9.5% for allografts vs. 8.5% for anastomosis) between the two groups, Dr Kleive and his colleagues reported.
The proportion of patients with grade C stenosis at last available imaging scan was significantly higher in the allograft group (26/42 [61.9%] vs. 13 of 66 [19.7%] for the anastomosis group; P less than .01). A subgroup analysis of 10 patients in the allograft group showed the presence of donor-specific antibodies in all patients. This could indicate that graft rejection was a contributing factor to the statistically higher development of severe stenosis in allograft vs. anastomosis patients, the authors suggested.
“This study shows that the short-term outcome of SMV/PV reconstruction with interposed cold-stored cadaveric venous allografts is comparable to that of reconstruction with primary end-to-end anastomosis,” the researchers concluded.
Dr. Kleive and his colleagues reported that they had no conflicts of interest.
FROM THE JOURNAL OF VASCULAR SURGERY: VENOUS AND LYMPHATIC DISEASES
Key clinical point:
Major finding: There was no statistically significant difference in the number of patients with major complications or early failure at the reconstruction site between the allograft and the anastomosis groups.
Data source: A retrospective review of all 171 patients undergoing pancreatic surgery with venous resection and reconstruction at a single center between January 2006 and December 2015.
Disclosures: The authors reported that they had no conflicts of interest.