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Guideline-recommended beta-blockers before noncardiac surgery shown to increase mortality by 27%
More than 1 in 4 patients who died from all causes after noncardiac surgery may have survived if they were not treated with perioperative beta-blockers as specified by joint American College of Cardiology Foundation/American Heart Association and separate European Society of Cardiology guidelines.
These guidelines recommend perioperative beta-blockers in all patients undergoing vascular or intermediate-risk surgery with coronary artery disease, or with more than one risk factor for CAD, or with preexisting beta-blockade. These are all iatrogenic deaths, according to a meta-analysis of secure studies, which excluded data from the now discredited Dutch Echocardiographic Cardiac Risk Evaluation Applying Stress Echocardiography (DECREASE) family of trials.
"Refraining from this ESC [European Society of Cardiology] guideline would therefore be expected to prevent up to 10,000 iatrogenic deaths each year in the U.K.," according to Dr. Sonia Bouri and her coauthors at the National Heart and Lung Institute, Imperial College London.
The researchers analyzed nine secure randomized trials totaling 10,529 patients who met the guideline criteria, 291 of whom died. They found that initiation of a course of beta-blockers as per guideline recommendations before surgery resulted in a 27% increase in mortality.
In the secure trials, use of perioperative beta-blockers decreased nonfatal myocardial infarction significantly (RR, 0.73; P = .001), but increased stroke (RR, 1.73; P =.05) and hypotension (RR, 1.51; P less than .00001), according to the authors, who presented their data in Heart (2013 July 31 [doi: 10.1136/heartjnl-2013-304262]).
Of the 291 deaths recorded in the secure trials, 162 deaths (3.21%) occurred in 5,264 patients randomized to beta-blockers, and 129 deaths (2.45%) occurred in the 5,265 patients randomized to placebo.
Thus, the initiation of a course of beta-blockers as per guideline recommendations before surgery resulted in a 27% increase in all-cause mortality, Dr. Bouri and her coauthors stated. "Any remaining [perioperative beta-blocker] enthusiasts might best channel their energy into a further randomized trial, which should be designed carefully and honestly," they added.
The results from the DECREASE family of trials substantially contradicted the meta-analysis of the secure trials on the effect on mortality (P = .05 for divergence).
"All studies investigated in the DECREASE family for which data had not been lost were found to be insecure because of serious flaws. In one case, it was clear that the entire study database had been fabricated. DECREASE I, published in 1999, escaped investigation as the terms of the investigation only reached back 10 years," the researchers reported.
When the ESC and American College of Cardiology Foundation/American Heart Association guidelines were formulated, "the inclusion of insecure data caused them to reach the conclusion that beta-blockade had a neutral effect on mortality and allowed them to focus on the reduction of non-fatal MI as a surrogate endpoint," the authors explained.
The DECREASE family of studies was discredited almost 2 years ago and subsequently underwent lengthy internal investigation, the results of which have been public for some time, according to the authors. "Nevertheless, neither the European Society of Cardiology nor the AHA guidelines have been retracted," they said.
"Patient safety being paramount, guidelines for perioperative beta-blockers should be retracted without further delay. Future guidelines should be accompanied by a commitment from named individuals to retract them immediately if the advice given is later revealed to be harmful," the authors concluded.
The authors reported that they had no conflicts of interest.
For those of us in the "perioperative care business," the results of this meta-analysis are neither surprising nor informative. The increased all-cause mortality with perioperative beta blockade in the POISE trial is well documented in the literature and the findings of this most recent study by Bouri and colleagues is dominated by POISE data.
 |
| Dr. Franklin Michota |
For those who might not recall POISE, it is the largest randomized clinical trial (RCT) to date that evaluated the safety and efficacy of perioperative beta-blockers in noncardiac surgery. A total of 8,351 patients aged older than 45 years who had or were at risk for atherosclerotic heart disease were randomized to beta-blockers or placebo.
In the treatment arm, patients received metoprolol CR (100 mg preop, 100 mg 6 hours postop, 200 mg 12 hours later, then daily for 30 days). This dose is significantly higher than what most clinicians are accustomed to using. And while it is true that we can no longer trust the conclusions from the DECREASE family of studies due to academic negligence, it does not equate to confirmatory evidence that titrated perioperative beta blockade at a lower dose than that used in POISE (thus avoiding sinus bradycardia and/or hypotension) is of no benefit or harmful. Unfortunately, we just won't know either way until further investigation is performed.
 |
| Dr. Amir Jaffer |
To extrapolate that more than 1 in 4 patients who died from all causes after noncardiac surgery may have survived if they were not treated with perioperative beta-blockers as specified by the ACC/AHA and separate ESC guidelines is pure sensationalism.
Following publication of the POISE trial, the ACC/AHA did publish a focused update on perioperative beta-blockers and specifically noted the possibility of harm from these medications and the importance of careful dose titration. Given the anecdotal experience by all of us who have titrated beta-blockers perioperatively, we find it difficult to believe that such an approach is causing harm. We certainly do question now whether such an approach is doing the patient any good until proven prospectively in a large RCT.
Dr. Franklin A. Michota is director of academic affairs in the department of hospital medicine at the Cleveland Clinic. Dr. Amir K. Jaffer is assistant chief medical officer and division chief of hospital medicine at Rush University Medical Center, Chicago. They are advisers to Hospitalist News.
For those of us in the "perioperative care business," the results of this meta-analysis are neither surprising nor informative. The increased all-cause mortality with perioperative beta blockade in the POISE trial is well documented in the literature and the findings of this most recent study by Bouri and colleagues is dominated by POISE data.
|
| Dr. Franklin Michota |
For those who might not recall POISE, it is the largest randomized clinical trial (RCT) to date that evaluated the safety and efficacy of perioperative beta-blockers in noncardiac surgery. A total of 8,351 patients aged older than 45 years who had or were at risk for atherosclerotic heart disease were randomized to beta-blockers or placebo.
In the treatment arm, patients received metoprolol CR (100 mg preop, 100 mg 6 hours postop, 200 mg 12 hours later, then daily for 30 days). This dose is significantly higher than what most clinicians are accustomed to using. And while it is true that we can no longer trust the conclusions from the DECREASE family of studies due to academic negligence, it does not equate to confirmatory evidence that titrated perioperative beta blockade at a lower dose than that used in POISE (thus avoiding sinus bradycardia and/or hypotension) is of no benefit or harmful. Unfortunately, we just won't know either way until further investigation is performed.
|
| Dr. Amir Jaffer |
To extrapolate that more than 1 in 4 patients who died from all causes after noncardiac surgery may have survived if they were not treated with perioperative beta-blockers as specified by the ACC/AHA and separate ESC guidelines is pure sensationalism.
Following publication of the POISE trial, the ACC/AHA did publish a focused update on perioperative beta-blockers and specifically noted the possibility of harm from these medications and the importance of careful dose titration. Given the anecdotal experience by all of us who have titrated beta-blockers perioperatively, we find it difficult to believe that such an approach is causing harm. We certainly do question now whether such an approach is doing the patient any good until proven prospectively in a large RCT.
Dr. Franklin A. Michota is director of academic affairs in the department of hospital medicine at the Cleveland Clinic. Dr. Amir K. Jaffer is assistant chief medical officer and division chief of hospital medicine at Rush University Medical Center, Chicago. They are advisers to Hospitalist News.
For those of us in the "perioperative care business," the results of this meta-analysis are neither surprising nor informative. The increased all-cause mortality with perioperative beta blockade in the POISE trial is well documented in the literature and the findings of this most recent study by Bouri and colleagues is dominated by POISE data.
|
| Dr. Franklin Michota |
For those who might not recall POISE, it is the largest randomized clinical trial (RCT) to date that evaluated the safety and efficacy of perioperative beta-blockers in noncardiac surgery. A total of 8,351 patients aged older than 45 years who had or were at risk for atherosclerotic heart disease were randomized to beta-blockers or placebo.
In the treatment arm, patients received metoprolol CR (100 mg preop, 100 mg 6 hours postop, 200 mg 12 hours later, then daily for 30 days). This dose is significantly higher than what most clinicians are accustomed to using. And while it is true that we can no longer trust the conclusions from the DECREASE family of studies due to academic negligence, it does not equate to confirmatory evidence that titrated perioperative beta blockade at a lower dose than that used in POISE (thus avoiding sinus bradycardia and/or hypotension) is of no benefit or harmful. Unfortunately, we just won't know either way until further investigation is performed.
|
| Dr. Amir Jaffer |
To extrapolate that more than 1 in 4 patients who died from all causes after noncardiac surgery may have survived if they were not treated with perioperative beta-blockers as specified by the ACC/AHA and separate ESC guidelines is pure sensationalism.
Following publication of the POISE trial, the ACC/AHA did publish a focused update on perioperative beta-blockers and specifically noted the possibility of harm from these medications and the importance of careful dose titration. Given the anecdotal experience by all of us who have titrated beta-blockers perioperatively, we find it difficult to believe that such an approach is causing harm. We certainly do question now whether such an approach is doing the patient any good until proven prospectively in a large RCT.
Dr. Franklin A. Michota is director of academic affairs in the department of hospital medicine at the Cleveland Clinic. Dr. Amir K. Jaffer is assistant chief medical officer and division chief of hospital medicine at Rush University Medical Center, Chicago. They are advisers to Hospitalist News.
More than 1 in 4 patients who died from all causes after noncardiac surgery may have survived if they were not treated with perioperative beta-blockers as specified by joint American College of Cardiology Foundation/American Heart Association and separate European Society of Cardiology guidelines.
These guidelines recommend perioperative beta-blockers in all patients undergoing vascular or intermediate-risk surgery with coronary artery disease, or with more than one risk factor for CAD, or with preexisting beta-blockade. These are all iatrogenic deaths, according to a meta-analysis of secure studies, which excluded data from the now discredited Dutch Echocardiographic Cardiac Risk Evaluation Applying Stress Echocardiography (DECREASE) family of trials.
"Refraining from this ESC [European Society of Cardiology] guideline would therefore be expected to prevent up to 10,000 iatrogenic deaths each year in the U.K.," according to Dr. Sonia Bouri and her coauthors at the National Heart and Lung Institute, Imperial College London.
The researchers analyzed nine secure randomized trials totaling 10,529 patients who met the guideline criteria, 291 of whom died. They found that initiation of a course of beta-blockers as per guideline recommendations before surgery resulted in a 27% increase in mortality.
In the secure trials, use of perioperative beta-blockers decreased nonfatal myocardial infarction significantly (RR, 0.73; P = .001), but increased stroke (RR, 1.73; P =.05) and hypotension (RR, 1.51; P less than .00001), according to the authors, who presented their data in Heart (2013 July 31 [doi: 10.1136/heartjnl-2013-304262]).
Of the 291 deaths recorded in the secure trials, 162 deaths (3.21%) occurred in 5,264 patients randomized to beta-blockers, and 129 deaths (2.45%) occurred in the 5,265 patients randomized to placebo.
Thus, the initiation of a course of beta-blockers as per guideline recommendations before surgery resulted in a 27% increase in all-cause mortality, Dr. Bouri and her coauthors stated. "Any remaining [perioperative beta-blocker] enthusiasts might best channel their energy into a further randomized trial, which should be designed carefully and honestly," they added.
The results from the DECREASE family of trials substantially contradicted the meta-analysis of the secure trials on the effect on mortality (P = .05 for divergence).
"All studies investigated in the DECREASE family for which data had not been lost were found to be insecure because of serious flaws. In one case, it was clear that the entire study database had been fabricated. DECREASE I, published in 1999, escaped investigation as the terms of the investigation only reached back 10 years," the researchers reported.
When the ESC and American College of Cardiology Foundation/American Heart Association guidelines were formulated, "the inclusion of insecure data caused them to reach the conclusion that beta-blockade had a neutral effect on mortality and allowed them to focus on the reduction of non-fatal MI as a surrogate endpoint," the authors explained.
The DECREASE family of studies was discredited almost 2 years ago and subsequently underwent lengthy internal investigation, the results of which have been public for some time, according to the authors. "Nevertheless, neither the European Society of Cardiology nor the AHA guidelines have been retracted," they said.
"Patient safety being paramount, guidelines for perioperative beta-blockers should be retracted without further delay. Future guidelines should be accompanied by a commitment from named individuals to retract them immediately if the advice given is later revealed to be harmful," the authors concluded.
The authors reported that they had no conflicts of interest.
More than 1 in 4 patients who died from all causes after noncardiac surgery may have survived if they were not treated with perioperative beta-blockers as specified by joint American College of Cardiology Foundation/American Heart Association and separate European Society of Cardiology guidelines.
These guidelines recommend perioperative beta-blockers in all patients undergoing vascular or intermediate-risk surgery with coronary artery disease, or with more than one risk factor for CAD, or with preexisting beta-blockade. These are all iatrogenic deaths, according to a meta-analysis of secure studies, which excluded data from the now discredited Dutch Echocardiographic Cardiac Risk Evaluation Applying Stress Echocardiography (DECREASE) family of trials.
"Refraining from this ESC [European Society of Cardiology] guideline would therefore be expected to prevent up to 10,000 iatrogenic deaths each year in the U.K.," according to Dr. Sonia Bouri and her coauthors at the National Heart and Lung Institute, Imperial College London.
The researchers analyzed nine secure randomized trials totaling 10,529 patients who met the guideline criteria, 291 of whom died. They found that initiation of a course of beta-blockers as per guideline recommendations before surgery resulted in a 27% increase in mortality.
In the secure trials, use of perioperative beta-blockers decreased nonfatal myocardial infarction significantly (RR, 0.73; P = .001), but increased stroke (RR, 1.73; P =.05) and hypotension (RR, 1.51; P less than .00001), according to the authors, who presented their data in Heart (2013 July 31 [doi: 10.1136/heartjnl-2013-304262]).
Of the 291 deaths recorded in the secure trials, 162 deaths (3.21%) occurred in 5,264 patients randomized to beta-blockers, and 129 deaths (2.45%) occurred in the 5,265 patients randomized to placebo.
Thus, the initiation of a course of beta-blockers as per guideline recommendations before surgery resulted in a 27% increase in all-cause mortality, Dr. Bouri and her coauthors stated. "Any remaining [perioperative beta-blocker] enthusiasts might best channel their energy into a further randomized trial, which should be designed carefully and honestly," they added.
The results from the DECREASE family of trials substantially contradicted the meta-analysis of the secure trials on the effect on mortality (P = .05 for divergence).
"All studies investigated in the DECREASE family for which data had not been lost were found to be insecure because of serious flaws. In one case, it was clear that the entire study database had been fabricated. DECREASE I, published in 1999, escaped investigation as the terms of the investigation only reached back 10 years," the researchers reported.
When the ESC and American College of Cardiology Foundation/American Heart Association guidelines were formulated, "the inclusion of insecure data caused them to reach the conclusion that beta-blockade had a neutral effect on mortality and allowed them to focus on the reduction of non-fatal MI as a surrogate endpoint," the authors explained.
The DECREASE family of studies was discredited almost 2 years ago and subsequently underwent lengthy internal investigation, the results of which have been public for some time, according to the authors. "Nevertheless, neither the European Society of Cardiology nor the AHA guidelines have been retracted," they said.
"Patient safety being paramount, guidelines for perioperative beta-blockers should be retracted without further delay. Future guidelines should be accompanied by a commitment from named individuals to retract them immediately if the advice given is later revealed to be harmful," the authors concluded.
The authors reported that they had no conflicts of interest.
FROM HEART
Tools help predict VTE after abdominal, thoracic surgery
Two simple-to-use calculation tools, which physicians can use to predict separately the 30-day risk of postoperative venous thromboembolism in hospital and after discharge, have been developed. Researchers based the two nomograms on the results of a retrospective analysis of more than 450,000 thoracic and abdominal surgical patients in the American College of Surgeons National Surgical Quality Improvement Program database.
"Substantial variation exists in the incidence of VTE [venous thromboembolism] and VTEDC [venous thromboembolism after hospital discharge] after abdominal or thoracic surgery, depending on patient and procedural factors," wrote Dr. Robert Canter, Dr. Dhruvil R. Shah, and colleagues at the University of California, Davis. They analyzed these factors to determine statistically significant risks in order to construct the predictive nomograms, according to their report published in the July issue of the Journal of Surgical Research. Dr. Canter is the senior author of the study and associate professor of surgery in the Division of Surgical Oncology at UC Davis.*
The authors used data obtained from the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) to construct a nomogram by which physicians could use a ruler and draw lines from each separate risk factor on a no-yes gridline to a point score for that factor. By adding the point results for all factors, the total number of points could then be used to calculate the 30-day risk of developing a VTE. A separate nomogram using the same process was constructed for calculating the risk of a VTEDC.
The researchers assessed 471,867 patients who underwent inpatient abdominal or thoracic operations between 2005 and 2010. Patients who underwent primary vascular and spine operations were excluded. The overall unadjusted, 30-day incidence of postoperative VT) in these patients was 1.5% and that of VTEDC was 0.5%, and the annual incidence rates remained unchanged over the period studied. The median time to VTE was 9 days and the median time to VTEDC was 17 days, and these also did not change over the study period.
The majority of patients were white (75.5%) and men (59%), with a mean age of 54 years and a mean body mass index of 31 kg/m2; 93% of the patients were functionally independent.
Comorbidities included smoking (19%), history of preoperative infection or sepsis (16.5%), diabetes (15%), and a variety of cardiovascular conditions or procedures (9%). The vast majority of operations were abdominal (98%), with most performed on the gastrointestinal tract (51.5%). Thoracic operations accounted for 2.1%. Minimally invasive (excluding bariatric) surgery was performed in 37% of cases, with 20% of all operations performed for cancer. A total of 11% of patients experienced one or more major postoperative complications within 30 days of the operation, including post discharge.
Multivariate analysis showed that the significant predictors of both VTE and VTEDC were age, body mass index, presence of postoperative infection, operation for cancer, procedure type (primarily splenectomy), multivisceral resection, and nonbariatric laparoscopic surgery. Significant factors predicting VTE but not VTEDC were a history of chronic obstructive pulmonary disease, disseminated cancer, and emergent operation (J. Surg. Res. 2013;183:462-71).
In addition to the nomogram, the researchers used internally developed concordance indices to measure the probability of concordance between the predicted and measured outcomes and found that these were 0.77 for VTE and 0.67 for VTEDC. They acknowledge that the lower value for VTEDC is a probable indicator of unknown and uncaptured risk factors, possibly including socioeconomic status, a change in postoperative functional status,
Limitations of the study included those inherent to using the ACS-NSQUIP database, which meant that they could not identify patients who had a prior history of VTE or central line placement, both of which have been cited as VTE risk factors, according to the researchers. In addition, asymptomatic VTE events and events for which patients did not receive anticoagulation were not captured in the database.
"Although these nomograms require external validation to ensure reproducibility, these tools will aid clinicians, researchers, and administrators in determining which subset of patients undergoing abdominal or general thoracic general surgical operations are at highest risk for postoperative VTE and VTEDC. Our data may allow for more targeted quality improvement interventions to reduce VTE and VTEDC" in these patients, the researchers concluded.
The authors disclosed no conflicts that the editors of the journal determined should be reported in the article.
*UPDATED: This story was updated to include Dr. Canter's information and photo.
Two simple-to-use calculation tools, which physicians can use to predict separately the 30-day risk of postoperative venous thromboembolism in hospital and after discharge, have been developed. Researchers based the two nomograms on the results of a retrospective analysis of more than 450,000 thoracic and abdominal surgical patients in the American College of Surgeons National Surgical Quality Improvement Program database.
"Substantial variation exists in the incidence of VTE [venous thromboembolism] and VTEDC [venous thromboembolism after hospital discharge] after abdominal or thoracic surgery, depending on patient and procedural factors," wrote Dr. Robert Canter, Dr. Dhruvil R. Shah, and colleagues at the University of California, Davis. They analyzed these factors to determine statistically significant risks in order to construct the predictive nomograms, according to their report published in the July issue of the Journal of Surgical Research. Dr. Canter is the senior author of the study and associate professor of surgery in the Division of Surgical Oncology at UC Davis.*
The authors used data obtained from the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) to construct a nomogram by which physicians could use a ruler and draw lines from each separate risk factor on a no-yes gridline to a point score for that factor. By adding the point results for all factors, the total number of points could then be used to calculate the 30-day risk of developing a VTE. A separate nomogram using the same process was constructed for calculating the risk of a VTEDC.
The researchers assessed 471,867 patients who underwent inpatient abdominal or thoracic operations between 2005 and 2010. Patients who underwent primary vascular and spine operations were excluded. The overall unadjusted, 30-day incidence of postoperative VT) in these patients was 1.5% and that of VTEDC was 0.5%, and the annual incidence rates remained unchanged over the period studied. The median time to VTE was 9 days and the median time to VTEDC was 17 days, and these also did not change over the study period.
The majority of patients were white (75.5%) and men (59%), with a mean age of 54 years and a mean body mass index of 31 kg/m2; 93% of the patients were functionally independent.
Comorbidities included smoking (19%), history of preoperative infection or sepsis (16.5%), diabetes (15%), and a variety of cardiovascular conditions or procedures (9%). The vast majority of operations were abdominal (98%), with most performed on the gastrointestinal tract (51.5%). Thoracic operations accounted for 2.1%. Minimally invasive (excluding bariatric) surgery was performed in 37% of cases, with 20% of all operations performed for cancer. A total of 11% of patients experienced one or more major postoperative complications within 30 days of the operation, including post discharge.
Multivariate analysis showed that the significant predictors of both VTE and VTEDC were age, body mass index, presence of postoperative infection, operation for cancer, procedure type (primarily splenectomy), multivisceral resection, and nonbariatric laparoscopic surgery. Significant factors predicting VTE but not VTEDC were a history of chronic obstructive pulmonary disease, disseminated cancer, and emergent operation (J. Surg. Res. 2013;183:462-71).
In addition to the nomogram, the researchers used internally developed concordance indices to measure the probability of concordance between the predicted and measured outcomes and found that these were 0.77 for VTE and 0.67 for VTEDC. They acknowledge that the lower value for VTEDC is a probable indicator of unknown and uncaptured risk factors, possibly including socioeconomic status, a change in postoperative functional status,
Limitations of the study included those inherent to using the ACS-NSQUIP database, which meant that they could not identify patients who had a prior history of VTE or central line placement, both of which have been cited as VTE risk factors, according to the researchers. In addition, asymptomatic VTE events and events for which patients did not receive anticoagulation were not captured in the database.
"Although these nomograms require external validation to ensure reproducibility, these tools will aid clinicians, researchers, and administrators in determining which subset of patients undergoing abdominal or general thoracic general surgical operations are at highest risk for postoperative VTE and VTEDC. Our data may allow for more targeted quality improvement interventions to reduce VTE and VTEDC" in these patients, the researchers concluded.
The authors disclosed no conflicts that the editors of the journal determined should be reported in the article.
*UPDATED: This story was updated to include Dr. Canter's information and photo.
Two simple-to-use calculation tools, which physicians can use to predict separately the 30-day risk of postoperative venous thromboembolism in hospital and after discharge, have been developed. Researchers based the two nomograms on the results of a retrospective analysis of more than 450,000 thoracic and abdominal surgical patients in the American College of Surgeons National Surgical Quality Improvement Program database.
"Substantial variation exists in the incidence of VTE [venous thromboembolism] and VTEDC [venous thromboembolism after hospital discharge] after abdominal or thoracic surgery, depending on patient and procedural factors," wrote Dr. Robert Canter, Dr. Dhruvil R. Shah, and colleagues at the University of California, Davis. They analyzed these factors to determine statistically significant risks in order to construct the predictive nomograms, according to their report published in the July issue of the Journal of Surgical Research. Dr. Canter is the senior author of the study and associate professor of surgery in the Division of Surgical Oncology at UC Davis.*
The authors used data obtained from the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) to construct a nomogram by which physicians could use a ruler and draw lines from each separate risk factor on a no-yes gridline to a point score for that factor. By adding the point results for all factors, the total number of points could then be used to calculate the 30-day risk of developing a VTE. A separate nomogram using the same process was constructed for calculating the risk of a VTEDC.
The researchers assessed 471,867 patients who underwent inpatient abdominal or thoracic operations between 2005 and 2010. Patients who underwent primary vascular and spine operations were excluded. The overall unadjusted, 30-day incidence of postoperative VT) in these patients was 1.5% and that of VTEDC was 0.5%, and the annual incidence rates remained unchanged over the period studied. The median time to VTE was 9 days and the median time to VTEDC was 17 days, and these also did not change over the study period.
The majority of patients were white (75.5%) and men (59%), with a mean age of 54 years and a mean body mass index of 31 kg/m2; 93% of the patients were functionally independent.
Comorbidities included smoking (19%), history of preoperative infection or sepsis (16.5%), diabetes (15%), and a variety of cardiovascular conditions or procedures (9%). The vast majority of operations were abdominal (98%), with most performed on the gastrointestinal tract (51.5%). Thoracic operations accounted for 2.1%. Minimally invasive (excluding bariatric) surgery was performed in 37% of cases, with 20% of all operations performed for cancer. A total of 11% of patients experienced one or more major postoperative complications within 30 days of the operation, including post discharge.
Multivariate analysis showed that the significant predictors of both VTE and VTEDC were age, body mass index, presence of postoperative infection, operation for cancer, procedure type (primarily splenectomy), multivisceral resection, and nonbariatric laparoscopic surgery. Significant factors predicting VTE but not VTEDC were a history of chronic obstructive pulmonary disease, disseminated cancer, and emergent operation (J. Surg. Res. 2013;183:462-71).
In addition to the nomogram, the researchers used internally developed concordance indices to measure the probability of concordance between the predicted and measured outcomes and found that these were 0.77 for VTE and 0.67 for VTEDC. They acknowledge that the lower value for VTEDC is a probable indicator of unknown and uncaptured risk factors, possibly including socioeconomic status, a change in postoperative functional status,
Limitations of the study included those inherent to using the ACS-NSQUIP database, which meant that they could not identify patients who had a prior history of VTE or central line placement, both of which have been cited as VTE risk factors, according to the researchers. In addition, asymptomatic VTE events and events for which patients did not receive anticoagulation were not captured in the database.
"Although these nomograms require external validation to ensure reproducibility, these tools will aid clinicians, researchers, and administrators in determining which subset of patients undergoing abdominal or general thoracic general surgical operations are at highest risk for postoperative VTE and VTEDC. Our data may allow for more targeted quality improvement interventions to reduce VTE and VTEDC" in these patients, the researchers concluded.
The authors disclosed no conflicts that the editors of the journal determined should be reported in the article.
*UPDATED: This story was updated to include Dr. Canter's information and photo.
FROM THE JOURNAL OF SURGICAL RESEARCH
SVS Resident Research Prize given to AAA study
Dr. Nathan D. Airhart, Washington University School of Medicine, St. Louis, was the recipient of this year’s SVS Foundation Resident Research Prize Paper, which was presented at the Vascular Annual Meeting as part of the William J. von Liebig Forum, which features the best in resident research.
Dr. Airhart, his mentor, Dr. John A. Curci, and his colleagues studied the specific contribution of the vascular smooth muscle cells (SMCs) to the destruction of the elastic proteins that are uniquely absent in the walls of abdominal aortic aneurysms (AAAs). "Although the SMC is the dominant cell type in the aortic wall, our understanding of the role of these cells in aneurysms has been very limited," said Dr. Airhart.
To directly study the function of these cells, Dr. Airhart and his colleagues embarked on an ambitious project to isolate live SMCs from AAAs, normal abdominal aorta (NAA), and plaque from carotid endarterectomy (CEA) procedures. The group profiled the mRNA produced by these cultured cells by microarray and clearly demonstrated a unique pattern of expression of the AAA-SMC.
"The mRNA profiles confirmed that the AAA cells were likely interacting with the matrix differently than the other SMCs, but it did not necessarily tell us how they were influencing aneurysm development," said Dr. Airhart. To better understand the role of these cells, the investigators evaluated the ability of these cells to break down elastic fibers in culture.
Under standard culture conditions, AAA-SMCs were able to degrade three times more elastin than the NAA-SMCs. "Even more remarkable was the finding that co-culture with activated macrophages – a cell type always found in the wall of aneurysms – resulted in a further doubling of the elastic fiber damage by the AAA-SMCs. Co-culture of macrophages with NAA-SMCs had no effect on the elastin degraded," said Dr. Airhart.
Further experiments suggested that the enzymes principally responsible for the elastolytic activity of these cells are the matrix metalloproteinases (MMPs). Increases in the production and/or activation of MMP-2 and/or MMP-9 were prominently found in cultures of AAA-SMCs.
"These studies present the strongest evidence that AAA-SMCs exhibit a disease-specific gene expression pattern and can very potently damage the elastic fiber matrix in the aortic wall. The unique and remarkable synergy with activated inflammatory cells might help explain the characteristic elastin loss of aortic aneurysms. Future studies will allow us to understand and alter the cellular mechanisms which lead to increased production and activation of elastolytic MMPs by these cells," Dr. Curci concluded.
The prestigious Resident Research Prize is intended to motivate new physicians to pursue vascular research. The prize recipient is invited to present his or her research results at the Society for Vascular Surgery’s Vascular Annual Meeting and the prize includes a 1-year subscription to the Journal of Vascular Surgery.
Dr. Nathan D. Airhart, Washington University School of Medicine, St. Louis, was the recipient of this year’s SVS Foundation Resident Research Prize Paper, which was presented at the Vascular Annual Meeting as part of the William J. von Liebig Forum, which features the best in resident research.
Dr. Airhart, his mentor, Dr. John A. Curci, and his colleagues studied the specific contribution of the vascular smooth muscle cells (SMCs) to the destruction of the elastic proteins that are uniquely absent in the walls of abdominal aortic aneurysms (AAAs). "Although the SMC is the dominant cell type in the aortic wall, our understanding of the role of these cells in aneurysms has been very limited," said Dr. Airhart.
To directly study the function of these cells, Dr. Airhart and his colleagues embarked on an ambitious project to isolate live SMCs from AAAs, normal abdominal aorta (NAA), and plaque from carotid endarterectomy (CEA) procedures. The group profiled the mRNA produced by these cultured cells by microarray and clearly demonstrated a unique pattern of expression of the AAA-SMC.
"The mRNA profiles confirmed that the AAA cells were likely interacting with the matrix differently than the other SMCs, but it did not necessarily tell us how they were influencing aneurysm development," said Dr. Airhart. To better understand the role of these cells, the investigators evaluated the ability of these cells to break down elastic fibers in culture.
Under standard culture conditions, AAA-SMCs were able to degrade three times more elastin than the NAA-SMCs. "Even more remarkable was the finding that co-culture with activated macrophages – a cell type always found in the wall of aneurysms – resulted in a further doubling of the elastic fiber damage by the AAA-SMCs. Co-culture of macrophages with NAA-SMCs had no effect on the elastin degraded," said Dr. Airhart.
Further experiments suggested that the enzymes principally responsible for the elastolytic activity of these cells are the matrix metalloproteinases (MMPs). Increases in the production and/or activation of MMP-2 and/or MMP-9 were prominently found in cultures of AAA-SMCs.
"These studies present the strongest evidence that AAA-SMCs exhibit a disease-specific gene expression pattern and can very potently damage the elastic fiber matrix in the aortic wall. The unique and remarkable synergy with activated inflammatory cells might help explain the characteristic elastin loss of aortic aneurysms. Future studies will allow us to understand and alter the cellular mechanisms which lead to increased production and activation of elastolytic MMPs by these cells," Dr. Curci concluded.
The prestigious Resident Research Prize is intended to motivate new physicians to pursue vascular research. The prize recipient is invited to present his or her research results at the Society for Vascular Surgery’s Vascular Annual Meeting and the prize includes a 1-year subscription to the Journal of Vascular Surgery.
Dr. Nathan D. Airhart, Washington University School of Medicine, St. Louis, was the recipient of this year’s SVS Foundation Resident Research Prize Paper, which was presented at the Vascular Annual Meeting as part of the William J. von Liebig Forum, which features the best in resident research.
Dr. Airhart, his mentor, Dr. John A. Curci, and his colleagues studied the specific contribution of the vascular smooth muscle cells (SMCs) to the destruction of the elastic proteins that are uniquely absent in the walls of abdominal aortic aneurysms (AAAs). "Although the SMC is the dominant cell type in the aortic wall, our understanding of the role of these cells in aneurysms has been very limited," said Dr. Airhart.
To directly study the function of these cells, Dr. Airhart and his colleagues embarked on an ambitious project to isolate live SMCs from AAAs, normal abdominal aorta (NAA), and plaque from carotid endarterectomy (CEA) procedures. The group profiled the mRNA produced by these cultured cells by microarray and clearly demonstrated a unique pattern of expression of the AAA-SMC.
"The mRNA profiles confirmed that the AAA cells were likely interacting with the matrix differently than the other SMCs, but it did not necessarily tell us how they were influencing aneurysm development," said Dr. Airhart. To better understand the role of these cells, the investigators evaluated the ability of these cells to break down elastic fibers in culture.
Under standard culture conditions, AAA-SMCs were able to degrade three times more elastin than the NAA-SMCs. "Even more remarkable was the finding that co-culture with activated macrophages – a cell type always found in the wall of aneurysms – resulted in a further doubling of the elastic fiber damage by the AAA-SMCs. Co-culture of macrophages with NAA-SMCs had no effect on the elastin degraded," said Dr. Airhart.
Further experiments suggested that the enzymes principally responsible for the elastolytic activity of these cells are the matrix metalloproteinases (MMPs). Increases in the production and/or activation of MMP-2 and/or MMP-9 were prominently found in cultures of AAA-SMCs.
"These studies present the strongest evidence that AAA-SMCs exhibit a disease-specific gene expression pattern and can very potently damage the elastic fiber matrix in the aortic wall. The unique and remarkable synergy with activated inflammatory cells might help explain the characteristic elastin loss of aortic aneurysms. Future studies will allow us to understand and alter the cellular mechanisms which lead to increased production and activation of elastolytic MMPs by these cells," Dr. Curci concluded.
The prestigious Resident Research Prize is intended to motivate new physicians to pursue vascular research. The prize recipient is invited to present his or her research results at the Society for Vascular Surgery’s Vascular Annual Meeting and the prize includes a 1-year subscription to the Journal of Vascular Surgery.
Aging population will need more ED capacity, admissions
The aging of the U.S. population will lead not to increased emergency department visits, but to an increase in "boarding" and an increase in subsequent hospital admissions, according to the results of a data analysis.
The researchers used the National Hospital Ambulatory Medical Care Survey and data from the U. S. Census Bureau.
From 1997 to 2009, the population grew by 15%, while annual emergency department visits increased by 43%, prompting the Institute of Medicine to describe U.S. emergency care as "at the breaking point."
Moreover, the U.S. population is aging, and visits by older patients are viewed as a driving force in demand for emergency department services, according to Dr. Daniel J. Pallin, director of research in the department of emergency medicine at Brigham and Women’s Hospital, Boston, and his colleagues.
Using hospitalization rates observed during 1993-2009 and age subgroup–specific values from the period 2003-2009, Dr. Pallin and his colleagues modeled the effect of population aging on the demand for emergency department services. The results of their research – projecting through the years 2009-2050 – appear in the July issue of Health Affairs.
Overall, their projections showed that as the population increased at a growth factor of 1.4 (from 307 million in 2009 to 439 million in 2050), ED visits also increased at the same rate of 1.4 (from 136 million to 197 million), "refuting our initial hypothesis" that an aging population would lead to more ED visits, the researchers explained.
Their subgroup analysis provide an explanation. It showed that there were three peaks in the relationship of age to ED visit rates. The yearly rate of visits was 7 for every 10 children aged 0-4 years; 5.4 for every 10 adults aged 20-24; and 10 visits for every 10 adults aged 95-99. "Most notable is the fact that adults ages 60-80, who are the most numerous older Americans, are not heavy uses of the ED. For example, there are only 3.5 visits per year for every 10 adults ages 65-69," the researchers said.
"We observe that it is actually infants and young adults, not the elderly, who account for the largest number of ED visits. Although it is true that people older than 80 are most likely to visit the ED, they make up only 3.7% of the population and thus contribute little to the total national number of visits," the researchers wrote.
In contrast, the visit lengths in the ED (calculated as visit length minus waiting time) increased almost linearly with age. The mean visit length for small children was about 1.6 hours vs. more than 3.5 hours for the oldest patients.
Similarly, the likelihood of a hospital admission from an ED increased with age: 10% in small children and rising to almost 50% for the oldest patients. Patients use ED resources while waiting to move to hospital rooms, and this scenario, known as ‘boarding,’ is a major cause of ED crowding and a threat to patient safety, the researchers stated.
"We project that the aggregate length of ED visits will increase 10% by 2050. To keep pace, EDs must expand 10% faster than population growth, or the process of hospital admission will have to become more efficient," they noted (Health Aff. 2013;32:1-7).
"Hospitalizations from the ED will increase 23% faster than the anticipated rate of population growth," and to keep pace, hospitals must grow faster than the population and must optimize movement of admitted emergency department patients, they concluded.
The authors reported no relevant disclosures. The research was funded by a seed grant from the Brigham and Women’s Hospital’s department of emergency medicine.
The aging of the U.S. population will lead not to increased emergency department visits, but to an increase in "boarding" and an increase in subsequent hospital admissions, according to the results of a data analysis.
The researchers used the National Hospital Ambulatory Medical Care Survey and data from the U. S. Census Bureau.
From 1997 to 2009, the population grew by 15%, while annual emergency department visits increased by 43%, prompting the Institute of Medicine to describe U.S. emergency care as "at the breaking point."
Moreover, the U.S. population is aging, and visits by older patients are viewed as a driving force in demand for emergency department services, according to Dr. Daniel J. Pallin, director of research in the department of emergency medicine at Brigham and Women’s Hospital, Boston, and his colleagues.
Using hospitalization rates observed during 1993-2009 and age subgroup–specific values from the period 2003-2009, Dr. Pallin and his colleagues modeled the effect of population aging on the demand for emergency department services. The results of their research – projecting through the years 2009-2050 – appear in the July issue of Health Affairs.
Overall, their projections showed that as the population increased at a growth factor of 1.4 (from 307 million in 2009 to 439 million in 2050), ED visits also increased at the same rate of 1.4 (from 136 million to 197 million), "refuting our initial hypothesis" that an aging population would lead to more ED visits, the researchers explained.
Their subgroup analysis provide an explanation. It showed that there were three peaks in the relationship of age to ED visit rates. The yearly rate of visits was 7 for every 10 children aged 0-4 years; 5.4 for every 10 adults aged 20-24; and 10 visits for every 10 adults aged 95-99. "Most notable is the fact that adults ages 60-80, who are the most numerous older Americans, are not heavy uses of the ED. For example, there are only 3.5 visits per year for every 10 adults ages 65-69," the researchers said.
"We observe that it is actually infants and young adults, not the elderly, who account for the largest number of ED visits. Although it is true that people older than 80 are most likely to visit the ED, they make up only 3.7% of the population and thus contribute little to the total national number of visits," the researchers wrote.
In contrast, the visit lengths in the ED (calculated as visit length minus waiting time) increased almost linearly with age. The mean visit length for small children was about 1.6 hours vs. more than 3.5 hours for the oldest patients.
Similarly, the likelihood of a hospital admission from an ED increased with age: 10% in small children and rising to almost 50% for the oldest patients. Patients use ED resources while waiting to move to hospital rooms, and this scenario, known as ‘boarding,’ is a major cause of ED crowding and a threat to patient safety, the researchers stated.
"We project that the aggregate length of ED visits will increase 10% by 2050. To keep pace, EDs must expand 10% faster than population growth, or the process of hospital admission will have to become more efficient," they noted (Health Aff. 2013;32:1-7).
"Hospitalizations from the ED will increase 23% faster than the anticipated rate of population growth," and to keep pace, hospitals must grow faster than the population and must optimize movement of admitted emergency department patients, they concluded.
The authors reported no relevant disclosures. The research was funded by a seed grant from the Brigham and Women’s Hospital’s department of emergency medicine.
The aging of the U.S. population will lead not to increased emergency department visits, but to an increase in "boarding" and an increase in subsequent hospital admissions, according to the results of a data analysis.
The researchers used the National Hospital Ambulatory Medical Care Survey and data from the U. S. Census Bureau.
From 1997 to 2009, the population grew by 15%, while annual emergency department visits increased by 43%, prompting the Institute of Medicine to describe U.S. emergency care as "at the breaking point."
Moreover, the U.S. population is aging, and visits by older patients are viewed as a driving force in demand for emergency department services, according to Dr. Daniel J. Pallin, director of research in the department of emergency medicine at Brigham and Women’s Hospital, Boston, and his colleagues.
Using hospitalization rates observed during 1993-2009 and age subgroup–specific values from the period 2003-2009, Dr. Pallin and his colleagues modeled the effect of population aging on the demand for emergency department services. The results of their research – projecting through the years 2009-2050 – appear in the July issue of Health Affairs.
Overall, their projections showed that as the population increased at a growth factor of 1.4 (from 307 million in 2009 to 439 million in 2050), ED visits also increased at the same rate of 1.4 (from 136 million to 197 million), "refuting our initial hypothesis" that an aging population would lead to more ED visits, the researchers explained.
Their subgroup analysis provide an explanation. It showed that there were three peaks in the relationship of age to ED visit rates. The yearly rate of visits was 7 for every 10 children aged 0-4 years; 5.4 for every 10 adults aged 20-24; and 10 visits for every 10 adults aged 95-99. "Most notable is the fact that adults ages 60-80, who are the most numerous older Americans, are not heavy uses of the ED. For example, there are only 3.5 visits per year for every 10 adults ages 65-69," the researchers said.
"We observe that it is actually infants and young adults, not the elderly, who account for the largest number of ED visits. Although it is true that people older than 80 are most likely to visit the ED, they make up only 3.7% of the population and thus contribute little to the total national number of visits," the researchers wrote.
In contrast, the visit lengths in the ED (calculated as visit length minus waiting time) increased almost linearly with age. The mean visit length for small children was about 1.6 hours vs. more than 3.5 hours for the oldest patients.
Similarly, the likelihood of a hospital admission from an ED increased with age: 10% in small children and rising to almost 50% for the oldest patients. Patients use ED resources while waiting to move to hospital rooms, and this scenario, known as ‘boarding,’ is a major cause of ED crowding and a threat to patient safety, the researchers stated.
"We project that the aggregate length of ED visits will increase 10% by 2050. To keep pace, EDs must expand 10% faster than population growth, or the process of hospital admission will have to become more efficient," they noted (Health Aff. 2013;32:1-7).
"Hospitalizations from the ED will increase 23% faster than the anticipated rate of population growth," and to keep pace, hospitals must grow faster than the population and must optimize movement of admitted emergency department patients, they concluded.
The authors reported no relevant disclosures. The research was funded by a seed grant from the Brigham and Women’s Hospital’s department of emergency medicine.
FROM HEALTH AFFAIRS
Risks for poorer outcomes of ASO for TGA
Neoaortic root dilation and neoaortic valve regurgitation are common complications in infants with transposition of the great arteries who undergo an arterial switch operation for repair, and the risk of developing these changes in the neoaorta increases over time, according to the results of a retrospective database study of patients at Children’s Hospital of Wisconsin.
In addition, when dilation occurs, the dimensions may progressively enlarge over time, making it important to maintain lifelong surveillance of this population.
Although perioperative mortality and long-term survival (assessed up to 30 years) has improved in more recent eras for use of an arterial switch operation (ASO) for transposition of the great arteries (TGA), these long-term studies have also shown important late complications that may contribute to late morbidity and the need for reoperation, according to Dr. Jennifer G. Co-Vu and her colleagues at the Medical College of Wisconsin, Milwaukee.
They performed their study to determine the prevalence of neoaortic root dilation and neoaortic valve regurgitation in patients treated at their institution and to determine risk factors involved in the development of these late complications.
Out of 247 patients with TGA treated with an ASO at the hospital, there were 124 patients who had at least one available postoperative transthoracic echocardiogram at least 1 year after the ASO. Median age of these patients was 0.2 months at the time of their ASO and 7.2 years at their last follow-up; 71% were boys (Ann. Thorac. Surg. 2013;95:1654-9).
Retrospective measurements of the neoaortic annulus and root were performed on all available transthoracic echocardiograms and the severity of neoaortic valve regurgitation was determined by assessing the width of the color Doppler jet of regurgitation measured at the level of the valve in the parasternal long-axis view. A jet width of 1-4 mm was defined as trivial to mild; 4-6 mm was defined as moderate; and greater than 6 mm indicated severe regurgitation, according to the researchers. Significant regurgitation was defined as moderate or severe. Significant neoaortic annulus dilation was defined as a z score of 2.5 or greater.
They evaluated potential risk factors for the development of neoaortic root dilation, annulus dilation, and neoaortic valve regurgitation.
Significant neoaortic root dilation developed in 88 of 124 (66%) of the patients during follow-up, with the probability of being free from a root diameter z score of 2.5 or greater of 84%, 67%, 47%, and 32% at 1, 5, 10, and 15 years, respectively. Significant risk factors predicting neoaortic root dilation using multivariate analysis were a history of double outlet right ventricle (DORV), previous pulmonary artery (PA) banding, and length of follow-up. A history of ventricular septal defect (VSD), coarctation, left ventricular outflow tract obstruction, and age at ASO were not significant risk factors.
Significant annulus dilation occurred in 54% of patients, with significant risk factors including a history of VSD, history of DORV, and the presence of a dilated neoaortic root. History of PA banding and length of follow-up were not significant. Moderate or severe neoaortic valve regurgitation occurred in 17 of 124 (14%) of the patients, with a probability of being free of these levels of regurgitation of 96%, 92%, 89%, and 75% at 1, 5, 10, and 15 years, respectively. The significant risk factors for regurgitation were history of DORV, VSD, left ventricular outflow tract obstruction, and length of follow-up. No patient in the series required reintervention on the neoaorta.
The authors had no disclosures.
Most people living with congenital heart disease are now adults. Unfortunately the majority of these adults, for unclear reasons, are not receiving expert care by congenital heart specialists. Perhaps some of these adults have a misperception that they are cured. Dr. Co-Vu and coauthors at the Medical College of Wisconsin confirm that the highly successful arterial switch operation is not a "cure."
| Dr. Williams |
Their important, carefully executed echo study demonstrates important progressive increases in measured diameters of the neoaortic annulus and neoaortic root over the first 15 years of life. The
authors point out that the dilation has not as yet led to a need for reintervention, and the late prevalence of neoaortic regurgitation is not high, although it too is slowly increasing over time. Their message is a clarion call for lifelong clinical surveillance following an arterial switch operation – a message that should be applied to all patients with congenital heart disease.
Dr. William G. Williams is executive director of the Congenital Heart Surgeons’ Society Data Center, Toronto, and emeritus professor of surgery, University of Toronto, and an associate medical editor for Thoracic Surgery News.
Most people living with congenital heart disease are now adults. Unfortunately the majority of these adults, for unclear reasons, are not receiving expert care by congenital heart specialists. Perhaps some of these adults have a misperception that they are cured. Dr. Co-Vu and coauthors at the Medical College of Wisconsin confirm that the highly successful arterial switch operation is not a "cure."
| Dr. Williams |
Their important, carefully executed echo study demonstrates important progressive increases in measured diameters of the neoaortic annulus and neoaortic root over the first 15 years of life. The
authors point out that the dilation has not as yet led to a need for reintervention, and the late prevalence of neoaortic regurgitation is not high, although it too is slowly increasing over time. Their message is a clarion call for lifelong clinical surveillance following an arterial switch operation – a message that should be applied to all patients with congenital heart disease.
Dr. William G. Williams is executive director of the Congenital Heart Surgeons’ Society Data Center, Toronto, and emeritus professor of surgery, University of Toronto, and an associate medical editor for Thoracic Surgery News.
Most people living with congenital heart disease are now adults. Unfortunately the majority of these adults, for unclear reasons, are not receiving expert care by congenital heart specialists. Perhaps some of these adults have a misperception that they are cured. Dr. Co-Vu and coauthors at the Medical College of Wisconsin confirm that the highly successful arterial switch operation is not a "cure."
| Dr. Williams |
Their important, carefully executed echo study demonstrates important progressive increases in measured diameters of the neoaortic annulus and neoaortic root over the first 15 years of life. The
authors point out that the dilation has not as yet led to a need for reintervention, and the late prevalence of neoaortic regurgitation is not high, although it too is slowly increasing over time. Their message is a clarion call for lifelong clinical surveillance following an arterial switch operation – a message that should be applied to all patients with congenital heart disease.
Dr. William G. Williams is executive director of the Congenital Heart Surgeons’ Society Data Center, Toronto, and emeritus professor of surgery, University of Toronto, and an associate medical editor for Thoracic Surgery News.
Neoaortic root dilation and neoaortic valve regurgitation are common complications in infants with transposition of the great arteries who undergo an arterial switch operation for repair, and the risk of developing these changes in the neoaorta increases over time, according to the results of a retrospective database study of patients at Children’s Hospital of Wisconsin.
In addition, when dilation occurs, the dimensions may progressively enlarge over time, making it important to maintain lifelong surveillance of this population.
Although perioperative mortality and long-term survival (assessed up to 30 years) has improved in more recent eras for use of an arterial switch operation (ASO) for transposition of the great arteries (TGA), these long-term studies have also shown important late complications that may contribute to late morbidity and the need for reoperation, according to Dr. Jennifer G. Co-Vu and her colleagues at the Medical College of Wisconsin, Milwaukee.
They performed their study to determine the prevalence of neoaortic root dilation and neoaortic valve regurgitation in patients treated at their institution and to determine risk factors involved in the development of these late complications.
Out of 247 patients with TGA treated with an ASO at the hospital, there were 124 patients who had at least one available postoperative transthoracic echocardiogram at least 1 year after the ASO. Median age of these patients was 0.2 months at the time of their ASO and 7.2 years at their last follow-up; 71% were boys (Ann. Thorac. Surg. 2013;95:1654-9).
Retrospective measurements of the neoaortic annulus and root were performed on all available transthoracic echocardiograms and the severity of neoaortic valve regurgitation was determined by assessing the width of the color Doppler jet of regurgitation measured at the level of the valve in the parasternal long-axis view. A jet width of 1-4 mm was defined as trivial to mild; 4-6 mm was defined as moderate; and greater than 6 mm indicated severe regurgitation, according to the researchers. Significant regurgitation was defined as moderate or severe. Significant neoaortic annulus dilation was defined as a z score of 2.5 or greater.
They evaluated potential risk factors for the development of neoaortic root dilation, annulus dilation, and neoaortic valve regurgitation.
Significant neoaortic root dilation developed in 88 of 124 (66%) of the patients during follow-up, with the probability of being free from a root diameter z score of 2.5 or greater of 84%, 67%, 47%, and 32% at 1, 5, 10, and 15 years, respectively. Significant risk factors predicting neoaortic root dilation using multivariate analysis were a history of double outlet right ventricle (DORV), previous pulmonary artery (PA) banding, and length of follow-up. A history of ventricular septal defect (VSD), coarctation, left ventricular outflow tract obstruction, and age at ASO were not significant risk factors.
Significant annulus dilation occurred in 54% of patients, with significant risk factors including a history of VSD, history of DORV, and the presence of a dilated neoaortic root. History of PA banding and length of follow-up were not significant. Moderate or severe neoaortic valve regurgitation occurred in 17 of 124 (14%) of the patients, with a probability of being free of these levels of regurgitation of 96%, 92%, 89%, and 75% at 1, 5, 10, and 15 years, respectively. The significant risk factors for regurgitation were history of DORV, VSD, left ventricular outflow tract obstruction, and length of follow-up. No patient in the series required reintervention on the neoaorta.
The authors had no disclosures.
Neoaortic root dilation and neoaortic valve regurgitation are common complications in infants with transposition of the great arteries who undergo an arterial switch operation for repair, and the risk of developing these changes in the neoaorta increases over time, according to the results of a retrospective database study of patients at Children’s Hospital of Wisconsin.
In addition, when dilation occurs, the dimensions may progressively enlarge over time, making it important to maintain lifelong surveillance of this population.
Although perioperative mortality and long-term survival (assessed up to 30 years) has improved in more recent eras for use of an arterial switch operation (ASO) for transposition of the great arteries (TGA), these long-term studies have also shown important late complications that may contribute to late morbidity and the need for reoperation, according to Dr. Jennifer G. Co-Vu and her colleagues at the Medical College of Wisconsin, Milwaukee.
They performed their study to determine the prevalence of neoaortic root dilation and neoaortic valve regurgitation in patients treated at their institution and to determine risk factors involved in the development of these late complications.
Out of 247 patients with TGA treated with an ASO at the hospital, there were 124 patients who had at least one available postoperative transthoracic echocardiogram at least 1 year after the ASO. Median age of these patients was 0.2 months at the time of their ASO and 7.2 years at their last follow-up; 71% were boys (Ann. Thorac. Surg. 2013;95:1654-9).
Retrospective measurements of the neoaortic annulus and root were performed on all available transthoracic echocardiograms and the severity of neoaortic valve regurgitation was determined by assessing the width of the color Doppler jet of regurgitation measured at the level of the valve in the parasternal long-axis view. A jet width of 1-4 mm was defined as trivial to mild; 4-6 mm was defined as moderate; and greater than 6 mm indicated severe regurgitation, according to the researchers. Significant regurgitation was defined as moderate or severe. Significant neoaortic annulus dilation was defined as a z score of 2.5 or greater.
They evaluated potential risk factors for the development of neoaortic root dilation, annulus dilation, and neoaortic valve regurgitation.
Significant neoaortic root dilation developed in 88 of 124 (66%) of the patients during follow-up, with the probability of being free from a root diameter z score of 2.5 or greater of 84%, 67%, 47%, and 32% at 1, 5, 10, and 15 years, respectively. Significant risk factors predicting neoaortic root dilation using multivariate analysis were a history of double outlet right ventricle (DORV), previous pulmonary artery (PA) banding, and length of follow-up. A history of ventricular septal defect (VSD), coarctation, left ventricular outflow tract obstruction, and age at ASO were not significant risk factors.
Significant annulus dilation occurred in 54% of patients, with significant risk factors including a history of VSD, history of DORV, and the presence of a dilated neoaortic root. History of PA banding and length of follow-up were not significant. Moderate or severe neoaortic valve regurgitation occurred in 17 of 124 (14%) of the patients, with a probability of being free of these levels of regurgitation of 96%, 92%, 89%, and 75% at 1, 5, 10, and 15 years, respectively. The significant risk factors for regurgitation were history of DORV, VSD, left ventricular outflow tract obstruction, and length of follow-up. No patient in the series required reintervention on the neoaorta.
The authors had no disclosures.
Ancient Aneurysms
Before anesthetics, before antibiotics, before surgery had even become a scientific discipline, surgeons throughout history did not shy away from the treatment of aneurysms, aortic or otherwise. However varied their success, these ancient surgeons pioneered techniques that would become perfected in much later eras, clearly demonstrating the quest for innovation in helping their patients that has been and is still a hallmark of the surgeon’s art.
What follows is a brief summary of a few of those pre-Hunterian pioneers. For more extensive reviews see the sources below.
According to Dr. William Osler (1849 -1914), aneurysm, probably posttraumatic, was first described in the Ebers Papyrus from Egypt around 4000 years ago. The famous Greco-Roman physician, Galen (circa 129 -200 A.D.), later defined an aneurysm as a "localized pulsatile swelling which disappeared on pressure."
But the most influential surgeon with regard to aneurysm treatment in the ancient era was Antyllus, who lived during the first half of the second century A.D. Although his original works were lost, they are discussed in the later writings of Oribasius (c. 320 – 400), who described Antyllus' methods for performing many different operations, including tracheotomy and the extraction of cataracts. Of particular interest is his operation for aneurysm, which remained the standard until the era of John Hunter in the 18th century.
Oribasius reported Antyllus as declining to operate on exceptionally big aneurysms, but for those others in the extremities, the limbs, and the head, he applied ligatures to the arteries that entered and left the aneurysm and then cut into the aneurysm sac, evacuated the contents, and packed the cavity. Antyllus did not resect the aneurysm sac and was quoted as saying: "Those who tie the artery, as I advise, at each extremity, but amputate the intervening dilated part, perform a dangerous operation. The violent tension of the arterial pneuma often displaces the ligatures."
According to Dr. David Berqvist, the influence of Middle Eastern medicine on how to look at aneurysmal disease is exemplified by The Synagogue Medica, written by Oribasius (325–403), which classified aneurysms into true and false aneurysms at a remarkably early period :
"There are two types of aneurysms: the first is due to dilatation of the arteries and the second is caused by rupture of the artery emptying blood into the tissues. When an aneurysm is due to dilatation, the form is cylindrical, while the one caused by injury is round."
In his survey of surgical history, Dr. Michael DeBakey discussed the writings of Aetius of Amida, during the seventh century who wrote De vasorum dilatatione (On the Dilatation of the Vessels), which is now in the Vatican library. The volume discusses aneurysms, and it suggests that the author had some knowledge of the Antyllus operation, as evidenced by the quoted passage:
"An aneurysm located in the bend of the elbow is treated thus. First we carefully trace the artery leading to it, from armpit to elbow, along the inside of the upper arm. Then we make an incision on the inside of the arm, three or four finger-breadths below the armpit, where the artery is felt most easily. We gradually expose the blood vessel and, when it can be lifted free with a hook, we tie it off with two firm ligatures and divide it between them. We fill the wound with incense and lint dressing, then apply a bandage. Next we open the aneurysm itself and no longer need fear bleeding. We remove the blood clots present, and seek the artery which brought the blood. Once found, it is lifted free with the hook, and tied as before. By again filling the wound with incense, we stimulate good suppuration."
Similarly, Albucasis (Abu-al Quasim) of Cordoba (936–1013) wrote a textbook on surgery and instruments, recording how to treat an aneurysm, as well, following much the same recommendations as given by Antyllus 800 years earlier: after a longitudinal skin incision, the aneurysm is dissected free, the arteries on both sides ligated, and then the aneurysm is punctured with a knife. The wound is left open and dressed until healing.
More than 500 years later, with little having changed, Andreas Vesalius (1514-1564) described thoracic and abdominal aortic aneurysms. His friend and colleague Ambroise Paré (1510-1590) advocated use of a proximal ligature to treat aneurysms, but argued that the sac should not be opened because of the danger of lethal bleeding. Paré described a case of ruptured aneurysm of the thoracic aorta and commented that, "The aneurysms which happen in the internal parts are incurable."
In medieval times the antecubital fossa aneurysm was quite common as a complication of the common practice of bloodletting by puncture of the median basilic vein, and by 1680, Matthaus Gottfried Purmann (1649-1711) was reporting on an operation on an antecubital space aneurysm in which he ligated the artery above and below the aneurysm and removed the sac.
It is unfortunate for this development of medicine that there was a great discontinuity between the classical world and the modern due to the decline of the transmission of earlier knowledge and the decline in medical and surgical activities in the Medieval period, according to Dr. DeBakey. As a prime example, he described how, when John Hunter finally developed his method for treating aneurysms, "he never referred to Antyllus, who performed basically the same procedure about 15 centuries previously, or that of Aetius, who also performed a similar procedure about 1,000 years earlier."
But whatever the discontinuities, medical development took a tremendous leap forward in a rapid amount of time, and Hunter’s refinements of the technique for treating aneurysms helped launch the modern vascular surgery era.
Sources and additional information
1) Thompson, J. E., Early history of aortic surgery. J. Vasc. Surg. 1998;28: 746-52.
2) Bergqvist, D., Historical aspects on aneurysmal disease. Scandinavian J. Surg. 2008; 97: 90-9
3) DeBakey, M., A surgical perspective. Ann. Surg. 1991; 213: 499-531.
Before anesthetics, before antibiotics, before surgery had even become a scientific discipline, surgeons throughout history did not shy away from the treatment of aneurysms, aortic or otherwise. However varied their success, these ancient surgeons pioneered techniques that would become perfected in much later eras, clearly demonstrating the quest for innovation in helping their patients that has been and is still a hallmark of the surgeon’s art.
What follows is a brief summary of a few of those pre-Hunterian pioneers. For more extensive reviews see the sources below.
According to Dr. William Osler (1849 -1914), aneurysm, probably posttraumatic, was first described in the Ebers Papyrus from Egypt around 4000 years ago. The famous Greco-Roman physician, Galen (circa 129 -200 A.D.), later defined an aneurysm as a "localized pulsatile swelling which disappeared on pressure."
But the most influential surgeon with regard to aneurysm treatment in the ancient era was Antyllus, who lived during the first half of the second century A.D. Although his original works were lost, they are discussed in the later writings of Oribasius (c. 320 – 400), who described Antyllus' methods for performing many different operations, including tracheotomy and the extraction of cataracts. Of particular interest is his operation for aneurysm, which remained the standard until the era of John Hunter in the 18th century.
Oribasius reported Antyllus as declining to operate on exceptionally big aneurysms, but for those others in the extremities, the limbs, and the head, he applied ligatures to the arteries that entered and left the aneurysm and then cut into the aneurysm sac, evacuated the contents, and packed the cavity. Antyllus did not resect the aneurysm sac and was quoted as saying: "Those who tie the artery, as I advise, at each extremity, but amputate the intervening dilated part, perform a dangerous operation. The violent tension of the arterial pneuma often displaces the ligatures."
According to Dr. David Berqvist, the influence of Middle Eastern medicine on how to look at aneurysmal disease is exemplified by The Synagogue Medica, written by Oribasius (325–403), which classified aneurysms into true and false aneurysms at a remarkably early period :
"There are two types of aneurysms: the first is due to dilatation of the arteries and the second is caused by rupture of the artery emptying blood into the tissues. When an aneurysm is due to dilatation, the form is cylindrical, while the one caused by injury is round."
In his survey of surgical history, Dr. Michael DeBakey discussed the writings of Aetius of Amida, during the seventh century who wrote De vasorum dilatatione (On the Dilatation of the Vessels), which is now in the Vatican library. The volume discusses aneurysms, and it suggests that the author had some knowledge of the Antyllus operation, as evidenced by the quoted passage:
"An aneurysm located in the bend of the elbow is treated thus. First we carefully trace the artery leading to it, from armpit to elbow, along the inside of the upper arm. Then we make an incision on the inside of the arm, three or four finger-breadths below the armpit, where the artery is felt most easily. We gradually expose the blood vessel and, when it can be lifted free with a hook, we tie it off with two firm ligatures and divide it between them. We fill the wound with incense and lint dressing, then apply a bandage. Next we open the aneurysm itself and no longer need fear bleeding. We remove the blood clots present, and seek the artery which brought the blood. Once found, it is lifted free with the hook, and tied as before. By again filling the wound with incense, we stimulate good suppuration."
Similarly, Albucasis (Abu-al Quasim) of Cordoba (936–1013) wrote a textbook on surgery and instruments, recording how to treat an aneurysm, as well, following much the same recommendations as given by Antyllus 800 years earlier: after a longitudinal skin incision, the aneurysm is dissected free, the arteries on both sides ligated, and then the aneurysm is punctured with a knife. The wound is left open and dressed until healing.
More than 500 years later, with little having changed, Andreas Vesalius (1514-1564) described thoracic and abdominal aortic aneurysms. His friend and colleague Ambroise Paré (1510-1590) advocated use of a proximal ligature to treat aneurysms, but argued that the sac should not be opened because of the danger of lethal bleeding. Paré described a case of ruptured aneurysm of the thoracic aorta and commented that, "The aneurysms which happen in the internal parts are incurable."
In medieval times the antecubital fossa aneurysm was quite common as a complication of the common practice of bloodletting by puncture of the median basilic vein, and by 1680, Matthaus Gottfried Purmann (1649-1711) was reporting on an operation on an antecubital space aneurysm in which he ligated the artery above and below the aneurysm and removed the sac.
It is unfortunate for this development of medicine that there was a great discontinuity between the classical world and the modern due to the decline of the transmission of earlier knowledge and the decline in medical and surgical activities in the Medieval period, according to Dr. DeBakey. As a prime example, he described how, when John Hunter finally developed his method for treating aneurysms, "he never referred to Antyllus, who performed basically the same procedure about 15 centuries previously, or that of Aetius, who also performed a similar procedure about 1,000 years earlier."
But whatever the discontinuities, medical development took a tremendous leap forward in a rapid amount of time, and Hunter’s refinements of the technique for treating aneurysms helped launch the modern vascular surgery era.
Sources and additional information
1) Thompson, J. E., Early history of aortic surgery. J. Vasc. Surg. 1998;28: 746-52.
2) Bergqvist, D., Historical aspects on aneurysmal disease. Scandinavian J. Surg. 2008; 97: 90-9
3) DeBakey, M., A surgical perspective. Ann. Surg. 1991; 213: 499-531.
Before anesthetics, before antibiotics, before surgery had even become a scientific discipline, surgeons throughout history did not shy away from the treatment of aneurysms, aortic or otherwise. However varied their success, these ancient surgeons pioneered techniques that would become perfected in much later eras, clearly demonstrating the quest for innovation in helping their patients that has been and is still a hallmark of the surgeon’s art.
What follows is a brief summary of a few of those pre-Hunterian pioneers. For more extensive reviews see the sources below.
According to Dr. William Osler (1849 -1914), aneurysm, probably posttraumatic, was first described in the Ebers Papyrus from Egypt around 4000 years ago. The famous Greco-Roman physician, Galen (circa 129 -200 A.D.), later defined an aneurysm as a "localized pulsatile swelling which disappeared on pressure."
But the most influential surgeon with regard to aneurysm treatment in the ancient era was Antyllus, who lived during the first half of the second century A.D. Although his original works were lost, they are discussed in the later writings of Oribasius (c. 320 – 400), who described Antyllus' methods for performing many different operations, including tracheotomy and the extraction of cataracts. Of particular interest is his operation for aneurysm, which remained the standard until the era of John Hunter in the 18th century.
Oribasius reported Antyllus as declining to operate on exceptionally big aneurysms, but for those others in the extremities, the limbs, and the head, he applied ligatures to the arteries that entered and left the aneurysm and then cut into the aneurysm sac, evacuated the contents, and packed the cavity. Antyllus did not resect the aneurysm sac and was quoted as saying: "Those who tie the artery, as I advise, at each extremity, but amputate the intervening dilated part, perform a dangerous operation. The violent tension of the arterial pneuma often displaces the ligatures."
According to Dr. David Berqvist, the influence of Middle Eastern medicine on how to look at aneurysmal disease is exemplified by The Synagogue Medica, written by Oribasius (325–403), which classified aneurysms into true and false aneurysms at a remarkably early period :
"There are two types of aneurysms: the first is due to dilatation of the arteries and the second is caused by rupture of the artery emptying blood into the tissues. When an aneurysm is due to dilatation, the form is cylindrical, while the one caused by injury is round."
In his survey of surgical history, Dr. Michael DeBakey discussed the writings of Aetius of Amida, during the seventh century who wrote De vasorum dilatatione (On the Dilatation of the Vessels), which is now in the Vatican library. The volume discusses aneurysms, and it suggests that the author had some knowledge of the Antyllus operation, as evidenced by the quoted passage:
"An aneurysm located in the bend of the elbow is treated thus. First we carefully trace the artery leading to it, from armpit to elbow, along the inside of the upper arm. Then we make an incision on the inside of the arm, three or four finger-breadths below the armpit, where the artery is felt most easily. We gradually expose the blood vessel and, when it can be lifted free with a hook, we tie it off with two firm ligatures and divide it between them. We fill the wound with incense and lint dressing, then apply a bandage. Next we open the aneurysm itself and no longer need fear bleeding. We remove the blood clots present, and seek the artery which brought the blood. Once found, it is lifted free with the hook, and tied as before. By again filling the wound with incense, we stimulate good suppuration."
Similarly, Albucasis (Abu-al Quasim) of Cordoba (936–1013) wrote a textbook on surgery and instruments, recording how to treat an aneurysm, as well, following much the same recommendations as given by Antyllus 800 years earlier: after a longitudinal skin incision, the aneurysm is dissected free, the arteries on both sides ligated, and then the aneurysm is punctured with a knife. The wound is left open and dressed until healing.
More than 500 years later, with little having changed, Andreas Vesalius (1514-1564) described thoracic and abdominal aortic aneurysms. His friend and colleague Ambroise Paré (1510-1590) advocated use of a proximal ligature to treat aneurysms, but argued that the sac should not be opened because of the danger of lethal bleeding. Paré described a case of ruptured aneurysm of the thoracic aorta and commented that, "The aneurysms which happen in the internal parts are incurable."
In medieval times the antecubital fossa aneurysm was quite common as a complication of the common practice of bloodletting by puncture of the median basilic vein, and by 1680, Matthaus Gottfried Purmann (1649-1711) was reporting on an operation on an antecubital space aneurysm in which he ligated the artery above and below the aneurysm and removed the sac.
It is unfortunate for this development of medicine that there was a great discontinuity between the classical world and the modern due to the decline of the transmission of earlier knowledge and the decline in medical and surgical activities in the Medieval period, according to Dr. DeBakey. As a prime example, he described how, when John Hunter finally developed his method for treating aneurysms, "he never referred to Antyllus, who performed basically the same procedure about 15 centuries previously, or that of Aetius, who also performed a similar procedure about 1,000 years earlier."
But whatever the discontinuities, medical development took a tremendous leap forward in a rapid amount of time, and Hunter’s refinements of the technique for treating aneurysms helped launch the modern vascular surgery era.
Sources and additional information
1) Thompson, J. E., Early history of aortic surgery. J. Vasc. Surg. 1998;28: 746-52.
2) Bergqvist, D., Historical aspects on aneurysmal disease. Scandinavian J. Surg. 2008; 97: 90-9
3) DeBakey, M., A surgical perspective. Ann. Surg. 1991; 213: 499-531.
Physician passengers handle half of in-flight emergencies
In nearly half of all in-flight medical emergencies, an on-board physician volunteer is the first medical responder, based on a retrospective analysis of nearly 12,000 medical emergency calls over a 3-year period from five domestic and international airlines to a physician-directed medical communications center.
Few in-flight emergencies resulted in diversion of the aircraft or death. Most events were related to syncope (37%), respiratory symptoms (12%), or gastrointestinal distress (9.5%).
The 11,920 in-flight emergencies occurred among an estimated 744 million airline passengers, representing approximately 10% of the global passenger flight volume from Jan, 1, 2008, through Oct. 31, 2010, for an estimated 44,000 such emergencies worldwide each year, according to Dr. Drew C. Peterson of the department of emergency medicine at the University of Pittsburgh, and his colleagues.
An AED was applied in 24 cases of cardiac arrest; with shock delivery in 5 cases. Post flight follow-up was available for 91.6% of patients. The mean age of the 36 passengers who died (30 died in-flight) was 59 years (N. Engl. J. Med. 2013;368:2075-83).
For 31% of patients, the medical situation resolved sufficiently before landing and EMS personnel were not requested. Of the remaining patients, 37% were transported to a hospital emergency department. Of these, 54% were discharged; 32% were admitted or left against medical advice; 13% were lost to follow-up; and 0.6% died.
On-board assistance was provided by physicians (48%), nurses (20%), emergency medical service providers (4.4%), or other health care professionals (3.7%). Aircraft diversions occurred in 7.3% of cases, and the factors most strongly associated with diversion were AED use (applied to 1.3% of patients) and on-board assistance by an EMS provider as the highest level of provider. Hospital admission was associated with possible stroke (odds ratio, 3.36; confidence interval, 1.88-6.03), respiratory symptoms (OR, 2.12; CI, 1.48-3.06), and cardiac symptoms (OR, 1.95; CI, 1.37-2.77).
The 1998 Aviation Safety Medical Assistance Act includes a Good Samaritan provision, protecting passengers from liability other than liability for gross negligence or willful misconduct, therefore: "Although there is no legal obligation to intervene, we believe that physicians and other health care providers have a moral and professional obligation to act as Good Samaritans," the authors stated.
"The emergency medical kit available on every commercial airline regulated by the Federal Aviation Administration is usually sufficient to initiate treatment of serious problems," according to Dr. Peterson and his colleagues. "Symptoms can often be managed in collaboration with the flight attendants, who are well versed in the equipment the airplanes carry and in operational procedures."
The authors recommended that health care providers identify themselves during in-flight medical emergencies and specify their level of expertise to the flight crew; assess the patient by identifying the chief problem and duration as well as associated and high-risk symptoms (such as chest pain, shortness of breath, nausea or vomiting, or unilateral weakness or numbness); assess vital signs; ask for the emergency medical kit, administer oxygen as needed, and initiate consultation with a ground-based consultant if the flight crew has not already done so.
"On the basis of our findings, we believe that airline passengers who are health care professionals should be aware of their potential role as volunteer responders to in-flight medical emergencies. We also advocate for systematic tracking of all in-flight medical emergencies, including outcomes, to better guide interventions in this sequestered population," the researchers concluded.
The authors reported no potential conflicts of interest relevant to the article.
In nearly half of all in-flight medical emergencies, an on-board physician volunteer is the first medical responder, based on a retrospective analysis of nearly 12,000 medical emergency calls over a 3-year period from five domestic and international airlines to a physician-directed medical communications center.
Few in-flight emergencies resulted in diversion of the aircraft or death. Most events were related to syncope (37%), respiratory symptoms (12%), or gastrointestinal distress (9.5%).
The 11,920 in-flight emergencies occurred among an estimated 744 million airline passengers, representing approximately 10% of the global passenger flight volume from Jan, 1, 2008, through Oct. 31, 2010, for an estimated 44,000 such emergencies worldwide each year, according to Dr. Drew C. Peterson of the department of emergency medicine at the University of Pittsburgh, and his colleagues.
An AED was applied in 24 cases of cardiac arrest; with shock delivery in 5 cases. Post flight follow-up was available for 91.6% of patients. The mean age of the 36 passengers who died (30 died in-flight) was 59 years (N. Engl. J. Med. 2013;368:2075-83).
For 31% of patients, the medical situation resolved sufficiently before landing and EMS personnel were not requested. Of the remaining patients, 37% were transported to a hospital emergency department. Of these, 54% were discharged; 32% were admitted or left against medical advice; 13% were lost to follow-up; and 0.6% died.
On-board assistance was provided by physicians (48%), nurses (20%), emergency medical service providers (4.4%), or other health care professionals (3.7%). Aircraft diversions occurred in 7.3% of cases, and the factors most strongly associated with diversion were AED use (applied to 1.3% of patients) and on-board assistance by an EMS provider as the highest level of provider. Hospital admission was associated with possible stroke (odds ratio, 3.36; confidence interval, 1.88-6.03), respiratory symptoms (OR, 2.12; CI, 1.48-3.06), and cardiac symptoms (OR, 1.95; CI, 1.37-2.77).
The 1998 Aviation Safety Medical Assistance Act includes a Good Samaritan provision, protecting passengers from liability other than liability for gross negligence or willful misconduct, therefore: "Although there is no legal obligation to intervene, we believe that physicians and other health care providers have a moral and professional obligation to act as Good Samaritans," the authors stated.
"The emergency medical kit available on every commercial airline regulated by the Federal Aviation Administration is usually sufficient to initiate treatment of serious problems," according to Dr. Peterson and his colleagues. "Symptoms can often be managed in collaboration with the flight attendants, who are well versed in the equipment the airplanes carry and in operational procedures."
The authors recommended that health care providers identify themselves during in-flight medical emergencies and specify their level of expertise to the flight crew; assess the patient by identifying the chief problem and duration as well as associated and high-risk symptoms (such as chest pain, shortness of breath, nausea or vomiting, or unilateral weakness or numbness); assess vital signs; ask for the emergency medical kit, administer oxygen as needed, and initiate consultation with a ground-based consultant if the flight crew has not already done so.
"On the basis of our findings, we believe that airline passengers who are health care professionals should be aware of their potential role as volunteer responders to in-flight medical emergencies. We also advocate for systematic tracking of all in-flight medical emergencies, including outcomes, to better guide interventions in this sequestered population," the researchers concluded.
The authors reported no potential conflicts of interest relevant to the article.
In nearly half of all in-flight medical emergencies, an on-board physician volunteer is the first medical responder, based on a retrospective analysis of nearly 12,000 medical emergency calls over a 3-year period from five domestic and international airlines to a physician-directed medical communications center.
Few in-flight emergencies resulted in diversion of the aircraft or death. Most events were related to syncope (37%), respiratory symptoms (12%), or gastrointestinal distress (9.5%).
The 11,920 in-flight emergencies occurred among an estimated 744 million airline passengers, representing approximately 10% of the global passenger flight volume from Jan, 1, 2008, through Oct. 31, 2010, for an estimated 44,000 such emergencies worldwide each year, according to Dr. Drew C. Peterson of the department of emergency medicine at the University of Pittsburgh, and his colleagues.
An AED was applied in 24 cases of cardiac arrest; with shock delivery in 5 cases. Post flight follow-up was available for 91.6% of patients. The mean age of the 36 passengers who died (30 died in-flight) was 59 years (N. Engl. J. Med. 2013;368:2075-83).
For 31% of patients, the medical situation resolved sufficiently before landing and EMS personnel were not requested. Of the remaining patients, 37% were transported to a hospital emergency department. Of these, 54% were discharged; 32% were admitted or left against medical advice; 13% were lost to follow-up; and 0.6% died.
On-board assistance was provided by physicians (48%), nurses (20%), emergency medical service providers (4.4%), or other health care professionals (3.7%). Aircraft diversions occurred in 7.3% of cases, and the factors most strongly associated with diversion were AED use (applied to 1.3% of patients) and on-board assistance by an EMS provider as the highest level of provider. Hospital admission was associated with possible stroke (odds ratio, 3.36; confidence interval, 1.88-6.03), respiratory symptoms (OR, 2.12; CI, 1.48-3.06), and cardiac symptoms (OR, 1.95; CI, 1.37-2.77).
The 1998 Aviation Safety Medical Assistance Act includes a Good Samaritan provision, protecting passengers from liability other than liability for gross negligence or willful misconduct, therefore: "Although there is no legal obligation to intervene, we believe that physicians and other health care providers have a moral and professional obligation to act as Good Samaritans," the authors stated.
"The emergency medical kit available on every commercial airline regulated by the Federal Aviation Administration is usually sufficient to initiate treatment of serious problems," according to Dr. Peterson and his colleagues. "Symptoms can often be managed in collaboration with the flight attendants, who are well versed in the equipment the airplanes carry and in operational procedures."
The authors recommended that health care providers identify themselves during in-flight medical emergencies and specify their level of expertise to the flight crew; assess the patient by identifying the chief problem and duration as well as associated and high-risk symptoms (such as chest pain, shortness of breath, nausea or vomiting, or unilateral weakness or numbness); assess vital signs; ask for the emergency medical kit, administer oxygen as needed, and initiate consultation with a ground-based consultant if the flight crew has not already done so.
"On the basis of our findings, we believe that airline passengers who are health care professionals should be aware of their potential role as volunteer responders to in-flight medical emergencies. We also advocate for systematic tracking of all in-flight medical emergencies, including outcomes, to better guide interventions in this sequestered population," the researchers concluded.
The authors reported no potential conflicts of interest relevant to the article.
FROM THE NEW ENGLAND JOURNAL OF MEDICINE
Dilation and regurgitation complicate outcomes of ASO for TGA
Neoaortic root dilation and neoaortic valve regurgitation are common complications in infants with transposition of the great arteries who undergo an arterial switch operation for repair, and the risk of developing these changes in the neoaorta increases over time, according to the results of a retrospective database study of patients at Children’s Hospital of Wisconsin.
In addition, when dilation occurs, the dimensions may progressively enlarge over time, making it important to maintain lifelong surveillance of this population, according to a report published the Annals of Thoracic Surgery.
Although perioperative mortality and long-term survival (assessed up to 30 years) has improved in more recent eras for use of an arterial switch operation (ASO) for transposition of the great arteries (TGA), these long-term studies have also shown important late complications that may contribute to late morbidity and the need for reoperation, according to Dr. Jennifer G. Co-Vu and her colleagues at the Medical College of Wisconsin, Milwaukee.
These complications include coronary artery insufficiency, right ventricular outflow tract obstructions, and problems with the native pulmonary root and the pulmonary valve functioning as the neoaortic root and the neoaortic valve, respectively. Dr. Co-Vu and her colleagues performed their study to determine the prevalence of neoaortic root dilation and neoaortic valve regurgitation in patients treated at their institution and to determine risk factors involved in the development of these late complications.
Out of 247 patients with TGA treated with an ASO at the hospital, there were 124 patients who had at least one available postoperative transthoracic echocardiogram at least 1 year after the ASO. Median age of these patients was 0.2 months at the time of their ASO and 7.2 years at their last follow-up; 71% were boys (Ann. Thorac. Surg. 2013;95:1654-9).
Retrospective measurements of the neoaortic annulus and root were performed on all available transthoracic echocardiograms and the severity of neoaortic valve regurgitation was determined by assessing the width of the color Doppler jet of regurgitation measured at the level of the valve in the parasternal long-axis view. A jet width of 1-4 mm was defined as trivial to mild; 4-6 mm was defined as moderate; and greater than 6 mm indicated severe regurgitation, according to the researchers. Significant regurgitation was defined as moderate or severe. Significant neoaortic annulus dilation was defined as a z score of 2.5 or greater.
They evaluated potential risk factors for the development of neoaortic root dilation, annulus dilation, and neoaortic valve regurgitation, including age at ASO, sex, weight, coexisting lesions, prior interventions, and associated operations with the ASO. Coexisting lesions and prior interventions occurred in nearly 60% of the patients. The most common previous intervention was balloon atrial septostomy (54%).
Significant neoaortic root dilation developed in 88 of 124 (66%) of the patients during follow-up, with the probability of being free from a root diameter z score of 2.5 or greater of 84%, 67%, 47% and 32% at 1, 5, 10, and 15 years, respectively. Significant risk factors predicting neoaortic root dilation using multivariate analysis were a history of double outlet right ventricle (DORV), previous pulmonary artery (PA) banding, and length of follow-up. A history of ventricular septal defect (VSD), coarctation, left ventricular outflow tract obstruction, and age at ASO were not significant risk factors.
Significant annulus dilation occurred in 54% of patients, with significant risk factors including a history of VSD, history of DORV, and the presence of a dilated neoaortic root. History of PA banding and length of follow-up were not significant.
Moderate or severe neoaortic valve regurgitation occurred in 17 of 124 (14%) of the patients, with a probability of being free of these levels of regurgitation of 96%, 92%, 89%, and 75% at 1, 5, 10, and 15 years, respectively. The significant risk factors for regurgitation were history of DORV, VSD, left ventricular outflow tract obstruction, and length of follow-up.
No patient in the series reported by the researchers required reintervention on the neoaorta.
Limitations of the study included its retrospective nature; the lack of postoperative echocardiograms on all patients, which raises questions of selection bias; and an inability to account for changes in surgical and postoperative management over time, the authors noted.
"Neoaortic root dilation and neoaortic valve regurgitation are common complications in patients with TGA after repair with ASO. Patients with DORV morphologies or previous PA banding may be at higher risk for these complications," the researchers concluded.
The authors had no relevant disclosures.
Most people living with congenital heart disease are now adults. Unfortunately the majority of these adults, for unclear reasons, are not receiving expert care by congenital heart specialists. Perhaps some of these adults have a misperception that they are cured. Co-Vu and coauthors at the Medical College of Wisconsin confirm that the highly successful arterial switch operation is not a ‘cure.’ Their important, carefully executed echo study demonstrates important progressive increases in measured diameters of the neoaortic annulus and neoaortic root over the first 15 years of life. The authors point out that the dilation has not as yet led to a need for reintervention, and the late prevalence of neoaortic regurgitation is not high, although it too is slowly increasing over time. Their message is a clarion call for lifelong clinical surveillance following an arterial switch operation; a message that should be applied to all patients with congenital heart disease.
Dr. William G. Williams is executive director of the Congenital Heart Surgeons’ Society Data Center, Toronto, and emeritus professor of surgery, University of Toronto, and an associate medical editor for Thoracic Surgery News.
Most people living with congenital heart disease are now adults. Unfortunately the majority of these adults, for unclear reasons, are not receiving expert care by congenital heart specialists. Perhaps some of these adults have a misperception that they are cured. Co-Vu and coauthors at the Medical College of Wisconsin confirm that the highly successful arterial switch operation is not a ‘cure.’ Their important, carefully executed echo study demonstrates important progressive increases in measured diameters of the neoaortic annulus and neoaortic root over the first 15 years of life. The authors point out that the dilation has not as yet led to a need for reintervention, and the late prevalence of neoaortic regurgitation is not high, although it too is slowly increasing over time. Their message is a clarion call for lifelong clinical surveillance following an arterial switch operation; a message that should be applied to all patients with congenital heart disease.
Dr. William G. Williams is executive director of the Congenital Heart Surgeons’ Society Data Center, Toronto, and emeritus professor of surgery, University of Toronto, and an associate medical editor for Thoracic Surgery News.
Most people living with congenital heart disease are now adults. Unfortunately the majority of these adults, for unclear reasons, are not receiving expert care by congenital heart specialists. Perhaps some of these adults have a misperception that they are cured. Co-Vu and coauthors at the Medical College of Wisconsin confirm that the highly successful arterial switch operation is not a ‘cure.’ Their important, carefully executed echo study demonstrates important progressive increases in measured diameters of the neoaortic annulus and neoaortic root over the first 15 years of life. The authors point out that the dilation has not as yet led to a need for reintervention, and the late prevalence of neoaortic regurgitation is not high, although it too is slowly increasing over time. Their message is a clarion call for lifelong clinical surveillance following an arterial switch operation; a message that should be applied to all patients with congenital heart disease.
Dr. William G. Williams is executive director of the Congenital Heart Surgeons’ Society Data Center, Toronto, and emeritus professor of surgery, University of Toronto, and an associate medical editor for Thoracic Surgery News.
Neoaortic root dilation and neoaortic valve regurgitation are common complications in infants with transposition of the great arteries who undergo an arterial switch operation for repair, and the risk of developing these changes in the neoaorta increases over time, according to the results of a retrospective database study of patients at Children’s Hospital of Wisconsin.
In addition, when dilation occurs, the dimensions may progressively enlarge over time, making it important to maintain lifelong surveillance of this population, according to a report published the Annals of Thoracic Surgery.
Although perioperative mortality and long-term survival (assessed up to 30 years) has improved in more recent eras for use of an arterial switch operation (ASO) for transposition of the great arteries (TGA), these long-term studies have also shown important late complications that may contribute to late morbidity and the need for reoperation, according to Dr. Jennifer G. Co-Vu and her colleagues at the Medical College of Wisconsin, Milwaukee.
These complications include coronary artery insufficiency, right ventricular outflow tract obstructions, and problems with the native pulmonary root and the pulmonary valve functioning as the neoaortic root and the neoaortic valve, respectively. Dr. Co-Vu and her colleagues performed their study to determine the prevalence of neoaortic root dilation and neoaortic valve regurgitation in patients treated at their institution and to determine risk factors involved in the development of these late complications.
Out of 247 patients with TGA treated with an ASO at the hospital, there were 124 patients who had at least one available postoperative transthoracic echocardiogram at least 1 year after the ASO. Median age of these patients was 0.2 months at the time of their ASO and 7.2 years at their last follow-up; 71% were boys (Ann. Thorac. Surg. 2013;95:1654-9).
Retrospective measurements of the neoaortic annulus and root were performed on all available transthoracic echocardiograms and the severity of neoaortic valve regurgitation was determined by assessing the width of the color Doppler jet of regurgitation measured at the level of the valve in the parasternal long-axis view. A jet width of 1-4 mm was defined as trivial to mild; 4-6 mm was defined as moderate; and greater than 6 mm indicated severe regurgitation, according to the researchers. Significant regurgitation was defined as moderate or severe. Significant neoaortic annulus dilation was defined as a z score of 2.5 or greater.
They evaluated potential risk factors for the development of neoaortic root dilation, annulus dilation, and neoaortic valve regurgitation, including age at ASO, sex, weight, coexisting lesions, prior interventions, and associated operations with the ASO. Coexisting lesions and prior interventions occurred in nearly 60% of the patients. The most common previous intervention was balloon atrial septostomy (54%).
Significant neoaortic root dilation developed in 88 of 124 (66%) of the patients during follow-up, with the probability of being free from a root diameter z score of 2.5 or greater of 84%, 67%, 47% and 32% at 1, 5, 10, and 15 years, respectively. Significant risk factors predicting neoaortic root dilation using multivariate analysis were a history of double outlet right ventricle (DORV), previous pulmonary artery (PA) banding, and length of follow-up. A history of ventricular septal defect (VSD), coarctation, left ventricular outflow tract obstruction, and age at ASO were not significant risk factors.
Significant annulus dilation occurred in 54% of patients, with significant risk factors including a history of VSD, history of DORV, and the presence of a dilated neoaortic root. History of PA banding and length of follow-up were not significant.
Moderate or severe neoaortic valve regurgitation occurred in 17 of 124 (14%) of the patients, with a probability of being free of these levels of regurgitation of 96%, 92%, 89%, and 75% at 1, 5, 10, and 15 years, respectively. The significant risk factors for regurgitation were history of DORV, VSD, left ventricular outflow tract obstruction, and length of follow-up.
No patient in the series reported by the researchers required reintervention on the neoaorta.
Limitations of the study included its retrospective nature; the lack of postoperative echocardiograms on all patients, which raises questions of selection bias; and an inability to account for changes in surgical and postoperative management over time, the authors noted.
"Neoaortic root dilation and neoaortic valve regurgitation are common complications in patients with TGA after repair with ASO. Patients with DORV morphologies or previous PA banding may be at higher risk for these complications," the researchers concluded.
The authors had no relevant disclosures.
Neoaortic root dilation and neoaortic valve regurgitation are common complications in infants with transposition of the great arteries who undergo an arterial switch operation for repair, and the risk of developing these changes in the neoaorta increases over time, according to the results of a retrospective database study of patients at Children’s Hospital of Wisconsin.
In addition, when dilation occurs, the dimensions may progressively enlarge over time, making it important to maintain lifelong surveillance of this population, according to a report published the Annals of Thoracic Surgery.
Although perioperative mortality and long-term survival (assessed up to 30 years) has improved in more recent eras for use of an arterial switch operation (ASO) for transposition of the great arteries (TGA), these long-term studies have also shown important late complications that may contribute to late morbidity and the need for reoperation, according to Dr. Jennifer G. Co-Vu and her colleagues at the Medical College of Wisconsin, Milwaukee.
These complications include coronary artery insufficiency, right ventricular outflow tract obstructions, and problems with the native pulmonary root and the pulmonary valve functioning as the neoaortic root and the neoaortic valve, respectively. Dr. Co-Vu and her colleagues performed their study to determine the prevalence of neoaortic root dilation and neoaortic valve regurgitation in patients treated at their institution and to determine risk factors involved in the development of these late complications.
Out of 247 patients with TGA treated with an ASO at the hospital, there were 124 patients who had at least one available postoperative transthoracic echocardiogram at least 1 year after the ASO. Median age of these patients was 0.2 months at the time of their ASO and 7.2 years at their last follow-up; 71% were boys (Ann. Thorac. Surg. 2013;95:1654-9).
Retrospective measurements of the neoaortic annulus and root were performed on all available transthoracic echocardiograms and the severity of neoaortic valve regurgitation was determined by assessing the width of the color Doppler jet of regurgitation measured at the level of the valve in the parasternal long-axis view. A jet width of 1-4 mm was defined as trivial to mild; 4-6 mm was defined as moderate; and greater than 6 mm indicated severe regurgitation, according to the researchers. Significant regurgitation was defined as moderate or severe. Significant neoaortic annulus dilation was defined as a z score of 2.5 or greater.
They evaluated potential risk factors for the development of neoaortic root dilation, annulus dilation, and neoaortic valve regurgitation, including age at ASO, sex, weight, coexisting lesions, prior interventions, and associated operations with the ASO. Coexisting lesions and prior interventions occurred in nearly 60% of the patients. The most common previous intervention was balloon atrial septostomy (54%).
Significant neoaortic root dilation developed in 88 of 124 (66%) of the patients during follow-up, with the probability of being free from a root diameter z score of 2.5 or greater of 84%, 67%, 47% and 32% at 1, 5, 10, and 15 years, respectively. Significant risk factors predicting neoaortic root dilation using multivariate analysis were a history of double outlet right ventricle (DORV), previous pulmonary artery (PA) banding, and length of follow-up. A history of ventricular septal defect (VSD), coarctation, left ventricular outflow tract obstruction, and age at ASO were not significant risk factors.
Significant annulus dilation occurred in 54% of patients, with significant risk factors including a history of VSD, history of DORV, and the presence of a dilated neoaortic root. History of PA banding and length of follow-up were not significant.
Moderate or severe neoaortic valve regurgitation occurred in 17 of 124 (14%) of the patients, with a probability of being free of these levels of regurgitation of 96%, 92%, 89%, and 75% at 1, 5, 10, and 15 years, respectively. The significant risk factors for regurgitation were history of DORV, VSD, left ventricular outflow tract obstruction, and length of follow-up.
No patient in the series reported by the researchers required reintervention on the neoaorta.
Limitations of the study included its retrospective nature; the lack of postoperative echocardiograms on all patients, which raises questions of selection bias; and an inability to account for changes in surgical and postoperative management over time, the authors noted.
"Neoaortic root dilation and neoaortic valve regurgitation are common complications in patients with TGA after repair with ASO. Patients with DORV morphologies or previous PA banding may be at higher risk for these complications," the researchers concluded.
The authors had no relevant disclosures.
FROM ANNALS OF THORACIC SURGERY
Novel MERS coronavirus continues spread
The Centers for Disease Control and Prevention and the World Health Organization are continuing to monitor the spread of the newly named Middle East Respiratory Syndrome (MERS) caused by the MERS-Coronavirus (MERS-CoV). As of June 5, 2013, there were 55 confirmed cases worldwide (mostly in the Middle East) resulting in 30 fatalities (54.5%), according to the two organizations.
There is clear evidence of human-to-human transmission, the CDC reported in an overview presented on its website, with aerosol droplet and contact transmission both considered possible. As yet there have been no reports of infection in the United States, although the virus has reached Europe, including France, Italy, and the United Kingdom. The three cases reported in Italy in May were the most recent of the eight reported clusters and resulted from an index case that had recently traveled from Jordan after a 40-day visit. Two more patients were infected after having close contact with that individual.
MERS-CoV (originally referred to as novel coronavirus or nCoV) genetic sequencing has shown that it is similar to coronaviruses found in bats and is not the same as the virus that caused severe acute respiratory syndrome (SARS) in 2003. Patients with MERS typically develop severe acute respiratory illness with symptoms of fever, cough, and shortness of breath, although some patients were reported as having only a mild respiratory illness.
The CDC has developed molecular diagnostic kits for MERS-CoV, which are being made available to state health departments. Although there are currently no travel advisories in place, the CDC is advising individuals who develop a fever and symptoms of lower respiratory illness (such as cough and shortness of breath) within 10 days of traveling from countries in the Arabian Peninsula or neighboring countries to see their health care providers and mention their recent travel. State and local health departments are advised to report patients under investigation (PUI) for MERS-CoV to CDC. These include patients who have all of the following characteristics:
• Acute respiratory infection, which may include a fever greater than or equal to 38° C and cough.
• Suspicion of pulmonary parenchymal disease.
• A history of travel from the Arabian Peninsula and neighboring countries (Bahrain, Iraq, Iran, Israel, Jordan, Kuwait, Lebanon, Oman, Palestinian territories, Qatar, Saudi Arabia, Syria, the United Arab Emirates, and Yemen).
• No other etiology for the illness, including all clinically indicated tests for community acquired pneumonia.
Interim guidance documents for health care providers, health departments, and laboratories are available on the CDC website.
As yet, CDC officials have issued no travel advisories for the countries in which MERS has been detected, and they reported that they are in the process of discussing the development of possible vaccines with industry.
The Centers for Disease Control and Prevention and the World Health Organization are continuing to monitor the spread of the newly named Middle East Respiratory Syndrome (MERS) caused by the MERS-Coronavirus (MERS-CoV). As of June 5, 2013, there were 55 confirmed cases worldwide (mostly in the Middle East) resulting in 30 fatalities (54.5%), according to the two organizations.
There is clear evidence of human-to-human transmission, the CDC reported in an overview presented on its website, with aerosol droplet and contact transmission both considered possible. As yet there have been no reports of infection in the United States, although the virus has reached Europe, including France, Italy, and the United Kingdom. The three cases reported in Italy in May were the most recent of the eight reported clusters and resulted from an index case that had recently traveled from Jordan after a 40-day visit. Two more patients were infected after having close contact with that individual.
MERS-CoV (originally referred to as novel coronavirus or nCoV) genetic sequencing has shown that it is similar to coronaviruses found in bats and is not the same as the virus that caused severe acute respiratory syndrome (SARS) in 2003. Patients with MERS typically develop severe acute respiratory illness with symptoms of fever, cough, and shortness of breath, although some patients were reported as having only a mild respiratory illness.
The CDC has developed molecular diagnostic kits for MERS-CoV, which are being made available to state health departments. Although there are currently no travel advisories in place, the CDC is advising individuals who develop a fever and symptoms of lower respiratory illness (such as cough and shortness of breath) within 10 days of traveling from countries in the Arabian Peninsula or neighboring countries to see their health care providers and mention their recent travel. State and local health departments are advised to report patients under investigation (PUI) for MERS-CoV to CDC. These include patients who have all of the following characteristics:
• Acute respiratory infection, which may include a fever greater than or equal to 38° C and cough.
• Suspicion of pulmonary parenchymal disease.
• A history of travel from the Arabian Peninsula and neighboring countries (Bahrain, Iraq, Iran, Israel, Jordan, Kuwait, Lebanon, Oman, Palestinian territories, Qatar, Saudi Arabia, Syria, the United Arab Emirates, and Yemen).
• No other etiology for the illness, including all clinically indicated tests for community acquired pneumonia.
Interim guidance documents for health care providers, health departments, and laboratories are available on the CDC website.
As yet, CDC officials have issued no travel advisories for the countries in which MERS has been detected, and they reported that they are in the process of discussing the development of possible vaccines with industry.
The Centers for Disease Control and Prevention and the World Health Organization are continuing to monitor the spread of the newly named Middle East Respiratory Syndrome (MERS) caused by the MERS-Coronavirus (MERS-CoV). As of June 5, 2013, there were 55 confirmed cases worldwide (mostly in the Middle East) resulting in 30 fatalities (54.5%), according to the two organizations.
There is clear evidence of human-to-human transmission, the CDC reported in an overview presented on its website, with aerosol droplet and contact transmission both considered possible. As yet there have been no reports of infection in the United States, although the virus has reached Europe, including France, Italy, and the United Kingdom. The three cases reported in Italy in May were the most recent of the eight reported clusters and resulted from an index case that had recently traveled from Jordan after a 40-day visit. Two more patients were infected after having close contact with that individual.
MERS-CoV (originally referred to as novel coronavirus or nCoV) genetic sequencing has shown that it is similar to coronaviruses found in bats and is not the same as the virus that caused severe acute respiratory syndrome (SARS) in 2003. Patients with MERS typically develop severe acute respiratory illness with symptoms of fever, cough, and shortness of breath, although some patients were reported as having only a mild respiratory illness.
The CDC has developed molecular diagnostic kits for MERS-CoV, which are being made available to state health departments. Although there are currently no travel advisories in place, the CDC is advising individuals who develop a fever and symptoms of lower respiratory illness (such as cough and shortness of breath) within 10 days of traveling from countries in the Arabian Peninsula or neighboring countries to see their health care providers and mention their recent travel. State and local health departments are advised to report patients under investigation (PUI) for MERS-CoV to CDC. These include patients who have all of the following characteristics:
• Acute respiratory infection, which may include a fever greater than or equal to 38° C and cough.
• Suspicion of pulmonary parenchymal disease.
• A history of travel from the Arabian Peninsula and neighboring countries (Bahrain, Iraq, Iran, Israel, Jordan, Kuwait, Lebanon, Oman, Palestinian territories, Qatar, Saudi Arabia, Syria, the United Arab Emirates, and Yemen).
• No other etiology for the illness, including all clinically indicated tests for community acquired pneumonia.
Interim guidance documents for health care providers, health departments, and laboratories are available on the CDC website.
As yet, CDC officials have issued no travel advisories for the countries in which MERS has been detected, and they reported that they are in the process of discussing the development of possible vaccines with industry.
Study: Early esophageal cancer staging suspect
LOS ANGELES – Clinical staging of T2N0 esophageal cancer remains unreliable, despite advances in staging techniques, a study has shown.
The addition of endoscopic ultrasound and PET/CT has improved the ability to clinically stage esophageal cancer overall, but clinical staging of T2N0 disease has generally been less reliable than staging of more advanced disease. The subset of patients with T2N0 disease, which accounts for only a small portion of esophageal resections, has been a difficult group to study because single-center investigations involve a limited number of patients, Dr. Traves D. Crabtree said at the annual meeting of the Society of Thoracic Surgeons in the prestigious Richard E. Clark Paper for General Thoracic Surgery.
Dr. Crabtree of Washington University, St. Louis, and his colleagues examined the adequacy of clinical staging of T2N0 disease using the Society of Thoracic Surgeons (STS) General Thoracic Surgery Database.
The researchers identified 810 patients clinically staged as T2N0 from 2002 to 2011 and excluded 58 because of inadequate pathologic staging data. Clinical stage, pathologic stage, and preoperative characteristics were recorded for each patient and multivariable analysis was used to identify factors associated with upstaging at the time of surgery.
Among 752 patients with clinically staged T2N0, the investigators found that 482 went directly to surgery. Of these, 27.4% (132) were confirmed as pathologic T2N0. A total of 25.9% (125) were downstaged (T1N0), while 46.7% (225) were upstaged (T3-4N0 or TanyN1-3).
Tumor depth (pT3-4) accounted for 18.2% of upstaging while nodal upstaging occurred in approximately 82%. When logistic regression was used, male sex was associated with upstaging (odds ratio = 1.85, P = .024). By analyzing the part of the database that included tumor grade (between the years 2009 and 2011), the investigators found that a higher histologic grade was significantly associated with upstaging (P = .004).
"Over one-third of surgeons have opted to treat T2N0 disease with induction therapy, despite the fact that one-quarter of these patients will be pT1N0," he said.
"This is the first large-scale multi-institutional study of clinical T2N0 patients using the STS General Thoracic Surgery Database. These data highlight the inaccuracy associated with clinical staging of T2N0 esophageal cancer and may influence the surgeon’s decision-making process in choosing a treatment regimen for these patients," Dr. Crabtree added in an interview.
"Given the current limitations of clinical staging of T2N0 patients, the incidence of occult nodal disease, and the similar perioperative outcomes among patients treated with and without induction therapy, these patients may more likely be treated with induction therapy in the future. Additional studies are needed to compare long-term outcomes between patients receiving induction therapy, vs. those clinical T2N0 patients going directly to surgery, before a definitive recommendation can be made," he concluded.
Dr. Crabtree reported that he had no relevant financial disclosures.
LOS ANGELES – Clinical staging of T2N0 esophageal cancer remains unreliable, despite advances in staging techniques, a study has shown.
The addition of endoscopic ultrasound and PET/CT has improved the ability to clinically stage esophageal cancer overall, but clinical staging of T2N0 disease has generally been less reliable than staging of more advanced disease. The subset of patients with T2N0 disease, which accounts for only a small portion of esophageal resections, has been a difficult group to study because single-center investigations involve a limited number of patients, Dr. Traves D. Crabtree said at the annual meeting of the Society of Thoracic Surgeons in the prestigious Richard E. Clark Paper for General Thoracic Surgery.
Dr. Crabtree of Washington University, St. Louis, and his colleagues examined the adequacy of clinical staging of T2N0 disease using the Society of Thoracic Surgeons (STS) General Thoracic Surgery Database.
The researchers identified 810 patients clinically staged as T2N0 from 2002 to 2011 and excluded 58 because of inadequate pathologic staging data. Clinical stage, pathologic stage, and preoperative characteristics were recorded for each patient and multivariable analysis was used to identify factors associated with upstaging at the time of surgery.
Among 752 patients with clinically staged T2N0, the investigators found that 482 went directly to surgery. Of these, 27.4% (132) were confirmed as pathologic T2N0. A total of 25.9% (125) were downstaged (T1N0), while 46.7% (225) were upstaged (T3-4N0 or TanyN1-3).
Tumor depth (pT3-4) accounted for 18.2% of upstaging while nodal upstaging occurred in approximately 82%. When logistic regression was used, male sex was associated with upstaging (odds ratio = 1.85, P = .024). By analyzing the part of the database that included tumor grade (between the years 2009 and 2011), the investigators found that a higher histologic grade was significantly associated with upstaging (P = .004).
"Over one-third of surgeons have opted to treat T2N0 disease with induction therapy, despite the fact that one-quarter of these patients will be pT1N0," he said.
"This is the first large-scale multi-institutional study of clinical T2N0 patients using the STS General Thoracic Surgery Database. These data highlight the inaccuracy associated with clinical staging of T2N0 esophageal cancer and may influence the surgeon’s decision-making process in choosing a treatment regimen for these patients," Dr. Crabtree added in an interview.
"Given the current limitations of clinical staging of T2N0 patients, the incidence of occult nodal disease, and the similar perioperative outcomes among patients treated with and without induction therapy, these patients may more likely be treated with induction therapy in the future. Additional studies are needed to compare long-term outcomes between patients receiving induction therapy, vs. those clinical T2N0 patients going directly to surgery, before a definitive recommendation can be made," he concluded.
Dr. Crabtree reported that he had no relevant financial disclosures.
LOS ANGELES – Clinical staging of T2N0 esophageal cancer remains unreliable, despite advances in staging techniques, a study has shown.
The addition of endoscopic ultrasound and PET/CT has improved the ability to clinically stage esophageal cancer overall, but clinical staging of T2N0 disease has generally been less reliable than staging of more advanced disease. The subset of patients with T2N0 disease, which accounts for only a small portion of esophageal resections, has been a difficult group to study because single-center investigations involve a limited number of patients, Dr. Traves D. Crabtree said at the annual meeting of the Society of Thoracic Surgeons in the prestigious Richard E. Clark Paper for General Thoracic Surgery.
Dr. Crabtree of Washington University, St. Louis, and his colleagues examined the adequacy of clinical staging of T2N0 disease using the Society of Thoracic Surgeons (STS) General Thoracic Surgery Database.
The researchers identified 810 patients clinically staged as T2N0 from 2002 to 2011 and excluded 58 because of inadequate pathologic staging data. Clinical stage, pathologic stage, and preoperative characteristics were recorded for each patient and multivariable analysis was used to identify factors associated with upstaging at the time of surgery.
Among 752 patients with clinically staged T2N0, the investigators found that 482 went directly to surgery. Of these, 27.4% (132) were confirmed as pathologic T2N0. A total of 25.9% (125) were downstaged (T1N0), while 46.7% (225) were upstaged (T3-4N0 or TanyN1-3).
Tumor depth (pT3-4) accounted for 18.2% of upstaging while nodal upstaging occurred in approximately 82%. When logistic regression was used, male sex was associated with upstaging (odds ratio = 1.85, P = .024). By analyzing the part of the database that included tumor grade (between the years 2009 and 2011), the investigators found that a higher histologic grade was significantly associated with upstaging (P = .004).
"Over one-third of surgeons have opted to treat T2N0 disease with induction therapy, despite the fact that one-quarter of these patients will be pT1N0," he said.
"This is the first large-scale multi-institutional study of clinical T2N0 patients using the STS General Thoracic Surgery Database. These data highlight the inaccuracy associated with clinical staging of T2N0 esophageal cancer and may influence the surgeon’s decision-making process in choosing a treatment regimen for these patients," Dr. Crabtree added in an interview.
"Given the current limitations of clinical staging of T2N0 patients, the incidence of occult nodal disease, and the similar perioperative outcomes among patients treated with and without induction therapy, these patients may more likely be treated with induction therapy in the future. Additional studies are needed to compare long-term outcomes between patients receiving induction therapy, vs. those clinical T2N0 patients going directly to surgery, before a definitive recommendation can be made," he concluded.
Dr. Crabtree reported that he had no relevant financial disclosures.
AT THE ANNUAL MEETING OF THE SOCIETY OF THORACIC SURGEONS
Major Finding: Of 482 patients who went directly to surgery, 26% were downstaged, while 47% were upstaged.
Data Source: A retrospective, database analysis of 810 patients clinically staged as T2N0 from 2002 to 2011.
Disclosures: Dr. Crabtree reported that he had no relevant financial disclosures.
