Mark S. Lesney

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 (STS), in the prestigious Richard E. Clark Paper for General Thoracic Surgery.

Courtesy Martin Allred

Dr. Crabtree of Washington University, St. Louis, and his colleagues examined the adequacy of clinical staging of T2N0 disease using the 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.

[email protected]

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 (STS), in the prestigious Richard E. Clark Paper for General Thoracic Surgery.

Courtesy Martin Allred

Dr. Crabtree of Washington University, St. Louis, and his colleagues examined the adequacy of clinical staging of T2N0 disease using the 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.

[email protected]

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 (STS), in the prestigious Richard E. Clark Paper for General Thoracic Surgery.

Courtesy Martin Allred

Dr. Crabtree of Washington University, St. Louis, and his colleagues examined the adequacy of clinical staging of T2N0 disease using the 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.

[email protected]

LOS ANGELES – Single-institution reports regarding the benefits of beta-blocker use are conflicting, despite the fact that preoperative beta-blockade for coronary artery bypass grafting has become an accepted hospital quality metric, according to Dr. Damien J. LaPar and his colleagues.

Courtesy of Martin Allred

Dr. LaPar of the University of Virginia, Charlottesville reported the results of research undertaken to assess this issue based on a study of patient records from a statewide, multi-institutional Society of Thoracic Surgeons (STS)–certified database for isolated coronary artery bypass grafting (CABG) operations (2001-2011). He and his colleagues found that there was no difference seen in mortality, length of stay, or readmission comparing patients with or without preoperative beta-blocker use.

Their prestigious Richard E. Clark Paper for Adult Cardiac Surgery, presented at the annual meeting of the Society of Thoracic Surgeons, utilized the STS Adult Cardiac Surgery Database to demonstrate that the perceived benefits of using beta-blockers before CABG do not stand up as statistically significant improvements in outcomes.

"Preoperative beta-blocker use is not associated with improved patient outcomes or hospital resource utilization following" CABG, said Dr. LaPar.

Patients were stratified by preoperative beta-blocker use and the influence of preoperative beta-blockers on risk-adjusted outcomes was assessed by hierarchical regression modeling with adjustment for preoperative risk using calculated STS predictive risk indices.

A total of 43,747 patients with a mean age of around 64 years were included in the study; 80.2% of these patients were treated with beta-blockers. The median STS-predicted risk of mortality scores for beta-blocker patients were incrementally lower, compared with non–beta blocker patients (1.2% vs. 1.4%, P less than .001). Non–beta blocker patients more frequently developed pneumonia (3.5% vs. 2.8%, P = .001), while beta-blocker patients had surprisingly greater intraoperative blood usage (16.0% vs. 11.2%, P less than .001).

There was, however, no difference in unadjusted mortality (beta-blocker, 1.9%, vs. non beta-blocker, 2.2%; P = 0.15). After risk adjustment, preoperative beta-blocker use was not associated with mortality (P = .63), morbidity, length of stay (P = .79), or hospital readmission (P = .97).

"These data suggest that the use of preoperative beta-blockers for [CABG] operations should not be used as a measure of surgical quality," Dr. LaPar said.

"In an era of increasing pressure on individual hospital and surgical outcomes, the identification of appropriate measures of surgical quality remains critical," Dr. LaPar added in an interview.

"More importantly, as public reporting of surgeon outcomes becomes more common, the cardiothoracic surgical community must play a central role in providing updated data from which to base health care policy, hospital and surgeon reimbursement strategies, and referral patterns for cardiac surgical patients," he stated.

"The results of our study provide an updated reexamination of an issue of increasing debate and provide current clinical estimates on the adjusted impact of preoperative beta-blocker use on outcomes following isolated CABG operations. Future randomized controlled trials are needed to more clearly define a cause-effect relationship between preoperative beta-blocker therapy and coronary artery bypass grafting outcomes before the routine use of beta-blockade should be adopted as a quality performance measure by the cardiothoracic surgical community," Dr. LaPar concluded.

Dr. LaPar reported having no relevant conflicts of interest with regard to this paper; two of his colleagues reported serving as speakers or receiving funding from a variety of drug and device companies.

[email protected]

LOS ANGELES – Single-institution reports regarding the benefits of beta-blocker use are conflicting, despite the fact that preoperative beta-blockade for coronary artery bypass grafting has become an accepted hospital quality metric, according to Dr. Damien J. LaPar and his colleagues.

Courtesy of Martin Allred

Dr. LaPar of the University of Virginia, Charlottesville reported the results of research undertaken to assess this issue based on a study of patient records from a statewide, multi-institutional Society of Thoracic Surgeons (STS)–certified database for isolated coronary artery bypass grafting (CABG) operations (2001-2011). He and his colleagues found that there was no difference seen in mortality, length of stay, or readmission comparing patients with or without preoperative beta-blocker use.

Their prestigious Richard E. Clark Paper for Adult Cardiac Surgery, presented at the annual meeting of the Society of Thoracic Surgeons, utilized the STS Adult Cardiac Surgery Database to demonstrate that the perceived benefits of using beta-blockers before CABG do not stand up as statistically significant improvements in outcomes.

"Preoperative beta-blocker use is not associated with improved patient outcomes or hospital resource utilization following" CABG, said Dr. LaPar.

Patients were stratified by preoperative beta-blocker use and the influence of preoperative beta-blockers on risk-adjusted outcomes was assessed by hierarchical regression modeling with adjustment for preoperative risk using calculated STS predictive risk indices.

A total of 43,747 patients with a mean age of around 64 years were included in the study; 80.2% of these patients were treated with beta-blockers. The median STS-predicted risk of mortality scores for beta-blocker patients were incrementally lower, compared with non–beta blocker patients (1.2% vs. 1.4%, P less than .001). Non–beta blocker patients more frequently developed pneumonia (3.5% vs. 2.8%, P = .001), while beta-blocker patients had surprisingly greater intraoperative blood usage (16.0% vs. 11.2%, P less than .001).

There was, however, no difference in unadjusted mortality (beta-blocker, 1.9%, vs. non beta-blocker, 2.2%; P = 0.15). After risk adjustment, preoperative beta-blocker use was not associated with mortality (P = .63), morbidity, length of stay (P = .79), or hospital readmission (P = .97).

"These data suggest that the use of preoperative beta-blockers for [CABG] operations should not be used as a measure of surgical quality," Dr. LaPar said.

"In an era of increasing pressure on individual hospital and surgical outcomes, the identification of appropriate measures of surgical quality remains critical," Dr. LaPar added in an interview.

"More importantly, as public reporting of surgeon outcomes becomes more common, the cardiothoracic surgical community must play a central role in providing updated data from which to base health care policy, hospital and surgeon reimbursement strategies, and referral patterns for cardiac surgical patients," he stated.

"The results of our study provide an updated reexamination of an issue of increasing debate and provide current clinical estimates on the adjusted impact of preoperative beta-blocker use on outcomes following isolated CABG operations. Future randomized controlled trials are needed to more clearly define a cause-effect relationship between preoperative beta-blocker therapy and coronary artery bypass grafting outcomes before the routine use of beta-blockade should be adopted as a quality performance measure by the cardiothoracic surgical community," Dr. LaPar concluded.

Dr. LaPar reported having no relevant conflicts of interest with regard to this paper; two of his colleagues reported serving as speakers or receiving funding from a variety of drug and device companies.

[email protected]

LOS ANGELES – Single-institution reports regarding the benefits of beta-blocker use are conflicting, despite the fact that preoperative beta-blockade for coronary artery bypass grafting has become an accepted hospital quality metric, according to Dr. Damien J. LaPar and his colleagues.

Courtesy of Martin Allred

Dr. LaPar of the University of Virginia, Charlottesville reported the results of research undertaken to assess this issue based on a study of patient records from a statewide, multi-institutional Society of Thoracic Surgeons (STS)–certified database for isolated coronary artery bypass grafting (CABG) operations (2001-2011). He and his colleagues found that there was no difference seen in mortality, length of stay, or readmission comparing patients with or without preoperative beta-blocker use.

Their prestigious Richard E. Clark Paper for Adult Cardiac Surgery, presented at the annual meeting of the Society of Thoracic Surgeons, utilized the STS Adult Cardiac Surgery Database to demonstrate that the perceived benefits of using beta-blockers before CABG do not stand up as statistically significant improvements in outcomes.

"Preoperative beta-blocker use is not associated with improved patient outcomes or hospital resource utilization following" CABG, said Dr. LaPar.

Patients were stratified by preoperative beta-blocker use and the influence of preoperative beta-blockers on risk-adjusted outcomes was assessed by hierarchical regression modeling with adjustment for preoperative risk using calculated STS predictive risk indices.

A total of 43,747 patients with a mean age of around 64 years were included in the study; 80.2% of these patients were treated with beta-blockers. The median STS-predicted risk of mortality scores for beta-blocker patients were incrementally lower, compared with non–beta blocker patients (1.2% vs. 1.4%, P less than .001). Non–beta blocker patients more frequently developed pneumonia (3.5% vs. 2.8%, P = .001), while beta-blocker patients had surprisingly greater intraoperative blood usage (16.0% vs. 11.2%, P less than .001).

There was, however, no difference in unadjusted mortality (beta-blocker, 1.9%, vs. non beta-blocker, 2.2%; P = 0.15). After risk adjustment, preoperative beta-blocker use was not associated with mortality (P = .63), morbidity, length of stay (P = .79), or hospital readmission (P = .97).

"These data suggest that the use of preoperative beta-blockers for [CABG] operations should not be used as a measure of surgical quality," Dr. LaPar said.

"In an era of increasing pressure on individual hospital and surgical outcomes, the identification of appropriate measures of surgical quality remains critical," Dr. LaPar added in an interview.

"More importantly, as public reporting of surgeon outcomes becomes more common, the cardiothoracic surgical community must play a central role in providing updated data from which to base health care policy, hospital and surgeon reimbursement strategies, and referral patterns for cardiac surgical patients," he stated.

"The results of our study provide an updated reexamination of an issue of increasing debate and provide current clinical estimates on the adjusted impact of preoperative beta-blocker use on outcomes following isolated CABG operations. Future randomized controlled trials are needed to more clearly define a cause-effect relationship between preoperative beta-blocker therapy and coronary artery bypass grafting outcomes before the routine use of beta-blockade should be adopted as a quality performance measure by the cardiothoracic surgical community," Dr. LaPar concluded.

Dr. LaPar reported having no relevant conflicts of interest with regard to this paper; two of his colleagues reported serving as speakers or receiving funding from a variety of drug and device companies.

[email protected]

LOS ANGELES – Single-institution reports regarding the benefits of beta-blocker use are conflicting, despite the fact that preoperative beta-blockade for coronary artery bypass grafting has become an accepted hospital quality metric, according to Dr. Damien J. LaPar and his colleagues.

Dr. LaPar of the University of Virginia, Charlottesville reported the results of research undertaken to assess this issue based on a study of patient records from a statewide, multi-institutional Society of Thoracic Surgeons (STS)–certified database for isolated coronary artery bypass grafting (CABG) operations (2001-2011). He and his colleagues found that there was no difference seen in mortality, length of stay, or readmission comparing patients with or without preoperative beta-blocker use.

Courtesy Martin Allred

Their prestigious Richard E. Clark Paper for Adult Cardiac Surgery, presented at the annual meeting of the Society of Thoracic Surgeons, utilized the STS Adult Cardiac Surgery Database to demonstrate that the perceived benefits of using beta-blockers before CABG do not stand up as statistically significant improvements in outcomes.

"Preoperative beta-blocker use is not associated with improved patient outcomes or hospital resource utilization following" CABG, said Dr. LaPar.

Patients were stratified by preoperative beta-blocker use and the influence of preoperative beta-blockers on risk-adjusted outcomes was assessed by hierarchical regression modeling with adjustment for preoperative risk using calculated STS predictive risk indices.

A total of 43,747 patients with a mean age of around 64 years were included in the study; 80.2% of these patients were treated with beta-blockers. The median STS-predicted risk of mortality scores for beta-blocker patients were incrementally lower, compared with non–beta blocker patients (1.2% vs. 1.4%, P less than .001). Non–beta blocker patients more frequently developed pneumonia (3.5% vs. 2.8%, P = .001), while beta-blocker patients had surprisingly greater intraoperative blood usage (16.0% vs. 11.2%, P less than .001).

There was, however, no difference in unadjusted mortality (beta-blocker, 1.9%, vs. non beta-blocker, 2.2%; P = 0.15). After risk adjustment, preoperative beta-blocker use was not associated with mortality (P = .63), morbidity, length of stay (P = .79), or hospital readmission (P = .97).

"These data suggest that the use of preoperative beta-blockers for [CABG] operations should not be used as a measure of surgical quality," Dr. LaPar said.

"In an era of increasing pressure on individual hospital and surgical outcomes, the identification of appropriate measures of surgical quality remains critical," Dr. LaPar added in an interview.

"More importantly, as public reporting of surgeon outcomes becomes more common, the cardiothoracic surgical community must play a central role in providing updated data from which to base health care policy, hospital and surgeon reimbursement strategies, and referral patterns for cardiac surgical patients," he stated.

"The results of our study provide an updated reexamination of an issue of increasing debate and provide current clinical estimates on the adjusted impact of preoperative beta-blocker use on outcomes following isolated CABG operations. Future randomized controlled trials are needed to more clearly define a cause-effect relationship between preoperative beta-blocker therapy and coronary artery bypass grafting outcomes before the routine use of beta-blockade should be adopted as a quality performance measure by the cardiothoracic surgical community," Dr. LaPar concluded.

Dr. LaPar reported having no relevant conflicts of interest with regard to this paper; two of his colleagues reported serving as speakers or receiving funding from a variety of drug and device companies.

[email protected]

LOS ANGELES – Single-institution reports regarding the benefits of beta-blocker use are conflicting, despite the fact that preoperative beta-blockade for coronary artery bypass grafting has become an accepted hospital quality metric, according to Dr. Damien J. LaPar and his colleagues.

Dr. LaPar of the University of Virginia, Charlottesville reported the results of research undertaken to assess this issue based on a study of patient records from a statewide, multi-institutional Society of Thoracic Surgeons (STS)–certified database for isolated coronary artery bypass grafting (CABG) operations (2001-2011). He and his colleagues found that there was no difference seen in mortality, length of stay, or readmission comparing patients with or without preoperative beta-blocker use.

Courtesy Martin Allred

Their prestigious Richard E. Clark Paper for Adult Cardiac Surgery, presented at the annual meeting of the Society of Thoracic Surgeons, utilized the STS Adult Cardiac Surgery Database to demonstrate that the perceived benefits of using beta-blockers before CABG do not stand up as statistically significant improvements in outcomes.

"Preoperative beta-blocker use is not associated with improved patient outcomes or hospital resource utilization following" CABG, said Dr. LaPar.

Patients were stratified by preoperative beta-blocker use and the influence of preoperative beta-blockers on risk-adjusted outcomes was assessed by hierarchical regression modeling with adjustment for preoperative risk using calculated STS predictive risk indices.

A total of 43,747 patients with a mean age of around 64 years were included in the study; 80.2% of these patients were treated with beta-blockers. The median STS-predicted risk of mortality scores for beta-blocker patients were incrementally lower, compared with non–beta blocker patients (1.2% vs. 1.4%, P less than .001). Non–beta blocker patients more frequently developed pneumonia (3.5% vs. 2.8%, P = .001), while beta-blocker patients had surprisingly greater intraoperative blood usage (16.0% vs. 11.2%, P less than .001).

There was, however, no difference in unadjusted mortality (beta-blocker, 1.9%, vs. non beta-blocker, 2.2%; P = 0.15). After risk adjustment, preoperative beta-blocker use was not associated with mortality (P = .63), morbidity, length of stay (P = .79), or hospital readmission (P = .97).

"These data suggest that the use of preoperative beta-blockers for [CABG] operations should not be used as a measure of surgical quality," Dr. LaPar said.

"In an era of increasing pressure on individual hospital and surgical outcomes, the identification of appropriate measures of surgical quality remains critical," Dr. LaPar added in an interview.

"More importantly, as public reporting of surgeon outcomes becomes more common, the cardiothoracic surgical community must play a central role in providing updated data from which to base health care policy, hospital and surgeon reimbursement strategies, and referral patterns for cardiac surgical patients," he stated.

"The results of our study provide an updated reexamination of an issue of increasing debate and provide current clinical estimates on the adjusted impact of preoperative beta-blocker use on outcomes following isolated CABG operations. Future randomized controlled trials are needed to more clearly define a cause-effect relationship between preoperative beta-blocker therapy and coronary artery bypass grafting outcomes before the routine use of beta-blockade should be adopted as a quality performance measure by the cardiothoracic surgical community," Dr. LaPar concluded.

Dr. LaPar reported having no relevant conflicts of interest with regard to this paper; two of his colleagues reported serving as speakers or receiving funding from a variety of drug and device companies.

[email protected]

LOS ANGELES – Single-institution reports regarding the benefits of beta-blocker use are conflicting, despite the fact that preoperative beta-blockade for coronary artery bypass grafting has become an accepted hospital quality metric, according to Dr. Damien J. LaPar and his colleagues.

Dr. LaPar of the University of Virginia, Charlottesville reported the results of research undertaken to assess this issue based on a study of patient records from a statewide, multi-institutional Society of Thoracic Surgeons (STS)–certified database for isolated coronary artery bypass grafting (CABG) operations (2001-2011). He and his colleagues found that there was no difference seen in mortality, length of stay, or readmission comparing patients with or without preoperative beta-blocker use.

Courtesy Martin Allred

Their prestigious Richard E. Clark Paper for Adult Cardiac Surgery, presented at the annual meeting of the Society of Thoracic Surgeons, utilized the STS Adult Cardiac Surgery Database to demonstrate that the perceived benefits of using beta-blockers before CABG do not stand up as statistically significant improvements in outcomes.

"Preoperative beta-blocker use is not associated with improved patient outcomes or hospital resource utilization following" CABG, said Dr. LaPar.

Patients were stratified by preoperative beta-blocker use and the influence of preoperative beta-blockers on risk-adjusted outcomes was assessed by hierarchical regression modeling with adjustment for preoperative risk using calculated STS predictive risk indices.

A total of 43,747 patients with a mean age of around 64 years were included in the study; 80.2% of these patients were treated with beta-blockers. The median STS-predicted risk of mortality scores for beta-blocker patients were incrementally lower, compared with non–beta blocker patients (1.2% vs. 1.4%, P less than .001). Non–beta blocker patients more frequently developed pneumonia (3.5% vs. 2.8%, P = .001), while beta-blocker patients had surprisingly greater intraoperative blood usage (16.0% vs. 11.2%, P less than .001).

There was, however, no difference in unadjusted mortality (beta-blocker, 1.9%, vs. non beta-blocker, 2.2%; P = 0.15). After risk adjustment, preoperative beta-blocker use was not associated with mortality (P = .63), morbidity, length of stay (P = .79), or hospital readmission (P = .97).

"These data suggest that the use of preoperative beta-blockers for [CABG] operations should not be used as a measure of surgical quality," Dr. LaPar said.

"In an era of increasing pressure on individual hospital and surgical outcomes, the identification of appropriate measures of surgical quality remains critical," Dr. LaPar added in an interview.

"More importantly, as public reporting of surgeon outcomes becomes more common, the cardiothoracic surgical community must play a central role in providing updated data from which to base health care policy, hospital and surgeon reimbursement strategies, and referral patterns for cardiac surgical patients," he stated.

"The results of our study provide an updated reexamination of an issue of increasing debate and provide current clinical estimates on the adjusted impact of preoperative beta-blocker use on outcomes following isolated CABG operations. Future randomized controlled trials are needed to more clearly define a cause-effect relationship between preoperative beta-blocker therapy and coronary artery bypass grafting outcomes before the routine use of beta-blockade should be adopted as a quality performance measure by the cardiothoracic surgical community," Dr. LaPar concluded.

Dr. LaPar reported having no relevant conflicts of interest with regard to this paper; two of his colleagues reported serving as speakers or receiving funding from a variety of drug and device companies.

[email protected]

LOS ANGELES – Ebstein’s malformation is a rare congenital cardiac anomaly. Surgery for Ebstein’s involves a range of procedures, and with low institutional volumes, the only available data on treatment are limited to individual reports demonstrating highly variable approaches. Neonates in particular are at risk for poor outcomes, showing significantly higher mortality than infants, children, and adults, according to a database study presented by Dr. Ryan R. Davies at the annual meeting of the Society of Thoracic Surgeons.

Dr. Davies of the Nemours/A.I. duPont Hospital for Children, Wilmington, Del., and his colleagues performed a retrospective study of procedures performed on patients with a primary diagnosis of Ebstein’s malformation (2002-2009) in the STS Congenital Heart Surgery Database.

A total of 595 operations on patients with Ebstein’s were included: 116 on neonates (19%), 122 on infants (21%), 264 on children (44%), and 93 on adults (16%). The authors found that average annual institutional case volumes were low (median, 1 case/year), and procedures varied according to age. Neonates had a high rate of palliative procedures: tricuspid valve (TV) closure (16%) and systemic-to-pulmonary shunts with or without TV closure (37%) and isolated TV closure (8.6%), with Ebstein’s repair or TV valvuloplasty performed in 32%.

Infants usually underwent superior cavopulmonary connections (52%).

Among older patients, procedures were mostly in three categories: TV surgery (children, 55%; adults, 69%), arrhythmia procedures (children, 9%; adults, 17%), and Fontan (children, 16%). In-hospital mortality was higher among neonatal patients (23%) than in infants (4%), children (0.8%), and adults (1.1%).

Among neonates, 36 subsequent procedures were performed during the same hospitalization in 27 patients (23%); including TV closure (11%); shunt (15%); Ebstein’s repair (17%) or TV replacement (15%); and heart transplantation (7.4%). Mortality was similar among neonates who had a second procedure and those who did not (27% vs. 23%, respectively). ECMO (extracorporeal membrane oxygenation) was used in 9% of neonates but in less than 2% of patients in other age groups.

"This study represents a broad overview of the diverse options for surgical treatment of Ebstein’s anomaly. It shows the challenges faced in caring for extremely ill neonatal patients. We have also shown that repair of Ebstein’s anomaly is performed infrequently at most centers, limiting the ability of individual series to define optimal management strategies," Dr. Davies said in an interview.

"Unfortunately, currently available databases do not contain information that may be important in defining such strategies (both surgical and nonsurgical), including anatomic and physiologic variables – whether they are neonates presenting in severe heart failure or older patients presenting for tricuspid valve repair or replacement," he added.

"We feel that in this setting, a prospective multi-institutional study would be of significant value. It should include operative and nonoperative patients, as well as precise diagnostic information and procedural details, to evaluate long-term outcomes including survival, reoperation and other reinterventions, as well as neurodevelopmental outcomes, functional health status, and quality of life," Dr. Davies concluded.

Dr. Davies and his colleagues reported having no relevant disclosures.

[email protected]

LOS ANGELES – Ebstein’s malformation is a rare congenital cardiac anomaly. Surgery for Ebstein’s involves a range of procedures, and with low institutional volumes, the only available data on treatment are limited to individual reports demonstrating highly variable approaches. Neonates in particular are at risk for poor outcomes, showing significantly higher mortality than infants, children, and adults, according to a database study presented by Dr. Ryan R. Davies at the annual meeting of the Society of Thoracic Surgeons.

Dr. Davies of the Nemours/A.I. duPont Hospital for Children, Wilmington, Del., and his colleagues performed a retrospective study of procedures performed on patients with a primary diagnosis of Ebstein’s malformation (2002-2009) in the STS Congenital Heart Surgery Database.

A total of 595 operations on patients with Ebstein’s were included: 116 on neonates (19%), 122 on infants (21%), 264 on children (44%), and 93 on adults (16%). The authors found that average annual institutional case volumes were low (median, 1 case/year), and procedures varied according to age. Neonates had a high rate of palliative procedures: tricuspid valve (TV) closure (16%) and systemic-to-pulmonary shunts with or without TV closure (37%) and isolated TV closure (8.6%), with Ebstein’s repair or TV valvuloplasty performed in 32%.

Infants usually underwent superior cavopulmonary connections (52%).

Among older patients, procedures were mostly in three categories: TV surgery (children, 55%; adults, 69%), arrhythmia procedures (children, 9%; adults, 17%), and Fontan (children, 16%). In-hospital mortality was higher among neonatal patients (23%) than in infants (4%), children (0.8%), and adults (1.1%).

Among neonates, 36 subsequent procedures were performed during the same hospitalization in 27 patients (23%); including TV closure (11%); shunt (15%); Ebstein’s repair (17%) or TV replacement (15%); and heart transplantation (7.4%). Mortality was similar among neonates who had a second procedure and those who did not (27% vs. 23%, respectively). ECMO (extracorporeal membrane oxygenation) was used in 9% of neonates but in less than 2% of patients in other age groups.

"This study represents a broad overview of the diverse options for surgical treatment of Ebstein’s anomaly. It shows the challenges faced in caring for extremely ill neonatal patients. We have also shown that repair of Ebstein’s anomaly is performed infrequently at most centers, limiting the ability of individual series to define optimal management strategies," Dr. Davies said in an interview.

"Unfortunately, currently available databases do not contain information that may be important in defining such strategies (both surgical and nonsurgical), including anatomic and physiologic variables – whether they are neonates presenting in severe heart failure or older patients presenting for tricuspid valve repair or replacement," he added.

"We feel that in this setting, a prospective multi-institutional study would be of significant value. It should include operative and nonoperative patients, as well as precise diagnostic information and procedural details, to evaluate long-term outcomes including survival, reoperation and other reinterventions, as well as neurodevelopmental outcomes, functional health status, and quality of life," Dr. Davies concluded.

Dr. Davies and his colleagues reported having no relevant disclosures.

[email protected]

LOS ANGELES – Ebstein’s malformation is a rare congenital cardiac anomaly. Surgery for Ebstein’s involves a range of procedures, and with low institutional volumes, the only available data on treatment are limited to individual reports demonstrating highly variable approaches. Neonates in particular are at risk for poor outcomes, showing significantly higher mortality than infants, children, and adults, according to a database study presented by Dr. Ryan R. Davies at the annual meeting of the Society of Thoracic Surgeons.

Dr. Davies of the Nemours/A.I. duPont Hospital for Children, Wilmington, Del., and his colleagues performed a retrospective study of procedures performed on patients with a primary diagnosis of Ebstein’s malformation (2002-2009) in the STS Congenital Heart Surgery Database.

A total of 595 operations on patients with Ebstein’s were included: 116 on neonates (19%), 122 on infants (21%), 264 on children (44%), and 93 on adults (16%). The authors found that average annual institutional case volumes were low (median, 1 case/year), and procedures varied according to age. Neonates had a high rate of palliative procedures: tricuspid valve (TV) closure (16%) and systemic-to-pulmonary shunts with or without TV closure (37%) and isolated TV closure (8.6%), with Ebstein’s repair or TV valvuloplasty performed in 32%.

Infants usually underwent superior cavopulmonary connections (52%).

Among older patients, procedures were mostly in three categories: TV surgery (children, 55%; adults, 69%), arrhythmia procedures (children, 9%; adults, 17%), and Fontan (children, 16%). In-hospital mortality was higher among neonatal patients (23%) than in infants (4%), children (0.8%), and adults (1.1%).

Among neonates, 36 subsequent procedures were performed during the same hospitalization in 27 patients (23%); including TV closure (11%); shunt (15%); Ebstein’s repair (17%) or TV replacement (15%); and heart transplantation (7.4%). Mortality was similar among neonates who had a second procedure and those who did not (27% vs. 23%, respectively). ECMO (extracorporeal membrane oxygenation) was used in 9% of neonates but in less than 2% of patients in other age groups.

"This study represents a broad overview of the diverse options for surgical treatment of Ebstein’s anomaly. It shows the challenges faced in caring for extremely ill neonatal patients. We have also shown that repair of Ebstein’s anomaly is performed infrequently at most centers, limiting the ability of individual series to define optimal management strategies," Dr. Davies said in an interview.

"Unfortunately, currently available databases do not contain information that may be important in defining such strategies (both surgical and nonsurgical), including anatomic and physiologic variables – whether they are neonates presenting in severe heart failure or older patients presenting for tricuspid valve repair or replacement," he added.

"We feel that in this setting, a prospective multi-institutional study would be of significant value. It should include operative and nonoperative patients, as well as precise diagnostic information and procedural details, to evaluate long-term outcomes including survival, reoperation and other reinterventions, as well as neurodevelopmental outcomes, functional health status, and quality of life," Dr. Davies concluded.

Dr. Davies and his colleagues reported having no relevant disclosures.

[email protected]

The first endovascular treatment of an abdominal aortic aneurysm (EVAR) in North America was performed 20 years ago last November. Dr. Juan Parodi, Dr. Frank J. Veith, Dr. Michael L. Marin, Dr. Jacob Cynamon, and Dr. Claudio Schönholz performed the procedure on November 23, 1992.

Dr. Parodi originated the transformational surgical intervention when he performed the first EVAR 2 years earlier with Dr. Schönholz in Buenos Aires, Argentina.

Dr. Julio Palmaz, inventor of the balloon-expandable stent used in coronary arteries, and Dr. Parodi had been thinking about the use of stents and stent-grafts to treat abdominal aortic aneurysms (AAA).

Theoretical discussion translated relatively quickly to clinical reality, and by 1991, Dr. Parodi, Dr. Palmaz, and Dr. Hector Barone had published their landmark paper describing the first of several cases in which they successfully used EVAR.

These success stories galvanized the vascular group at Montefiore Medical Center in New York City, and when a perfect candidate arose for the new technique, they acted. In August 1992, a 76-year-old man who had numerous comorbidities, including severe oxygen-dependent pulmonary insufficiency, presented to Dr. Marin with a 7.5-cm painful and tender renal AAA. The patient’s comorbidities precluded open surgery. Dr. Marin consulted with Dr. Veith about other treatment options, including the possibility of the new endovascular technique.

As detailed by the participants in an historical note (Annals of Vascular Surgery 2005; 19:749-751), discussions ensued with Dr. Parodi. Dr. Marin and Dr. Veith even offered to visit Buenos Aires to observe the technique.

The procedure was planned to coincide with the November 1992 Montefiore/Einstein meeting, which Dr. Parodi planned to attend. But before this could take place, Johnson & Johnson, the company that held the Parodi and Palmaz patents, would have to approve the use of a large Palmaz stent in the United States.

The stent had not yet been approved by the Food and Drug Administration (FDA).

Dr. Parodi also requested the participation of Dr. Schönholz, an interventional radiologist with whom he routinely worked, and Dr. Barone, who was involved in assembling the various components of the EVAR system. .

Persuaded by Dr. Veith and Dr. Marin on compassionate grounds that the operation should be done, however, Johnson & Johnson agreed that Dr. Parodi could operate as long as he used his own stent setup.

The long-awaited operation was performed on November 23, 1992, by the team of Dr. Parodi, Dr. Schönholz, Dr. Veith, Dr. Marin, and Dr. Cynamon. They used a 22-mm Dacron prosthesis sewn to a large Palmaz-type stent, which was inserted via a right femoral arteriotomy. Digital fluoroscopic guidance was used, and the stent was fixed to the proximal nonaneurysmal aorta using a large balloon to expand the proximal stent.

Aneurysmal exclusion was demonstrated by a variety of imaging modalities, but perhaps more importantly, the prominent pulsation of the aneurysm was no longer present and the patient was able to be discharged a few days later with his symptoms relieved. He survived symptom-free for 9 months, and ultimately succumbed to cardiopulmonary comorbidities.

Nonetheless, EVAR had come to the United States and a revolution in vascular treatment was underway.

The first endovascular treatment of an abdominal aortic aneurysm (EVAR) in North America was performed 20 years ago last November. Dr. Juan Parodi, Dr. Frank J. Veith, Dr. Michael L. Marin, Dr. Jacob Cynamon, and Dr. Claudio Schönholz performed the procedure on November 23, 1992.

Dr. Parodi originated the transformational surgical intervention when he performed the first EVAR 2 years earlier with Dr. Schönholz in Buenos Aires, Argentina.

Dr. Julio Palmaz, inventor of the balloon-expandable stent used in coronary arteries, and Dr. Parodi had been thinking about the use of stents and stent-grafts to treat abdominal aortic aneurysms (AAA).

Theoretical discussion translated relatively quickly to clinical reality, and by 1991, Dr. Parodi, Dr. Palmaz, and Dr. Hector Barone had published their landmark paper describing the first of several cases in which they successfully used EVAR.

These success stories galvanized the vascular group at Montefiore Medical Center in New York City, and when a perfect candidate arose for the new technique, they acted. In August 1992, a 76-year-old man who had numerous comorbidities, including severe oxygen-dependent pulmonary insufficiency, presented to Dr. Marin with a 7.5-cm painful and tender renal AAA. The patient’s comorbidities precluded open surgery. Dr. Marin consulted with Dr. Veith about other treatment options, including the possibility of the new endovascular technique.

As detailed by the participants in an historical note (Annals of Vascular Surgery 2005; 19:749-751), discussions ensued with Dr. Parodi. Dr. Marin and Dr. Veith even offered to visit Buenos Aires to observe the technique.

The procedure was planned to coincide with the November 1992 Montefiore/Einstein meeting, which Dr. Parodi planned to attend. But before this could take place, Johnson & Johnson, the company that held the Parodi and Palmaz patents, would have to approve the use of a large Palmaz stent in the United States.

The stent had not yet been approved by the Food and Drug Administration (FDA).

Dr. Parodi also requested the participation of Dr. Schönholz, an interventional radiologist with whom he routinely worked, and Dr. Barone, who was involved in assembling the various components of the EVAR system. .

Persuaded by Dr. Veith and Dr. Marin on compassionate grounds that the operation should be done, however, Johnson & Johnson agreed that Dr. Parodi could operate as long as he used his own stent setup.

The long-awaited operation was performed on November 23, 1992, by the team of Dr. Parodi, Dr. Schönholz, Dr. Veith, Dr. Marin, and Dr. Cynamon. They used a 22-mm Dacron prosthesis sewn to a large Palmaz-type stent, which was inserted via a right femoral arteriotomy. Digital fluoroscopic guidance was used, and the stent was fixed to the proximal nonaneurysmal aorta using a large balloon to expand the proximal stent.

Aneurysmal exclusion was demonstrated by a variety of imaging modalities, but perhaps more importantly, the prominent pulsation of the aneurysm was no longer present and the patient was able to be discharged a few days later with his symptoms relieved. He survived symptom-free for 9 months, and ultimately succumbed to cardiopulmonary comorbidities.

Nonetheless, EVAR had come to the United States and a revolution in vascular treatment was underway.

The first endovascular treatment of an abdominal aortic aneurysm (EVAR) in North America was performed 20 years ago last November. Dr. Juan Parodi, Dr. Frank J. Veith, Dr. Michael L. Marin, Dr. Jacob Cynamon, and Dr. Claudio Schönholz performed the procedure on November 23, 1992.

Dr. Parodi originated the transformational surgical intervention when he performed the first EVAR 2 years earlier with Dr. Schönholz in Buenos Aires, Argentina.

Dr. Julio Palmaz, inventor of the balloon-expandable stent used in coronary arteries, and Dr. Parodi had been thinking about the use of stents and stent-grafts to treat abdominal aortic aneurysms (AAA).

Theoretical discussion translated relatively quickly to clinical reality, and by 1991, Dr. Parodi, Dr. Palmaz, and Dr. Hector Barone had published their landmark paper describing the first of several cases in which they successfully used EVAR.

These success stories galvanized the vascular group at Montefiore Medical Center in New York City, and when a perfect candidate arose for the new technique, they acted. In August 1992, a 76-year-old man who had numerous comorbidities, including severe oxygen-dependent pulmonary insufficiency, presented to Dr. Marin with a 7.5-cm painful and tender renal AAA. The patient’s comorbidities precluded open surgery. Dr. Marin consulted with Dr. Veith about other treatment options, including the possibility of the new endovascular technique.

As detailed by the participants in an historical note (Annals of Vascular Surgery 2005; 19:749-751), discussions ensued with Dr. Parodi. Dr. Marin and Dr. Veith even offered to visit Buenos Aires to observe the technique.

The procedure was planned to coincide with the November 1992 Montefiore/Einstein meeting, which Dr. Parodi planned to attend. But before this could take place, Johnson & Johnson, the company that held the Parodi and Palmaz patents, would have to approve the use of a large Palmaz stent in the United States.

The stent had not yet been approved by the Food and Drug Administration (FDA).

Dr. Parodi also requested the participation of Dr. Schönholz, an interventional radiologist with whom he routinely worked, and Dr. Barone, who was involved in assembling the various components of the EVAR system. .

Persuaded by Dr. Veith and Dr. Marin on compassionate grounds that the operation should be done, however, Johnson & Johnson agreed that Dr. Parodi could operate as long as he used his own stent setup.

The long-awaited operation was performed on November 23, 1992, by the team of Dr. Parodi, Dr. Schönholz, Dr. Veith, Dr. Marin, and Dr. Cynamon. They used a 22-mm Dacron prosthesis sewn to a large Palmaz-type stent, which was inserted via a right femoral arteriotomy. Digital fluoroscopic guidance was used, and the stent was fixed to the proximal nonaneurysmal aorta using a large balloon to expand the proximal stent.

Aneurysmal exclusion was demonstrated by a variety of imaging modalities, but perhaps more importantly, the prominent pulsation of the aneurysm was no longer present and the patient was able to be discharged a few days later with his symptoms relieved. He survived symptom-free for 9 months, and ultimately succumbed to cardiopulmonary comorbidities.

Nonetheless, EVAR had come to the United States and a revolution in vascular treatment was underway.

Advances in technology from new forms of operative procedures, medical treatment, and imaging to electronic health record systems are rapidly changing thoracic surgery practice and cost structure. In addition, new government and insurance initiatives are changing the playing field at the same time as a crisis in recruitment and an aging population threaten to create a shortage of thoracic surgeons. In the face of these changes, the need for strong and polished leadership at all levels becomes a necessity.

To address these new leadership demands, specific training has become an imperative, and the American Association for Thoracic Surgery (AATS) has taken the initiative in this area by sponsoring new courses to further empower the current and upcoming generation of leaders.

Courtesy of Heratch Photography

The Brandeis University Advanced Leadership Program held September 20-23 was sponsored by the AATS and was supported in part by an unrestricted educational grant from Covidien. It was provided through the Brandeis' Heller School?s Executive Education Program, which creates courses in conjunction with client input to provide leaders and upcoming leaders "with concepts and tools needed to impact policy and improve performance," according to the program website. The courses are designed to allow participants to "measure, assess, and benchmark performance, and build commitment to operational excellence. The interactive sessions build on existing expertise and experience, and spark new ideas and skills in a collegial environment with peers."

The program website also notes that "the current environment demands that physician leaders develop a balance of policy and management skills in order to be effective." This environment requires building knowledge and skills that will improve the performance of their teams and organization and increase their personal and professional satisfaction-and impact, according to Dr. Jon Chilingerian, Ph.D., director of the Heller School program.

Dr. John S. Ikonomidis, who is chief of the division of cardiothoracic surgery at the Medical University of South Carolina, Charleston, summarized his experience of the course: "Dr. Chilingerian oversaw a very fast-paced and concentrated learning experience. Numerous subjects such as collective intelligence and strategic thinking in health care, effective leadership styles, the care and process of patient flow, leading change, and conflict negotiation were covered in great detail." Formal presentations were supplemented with group breakout sessions and computer simulations and several guest lecturers also provided valuable and diverse perspectives, according to Dr. Ikonomidis.

"For me, the highlight of the course was the highly entertaining and informative lecture given by Stuart Altman on the history, current status, and future directions of federal health care management. This was truly a fantastic course that I would recommend to anyone interested in the science and practice of health care leadership," he added.

Dr. Michael J. Liptay, another course participant, stated that "With the changing landscape of health care and a perceived dearth of physician leaders, surgeons should be well positioned with our natural leadership ability. This course provided thoughtful advice in adapting from an autocratic style most familiar in the operating room to one of effective engaging leadership. The most important lesson for me was that the successful leader doesn?t spend time persuading everyone to buy into his vision; but rather frames and asks powerful questions en route to creating a respectful dialogue. Through this process emerges a consensus and commitment to strategic goals." Dr. Liptay is chief of the division of thoracic surgery and program director, Thoracic Surgery Residency, Rush University Medical Center, Chicago, and an associate medical editor for Thoracic Surgery News.

According to course participant Dr. Jean-Francois Legare, associate professor of surgery, Dalhousie University, Halifax, N.S.: "I wish I would have taken this type of course much earlier in my career. I see now many occasions where I made mistakes I could have avoided. I speak as a Canadian entering my mid-career and realizing that health administration is an essential part of my daily work. I now feel better equipped to handle and advocate for myself and my colleagues and defend our interests and the interests of our patients. I am very grateful of the opportunity that was offered to me to attend that course."

Dr. Kirk Kanter, chief of pediatric cardiac surgery, Emory University, Atlanta, who also participated, added: "I found the AATS leadership course to be extremely valuable and provocative. The ability to interact in the classroom with the faculty and with other cardiothoracic surgeons immensely enhanced the entire training program. It was an extremely valuable investment in time, and I hope that in the future I will be able to participate in similar courses. I recommend it highly to any cardiothoracic surgeon who is interested in not only the interaction with his colleagues (both surgeons and administrators) in the hospital, [but also] getting an insight into the health care system as a whole."

Dr. Kevin Lobdell of Levine Children?s Hospital of North Carolina, Charlotte, summarized the course: "Based on my experience and conversations with the international cadre of distinguished colleagues, it was highly regarded and an unmitigated success. It was valuable to leaders at various levels, fostering expansion of their education and professional horizons through the intimate and interactive process."

This AATS-sponsored course is in addition to the highly-rated AATS academy program held immediately prior to the AATS annual meeting each year. The academy, inaugurated in 2009, provides a didactic and interactive program for new and upcoming CT-surgeon leaders, including networking opportunities with the goal of building professional relationships and future mentoring possibilities with faculty members who have been selected based upon their expertise, according to the AATS.

None of the participant doctors quoted had a financial interest in the course.

Advances in technology from new forms of operative procedures, medical treatment, and imaging to electronic health record systems are rapidly changing thoracic surgery practice and cost structure. In addition, new government and insurance initiatives are changing the playing field at the same time as a crisis in recruitment and an aging population threaten to create a shortage of thoracic surgeons. In the face of these changes, the need for strong and polished leadership at all levels becomes a necessity.

To address these new leadership demands, specific training has become an imperative, and the American Association for Thoracic Surgery (AATS) has taken the initiative in this area by sponsoring new courses to further empower the current and upcoming generation of leaders.

Courtesy of Heratch Photography

The Brandeis University Advanced Leadership Program held September 20-23 was sponsored by the AATS and was supported in part by an unrestricted educational grant from Covidien. It was provided through the Brandeis' Heller School?s Executive Education Program, which creates courses in conjunction with client input to provide leaders and upcoming leaders "with concepts and tools needed to impact policy and improve performance," according to the program website. The courses are designed to allow participants to "measure, assess, and benchmark performance, and build commitment to operational excellence. The interactive sessions build on existing expertise and experience, and spark new ideas and skills in a collegial environment with peers."

The program website also notes that "the current environment demands that physician leaders develop a balance of policy and management skills in order to be effective." This environment requires building knowledge and skills that will improve the performance of their teams and organization and increase their personal and professional satisfaction-and impact, according to Dr. Jon Chilingerian, Ph.D., director of the Heller School program.

Dr. John S. Ikonomidis, who is chief of the division of cardiothoracic surgery at the Medical University of South Carolina, Charleston, summarized his experience of the course: "Dr. Chilingerian oversaw a very fast-paced and concentrated learning experience. Numerous subjects such as collective intelligence and strategic thinking in health care, effective leadership styles, the care and process of patient flow, leading change, and conflict negotiation were covered in great detail." Formal presentations were supplemented with group breakout sessions and computer simulations and several guest lecturers also provided valuable and diverse perspectives, according to Dr. Ikonomidis.

"For me, the highlight of the course was the highly entertaining and informative lecture given by Stuart Altman on the history, current status, and future directions of federal health care management. This was truly a fantastic course that I would recommend to anyone interested in the science and practice of health care leadership," he added.

Dr. Michael J. Liptay, another course participant, stated that "With the changing landscape of health care and a perceived dearth of physician leaders, surgeons should be well positioned with our natural leadership ability. This course provided thoughtful advice in adapting from an autocratic style most familiar in the operating room to one of effective engaging leadership. The most important lesson for me was that the successful leader doesn?t spend time persuading everyone to buy into his vision; but rather frames and asks powerful questions en route to creating a respectful dialogue. Through this process emerges a consensus and commitment to strategic goals." Dr. Liptay is chief of the division of thoracic surgery and program director, Thoracic Surgery Residency, Rush University Medical Center, Chicago, and an associate medical editor for Thoracic Surgery News.

According to course participant Dr. Jean-Francois Legare, associate professor of surgery, Dalhousie University, Halifax, N.S.: "I wish I would have taken this type of course much earlier in my career. I see now many occasions where I made mistakes I could have avoided. I speak as a Canadian entering my mid-career and realizing that health administration is an essential part of my daily work. I now feel better equipped to handle and advocate for myself and my colleagues and defend our interests and the interests of our patients. I am very grateful of the opportunity that was offered to me to attend that course."

Dr. Kirk Kanter, chief of pediatric cardiac surgery, Emory University, Atlanta, who also participated, added: "I found the AATS leadership course to be extremely valuable and provocative. The ability to interact in the classroom with the faculty and with other cardiothoracic surgeons immensely enhanced the entire training program. It was an extremely valuable investment in time, and I hope that in the future I will be able to participate in similar courses. I recommend it highly to any cardiothoracic surgeon who is interested in not only the interaction with his colleagues (both surgeons and administrators) in the hospital, [but also] getting an insight into the health care system as a whole."

Dr. Kevin Lobdell of Levine Children?s Hospital of North Carolina, Charlotte, summarized the course: "Based on my experience and conversations with the international cadre of distinguished colleagues, it was highly regarded and an unmitigated success. It was valuable to leaders at various levels, fostering expansion of their education and professional horizons through the intimate and interactive process."

This AATS-sponsored course is in addition to the highly-rated AATS academy program held immediately prior to the AATS annual meeting each year. The academy, inaugurated in 2009, provides a didactic and interactive program for new and upcoming CT-surgeon leaders, including networking opportunities with the goal of building professional relationships and future mentoring possibilities with faculty members who have been selected based upon their expertise, according to the AATS.

None of the participant doctors quoted had a financial interest in the course.

Advances in technology from new forms of operative procedures, medical treatment, and imaging to electronic health record systems are rapidly changing thoracic surgery practice and cost structure. In addition, new government and insurance initiatives are changing the playing field at the same time as a crisis in recruitment and an aging population threaten to create a shortage of thoracic surgeons. In the face of these changes, the need for strong and polished leadership at all levels becomes a necessity.

To address these new leadership demands, specific training has become an imperative, and the American Association for Thoracic Surgery (AATS) has taken the initiative in this area by sponsoring new courses to further empower the current and upcoming generation of leaders.

Courtesy of Heratch Photography

The Brandeis University Advanced Leadership Program held September 20-23 was sponsored by the AATS and was supported in part by an unrestricted educational grant from Covidien. It was provided through the Brandeis' Heller School?s Executive Education Program, which creates courses in conjunction with client input to provide leaders and upcoming leaders "with concepts and tools needed to impact policy and improve performance," according to the program website. The courses are designed to allow participants to "measure, assess, and benchmark performance, and build commitment to operational excellence. The interactive sessions build on existing expertise and experience, and spark new ideas and skills in a collegial environment with peers."

The program website also notes that "the current environment demands that physician leaders develop a balance of policy and management skills in order to be effective." This environment requires building knowledge and skills that will improve the performance of their teams and organization and increase their personal and professional satisfaction-and impact, according to Dr. Jon Chilingerian, Ph.D., director of the Heller School program.

Dr. John S. Ikonomidis, who is chief of the division of cardiothoracic surgery at the Medical University of South Carolina, Charleston, summarized his experience of the course: "Dr. Chilingerian oversaw a very fast-paced and concentrated learning experience. Numerous subjects such as collective intelligence and strategic thinking in health care, effective leadership styles, the care and process of patient flow, leading change, and conflict negotiation were covered in great detail." Formal presentations were supplemented with group breakout sessions and computer simulations and several guest lecturers also provided valuable and diverse perspectives, according to Dr. Ikonomidis.

"For me, the highlight of the course was the highly entertaining and informative lecture given by Stuart Altman on the history, current status, and future directions of federal health care management. This was truly a fantastic course that I would recommend to anyone interested in the science and practice of health care leadership," he added.

Dr. Michael J. Liptay, another course participant, stated that "With the changing landscape of health care and a perceived dearth of physician leaders, surgeons should be well positioned with our natural leadership ability. This course provided thoughtful advice in adapting from an autocratic style most familiar in the operating room to one of effective engaging leadership. The most important lesson for me was that the successful leader doesn?t spend time persuading everyone to buy into his vision; but rather frames and asks powerful questions en route to creating a respectful dialogue. Through this process emerges a consensus and commitment to strategic goals." Dr. Liptay is chief of the division of thoracic surgery and program director, Thoracic Surgery Residency, Rush University Medical Center, Chicago, and an associate medical editor for Thoracic Surgery News.

According to course participant Dr. Jean-Francois Legare, associate professor of surgery, Dalhousie University, Halifax, N.S.: "I wish I would have taken this type of course much earlier in my career. I see now many occasions where I made mistakes I could have avoided. I speak as a Canadian entering my mid-career and realizing that health administration is an essential part of my daily work. I now feel better equipped to handle and advocate for myself and my colleagues and defend our interests and the interests of our patients. I am very grateful of the opportunity that was offered to me to attend that course."

Dr. Kirk Kanter, chief of pediatric cardiac surgery, Emory University, Atlanta, who also participated, added: "I found the AATS leadership course to be extremely valuable and provocative. The ability to interact in the classroom with the faculty and with other cardiothoracic surgeons immensely enhanced the entire training program. It was an extremely valuable investment in time, and I hope that in the future I will be able to participate in similar courses. I recommend it highly to any cardiothoracic surgeon who is interested in not only the interaction with his colleagues (both surgeons and administrators) in the hospital, [but also] getting an insight into the health care system as a whole."

Dr. Kevin Lobdell of Levine Children?s Hospital of North Carolina, Charlotte, summarized the course: "Based on my experience and conversations with the international cadre of distinguished colleagues, it was highly regarded and an unmitigated success. It was valuable to leaders at various levels, fostering expansion of their education and professional horizons through the intimate and interactive process."

This AATS-sponsored course is in addition to the highly-rated AATS academy program held immediately prior to the AATS annual meeting each year. The academy, inaugurated in 2009, provides a didactic and interactive program for new and upcoming CT-surgeon leaders, including networking opportunities with the goal of building professional relationships and future mentoring possibilities with faculty members who have been selected based upon their expertise, according to the AATS.

None of the participant doctors quoted had a financial interest in the course.

Advances in technology from new forms of operative procedures, medical treatment, and imaging to electronic health record systems are rapidly changing thoracic surgery practice and cost structure. In addition, new government and insurance initiatives are changing the playing field at the same time as a crisis in recruitment and an aging population threaten to create a shortage of thoracic surgeons. In the face of these changes, the need for strong and polished leadership at all levels becomes a necessity.

To address these new leadership demands, specific training has become an imperative, and the American Association for Thoracic Surgery (AATS) has taken the initiative in this area by sponsoring new courses to further empower the current and upcoming generation of leaders.

Courtesy of Heratch Photography

The Brandeis University Advanced Leadership Program held September 20-23 was sponsored by the AATS and was supported in part by an unrestricted educational grant from Covidien. It was provided through the Brandeis' Heller School?s Executive Education Program, which creates courses in conjunction with client input to provide leaders and upcoming leaders "with concepts and tools needed to impact policy and improve performance," according to the program website. The courses are designed to allow participants to "measure, assess, and benchmark performance, and build commitment to operational excellence. The interactive sessions build on existing expertise and experience, and spark new ideas and skills in a collegial environment with peers."

The program website also notes that "the current environment demands that physician leaders develop a balance of policy and management skills in order to be effective." This environment requires building knowledge and skills that will improve the performance of their teams and organization and increase their personal and professional satisfaction-and impact, according to Dr. Jon Chilingerian, Ph.D., director of the Heller School program.

Dr. John S. Ikonomidis, who is chief of the division of cardiothoracic surgery at the Medical University of South Carolina, Charleston, summarized his experience of the course: "Dr. Chilingerian oversaw a very fast-paced and concentrated learning experience. Numerous subjects such as collective intelligence and strategic thinking in health care, effective leadership styles, the care and process of patient flow, leading change, and conflict negotiation were covered in great detail." Formal presentations were supplemented with group breakout sessions and computer simulations and several guest lecturers also provided valuable and diverse perspectives, according to Dr. Ikonomidis.

"For me, the highlight of the course was the highly entertaining and informative lecture given by Stuart Altman on the history, current status, and future directions of federal health care management. This was truly a fantastic course that I would recommend to anyone interested in the science and practice of health care leadership," he added.

Dr. Michael J. Liptay, another course participant, stated that "With the changing landscape of health care and a perceived dearth of physician leaders, surgeons should be well positioned with our natural leadership ability. This course provided thoughtful advice in adapting from an autocratic style most familiar in the operating room to one of effective engaging leadership. The most important lesson for me was that the successful leader doesn?t spend time persuading everyone to buy into his vision; but rather frames and asks powerful questions en route to creating a respectful dialogue. Through this process emerges a consensus and commitment to strategic goals." Dr. Liptay is chief of the division of thoracic surgery and program director, Thoracic Surgery Residency, Rush University Medical Center, Chicago, and an associate medical editor for Thoracic Surgery News.

According to course participant Dr. Jean-Francois Legare, associate professor of surgery, Dalhousie University, Halifax, N.S.: "I wish I would have taken this type of course much earlier in my career. I see now many occasions where I made mistakes I could have avoided. I speak as a Canadian entering my mid-career and realizing that health administration is an essential part of my daily work. I now feel better equipped to handle and advocate for myself and my colleagues and defend our interests and the interests of our patients. I am very grateful of the opportunity that was offered to me to attend that course."

Dr. Kirk Kanter, chief of pediatric cardiac surgery, Emory University, Atlanta, who also participated, added: "I found the AATS leadership course to be extremely valuable and provocative. The ability to interact in the classroom with the faculty and with other cardiothoracic surgeons immensely enhanced the entire training program. It was an extremely valuable investment in time, and I hope that in the future I will be able to participate in similar courses. I recommend it highly to any cardiothoracic surgeon who is interested in not only the interaction with his colleagues (both surgeons and administrators) in the hospital, [but also] getting an insight into the health care system as a whole."

Dr. Kevin Lobdell of Levine Children?s Hospital of North Carolina, Charlotte, summarized the course: "Based on my experience and conversations with the international cadre of distinguished colleagues, it was highly regarded and an unmitigated success. It was valuable to leaders at various levels, fostering expansion of their education and professional horizons through the intimate and interactive process."

This AATS-sponsored course is in addition to the highly-rated AATS academy program held immediately prior to the AATS annual meeting each year. The academy, inaugurated in 2009, provides a didactic and interactive program for new and upcoming CT-surgeon leaders, including networking opportunities with the goal of building professional relationships and future mentoring possibilities with faculty members who have been selected based upon their expertise, according to the AATS.

None of the participant doctors quoted had a financial interest in the course.

Advances in technology from new forms of operative procedures, medical treatment, and imaging to electronic health record systems are rapidly changing thoracic surgery practice and cost structure. In addition, new government and insurance initiatives are changing the playing field at the same time as a crisis in recruitment and an aging population threaten to create a shortage of thoracic surgeons. In the face of these changes, the need for strong and polished leadership at all levels becomes a necessity.

To address these new leadership demands, specific training has become an imperative, and the American Association for Thoracic Surgery (AATS) has taken the initiative in this area by sponsoring new courses to further empower the current and upcoming generation of leaders.

Courtesy of Heratch Photography

The Brandeis University Advanced Leadership Program held September 20-23 was sponsored by the AATS and was supported in part by an unrestricted educational grant from Covidien. It was provided through the Brandeis' Heller School?s Executive Education Program, which creates courses in conjunction with client input to provide leaders and upcoming leaders "with concepts and tools needed to impact policy and improve performance," according to the program website. The courses are designed to allow participants to "measure, assess, and benchmark performance, and build commitment to operational excellence. The interactive sessions build on existing expertise and experience, and spark new ideas and skills in a collegial environment with peers."

The program website also notes that "the current environment demands that physician leaders develop a balance of policy and management skills in order to be effective." This environment requires building knowledge and skills that will improve the performance of their teams and organization and increase their personal and professional satisfaction-and impact, according to Dr. Jon Chilingerian, Ph.D., director of the Heller School program.

Dr. John S. Ikonomidis, who is chief of the division of cardiothoracic surgery at the Medical University of South Carolina, Charleston, summarized his experience of the course: "Dr. Chilingerian oversaw a very fast-paced and concentrated learning experience. Numerous subjects such as collective intelligence and strategic thinking in health care, effective leadership styles, the care and process of patient flow, leading change, and conflict negotiation were covered in great detail." Formal presentations were supplemented with group breakout sessions and computer simulations and several guest lecturers also provided valuable and diverse perspectives, according to Dr. Ikonomidis.

"For me, the highlight of the course was the highly entertaining and informative lecture given by Stuart Altman on the history, current status, and future directions of federal health care management. This was truly a fantastic course that I would recommend to anyone interested in the science and practice of health care leadership," he added.

Dr. Michael J. Liptay, another course participant, stated that "With the changing landscape of health care and a perceived dearth of physician leaders, surgeons should be well positioned with our natural leadership ability. This course provided thoughtful advice in adapting from an autocratic style most familiar in the operating room to one of effective engaging leadership. The most important lesson for me was that the successful leader doesn?t spend time persuading everyone to buy into his vision; but rather frames and asks powerful questions en route to creating a respectful dialogue. Through this process emerges a consensus and commitment to strategic goals." Dr. Liptay is chief of the division of thoracic surgery and program director, Thoracic Surgery Residency, Rush University Medical Center, Chicago, and an associate medical editor for Thoracic Surgery News.

According to course participant Dr. Jean-Francois Legare, associate professor of surgery, Dalhousie University, Halifax, N.S.: "I wish I would have taken this type of course much earlier in my career. I see now many occasions where I made mistakes I could have avoided. I speak as a Canadian entering my mid-career and realizing that health administration is an essential part of my daily work. I now feel better equipped to handle and advocate for myself and my colleagues and defend our interests and the interests of our patients. I am very grateful of the opportunity that was offered to me to attend that course."

Dr. Kirk Kanter, chief of pediatric cardiac surgery, Emory University, Atlanta, who also participated, added: "I found the AATS leadership course to be extremely valuable and provocative. The ability to interact in the classroom with the faculty and with other cardiothoracic surgeons immensely enhanced the entire training program. It was an extremely valuable investment in time, and I hope that in the future I will be able to participate in similar courses. I recommend it highly to any cardiothoracic surgeon who is interested in not only the interaction with his colleagues (both surgeons and administrators) in the hospital, [but also] getting an insight into the health care system as a whole."

Dr. Kevin Lobdell of Levine Children?s Hospital of North Carolina, Charlotte, summarized the course: "Based on my experience and conversations with the international cadre of distinguished colleagues, it was highly regarded and an unmitigated success. It was valuable to leaders at various levels, fostering expansion of their education and professional horizons through the intimate and interactive process."

This AATS-sponsored course is in addition to the highly-rated AATS academy program held immediately prior to the AATS annual meeting each year. The academy, inaugurated in 2009, provides a didactic and interactive program for new and upcoming CT-surgeon leaders, including networking opportunities with the goal of building professional relationships and future mentoring possibilities with faculty members who have been selected based upon their expertise, according to the AATS.

None of the participant doctors quoted had a financial interest in the course.

Advances in technology from new forms of operative procedures, medical treatment, and imaging to electronic health record systems are rapidly changing thoracic surgery practice and cost structure. In addition, new government and insurance initiatives are changing the playing field at the same time as a crisis in recruitment and an aging population threaten to create a shortage of thoracic surgeons. In the face of these changes, the need for strong and polished leadership at all levels becomes a necessity.

To address these new leadership demands, specific training has become an imperative, and the American Association for Thoracic Surgery (AATS) has taken the initiative in this area by sponsoring new courses to further empower the current and upcoming generation of leaders.

Courtesy of Heratch Photography

The Brandeis University Advanced Leadership Program held September 20-23 was sponsored by the AATS and was supported in part by an unrestricted educational grant from Covidien. It was provided through the Brandeis' Heller School?s Executive Education Program, which creates courses in conjunction with client input to provide leaders and upcoming leaders "with concepts and tools needed to impact policy and improve performance," according to the program website. The courses are designed to allow participants to "measure, assess, and benchmark performance, and build commitment to operational excellence. The interactive sessions build on existing expertise and experience, and spark new ideas and skills in a collegial environment with peers."

The program website also notes that "the current environment demands that physician leaders develop a balance of policy and management skills in order to be effective." This environment requires building knowledge and skills that will improve the performance of their teams and organization and increase their personal and professional satisfaction-and impact, according to Dr. Jon Chilingerian, Ph.D., director of the Heller School program.

Dr. John S. Ikonomidis, who is chief of the division of cardiothoracic surgery at the Medical University of South Carolina, Charleston, summarized his experience of the course: "Dr. Chilingerian oversaw a very fast-paced and concentrated learning experience. Numerous subjects such as collective intelligence and strategic thinking in health care, effective leadership styles, the care and process of patient flow, leading change, and conflict negotiation were covered in great detail." Formal presentations were supplemented with group breakout sessions and computer simulations and several guest lecturers also provided valuable and diverse perspectives, according to Dr. Ikonomidis.

"For me, the highlight of the course was the highly entertaining and informative lecture given by Stuart Altman on the history, current status, and future directions of federal health care management. This was truly a fantastic course that I would recommend to anyone interested in the science and practice of health care leadership," he added.

Dr. Michael J. Liptay, another course participant, stated that "With the changing landscape of health care and a perceived dearth of physician leaders, surgeons should be well positioned with our natural leadership ability. This course provided thoughtful advice in adapting from an autocratic style most familiar in the operating room to one of effective engaging leadership. The most important lesson for me was that the successful leader doesn?t spend time persuading everyone to buy into his vision; but rather frames and asks powerful questions en route to creating a respectful dialogue. Through this process emerges a consensus and commitment to strategic goals." Dr. Liptay is chief of the division of thoracic surgery and program director, Thoracic Surgery Residency, Rush University Medical Center, Chicago, and an associate medical editor for Thoracic Surgery News.

According to course participant Dr. Jean-Francois Legare, associate professor of surgery, Dalhousie University, Halifax, N.S.: "I wish I would have taken this type of course much earlier in my career. I see now many occasions where I made mistakes I could have avoided. I speak as a Canadian entering my mid-career and realizing that health administration is an essential part of my daily work. I now feel better equipped to handle and advocate for myself and my colleagues and defend our interests and the interests of our patients. I am very grateful of the opportunity that was offered to me to attend that course."

Dr. Kirk Kanter, chief of pediatric cardiac surgery, Emory University, Atlanta, who also participated, added: "I found the AATS leadership course to be extremely valuable and provocative. The ability to interact in the classroom with the faculty and with other cardiothoracic surgeons immensely enhanced the entire training program. It was an extremely valuable investment in time, and I hope that in the future I will be able to participate in similar courses. I recommend it highly to any cardiothoracic surgeon who is interested in not only the interaction with his colleagues (both surgeons and administrators) in the hospital, [but also] getting an insight into the health care system as a whole."

Dr. Kevin Lobdell of Levine Children?s Hospital of North Carolina, Charlotte, summarized the course: "Based on my experience and conversations with the international cadre of distinguished colleagues, it was highly regarded and an unmitigated success. It was valuable to leaders at various levels, fostering expansion of their education and professional horizons through the intimate and interactive process."

This AATS-sponsored course is in addition to the highly-rated AATS academy program held immediately prior to the AATS annual meeting each year. The academy, inaugurated in 2009, provides a didactic and interactive program for new and upcoming CT-surgeon leaders, including networking opportunities with the goal of building professional relationships and future mentoring possibilities with faculty members who have been selected based upon their expertise, according to the AATS.

None of the participant doctors quoted had a financial interest in the course.

Wide variation exists in the local treatment of donor site wounds after split-skin grafting, ranging from classic gauze dressings to modern silicone dressings.

In a multicenter randomized trial of 289 patients, hydrocolloid dressings led to a shorter healing time than other commonly used dressing materials for donor site wounds (DSWs) after split-skin grafting. Standard gauze dressings were found to increase the risk of infection, Dr. Fleur E. Brölmann said in presenting the study results at the Veith symposium on vascular medicine sponsored by the Cleveland Clinic.

A 14-center, six-armed, randomized clinical trial (stratified per center) compared six wound dressing materials in adults with DSWs larger than 10 cm² for any indication. Primary outcomes were complete re-epithelialization and pain using a visual analog scale (VAS; 4 weeks). Secondary outcomes included itching (VAS; 4 weeks), adverse events, and scarring after 12 weeks as measured using the Patient and Observer Scar Assessment Scale (POSAS), said Dr. Brölmann, who is a Ph.D. candidate at the Academic Medical Center in Amsterdam.

Between October 2009 and December 2011, patients were randomized to either alginate (45 patients), film (49), gauze (50), hydrocolloid (47), hydrofiber (47), or silicone (48).

Time to complete re-epithelialization using hydrocolloid dressings (median 16 days) was 7 days shorter than with any other dressing, a significant difference, she said in her presentation titled "How To Treat Donor Site Wounds: An Evidence Based Approach."

Overall pain scores were low and slightly but significantly lower using film dressings. The infection rate among patients treated with gauzes was twice as high as in those receiving other dressings (18% vs. 9%; relative risk, 2.39; 95% confidence interval, 1.14-5.01). Patients receiving films were least satisfied with overall scar quality.

"This trial shows that hydrocolloid dressings led to the shortest healing time of DSWs among the dressings investigated, while gauzes should be avoided due to increased risk of infection," Dr. Brölmann said. Based on these results, hydrocolloid is the first-choice dressing for DSWs, and should be the standard of care, she added.

Wide variation exists in the local treatment of donor site wounds after split-skin grafting, ranging from classic gauze dressings to modern silicone dressings.

In a multicenter randomized trial of 289 patients, hydrocolloid dressings led to a shorter healing time than other commonly used dressing materials for donor site wounds (DSWs) after split-skin grafting. Standard gauze dressings were found to increase the risk of infection, Dr. Fleur E. Brölmann said in presenting the study results at the Veith symposium on vascular medicine sponsored by the Cleveland Clinic.

A 14-center, six-armed, randomized clinical trial (stratified per center) compared six wound dressing materials in adults with DSWs larger than 10 cm² for any indication. Primary outcomes were complete re-epithelialization and pain using a visual analog scale (VAS; 4 weeks). Secondary outcomes included itching (VAS; 4 weeks), adverse events, and scarring after 12 weeks as measured using the Patient and Observer Scar Assessment Scale (POSAS), said Dr. Brölmann, who is a Ph.D. candidate at the Academic Medical Center in Amsterdam.

Between October 2009 and December 2011, patients were randomized to either alginate (45 patients), film (49), gauze (50), hydrocolloid (47), hydrofiber (47), or silicone (48).

Time to complete re-epithelialization using hydrocolloid dressings (median 16 days) was 7 days shorter than with any other dressing, a significant difference, she said in her presentation titled "How To Treat Donor Site Wounds: An Evidence Based Approach."

Overall pain scores were low and slightly but significantly lower using film dressings. The infection rate among patients treated with gauzes was twice as high as in those receiving other dressings (18% vs. 9%; relative risk, 2.39; 95% confidence interval, 1.14-5.01). Patients receiving films were least satisfied with overall scar quality.

"This trial shows that hydrocolloid dressings led to the shortest healing time of DSWs among the dressings investigated, while gauzes should be avoided due to increased risk of infection," Dr. Brölmann said. Based on these results, hydrocolloid is the first-choice dressing for DSWs, and should be the standard of care, she added.

Wide variation exists in the local treatment of donor site wounds after split-skin grafting, ranging from classic gauze dressings to modern silicone dressings.

In a multicenter randomized trial of 289 patients, hydrocolloid dressings led to a shorter healing time than other commonly used dressing materials for donor site wounds (DSWs) after split-skin grafting. Standard gauze dressings were found to increase the risk of infection, Dr. Fleur E. Brölmann said in presenting the study results at the Veith symposium on vascular medicine sponsored by the Cleveland Clinic.

A 14-center, six-armed, randomized clinical trial (stratified per center) compared six wound dressing materials in adults with DSWs larger than 10 cm² for any indication. Primary outcomes were complete re-epithelialization and pain using a visual analog scale (VAS; 4 weeks). Secondary outcomes included itching (VAS; 4 weeks), adverse events, and scarring after 12 weeks as measured using the Patient and Observer Scar Assessment Scale (POSAS), said Dr. Brölmann, who is a Ph.D. candidate at the Academic Medical Center in Amsterdam.

Between October 2009 and December 2011, patients were randomized to either alginate (45 patients), film (49), gauze (50), hydrocolloid (47), hydrofiber (47), or silicone (48).

Time to complete re-epithelialization using hydrocolloid dressings (median 16 days) was 7 days shorter than with any other dressing, a significant difference, she said in her presentation titled "How To Treat Donor Site Wounds: An Evidence Based Approach."

Overall pain scores were low and slightly but significantly lower using film dressings. The infection rate among patients treated with gauzes was twice as high as in those receiving other dressings (18% vs. 9%; relative risk, 2.39; 95% confidence interval, 1.14-5.01). Patients receiving films were least satisfied with overall scar quality.

"This trial shows that hydrocolloid dressings led to the shortest healing time of DSWs among the dressings investigated, while gauzes should be avoided due to increased risk of infection," Dr. Brölmann said. Based on these results, hydrocolloid is the first-choice dressing for DSWs, and should be the standard of care, she added.

The outbreak of fungal meningitis caused by contaminated methylprednisolone has topped 200 patients and is likely to include more, according to a review article on the subject published online in the New England Journal of Medicine. The article was written in an attempt to answer some of the "numerous questions have been raised by physicians, patients who received injections from the implicated lots, and the public."

Despite the fact that the first case reported found the mold Aspergillus fumigatus as the cause of the meningitis, this organism was not been detected in any of the subsequent 200-plus cases and is no longer considered as the basis for appropriate treatment. Instead, the fungal plant pathogen, Exserohilum rostratum, has been cultured or identified using polymerase chain reaction assay from cerebrospinal fluid in at least 25 patients and was detected in at least one unopened vial from the implicated lot of methylprednisolone, according to Dr. Carol A. Kaufman of the Veterans Affairs Ann Arbor (Mich.) Healthcare System, and her colleagues from Alabama and Texas.

E. rostratum is a "black mold" containing melanin in its cell wall. It is rarely infectious to humans and is usually restricted to mild diseases, such as allergic sinusitis, keratitis, and localized soft-tissue infection. In tissues, E. rostratum has the same appearance of irregular, beaded hyphae as seen in many other dematiaceous fungi, and unlike the rarely septate, ribbonlike hyphae of Mucorales fungi or the acutely branching, hyaline hyphae of aspergillus species.

Recommendations for treating this rare infection are based on small case series, individual case reports, and personal experience, according to the authors of the review article (N. Engl. J. Med. 2012 [doi:10.10156/NEJMra1212617]). The Centers for Disease Control and Prevention is providing information on the outbreak with daily updates, along with appropriate diagnostic testing and treatment details on its website, according to the authors.

Initially, when the causative agent was not known and the only detected microorganism was A. fumigatus, high doses of both liposomal amphotericin B and voriconazole were recommended. Once the primary pathogen was determined to be the black mold, however, monotherapy with voriconazole was recommended, except for the sickest patients or those who had substantial side-effects to the drug. For these, amphotericin B could still play a role, the said.

Although exserohilum species are susceptible to available antifungals, for some strains, the minimal inhibitor concentration for the usually recommended agents, including voriconazole, is increased. Thus, susceptibility testing is advised, they added.

Because of the potential toxic effects of voriconazole, especially in the large doses recommended, and the host of drug-drug interactions in which it is involved, prophylactic use is not recommended, the authors said. They noted that side effects included visual hallucinations, which have been noted in patients treated during the outbreak. Other side effects can include photopsia, nausea, and hepatic enzyme elevation.

"Without objective evidence of infection in the cerebrospinal fluid, treatment is not recommended. However, patients who have symptoms should be monitored closely, and if there is even subtle progression of symptoms, a repeat lumbar puncture should be performed immediately. If the number of white cells has increased [reaching 5 mm³or more], then empirical antifungal treatment should be initiated immediately," the authors stated.

"It is encouraging to note that clinically apparent disease has developed in only a small percentage of exposed patients. Management recommendations will almost assuredly change as more information becomes available regarding the pathogenesis of these infections," they concluded.

Dr. Kaufman and the other authors reported having no relevant disclosures for their review paper.

The outbreak of fungal meningitis caused by contaminated methylprednisolone has topped 200 patients and is likely to include more, according to a review article on the subject published online in the New England Journal of Medicine. The article was written in an attempt to answer some of the "numerous questions have been raised by physicians, patients who received injections from the implicated lots, and the public."

Despite the fact that the first case reported found the mold Aspergillus fumigatus as the cause of the meningitis, this organism was not been detected in any of the subsequent 200-plus cases and is no longer considered as the basis for appropriate treatment. Instead, the fungal plant pathogen, Exserohilum rostratum, has been cultured or identified using polymerase chain reaction assay from cerebrospinal fluid in at least 25 patients and was detected in at least one unopened vial from the implicated lot of methylprednisolone, according to Dr. Carol A. Kaufman of the Veterans Affairs Ann Arbor (Mich.) Healthcare System, and her colleagues from Alabama and Texas.

E. rostratum is a "black mold" containing melanin in its cell wall. It is rarely infectious to humans and is usually restricted to mild diseases, such as allergic sinusitis, keratitis, and localized soft-tissue infection. In tissues, E. rostratum has the same appearance of irregular, beaded hyphae as seen in many other dematiaceous fungi, and unlike the rarely septate, ribbonlike hyphae of Mucorales fungi or the acutely branching, hyaline hyphae of aspergillus species.

Recommendations for treating this rare infection are based on small case series, individual case reports, and personal experience, according to the authors of the review article (N. Engl. J. Med. 2012 [doi:10.10156/NEJMra1212617]). The Centers for Disease Control and Prevention is providing information on the outbreak with daily updates, along with appropriate diagnostic testing and treatment details on its website, according to the authors.

Initially, when the causative agent was not known and the only detected microorganism was A. fumigatus, high doses of both liposomal amphotericin B and voriconazole were recommended. Once the primary pathogen was determined to be the black mold, however, monotherapy with voriconazole was recommended, except for the sickest patients or those who had substantial side-effects to the drug. For these, amphotericin B could still play a role, the said.

Although exserohilum species are susceptible to available antifungals, for some strains, the minimal inhibitor concentration for the usually recommended agents, including voriconazole, is increased. Thus, susceptibility testing is advised, they added.

Because of the potential toxic effects of voriconazole, especially in the large doses recommended, and the host of drug-drug interactions in which it is involved, prophylactic use is not recommended, the authors said. They noted that side effects included visual hallucinations, which have been noted in patients treated during the outbreak. Other side effects can include photopsia, nausea, and hepatic enzyme elevation.

"Without objective evidence of infection in the cerebrospinal fluid, treatment is not recommended. However, patients who have symptoms should be monitored closely, and if there is even subtle progression of symptoms, a repeat lumbar puncture should be performed immediately. If the number of white cells has increased [reaching 5 mm³or more], then empirical antifungal treatment should be initiated immediately," the authors stated.

"It is encouraging to note that clinically apparent disease has developed in only a small percentage of exposed patients. Management recommendations will almost assuredly change as more information becomes available regarding the pathogenesis of these infections," they concluded.

Dr. Kaufman and the other authors reported having no relevant disclosures for their review paper.

The outbreak of fungal meningitis caused by contaminated methylprednisolone has topped 200 patients and is likely to include more, according to a review article on the subject published online in the New England Journal of Medicine. The article was written in an attempt to answer some of the "numerous questions have been raised by physicians, patients who received injections from the implicated lots, and the public."

Despite the fact that the first case reported found the mold Aspergillus fumigatus as the cause of the meningitis, this organism was not been detected in any of the subsequent 200-plus cases and is no longer considered as the basis for appropriate treatment. Instead, the fungal plant pathogen, Exserohilum rostratum, has been cultured or identified using polymerase chain reaction assay from cerebrospinal fluid in at least 25 patients and was detected in at least one unopened vial from the implicated lot of methylprednisolone, according to Dr. Carol A. Kaufman of the Veterans Affairs Ann Arbor (Mich.) Healthcare System, and her colleagues from Alabama and Texas.

E. rostratum is a "black mold" containing melanin in its cell wall. It is rarely infectious to humans and is usually restricted to mild diseases, such as allergic sinusitis, keratitis, and localized soft-tissue infection. In tissues, E. rostratum has the same appearance of irregular, beaded hyphae as seen in many other dematiaceous fungi, and unlike the rarely septate, ribbonlike hyphae of Mucorales fungi or the acutely branching, hyaline hyphae of aspergillus species.

Recommendations for treating this rare infection are based on small case series, individual case reports, and personal experience, according to the authors of the review article (N. Engl. J. Med. 2012 [doi:10.10156/NEJMra1212617]). The Centers for Disease Control and Prevention is providing information on the outbreak with daily updates, along with appropriate diagnostic testing and treatment details on its website, according to the authors.

Initially, when the causative agent was not known and the only detected microorganism was A. fumigatus, high doses of both liposomal amphotericin B and voriconazole were recommended. Once the primary pathogen was determined to be the black mold, however, monotherapy with voriconazole was recommended, except for the sickest patients or those who had substantial side-effects to the drug. For these, amphotericin B could still play a role, the said.

Although exserohilum species are susceptible to available antifungals, for some strains, the minimal inhibitor concentration for the usually recommended agents, including voriconazole, is increased. Thus, susceptibility testing is advised, they added.

Because of the potential toxic effects of voriconazole, especially in the large doses recommended, and the host of drug-drug interactions in which it is involved, prophylactic use is not recommended, the authors said. They noted that side effects included visual hallucinations, which have been noted in patients treated during the outbreak. Other side effects can include photopsia, nausea, and hepatic enzyme elevation.

"Without objective evidence of infection in the cerebrospinal fluid, treatment is not recommended. However, patients who have symptoms should be monitored closely, and if there is even subtle progression of symptoms, a repeat lumbar puncture should be performed immediately. If the number of white cells has increased [reaching 5 mm³or more], then empirical antifungal treatment should be initiated immediately," the authors stated.

"It is encouraging to note that clinically apparent disease has developed in only a small percentage of exposed patients. Management recommendations will almost assuredly change as more information becomes available regarding the pathogenesis of these infections," they concluded.

Dr. Kaufman and the other authors reported having no relevant disclosures for their review paper.