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Pheochromocytoma linked to higher risk of postop complications
LAS VEGAS – Patients with pheochromocytoma are likely to have preoperative comorbidities that predispose them to postoperative cardiopulmonary complications, leading to a longer length of stay and greater hospital charges.
A 5-year national database review found high rates of chronic lung disease and malignant hypertension among these patients, Punam P. Parikh, MD, said at the Association for Academic Surgery/Society of University Surgeons Academic Surgical Congress.
“They are also at an increased risk for vascular injury during surgery, perhaps because these tumors are so vascular in nature, and associated intraoperative blood transfusion,” said Dr. Parikh of the University of Miami. Postoperatively, patients with pheochromocytoma are twice as likely to experience respiratory complications and almost eight times as likely to experience cardiac complications as patients with other hormonally active adrenal tumors.
Dr. Parikh queried the National Inpatient Sample to find patients who underwent adrenalectomy for the rare adrenal tumor from 2006 to 2011. Of 27,312 patients who had adrenalectomy during the 5-year period, 22% had hormonally active adrenal tumors. Of these, just 1.4% (85) were pheochromocytoma. Other hormonally active adrenal tumors were Conn’s syndrome (65%) and Cushing’s syndrome (33%).
A number of comorbidities were significantly more common among pheochromocytoma patients than among those with Conn’s and Cushing’s syndromes, including congestive heart failure (12% vs. 4% in the other syndromes) and malignant hypertension (5% vs. 3% and 0.3%, respectively). A third of pheochromocytoma patients also had diabetes.
The rate of intraoperative complications was significantly higher in these patients (22%) than in those with Conn’s and Cushing’s (11% and 17%). Vascular injury occurred in 6% vs. 2% and 4%, respectively. Almost a quarter of pheochromocytoma patients (21%) needed an intraoperative transfusion, compared with 2% of Conn’s patients and 3% of Cushing’s patients.
There were also more postoperative complications among pheochromocytoma patients than Conn’s or Cushing’s patients, including cardiac (6% vs. 0.4% and 0.6%) and pulmonary complications (17% vs. 6% and 9%).
Not surprisingly, Dr. Parikh said, pheochromocytoma patients had longer hospital stays (5 days), compared with patients with the other tumors (3 days). Hospital charges were also higher for those with pheochromocytoma ($50,000) than those with Conn’s or Cushing’s ($35,500 and $46,334, respectively).
A multivariate analysis concluded that pheochromocytoma was an independent risk factor for intraoperative blood transfusion (odds ratio, 4.2), postoperative cardiac complications (OR, 7.6), and postoperative respiratory complications (OR, 1.9).
Dr. Parikh suggested that patients with pheochromocytoma could benefit from some preoperative preparation.
“Because of these issues, these high-risk patients should undergo appropriate preoperative medical optimization in preparation for their adrenalectomy,” she noted.
She had no financial disclosures.
[email protected]
On Twitter @Alz_Gal
LAS VEGAS – Patients with pheochromocytoma are likely to have preoperative comorbidities that predispose them to postoperative cardiopulmonary complications, leading to a longer length of stay and greater hospital charges.
A 5-year national database review found high rates of chronic lung disease and malignant hypertension among these patients, Punam P. Parikh, MD, said at the Association for Academic Surgery/Society of University Surgeons Academic Surgical Congress.
“They are also at an increased risk for vascular injury during surgery, perhaps because these tumors are so vascular in nature, and associated intraoperative blood transfusion,” said Dr. Parikh of the University of Miami. Postoperatively, patients with pheochromocytoma are twice as likely to experience respiratory complications and almost eight times as likely to experience cardiac complications as patients with other hormonally active adrenal tumors.
Dr. Parikh queried the National Inpatient Sample to find patients who underwent adrenalectomy for the rare adrenal tumor from 2006 to 2011. Of 27,312 patients who had adrenalectomy during the 5-year period, 22% had hormonally active adrenal tumors. Of these, just 1.4% (85) were pheochromocytoma. Other hormonally active adrenal tumors were Conn’s syndrome (65%) and Cushing’s syndrome (33%).
A number of comorbidities were significantly more common among pheochromocytoma patients than among those with Conn’s and Cushing’s syndromes, including congestive heart failure (12% vs. 4% in the other syndromes) and malignant hypertension (5% vs. 3% and 0.3%, respectively). A third of pheochromocytoma patients also had diabetes.
The rate of intraoperative complications was significantly higher in these patients (22%) than in those with Conn’s and Cushing’s (11% and 17%). Vascular injury occurred in 6% vs. 2% and 4%, respectively. Almost a quarter of pheochromocytoma patients (21%) needed an intraoperative transfusion, compared with 2% of Conn’s patients and 3% of Cushing’s patients.
There were also more postoperative complications among pheochromocytoma patients than Conn’s or Cushing’s patients, including cardiac (6% vs. 0.4% and 0.6%) and pulmonary complications (17% vs. 6% and 9%).
Not surprisingly, Dr. Parikh said, pheochromocytoma patients had longer hospital stays (5 days), compared with patients with the other tumors (3 days). Hospital charges were also higher for those with pheochromocytoma ($50,000) than those with Conn’s or Cushing’s ($35,500 and $46,334, respectively).
A multivariate analysis concluded that pheochromocytoma was an independent risk factor for intraoperative blood transfusion (odds ratio, 4.2), postoperative cardiac complications (OR, 7.6), and postoperative respiratory complications (OR, 1.9).
Dr. Parikh suggested that patients with pheochromocytoma could benefit from some preoperative preparation.
“Because of these issues, these high-risk patients should undergo appropriate preoperative medical optimization in preparation for their adrenalectomy,” she noted.
She had no financial disclosures.
[email protected]
On Twitter @Alz_Gal
LAS VEGAS – Patients with pheochromocytoma are likely to have preoperative comorbidities that predispose them to postoperative cardiopulmonary complications, leading to a longer length of stay and greater hospital charges.
A 5-year national database review found high rates of chronic lung disease and malignant hypertension among these patients, Punam P. Parikh, MD, said at the Association for Academic Surgery/Society of University Surgeons Academic Surgical Congress.
“They are also at an increased risk for vascular injury during surgery, perhaps because these tumors are so vascular in nature, and associated intraoperative blood transfusion,” said Dr. Parikh of the University of Miami. Postoperatively, patients with pheochromocytoma are twice as likely to experience respiratory complications and almost eight times as likely to experience cardiac complications as patients with other hormonally active adrenal tumors.
Dr. Parikh queried the National Inpatient Sample to find patients who underwent adrenalectomy for the rare adrenal tumor from 2006 to 2011. Of 27,312 patients who had adrenalectomy during the 5-year period, 22% had hormonally active adrenal tumors. Of these, just 1.4% (85) were pheochromocytoma. Other hormonally active adrenal tumors were Conn’s syndrome (65%) and Cushing’s syndrome (33%).
A number of comorbidities were significantly more common among pheochromocytoma patients than among those with Conn’s and Cushing’s syndromes, including congestive heart failure (12% vs. 4% in the other syndromes) and malignant hypertension (5% vs. 3% and 0.3%, respectively). A third of pheochromocytoma patients also had diabetes.
The rate of intraoperative complications was significantly higher in these patients (22%) than in those with Conn’s and Cushing’s (11% and 17%). Vascular injury occurred in 6% vs. 2% and 4%, respectively. Almost a quarter of pheochromocytoma patients (21%) needed an intraoperative transfusion, compared with 2% of Conn’s patients and 3% of Cushing’s patients.
There were also more postoperative complications among pheochromocytoma patients than Conn’s or Cushing’s patients, including cardiac (6% vs. 0.4% and 0.6%) and pulmonary complications (17% vs. 6% and 9%).
Not surprisingly, Dr. Parikh said, pheochromocytoma patients had longer hospital stays (5 days), compared with patients with the other tumors (3 days). Hospital charges were also higher for those with pheochromocytoma ($50,000) than those with Conn’s or Cushing’s ($35,500 and $46,334, respectively).
A multivariate analysis concluded that pheochromocytoma was an independent risk factor for intraoperative blood transfusion (odds ratio, 4.2), postoperative cardiac complications (OR, 7.6), and postoperative respiratory complications (OR, 1.9).
Dr. Parikh suggested that patients with pheochromocytoma could benefit from some preoperative preparation.
“Because of these issues, these high-risk patients should undergo appropriate preoperative medical optimization in preparation for their adrenalectomy,” she noted.
She had no financial disclosures.
[email protected]
On Twitter @Alz_Gal
AT THE ACADEMIC SURGICAL CONGRESS
Key clinical point: that predispose them to postoperative complications and prolonged hospital stays.
Major finding: Pheochromocytoma patients had more postoperative complications than Conn’s or Cushing’s patients, including cardiac (6% vs. 0.4% and 0.6%) and pulmonary complications (17% vs. 6% and 9%).
Data source: The database review comprised more than 27,000 patients with adrenal tumors.
Disclosures: Dr. Parikh had no financial disclosures.
One-third of micropapillary thyroid cancer found to be multifocal
LAS VEGAS – Micropapillary thyroid carcinoma may not be as indolent as generally thought, according to the findings of a retrospective study of thyroidectomy cases.
A review of 213 patients diagnosed with the cancer found that 34% of them had multifocal disease, and 14%, metastatic disease, Maggie Bosley reported at the Association for Academic Surgery/Society of University Surgeons Academic Surgical Congress.
Ms. Bosley presented a review of 213 consecutive patients who underwent thyroidectomy from 2007 to 2015, and were found to have micropapillary thyroid cancer. She reviewed the pathology reports for tumor size, presence or absence of metastases in the central and lateral node basins, and multifocality.
Most of the patients (88%) were women, with an average age of 56 years, although the range was wide (18-89 years).
About a third of the patients (73; 34%) had multifocal disease. This was bilateral in 21 (29%). Metastasis to the central nodes was present in 31 patients (14%); 4 of these patients also had positive lateral neck node metastases (2%).
“Approximately 13% of patients with node metastasis also required selective lateral neck dissections,” Ms. Bosley said.
She noted that, in 2015, the American Thyroid Association published a set of guidelines for diagnosing and treating micropapillary cancer. The guidelines suggest that most of these cancers can be safely followed with ultrasound exams, if there is no extrathyroid extension or nodal metastasis.
“However, ultrasound surveillance [quality] is very operator dependent,” Ms. Bosley said. Technician skill “could potentially impact the quality of surveillance.”
She had no relevant financial declarations.
[email protected]
On Twitter @Alz_Gal
LAS VEGAS – Micropapillary thyroid carcinoma may not be as indolent as generally thought, according to the findings of a retrospective study of thyroidectomy cases.
A review of 213 patients diagnosed with the cancer found that 34% of them had multifocal disease, and 14%, metastatic disease, Maggie Bosley reported at the Association for Academic Surgery/Society of University Surgeons Academic Surgical Congress.
Ms. Bosley presented a review of 213 consecutive patients who underwent thyroidectomy from 2007 to 2015, and were found to have micropapillary thyroid cancer. She reviewed the pathology reports for tumor size, presence or absence of metastases in the central and lateral node basins, and multifocality.
Most of the patients (88%) were women, with an average age of 56 years, although the range was wide (18-89 years).
About a third of the patients (73; 34%) had multifocal disease. This was bilateral in 21 (29%). Metastasis to the central nodes was present in 31 patients (14%); 4 of these patients also had positive lateral neck node metastases (2%).
“Approximately 13% of patients with node metastasis also required selective lateral neck dissections,” Ms. Bosley said.
She noted that, in 2015, the American Thyroid Association published a set of guidelines for diagnosing and treating micropapillary cancer. The guidelines suggest that most of these cancers can be safely followed with ultrasound exams, if there is no extrathyroid extension or nodal metastasis.
“However, ultrasound surveillance [quality] is very operator dependent,” Ms. Bosley said. Technician skill “could potentially impact the quality of surveillance.”
She had no relevant financial declarations.
[email protected]
On Twitter @Alz_Gal
LAS VEGAS – Micropapillary thyroid carcinoma may not be as indolent as generally thought, according to the findings of a retrospective study of thyroidectomy cases.
A review of 213 patients diagnosed with the cancer found that 34% of them had multifocal disease, and 14%, metastatic disease, Maggie Bosley reported at the Association for Academic Surgery/Society of University Surgeons Academic Surgical Congress.
Ms. Bosley presented a review of 213 consecutive patients who underwent thyroidectomy from 2007 to 2015, and were found to have micropapillary thyroid cancer. She reviewed the pathology reports for tumor size, presence or absence of metastases in the central and lateral node basins, and multifocality.
Most of the patients (88%) were women, with an average age of 56 years, although the range was wide (18-89 years).
About a third of the patients (73; 34%) had multifocal disease. This was bilateral in 21 (29%). Metastasis to the central nodes was present in 31 patients (14%); 4 of these patients also had positive lateral neck node metastases (2%).
“Approximately 13% of patients with node metastasis also required selective lateral neck dissections,” Ms. Bosley said.
She noted that, in 2015, the American Thyroid Association published a set of guidelines for diagnosing and treating micropapillary cancer. The guidelines suggest that most of these cancers can be safely followed with ultrasound exams, if there is no extrathyroid extension or nodal metastasis.
“However, ultrasound surveillance [quality] is very operator dependent,” Ms. Bosley said. Technician skill “could potentially impact the quality of surveillance.”
She had no relevant financial declarations.
[email protected]
On Twitter @Alz_Gal
AT THE ACADEMIC SURGICAL CONGRESS
Key clinical point:
Major finding: Micropapillary thyroid cancer was metastatic in 14% of cases.
Data source: A review involving 213 patients.
Disclosures: Ms. Bosley had no relevant financial disclosures.
Intraoperative PTH spikes may mean multigland disease
SAN DIEGO – Intraoperative spikes of parathyroid hormone don’t predict a failed parathyroidectomy, according to a retrospective study of patients who had the surgery for hyperparathyroidism.
They should, however, raise the suspicion of multigland disease, Richard Teo said at the Association for Academic Surgery/Society of University Surgeons Academic Surgical Congress.
“Significantly more patients with intraoperative spikes didn’t achieve this drop, and they had a higher rate of multigland disease requiring bilateral neck exploration,” he said. “But although spikes did increase the suspicion of multigland disease, they did not affect the operative success rate in this study.”
He presented a retrospective analysis of 683 patients who underwent parathyroidectomy for hyperparathyroidism. These patients were largely female (76%). Those who had the intraoperative spikes were older (60 vs. 58 years) and had higher preoperative calcium than patients without spikes. There were no differences in parathyroid hormone (PTH) or creatinine levels.
Operative success – described as normocalcemia at least 6 months after surgery – occurred in 98% of the entire group. The operative failure rate was 0.9%, and the recurrence rate was 1%. About 5% of the entire group had multigland disease.
Intraoperative PTH spikes occurred in 224 patients (33%). Compared with those without spikes, patients with spikes were significantly less likely to achieve the PTH decrease of 50% or greater at 10 minutes after gland excision (70% vs. 90%).
Bilateral neck explorations were significantly more common among those with spikes (10% vs. 5%), as was multigland disease (8% vs. 3%). There was no significant difference in operative time (54 vs. 59 minutes).
Postoperative outcomes were similar. At last follow-up, calcium levels were identical (9.3 mg/dL) in the group with and the group without a spike in PTH. In addition, the PTH levels were not significantly different (47 vs. 57 pg/mL).
Operative success was achieved in 98% of both groups, with a 2% failure rate in both groups. Recurrence was slightly, though not significantly, less in the spike group (0.4% vs. 1.3%).
“We were able to show that intraoperative PTH spikes don’t predict a poor outcome of parathyroidectomy,” Mr. Teo said. “We also feel this study reaffirms the clinical utility of the 50% or greater intraoperative PTH drop as a predictor of the successful removal of all hypersecreting parathyroid tissue during parathyroidectomy guided by intraoperative PTH monitoring.”
He had no financial disclosures.
[email protected]
On Twitter @alz_gal
SAN DIEGO – Intraoperative spikes of parathyroid hormone don’t predict a failed parathyroidectomy, according to a retrospective study of patients who had the surgery for hyperparathyroidism.
They should, however, raise the suspicion of multigland disease, Richard Teo said at the Association for Academic Surgery/Society of University Surgeons Academic Surgical Congress.
“Significantly more patients with intraoperative spikes didn’t achieve this drop, and they had a higher rate of multigland disease requiring bilateral neck exploration,” he said. “But although spikes did increase the suspicion of multigland disease, they did not affect the operative success rate in this study.”
He presented a retrospective analysis of 683 patients who underwent parathyroidectomy for hyperparathyroidism. These patients were largely female (76%). Those who had the intraoperative spikes were older (60 vs. 58 years) and had higher preoperative calcium than patients without spikes. There were no differences in parathyroid hormone (PTH) or creatinine levels.
Operative success – described as normocalcemia at least 6 months after surgery – occurred in 98% of the entire group. The operative failure rate was 0.9%, and the recurrence rate was 1%. About 5% of the entire group had multigland disease.
Intraoperative PTH spikes occurred in 224 patients (33%). Compared with those without spikes, patients with spikes were significantly less likely to achieve the PTH decrease of 50% or greater at 10 minutes after gland excision (70% vs. 90%).
Bilateral neck explorations were significantly more common among those with spikes (10% vs. 5%), as was multigland disease (8% vs. 3%). There was no significant difference in operative time (54 vs. 59 minutes).
Postoperative outcomes were similar. At last follow-up, calcium levels were identical (9.3 mg/dL) in the group with and the group without a spike in PTH. In addition, the PTH levels were not significantly different (47 vs. 57 pg/mL).
Operative success was achieved in 98% of both groups, with a 2% failure rate in both groups. Recurrence was slightly, though not significantly, less in the spike group (0.4% vs. 1.3%).
“We were able to show that intraoperative PTH spikes don’t predict a poor outcome of parathyroidectomy,” Mr. Teo said. “We also feel this study reaffirms the clinical utility of the 50% or greater intraoperative PTH drop as a predictor of the successful removal of all hypersecreting parathyroid tissue during parathyroidectomy guided by intraoperative PTH monitoring.”
He had no financial disclosures.
[email protected]
On Twitter @alz_gal
SAN DIEGO – Intraoperative spikes of parathyroid hormone don’t predict a failed parathyroidectomy, according to a retrospective study of patients who had the surgery for hyperparathyroidism.
They should, however, raise the suspicion of multigland disease, Richard Teo said at the Association for Academic Surgery/Society of University Surgeons Academic Surgical Congress.
“Significantly more patients with intraoperative spikes didn’t achieve this drop, and they had a higher rate of multigland disease requiring bilateral neck exploration,” he said. “But although spikes did increase the suspicion of multigland disease, they did not affect the operative success rate in this study.”
He presented a retrospective analysis of 683 patients who underwent parathyroidectomy for hyperparathyroidism. These patients were largely female (76%). Those who had the intraoperative spikes were older (60 vs. 58 years) and had higher preoperative calcium than patients without spikes. There were no differences in parathyroid hormone (PTH) or creatinine levels.
Operative success – described as normocalcemia at least 6 months after surgery – occurred in 98% of the entire group. The operative failure rate was 0.9%, and the recurrence rate was 1%. About 5% of the entire group had multigland disease.
Intraoperative PTH spikes occurred in 224 patients (33%). Compared with those without spikes, patients with spikes were significantly less likely to achieve the PTH decrease of 50% or greater at 10 minutes after gland excision (70% vs. 90%).
Bilateral neck explorations were significantly more common among those with spikes (10% vs. 5%), as was multigland disease (8% vs. 3%). There was no significant difference in operative time (54 vs. 59 minutes).
Postoperative outcomes were similar. At last follow-up, calcium levels were identical (9.3 mg/dL) in the group with and the group without a spike in PTH. In addition, the PTH levels were not significantly different (47 vs. 57 pg/mL).
Operative success was achieved in 98% of both groups, with a 2% failure rate in both groups. Recurrence was slightly, though not significantly, less in the spike group (0.4% vs. 1.3%).
“We were able to show that intraoperative PTH spikes don’t predict a poor outcome of parathyroidectomy,” Mr. Teo said. “We also feel this study reaffirms the clinical utility of the 50% or greater intraoperative PTH drop as a predictor of the successful removal of all hypersecreting parathyroid tissue during parathyroidectomy guided by intraoperative PTH monitoring.”
He had no financial disclosures.
[email protected]
On Twitter @alz_gal
Key clinical point: Major finding: Intraoperative PTH spikes occurred in 33% of parathyroidectomy patients, and 8% of patients with spikes had multigland disease.
Data source: The retrospective study comprised 683 patients.
Disclosures: He had no financial disclosures.
Study finds Roux-en-Y safe, effective for older patients
LAS VEGAS – Older obese patients shouldn’t be excluded from undergoing a Roux-en-Y gastric bypass based on concern for their long-term survival.
A 30-year review has determined that patients 60 years and older who had the surgery lost most of their excess body weight, and lived just as long as an age- and weight- matched cohort.
“We found a major weight loss benefit and no long-term differences in survival,” Taryn Hassinger, MD, said at the Association for Academic Surgery/Society of University Surgeons Academic Surgical Congress. “Our data support the use of this surgery in the elderly to achieve safe and effective weight loss.”
These subjects were matched for age and baseline weight to a group of 425 who did not have any bariatric surgery. Survival data in the univariate analysis came from Social Security death records.
The groups were similar at baseline, with a mean age of 62 and a mean body mass index of 47 kg/m2. About half of each group had obstructive sleep apnea. Other comorbidities were osteoarthritis (63%), chronic obstructive pulmonary disease (24%), type 2 diabetes (58%), gastroesophageal reflux (52%), congestive heart failure (8%), and hypertension (78%). About a quarter of each group smoked.
Patients were followed for up to 6 years. At the end of follow-up, those who had the surgery had lost a mean of 84% of their excess body weight. There was hardly any weight loss evident in the control group – a mean reduction of 4.6%. At the end of the follow-up period, 90% of surgical patients and 93% of the control patients were still alive.
The study provides reassuring data in an area that has not been well explored, Dr. Hassinger added. The only extant studies have compared older and younger cohorts. Peter Muscarella, MD, who moderated the session, agreed.
“This is very interesting, and good to know as we continue to expand the use of Roux-en-Y into different populations,” said Dr. Muscarella, a surgeon at Montefiore Medical Center, New York. “We have already expanded it into the pediatric population and now we are looking at its use in older individuals. But one question is, are there epidemiologic data on obesity in elderly patients? In my own practice, I just don’t see a lot of obese elderly patients. Is this really a problem in our country?”
A 2012 paper published by the National Center for Health Statistics addressed this issue. Data from the National Health and Nutrition Examination Survey, 2007-2010, found that nearly one-third of U.S. adults aged 65 years and older were obese. Other key findings:
• Obesity prevalence was higher among those aged 65-74, compared with those aged 75 and over in both men and women.
• The prevalence of obesity in women aged 65-74 was higher than in women aged 75 and over in all racial and ethnic groups except non-Hispanic black women, where approximately one in two were obese among both age groups.
• Between 1999-2002 and 2007-2010, the prevalence of obesity among older men increased.
As the proportion of older adults increases in the U.S. population, surgeons are likely to see older patients who are candidates for bariatric surgery, Dr. Hassinger said.
“We believe that surgery may be an option for people who are in the 60-70 year range,” she said. “We do operate on those patients not infrequently.”
The investigator had no disclosures.
[email protected]
On Twitter @Alz_Gal
LAS VEGAS – Older obese patients shouldn’t be excluded from undergoing a Roux-en-Y gastric bypass based on concern for their long-term survival.
A 30-year review has determined that patients 60 years and older who had the surgery lost most of their excess body weight, and lived just as long as an age- and weight- matched cohort.
“We found a major weight loss benefit and no long-term differences in survival,” Taryn Hassinger, MD, said at the Association for Academic Surgery/Society of University Surgeons Academic Surgical Congress. “Our data support the use of this surgery in the elderly to achieve safe and effective weight loss.”
These subjects were matched for age and baseline weight to a group of 425 who did not have any bariatric surgery. Survival data in the univariate analysis came from Social Security death records.
The groups were similar at baseline, with a mean age of 62 and a mean body mass index of 47 kg/m2. About half of each group had obstructive sleep apnea. Other comorbidities were osteoarthritis (63%), chronic obstructive pulmonary disease (24%), type 2 diabetes (58%), gastroesophageal reflux (52%), congestive heart failure (8%), and hypertension (78%). About a quarter of each group smoked.
Patients were followed for up to 6 years. At the end of follow-up, those who had the surgery had lost a mean of 84% of their excess body weight. There was hardly any weight loss evident in the control group – a mean reduction of 4.6%. At the end of the follow-up period, 90% of surgical patients and 93% of the control patients were still alive.
The study provides reassuring data in an area that has not been well explored, Dr. Hassinger added. The only extant studies have compared older and younger cohorts. Peter Muscarella, MD, who moderated the session, agreed.
“This is very interesting, and good to know as we continue to expand the use of Roux-en-Y into different populations,” said Dr. Muscarella, a surgeon at Montefiore Medical Center, New York. “We have already expanded it into the pediatric population and now we are looking at its use in older individuals. But one question is, are there epidemiologic data on obesity in elderly patients? In my own practice, I just don’t see a lot of obese elderly patients. Is this really a problem in our country?”
A 2012 paper published by the National Center for Health Statistics addressed this issue. Data from the National Health and Nutrition Examination Survey, 2007-2010, found that nearly one-third of U.S. adults aged 65 years and older were obese. Other key findings:
• Obesity prevalence was higher among those aged 65-74, compared with those aged 75 and over in both men and women.
• The prevalence of obesity in women aged 65-74 was higher than in women aged 75 and over in all racial and ethnic groups except non-Hispanic black women, where approximately one in two were obese among both age groups.
• Between 1999-2002 and 2007-2010, the prevalence of obesity among older men increased.
As the proportion of older adults increases in the U.S. population, surgeons are likely to see older patients who are candidates for bariatric surgery, Dr. Hassinger said.
“We believe that surgery may be an option for people who are in the 60-70 year range,” she said. “We do operate on those patients not infrequently.”
The investigator had no disclosures.
[email protected]
On Twitter @Alz_Gal
LAS VEGAS – Older obese patients shouldn’t be excluded from undergoing a Roux-en-Y gastric bypass based on concern for their long-term survival.
A 30-year review has determined that patients 60 years and older who had the surgery lost most of their excess body weight, and lived just as long as an age- and weight- matched cohort.
“We found a major weight loss benefit and no long-term differences in survival,” Taryn Hassinger, MD, said at the Association for Academic Surgery/Society of University Surgeons Academic Surgical Congress. “Our data support the use of this surgery in the elderly to achieve safe and effective weight loss.”
These subjects were matched for age and baseline weight to a group of 425 who did not have any bariatric surgery. Survival data in the univariate analysis came from Social Security death records.
The groups were similar at baseline, with a mean age of 62 and a mean body mass index of 47 kg/m2. About half of each group had obstructive sleep apnea. Other comorbidities were osteoarthritis (63%), chronic obstructive pulmonary disease (24%), type 2 diabetes (58%), gastroesophageal reflux (52%), congestive heart failure (8%), and hypertension (78%). About a quarter of each group smoked.
Patients were followed for up to 6 years. At the end of follow-up, those who had the surgery had lost a mean of 84% of their excess body weight. There was hardly any weight loss evident in the control group – a mean reduction of 4.6%. At the end of the follow-up period, 90% of surgical patients and 93% of the control patients were still alive.
The study provides reassuring data in an area that has not been well explored, Dr. Hassinger added. The only extant studies have compared older and younger cohorts. Peter Muscarella, MD, who moderated the session, agreed.
“This is very interesting, and good to know as we continue to expand the use of Roux-en-Y into different populations,” said Dr. Muscarella, a surgeon at Montefiore Medical Center, New York. “We have already expanded it into the pediatric population and now we are looking at its use in older individuals. But one question is, are there epidemiologic data on obesity in elderly patients? In my own practice, I just don’t see a lot of obese elderly patients. Is this really a problem in our country?”
A 2012 paper published by the National Center for Health Statistics addressed this issue. Data from the National Health and Nutrition Examination Survey, 2007-2010, found that nearly one-third of U.S. adults aged 65 years and older were obese. Other key findings:
• Obesity prevalence was higher among those aged 65-74, compared with those aged 75 and over in both men and women.
• The prevalence of obesity in women aged 65-74 was higher than in women aged 75 and over in all racial and ethnic groups except non-Hispanic black women, where approximately one in two were obese among both age groups.
• Between 1999-2002 and 2007-2010, the prevalence of obesity among older men increased.
As the proportion of older adults increases in the U.S. population, surgeons are likely to see older patients who are candidates for bariatric surgery, Dr. Hassinger said.
“We believe that surgery may be an option for people who are in the 60-70 year range,” she said. “We do operate on those patients not infrequently.”
The investigator had no disclosures.
[email protected]
On Twitter @Alz_Gal
AT THE ACADEMIC SURGICAL CONGRESS
Key clinical point: Older patients can safely lose weight after Roux-en-Y gastric bypass without excess mortality risk.
Major finding: At the end of follow-up, patients had lost a mean of 84% of their excess body weight, compared with 4.6% loss in controls. Survival was similar (90% of surgical patients and 93% of controls).
Data source: The retrospective study comprised 107 patients and 425 controls.
Disclosures: The investigator had no disclosures.
Comorbid mental illness linked to worse surgical outcomes
LAS VEGAS – A comorbid mental illness may predispose surgical patients to poor outcomes, increasing the risk of postoperative complications, a prolonged length of stay, and – in some cases – even in-hospital mortality.
The link between mental illness and physical response to surgery is not well elucidated, and is likely an extremely complicated one, Elizabeth Bailey, MD, said at the Association for Academic Surgery/Society of University Surgeons Academic Surgical Congress.
Dr. Bailey said there is an extreme paucity of data on the relationship between mental illness and surgical outcomes. To investigate it, she examined 580,000 patient records contained in the National Inpatient Sample.
The cases spanned 2009-2011 and represented the four most common surgical procedures in the United States: cholecystectomy, appendectomy, adhesion excision/lysis, and colorectal resection.
She compared surgical outcomes among patients without a DSM-IV diagnosis and those with one of the five most common: mood disorder, anxiety, impulse control, schizophrenia, and substance abuse disorder.
The study’s primary outcomes were length of hospital stay, in-hospital mortality, and postoperative complications. Her analysis controlled for age, gender, race, admission status, operative approach, non–mental health comorbidities, insurance, and income.
Of the 580,000 in the study group 7% (39,000) had at least one of the mental health comorbidities. Mood disorder was the most common (59%), followed by substance abuse (24%), schizophrenia (13%), anxiety disorder (12%), and impulse control disorder (5%).
There were a number of significant baseline differences between those with a mental diagnosis and those without. Those with a DSM-IV diagnosis were younger (52 vs. 54 years), more often women (61% vs. 57%), and white (78% vs. 69%). They more often had additional physical comorbidities (80% vs. 68%). They were more likely to be admitted through the emergency room (74% vs. 71%), to have nonlaparoscopic surgery (60% vs 63%), to be on public insurance (53% vs. 43%), and to be in the lowest income quartile (28% vs. 25%).
Surgical outcomes were almost universally significantly worse among these patients. They were 41% more likely to experience a prolonged length of stay and 18% more likely to experience a complication. These included wound disruption, ileus, and small bowel obstruction. They faced a 24% increased risk for needing total parenteral nutrition; a 29% increased risk of abdominal pain; an 18% increased risk of percutaneous abdominal drainage; and a 15% increased risk of needing another operation in the same admission.
Dr. Bailey also broke down overall risks by DSM-IV diagnosis.
• Patients with a mood disorder were 35% more likely to have a prolonged length of stay and 13% more likely to have a surgical complication.
• Patients with an anxiety disorder were 16% more likely to have a prolonged length of stay and 10% more likely to have a complication.
• Patients with schizophrenia were 77% more likely to have a prolonged length of stay, 3% more likely to die, and 28% more likely to have a complication.
• Patients with substance abuse were 70% more likely to have a prolonged length of stay, 6% more likely to die, and 39% more likely to have a complication.
Interestingly, Dr. Bailey said, the risk of in-hospital death was 16% lower in patients with a mood disorder, 59% lower in those with an anxiety disorder, and 77% lower in those with an impulse control disorder.
She stressed that the National Inpatient Sample provides a limited look into a patient’s hospital experience. The study can’t assess how long patients were sick before they came to the hospital, their medications or medication adherence, or how well they managed their mental and physical comorbidities.
“While we lacked the means to delve into potential clinical mediators, look at unplanned readmissions, or the use of inpatient psychiatric consults, we can clearly see the association with worse surgical outcomes,” Dr. Bailey said. “Recognizing this is the first step in learning how to optimize care for this frequently marginalized population.”
She had no financial disclosures.
[email protected]
On Twitter @Alz_Gal
LAS VEGAS – A comorbid mental illness may predispose surgical patients to poor outcomes, increasing the risk of postoperative complications, a prolonged length of stay, and – in some cases – even in-hospital mortality.
The link between mental illness and physical response to surgery is not well elucidated, and is likely an extremely complicated one, Elizabeth Bailey, MD, said at the Association for Academic Surgery/Society of University Surgeons Academic Surgical Congress.
Dr. Bailey said there is an extreme paucity of data on the relationship between mental illness and surgical outcomes. To investigate it, she examined 580,000 patient records contained in the National Inpatient Sample.
The cases spanned 2009-2011 and represented the four most common surgical procedures in the United States: cholecystectomy, appendectomy, adhesion excision/lysis, and colorectal resection.
She compared surgical outcomes among patients without a DSM-IV diagnosis and those with one of the five most common: mood disorder, anxiety, impulse control, schizophrenia, and substance abuse disorder.
The study’s primary outcomes were length of hospital stay, in-hospital mortality, and postoperative complications. Her analysis controlled for age, gender, race, admission status, operative approach, non–mental health comorbidities, insurance, and income.
Of the 580,000 in the study group 7% (39,000) had at least one of the mental health comorbidities. Mood disorder was the most common (59%), followed by substance abuse (24%), schizophrenia (13%), anxiety disorder (12%), and impulse control disorder (5%).
There were a number of significant baseline differences between those with a mental diagnosis and those without. Those with a DSM-IV diagnosis were younger (52 vs. 54 years), more often women (61% vs. 57%), and white (78% vs. 69%). They more often had additional physical comorbidities (80% vs. 68%). They were more likely to be admitted through the emergency room (74% vs. 71%), to have nonlaparoscopic surgery (60% vs 63%), to be on public insurance (53% vs. 43%), and to be in the lowest income quartile (28% vs. 25%).
Surgical outcomes were almost universally significantly worse among these patients. They were 41% more likely to experience a prolonged length of stay and 18% more likely to experience a complication. These included wound disruption, ileus, and small bowel obstruction. They faced a 24% increased risk for needing total parenteral nutrition; a 29% increased risk of abdominal pain; an 18% increased risk of percutaneous abdominal drainage; and a 15% increased risk of needing another operation in the same admission.
Dr. Bailey also broke down overall risks by DSM-IV diagnosis.
• Patients with a mood disorder were 35% more likely to have a prolonged length of stay and 13% more likely to have a surgical complication.
• Patients with an anxiety disorder were 16% more likely to have a prolonged length of stay and 10% more likely to have a complication.
• Patients with schizophrenia were 77% more likely to have a prolonged length of stay, 3% more likely to die, and 28% more likely to have a complication.
• Patients with substance abuse were 70% more likely to have a prolonged length of stay, 6% more likely to die, and 39% more likely to have a complication.
Interestingly, Dr. Bailey said, the risk of in-hospital death was 16% lower in patients with a mood disorder, 59% lower in those with an anxiety disorder, and 77% lower in those with an impulse control disorder.
She stressed that the National Inpatient Sample provides a limited look into a patient’s hospital experience. The study can’t assess how long patients were sick before they came to the hospital, their medications or medication adherence, or how well they managed their mental and physical comorbidities.
“While we lacked the means to delve into potential clinical mediators, look at unplanned readmissions, or the use of inpatient psychiatric consults, we can clearly see the association with worse surgical outcomes,” Dr. Bailey said. “Recognizing this is the first step in learning how to optimize care for this frequently marginalized population.”
She had no financial disclosures.
[email protected]
On Twitter @Alz_Gal
LAS VEGAS – A comorbid mental illness may predispose surgical patients to poor outcomes, increasing the risk of postoperative complications, a prolonged length of stay, and – in some cases – even in-hospital mortality.
The link between mental illness and physical response to surgery is not well elucidated, and is likely an extremely complicated one, Elizabeth Bailey, MD, said at the Association for Academic Surgery/Society of University Surgeons Academic Surgical Congress.
Dr. Bailey said there is an extreme paucity of data on the relationship between mental illness and surgical outcomes. To investigate it, she examined 580,000 patient records contained in the National Inpatient Sample.
The cases spanned 2009-2011 and represented the four most common surgical procedures in the United States: cholecystectomy, appendectomy, adhesion excision/lysis, and colorectal resection.
She compared surgical outcomes among patients without a DSM-IV diagnosis and those with one of the five most common: mood disorder, anxiety, impulse control, schizophrenia, and substance abuse disorder.
The study’s primary outcomes were length of hospital stay, in-hospital mortality, and postoperative complications. Her analysis controlled for age, gender, race, admission status, operative approach, non–mental health comorbidities, insurance, and income.
Of the 580,000 in the study group 7% (39,000) had at least one of the mental health comorbidities. Mood disorder was the most common (59%), followed by substance abuse (24%), schizophrenia (13%), anxiety disorder (12%), and impulse control disorder (5%).
There were a number of significant baseline differences between those with a mental diagnosis and those without. Those with a DSM-IV diagnosis were younger (52 vs. 54 years), more often women (61% vs. 57%), and white (78% vs. 69%). They more often had additional physical comorbidities (80% vs. 68%). They were more likely to be admitted through the emergency room (74% vs. 71%), to have nonlaparoscopic surgery (60% vs 63%), to be on public insurance (53% vs. 43%), and to be in the lowest income quartile (28% vs. 25%).
Surgical outcomes were almost universally significantly worse among these patients. They were 41% more likely to experience a prolonged length of stay and 18% more likely to experience a complication. These included wound disruption, ileus, and small bowel obstruction. They faced a 24% increased risk for needing total parenteral nutrition; a 29% increased risk of abdominal pain; an 18% increased risk of percutaneous abdominal drainage; and a 15% increased risk of needing another operation in the same admission.
Dr. Bailey also broke down overall risks by DSM-IV diagnosis.
• Patients with a mood disorder were 35% more likely to have a prolonged length of stay and 13% more likely to have a surgical complication.
• Patients with an anxiety disorder were 16% more likely to have a prolonged length of stay and 10% more likely to have a complication.
• Patients with schizophrenia were 77% more likely to have a prolonged length of stay, 3% more likely to die, and 28% more likely to have a complication.
• Patients with substance abuse were 70% more likely to have a prolonged length of stay, 6% more likely to die, and 39% more likely to have a complication.
Interestingly, Dr. Bailey said, the risk of in-hospital death was 16% lower in patients with a mood disorder, 59% lower in those with an anxiety disorder, and 77% lower in those with an impulse control disorder.
She stressed that the National Inpatient Sample provides a limited look into a patient’s hospital experience. The study can’t assess how long patients were sick before they came to the hospital, their medications or medication adherence, or how well they managed their mental and physical comorbidities.
“While we lacked the means to delve into potential clinical mediators, look at unplanned readmissions, or the use of inpatient psychiatric consults, we can clearly see the association with worse surgical outcomes,” Dr. Bailey said. “Recognizing this is the first step in learning how to optimize care for this frequently marginalized population.”
She had no financial disclosures.
[email protected]
On Twitter @Alz_Gal
AT THE ACADEMIC SURGICAL CONGRESS
Key clinical point:
Major finding: They were 41% more likely to experience a prolonged length of stay and 18% more likely to experience a complication.
Data source: The database review comprised 580,000 patients.
Disclosures: Dr. Bailey had no financial disclosures.
Complicated appendicitis outcomes worse with delayed surgery
LAS VEGAS – Contrary to what some recent studies suggest, patients with complicated appendicitis may benefit from immediate surgery, with shorter hospital stays and fewer postoperative complications.
According to findings from a large database review, delaying the surgery for a complicated case is likely to result in worse patient outcomes, Matthew Symer, MD, said at the Association for Academic Surgery/Society of University Surgeons Academic Surgical Congress.
There are no firm guidelines about the timing of surgery for complicated appendicitis, he said. “There is in fact some controversy about the timing of surgery,” with studies coming to conflicting conclusions about the benefits and risks of both immediate and delayed treatment. “We theorized that the potential morbidity of operating at the height of the inflammatory process would be less than the risk of complications associated with delay,” he said.
To investigate the question, Dr. Symer and his colleagues queried the New York Statewide Planning and Research Cooperative Database, which contains information on all hospital admissions with an ICD-9 code on any patient covered by any payer in the state. Each patient has a unique identifier that allows tracking over time and across facilities.
From 2000 to 2013, the investigators identified 38,840 patients who presented with complicated appendicitis, defined as a perforation. Of these, 31,167 had an appendectomy within 1 year of the index admission. These patients were separated into two groups: those who had surgery within 48 hours of the index admission (28,015) and those who had later surgery (3,152).
The delayed surgery group was further parsed into three: those who had surgery during the index admission, but at least 48 hours after admission (51%); those who had an appendectomy at a subsequent urgent admission (23%); and those who had an elective interval appendectomy sometime within that year (26%).
In comparing the early vs. late surgery groups overall, Dr. Symer noticed some significant initial differences. Patients in the early surgery group were significantly younger (48 vs. 53 years), more likely to be male (55% vs. 47%), white (70% vs. 64%), and to have private insurance (53% vs. 45%).
Comorbidities were more common among the delayed surgery group. These included chronic obstructive pulmonary disease, renal failure, coronary artery disease, hypertension, diabetes, and congestive heart failure. Delayed-surgery patients were more likely to be treated at high-volume hospitals (45% vs. 34%).
Abscess was more common among the delayed surgery group (72% vs. 51%). Their median length of stay was significantly longer (9 vs. 5 days).
Delayed-surgery patients experienced significantly more iatrogenic complications (4% vs. 2%), and more urinary and wound complications. Overall, two or more complications occurred in 23% of the delayed surgery group and 14% of the early surgery group. The readmission rate was higher (28% vs. 18%). Significantly more in the delayed group reached the 75th percentile in hospital charges (62% vs. 26%).
In a multivariate regression analysis, patients with delayed surgery were more likely to experience a prolonged length of stay (odds ratio, 6); high hospital charges (OR, 4.8), iatrogenic complications (OR, 1.9), any complications (OR, 1.5) and readmission (OR, 1.5).
These findings were largely recapitulated when Dr. Symer broke the delayed group down into the three subgroups: patients who had surgery late in the index admission, patients who had an urgent later appendectomy, and patients who had a later elective procedure.
“All of these relationships held up, with patients who delayed surgery having worse overall complications, whether iatrogenic or any complications, more readmissions, and a longer stay in the hospital,” Dr. Symer said.
He had no financial disclosures.
[email protected]
On Twitter @Alz_Gal
LAS VEGAS – Contrary to what some recent studies suggest, patients with complicated appendicitis may benefit from immediate surgery, with shorter hospital stays and fewer postoperative complications.
According to findings from a large database review, delaying the surgery for a complicated case is likely to result in worse patient outcomes, Matthew Symer, MD, said at the Association for Academic Surgery/Society of University Surgeons Academic Surgical Congress.
There are no firm guidelines about the timing of surgery for complicated appendicitis, he said. “There is in fact some controversy about the timing of surgery,” with studies coming to conflicting conclusions about the benefits and risks of both immediate and delayed treatment. “We theorized that the potential morbidity of operating at the height of the inflammatory process would be less than the risk of complications associated with delay,” he said.
To investigate the question, Dr. Symer and his colleagues queried the New York Statewide Planning and Research Cooperative Database, which contains information on all hospital admissions with an ICD-9 code on any patient covered by any payer in the state. Each patient has a unique identifier that allows tracking over time and across facilities.
From 2000 to 2013, the investigators identified 38,840 patients who presented with complicated appendicitis, defined as a perforation. Of these, 31,167 had an appendectomy within 1 year of the index admission. These patients were separated into two groups: those who had surgery within 48 hours of the index admission (28,015) and those who had later surgery (3,152).
The delayed surgery group was further parsed into three: those who had surgery during the index admission, but at least 48 hours after admission (51%); those who had an appendectomy at a subsequent urgent admission (23%); and those who had an elective interval appendectomy sometime within that year (26%).
In comparing the early vs. late surgery groups overall, Dr. Symer noticed some significant initial differences. Patients in the early surgery group were significantly younger (48 vs. 53 years), more likely to be male (55% vs. 47%), white (70% vs. 64%), and to have private insurance (53% vs. 45%).
Comorbidities were more common among the delayed surgery group. These included chronic obstructive pulmonary disease, renal failure, coronary artery disease, hypertension, diabetes, and congestive heart failure. Delayed-surgery patients were more likely to be treated at high-volume hospitals (45% vs. 34%).
Abscess was more common among the delayed surgery group (72% vs. 51%). Their median length of stay was significantly longer (9 vs. 5 days).
Delayed-surgery patients experienced significantly more iatrogenic complications (4% vs. 2%), and more urinary and wound complications. Overall, two or more complications occurred in 23% of the delayed surgery group and 14% of the early surgery group. The readmission rate was higher (28% vs. 18%). Significantly more in the delayed group reached the 75th percentile in hospital charges (62% vs. 26%).
In a multivariate regression analysis, patients with delayed surgery were more likely to experience a prolonged length of stay (odds ratio, 6); high hospital charges (OR, 4.8), iatrogenic complications (OR, 1.9), any complications (OR, 1.5) and readmission (OR, 1.5).
These findings were largely recapitulated when Dr. Symer broke the delayed group down into the three subgroups: patients who had surgery late in the index admission, patients who had an urgent later appendectomy, and patients who had a later elective procedure.
“All of these relationships held up, with patients who delayed surgery having worse overall complications, whether iatrogenic or any complications, more readmissions, and a longer stay in the hospital,” Dr. Symer said.
He had no financial disclosures.
[email protected]
On Twitter @Alz_Gal
LAS VEGAS – Contrary to what some recent studies suggest, patients with complicated appendicitis may benefit from immediate surgery, with shorter hospital stays and fewer postoperative complications.
According to findings from a large database review, delaying the surgery for a complicated case is likely to result in worse patient outcomes, Matthew Symer, MD, said at the Association for Academic Surgery/Society of University Surgeons Academic Surgical Congress.
There are no firm guidelines about the timing of surgery for complicated appendicitis, he said. “There is in fact some controversy about the timing of surgery,” with studies coming to conflicting conclusions about the benefits and risks of both immediate and delayed treatment. “We theorized that the potential morbidity of operating at the height of the inflammatory process would be less than the risk of complications associated with delay,” he said.
To investigate the question, Dr. Symer and his colleagues queried the New York Statewide Planning and Research Cooperative Database, which contains information on all hospital admissions with an ICD-9 code on any patient covered by any payer in the state. Each patient has a unique identifier that allows tracking over time and across facilities.
From 2000 to 2013, the investigators identified 38,840 patients who presented with complicated appendicitis, defined as a perforation. Of these, 31,167 had an appendectomy within 1 year of the index admission. These patients were separated into two groups: those who had surgery within 48 hours of the index admission (28,015) and those who had later surgery (3,152).
The delayed surgery group was further parsed into three: those who had surgery during the index admission, but at least 48 hours after admission (51%); those who had an appendectomy at a subsequent urgent admission (23%); and those who had an elective interval appendectomy sometime within that year (26%).
In comparing the early vs. late surgery groups overall, Dr. Symer noticed some significant initial differences. Patients in the early surgery group were significantly younger (48 vs. 53 years), more likely to be male (55% vs. 47%), white (70% vs. 64%), and to have private insurance (53% vs. 45%).
Comorbidities were more common among the delayed surgery group. These included chronic obstructive pulmonary disease, renal failure, coronary artery disease, hypertension, diabetes, and congestive heart failure. Delayed-surgery patients were more likely to be treated at high-volume hospitals (45% vs. 34%).
Abscess was more common among the delayed surgery group (72% vs. 51%). Their median length of stay was significantly longer (9 vs. 5 days).
Delayed-surgery patients experienced significantly more iatrogenic complications (4% vs. 2%), and more urinary and wound complications. Overall, two or more complications occurred in 23% of the delayed surgery group and 14% of the early surgery group. The readmission rate was higher (28% vs. 18%). Significantly more in the delayed group reached the 75th percentile in hospital charges (62% vs. 26%).
In a multivariate regression analysis, patients with delayed surgery were more likely to experience a prolonged length of stay (odds ratio, 6); high hospital charges (OR, 4.8), iatrogenic complications (OR, 1.9), any complications (OR, 1.5) and readmission (OR, 1.5).
These findings were largely recapitulated when Dr. Symer broke the delayed group down into the three subgroups: patients who had surgery late in the index admission, patients who had an urgent later appendectomy, and patients who had a later elective procedure.
“All of these relationships held up, with patients who delayed surgery having worse overall complications, whether iatrogenic or any complications, more readmissions, and a longer stay in the hospital,” Dr. Symer said.
He had no financial disclosures.
[email protected]
On Twitter @Alz_Gal
AT THE ACADEMIC SURGICAL CONGRESS
Key clinical point: Delayed surgery for complicated appendicitis was associated with worse patient outcomes than immediate surgery.
Major finding: Patients with delayed surgery were more likely to experience a prolonged length of stay (odds ratio, 6); high hospital charges (OR, 4.8), iatrogenic complications (OR, 1.9), any complications (OR, 1.5) and readmission (OR, 1.5).
Data source: The database review comprised almost 39,000 patients.
Disclosures: Dr. Symer had no financial disclosures.
Four factors signal complicated appendicitis
LAS VEGAS – Four clinical and imaging characteristics can preoperatively identify cases of complicated appendicitis, potentially saving many from long and unnecessary courses of antibiotics.
In a retrospective study, increasing age and days of pain, combined with the size of the appendix and the presence of an appendicolith on imaging were significantly associated with a histopathologic diagnosis of complicated appendicitis, Jonathan Imran, MD, said at the Association for Academic Surgery/Society of University Surgeons Academic Surgical Congress.
“A lot of patients get tagged as complicated but they really aren’t,” said Dr. Imran, a surgical resident at the University of Texas, Dallas. “This definition then guides clinical assessment and has a profound impact on postoperative antibiotics and length of stay. Despite its common use, intraoperative assessment of complicated appendicitis remains subjective.”
On the other hand, the standard of a histopathologic diagnosis isn’t available during surgery to guide postoperative management. Dr. Imran and his colleagues sought to create a risk assessment tool to identify patients at risk of complicated appendicitis on the basis of clinical and imaging findings.
They retrospectively examined 1,066 patients who underwent appendectomy at a single institution from 2011 to 2013. They compared the intraoperative designations of simple and complicated appendicitis with the histopathologic diagnosis.
Of the 827 patients designated as having simple appendicitis during surgery, 763 (93%) were confirmed by histopathology. The remainder had complicated appendicitis on histopathology.
Of the 239 patients designated as having complicated appendicitis during surgery, 143 (60%) were confirmed by histopathology. The remainder actually had simple appendicitis. Of these 96 patients, 60% went on to have prolonged courses of antibiotics that, by definition, were unnecessary.
The team then looked at 30 patient variables in an attempt to construct a prediction tool. Among the significant associations with a complicated presentation were older age, type 2 diabetes, longer duration of pain, less lower left quadrant pain, higher median temperature, higher serum creatinine, longer time from presentation of symptoms to surgery, larger appendix diameter, abscess, and the presence of an appendicolith.
Four of these factors remained significantly associated with complicated appendicitis in a multivariate regression analysis:
• Age (per 10 years) – odds ratio, 1.25.
• Duration of pain (per day) – OR, 1.21.
• Appendix diameter on imaging (per mm) – OR, 1.10.
• Presence of an appendicolith on imaging – OR, 1.65.
These findings are the basis of a preoperative risk assessment score the team is developing, which will be prospectively tested.
“We hope that these predictors, in combination with improved intraoperative grading, could be used to achieve a more timely and accurate diagnosis of complicated appendicitis,” Dr. Imran said.
He had no financial disclosures.
[email protected]
On Twitter @alz_gal
LAS VEGAS – Four clinical and imaging characteristics can preoperatively identify cases of complicated appendicitis, potentially saving many from long and unnecessary courses of antibiotics.
In a retrospective study, increasing age and days of pain, combined with the size of the appendix and the presence of an appendicolith on imaging were significantly associated with a histopathologic diagnosis of complicated appendicitis, Jonathan Imran, MD, said at the Association for Academic Surgery/Society of University Surgeons Academic Surgical Congress.
“A lot of patients get tagged as complicated but they really aren’t,” said Dr. Imran, a surgical resident at the University of Texas, Dallas. “This definition then guides clinical assessment and has a profound impact on postoperative antibiotics and length of stay. Despite its common use, intraoperative assessment of complicated appendicitis remains subjective.”
On the other hand, the standard of a histopathologic diagnosis isn’t available during surgery to guide postoperative management. Dr. Imran and his colleagues sought to create a risk assessment tool to identify patients at risk of complicated appendicitis on the basis of clinical and imaging findings.
They retrospectively examined 1,066 patients who underwent appendectomy at a single institution from 2011 to 2013. They compared the intraoperative designations of simple and complicated appendicitis with the histopathologic diagnosis.
Of the 827 patients designated as having simple appendicitis during surgery, 763 (93%) were confirmed by histopathology. The remainder had complicated appendicitis on histopathology.
Of the 239 patients designated as having complicated appendicitis during surgery, 143 (60%) were confirmed by histopathology. The remainder actually had simple appendicitis. Of these 96 patients, 60% went on to have prolonged courses of antibiotics that, by definition, were unnecessary.
The team then looked at 30 patient variables in an attempt to construct a prediction tool. Among the significant associations with a complicated presentation were older age, type 2 diabetes, longer duration of pain, less lower left quadrant pain, higher median temperature, higher serum creatinine, longer time from presentation of symptoms to surgery, larger appendix diameter, abscess, and the presence of an appendicolith.
Four of these factors remained significantly associated with complicated appendicitis in a multivariate regression analysis:
• Age (per 10 years) – odds ratio, 1.25.
• Duration of pain (per day) – OR, 1.21.
• Appendix diameter on imaging (per mm) – OR, 1.10.
• Presence of an appendicolith on imaging – OR, 1.65.
These findings are the basis of a preoperative risk assessment score the team is developing, which will be prospectively tested.
“We hope that these predictors, in combination with improved intraoperative grading, could be used to achieve a more timely and accurate diagnosis of complicated appendicitis,” Dr. Imran said.
He had no financial disclosures.
[email protected]
On Twitter @alz_gal
LAS VEGAS – Four clinical and imaging characteristics can preoperatively identify cases of complicated appendicitis, potentially saving many from long and unnecessary courses of antibiotics.
In a retrospective study, increasing age and days of pain, combined with the size of the appendix and the presence of an appendicolith on imaging were significantly associated with a histopathologic diagnosis of complicated appendicitis, Jonathan Imran, MD, said at the Association for Academic Surgery/Society of University Surgeons Academic Surgical Congress.
“A lot of patients get tagged as complicated but they really aren’t,” said Dr. Imran, a surgical resident at the University of Texas, Dallas. “This definition then guides clinical assessment and has a profound impact on postoperative antibiotics and length of stay. Despite its common use, intraoperative assessment of complicated appendicitis remains subjective.”
On the other hand, the standard of a histopathologic diagnosis isn’t available during surgery to guide postoperative management. Dr. Imran and his colleagues sought to create a risk assessment tool to identify patients at risk of complicated appendicitis on the basis of clinical and imaging findings.
They retrospectively examined 1,066 patients who underwent appendectomy at a single institution from 2011 to 2013. They compared the intraoperative designations of simple and complicated appendicitis with the histopathologic diagnosis.
Of the 827 patients designated as having simple appendicitis during surgery, 763 (93%) were confirmed by histopathology. The remainder had complicated appendicitis on histopathology.
Of the 239 patients designated as having complicated appendicitis during surgery, 143 (60%) were confirmed by histopathology. The remainder actually had simple appendicitis. Of these 96 patients, 60% went on to have prolonged courses of antibiotics that, by definition, were unnecessary.
The team then looked at 30 patient variables in an attempt to construct a prediction tool. Among the significant associations with a complicated presentation were older age, type 2 diabetes, longer duration of pain, less lower left quadrant pain, higher median temperature, higher serum creatinine, longer time from presentation of symptoms to surgery, larger appendix diameter, abscess, and the presence of an appendicolith.
Four of these factors remained significantly associated with complicated appendicitis in a multivariate regression analysis:
• Age (per 10 years) – odds ratio, 1.25.
• Duration of pain (per day) – OR, 1.21.
• Appendix diameter on imaging (per mm) – OR, 1.10.
• Presence of an appendicolith on imaging – OR, 1.65.
These findings are the basis of a preoperative risk assessment score the team is developing, which will be prospectively tested.
“We hope that these predictors, in combination with improved intraoperative grading, could be used to achieve a more timely and accurate diagnosis of complicated appendicitis,” Dr. Imran said.
He had no financial disclosures.
[email protected]
On Twitter @alz_gal
Key clinical point: Two clinical signs and two imaging findings can help identify patients with complicated appendicitis.
Major finding: Older age, days of pain, appendix diameter, and the presence of an appendicolith significantly predicted a complicated presentation.
Data source: The retrospective study comprised 1,066 patients.
Disclosures: Dr. Imran had no financial disclosures.
Intrathecal hydromorphone boosts post-op pain control
LAS VEGAS – Intrathecal hydromorphone, administered alone or with lidocaine, effectively controlled pain and decreased postoperative opioid use after colorectal surgery in a retrospective study.
The technique was so effective that 28% of patients required no postoperative opioids at all, Amit Merchea, MD, said at the Association for Academic Surgery/Society of University Surgeons Academic Surgical Congress.
The intrathecal analgesic was part of an enhanced recovery pathway (ERP) for patients undergoing elective colorectal surgery at the Mayo Clinic, Jacksonville, Fla., where Dr. Merchea practices colorectal surgery.
Morphine has been the gold standard for this approach, he said. Dr. Merchea and his colleagues investigated the use of hydromorphone in 601 patients who underwent open or minimally invasive colorectal surgery at the Mayo Clinic from 2012 to 2013.
The patients were a median of 52 years old. The surgical approach was almost evenly split between open and laparoscopic. The median length of hospital stay was 3 days. All received intrathecal hydromorphone either alone (91%) or with a local anesthetic (9%).
Everyone was on the same presurgical and postsurgical pain control regimen, which consisted of celecoxib, gabapentin, and acetaminophen before surgery, followed by nonsteroidal anti-inflammatories and acetaminophen, with oxycodone as needed, after surgery.
Overall, the procedure was well tolerated, with seven cases of pruritus requiring Nubain (nalbuphine), one case of respiratory depression that required naloxone, and one postdural headache that required a patch. The rate of ileus was 16%.
At 4 hours, the median pain score was 3 on a 1- to 10-point scale. At 24 hours, it was a median of 4. By 48 hours, the median pain score was 6. This increase is to be expected as the hydrocodone exists in the intrathecal space for up to 36 hours, Dr. Merchea noted.
The median total oral morphine equivalent (OME) was 24; 170 patients (28%) needed no opioid medications after surgery.
He also presented outcomes by infusion composition. There was no difference in the rate of ileus among those who had hydromorphone alone and those who had it with lidocaine. The length of stay was 3 vs. 3.5 days, respectively. The only significant difference in pain scores was the 48-hour maximum, which was a median of 7 in the combination group and 6 in the hydromorphone-only group.
The combination group, however, required more postoperative opioids (33.8 vs. 22.5 OMEs). Significantly more patients in the hydromorphone-only group were able to go without any postoperative opioids (30% vs. 15%).
Dr. Merchea also broke down the results by hydromorphone dosage, but there were no significant differences in ileus rate, length of stay, or pain scores correlated with dosage. However, those who received higher doses were significantly more likely to need more postoperative opioids than those who had lower doses.
Session moderator Peter Muscarella, MD, of Montefiore Medical Center, New York, asked whether the intrathecal infusion was associated with hypotension. “Some of these procedures with epidural analgesics intraoperatively, we have seen shifts in blood pressure that result in excess fluid administration, sometimes leading to tissue complications.”
Dr. Merchea said hypotension was not an outcome of this trial, but that he has looked at it before. “We have previously reported that epidural analgesia was associated with a 15% occurrence of hypotension, but it had no clinical impact and didn’t warrant giving any additional fluids.”
Dr. Merchea had no relevant financial disclosures.
[email protected]
On Twitter @Alz_Gal
LAS VEGAS – Intrathecal hydromorphone, administered alone or with lidocaine, effectively controlled pain and decreased postoperative opioid use after colorectal surgery in a retrospective study.
The technique was so effective that 28% of patients required no postoperative opioids at all, Amit Merchea, MD, said at the Association for Academic Surgery/Society of University Surgeons Academic Surgical Congress.
The intrathecal analgesic was part of an enhanced recovery pathway (ERP) for patients undergoing elective colorectal surgery at the Mayo Clinic, Jacksonville, Fla., where Dr. Merchea practices colorectal surgery.
Morphine has been the gold standard for this approach, he said. Dr. Merchea and his colleagues investigated the use of hydromorphone in 601 patients who underwent open or minimally invasive colorectal surgery at the Mayo Clinic from 2012 to 2013.
The patients were a median of 52 years old. The surgical approach was almost evenly split between open and laparoscopic. The median length of hospital stay was 3 days. All received intrathecal hydromorphone either alone (91%) or with a local anesthetic (9%).
Everyone was on the same presurgical and postsurgical pain control regimen, which consisted of celecoxib, gabapentin, and acetaminophen before surgery, followed by nonsteroidal anti-inflammatories and acetaminophen, with oxycodone as needed, after surgery.
Overall, the procedure was well tolerated, with seven cases of pruritus requiring Nubain (nalbuphine), one case of respiratory depression that required naloxone, and one postdural headache that required a patch. The rate of ileus was 16%.
At 4 hours, the median pain score was 3 on a 1- to 10-point scale. At 24 hours, it was a median of 4. By 48 hours, the median pain score was 6. This increase is to be expected as the hydrocodone exists in the intrathecal space for up to 36 hours, Dr. Merchea noted.
The median total oral morphine equivalent (OME) was 24; 170 patients (28%) needed no opioid medications after surgery.
He also presented outcomes by infusion composition. There was no difference in the rate of ileus among those who had hydromorphone alone and those who had it with lidocaine. The length of stay was 3 vs. 3.5 days, respectively. The only significant difference in pain scores was the 48-hour maximum, which was a median of 7 in the combination group and 6 in the hydromorphone-only group.
The combination group, however, required more postoperative opioids (33.8 vs. 22.5 OMEs). Significantly more patients in the hydromorphone-only group were able to go without any postoperative opioids (30% vs. 15%).
Dr. Merchea also broke down the results by hydromorphone dosage, but there were no significant differences in ileus rate, length of stay, or pain scores correlated with dosage. However, those who received higher doses were significantly more likely to need more postoperative opioids than those who had lower doses.
Session moderator Peter Muscarella, MD, of Montefiore Medical Center, New York, asked whether the intrathecal infusion was associated with hypotension. “Some of these procedures with epidural analgesics intraoperatively, we have seen shifts in blood pressure that result in excess fluid administration, sometimes leading to tissue complications.”
Dr. Merchea said hypotension was not an outcome of this trial, but that he has looked at it before. “We have previously reported that epidural analgesia was associated with a 15% occurrence of hypotension, but it had no clinical impact and didn’t warrant giving any additional fluids.”
Dr. Merchea had no relevant financial disclosures.
[email protected]
On Twitter @Alz_Gal
LAS VEGAS – Intrathecal hydromorphone, administered alone or with lidocaine, effectively controlled pain and decreased postoperative opioid use after colorectal surgery in a retrospective study.
The technique was so effective that 28% of patients required no postoperative opioids at all, Amit Merchea, MD, said at the Association for Academic Surgery/Society of University Surgeons Academic Surgical Congress.
The intrathecal analgesic was part of an enhanced recovery pathway (ERP) for patients undergoing elective colorectal surgery at the Mayo Clinic, Jacksonville, Fla., where Dr. Merchea practices colorectal surgery.
Morphine has been the gold standard for this approach, he said. Dr. Merchea and his colleagues investigated the use of hydromorphone in 601 patients who underwent open or minimally invasive colorectal surgery at the Mayo Clinic from 2012 to 2013.
The patients were a median of 52 years old. The surgical approach was almost evenly split between open and laparoscopic. The median length of hospital stay was 3 days. All received intrathecal hydromorphone either alone (91%) or with a local anesthetic (9%).
Everyone was on the same presurgical and postsurgical pain control regimen, which consisted of celecoxib, gabapentin, and acetaminophen before surgery, followed by nonsteroidal anti-inflammatories and acetaminophen, with oxycodone as needed, after surgery.
Overall, the procedure was well tolerated, with seven cases of pruritus requiring Nubain (nalbuphine), one case of respiratory depression that required naloxone, and one postdural headache that required a patch. The rate of ileus was 16%.
At 4 hours, the median pain score was 3 on a 1- to 10-point scale. At 24 hours, it was a median of 4. By 48 hours, the median pain score was 6. This increase is to be expected as the hydrocodone exists in the intrathecal space for up to 36 hours, Dr. Merchea noted.
The median total oral morphine equivalent (OME) was 24; 170 patients (28%) needed no opioid medications after surgery.
He also presented outcomes by infusion composition. There was no difference in the rate of ileus among those who had hydromorphone alone and those who had it with lidocaine. The length of stay was 3 vs. 3.5 days, respectively. The only significant difference in pain scores was the 48-hour maximum, which was a median of 7 in the combination group and 6 in the hydromorphone-only group.
The combination group, however, required more postoperative opioids (33.8 vs. 22.5 OMEs). Significantly more patients in the hydromorphone-only group were able to go without any postoperative opioids (30% vs. 15%).
Dr. Merchea also broke down the results by hydromorphone dosage, but there were no significant differences in ileus rate, length of stay, or pain scores correlated with dosage. However, those who received higher doses were significantly more likely to need more postoperative opioids than those who had lower doses.
Session moderator Peter Muscarella, MD, of Montefiore Medical Center, New York, asked whether the intrathecal infusion was associated with hypotension. “Some of these procedures with epidural analgesics intraoperatively, we have seen shifts in blood pressure that result in excess fluid administration, sometimes leading to tissue complications.”
Dr. Merchea said hypotension was not an outcome of this trial, but that he has looked at it before. “We have previously reported that epidural analgesia was associated with a 15% occurrence of hypotension, but it had no clinical impact and didn’t warrant giving any additional fluids.”
Dr. Merchea had no relevant financial disclosures.
[email protected]
On Twitter @Alz_Gal
AT THE ACADEMIC SURGICAL CONGRESS
Key clinical point:
Major finding: About a quarter of patients (28%) needed no postoperative opioids.
Data source: A retrospective study of 601 patients.
Disclosures: Dr. Merchea had no relevant financial disclosures.
Bowel obstruction surgery complications predicted with risk tool
HOLLYWOOD, FLA. – A three-parameter scoring system predicts which patients are likely to experience complications from surgery for a small bowel obstruction.
The new tool – dubbed FAS (Functional status, American Society of Anesthesiologists [ASA] classification, and Sepsis) – focuses mostly on preoperative functional status and the presence of preoperative sepsis. It’s as accurate as a time-consuming 10-item Margenthaler system published in 2006, which requires data on blood chemistry, neurologic status, and cardiac and lung function as well as age, sepsis, and preoperative functional measures.
Small bowel obstruction is a common problem, said Dr. Asuzu, who is also a medical student at Yale University, New Haven, Conn. Whether to treat conservatively or surgically can be a complex decision. “Conservative treatment avoids postoperative complications, but there is a higher risk of occurrence and a quicker time to recurrence than with surgery. But surgery carries its own risks. If we could identify patients at high risk for complications, then perhaps we could push those patients more toward conservative treatment.”
The Margenthaler scoring system attempted to do just that. It was retrospectively validated in 2,000 patients included in the Veterans Affairs Surgical Quality Improvement Program database (VASQIP) who underwent surgery for small bowel obstruction. The authors examined about 60 clinical factors associated with postsurgical morbidity and mortality, finally settling on 10 that, when scored, accurately predicted 30-day morbidity and mortality.
These factors were:
• History of congestive heart failure
• Neurological deficit or stroke
• Chronic obstructive pulmonary disease
• Elevated white cell count
• Preoperative functional health status
• Surgery type
• Preoperative creatinine
• Wound classification
• ASA class
• Age
Dr. Asuzu and his mentor, Kevin Y. Pei, MD, FACS, wanted to come up with a more user-friendly risk assessment tool for patients undergoing open small bowel adhesiolysis. They focused on two measures of preoperative functional status: dependent vs. independent and ASA classification. Another measure – preoperative sepsis – estimated the impact of the patient’s current medical problem.
The tool was tested retrospectively in two independent cohorts extracted from the ACS National Surgery Quality Improvement Project (NSQIP) database. The initial discovery cohort comprised 6,036 patients; the replication cohort, 9,000. These patients had a mean age of 60 years and were relatively healthy, with low rates of congestive obstructive pulmonary disease, renal failure, cancer, bleeding disorders, and ascites. About half were taking antihypertensive medications and 5%, steroids.
Using multivariable regression, the authors developed a scoring system as follows:
• 6 points for each level of preoperative functional status (1 – independent, 2 – partially dependent, 3 – totally dependent)
• 6 points for each level of ASA classification (1 – no disturbance, 2 – mild disturbance, 3 – severe disturbance, 4 – life-threatening disturbance, and 5 – moribund state)
• 4 points for each level of perioperative sepsis (1 – systemic inflammatory response syndrome [SIRS], 2 – sepsis, 3 – septic shock)
In the discovery cohort, the three-item FAS tool was just as accurate as the Margenthaler tool, with an odds ratio of 1.11 vs 1.10 for any complication. The areas under the curve were 0.69 vs. 0.68. These results were virtually identical in the replication cohort.
With a combined total score of 32 as the cutoff, FAS yielded a specificity of 93% for predicting any complication and 92% for any of the six most common complications (ventilator dependence greater than 48 hours, pneumonia, superficial surgical site infection, postoperative sepsis, urinary tract infection, or unplanned intubation) in the replication cohort. The positive predictive value was 50% for any complication and 45% for the six most common complications, and the negative predictive values were 81% and nearly 85%, respectively.
“We are very pleased with how this performs,” Dr. Asuzu said in an interview. “It’s apparent that these three parameters are sufficient to tell us with a high level of specificity which patients could benefit from a more conservative approach. The next step is to prospectively validate it in a single center dataset.”
He said discriminating the most meaningful risk factors plainly showed that preoperative physical status is the best indicator of how well a patient will handle the surgery.
“It turns out that the biggest predictor of you how do after surgery is how you are doing before surgery. We can look at it as the how big the hit is, and the patient’s ability to take that hit. If their ability is already compromised, it’s a sign they might not do well.”
The “functional status” parameter may seem overly simplistic at first glance, he said. “But it really takes into account everything: the gout, the hypertension, the smoking, heart and respiratory and kidney function. All of this plays a role in functional status. I think this is why some of these more complex scores suffer. They’re not clear because there is so much overlap there.”
Dr. Asuzu had no financial disclosures.
[email protected]
On Twitter @Alz_Gal
HOLLYWOOD, FLA. – A three-parameter scoring system predicts which patients are likely to experience complications from surgery for a small bowel obstruction.
The new tool – dubbed FAS (Functional status, American Society of Anesthesiologists [ASA] classification, and Sepsis) – focuses mostly on preoperative functional status and the presence of preoperative sepsis. It’s as accurate as a time-consuming 10-item Margenthaler system published in 2006, which requires data on blood chemistry, neurologic status, and cardiac and lung function as well as age, sepsis, and preoperative functional measures.
Small bowel obstruction is a common problem, said Dr. Asuzu, who is also a medical student at Yale University, New Haven, Conn. Whether to treat conservatively or surgically can be a complex decision. “Conservative treatment avoids postoperative complications, but there is a higher risk of occurrence and a quicker time to recurrence than with surgery. But surgery carries its own risks. If we could identify patients at high risk for complications, then perhaps we could push those patients more toward conservative treatment.”
The Margenthaler scoring system attempted to do just that. It was retrospectively validated in 2,000 patients included in the Veterans Affairs Surgical Quality Improvement Program database (VASQIP) who underwent surgery for small bowel obstruction. The authors examined about 60 clinical factors associated with postsurgical morbidity and mortality, finally settling on 10 that, when scored, accurately predicted 30-day morbidity and mortality.
These factors were:
• History of congestive heart failure
• Neurological deficit or stroke
• Chronic obstructive pulmonary disease
• Elevated white cell count
• Preoperative functional health status
• Surgery type
• Preoperative creatinine
• Wound classification
• ASA class
• Age
Dr. Asuzu and his mentor, Kevin Y. Pei, MD, FACS, wanted to come up with a more user-friendly risk assessment tool for patients undergoing open small bowel adhesiolysis. They focused on two measures of preoperative functional status: dependent vs. independent and ASA classification. Another measure – preoperative sepsis – estimated the impact of the patient’s current medical problem.
The tool was tested retrospectively in two independent cohorts extracted from the ACS National Surgery Quality Improvement Project (NSQIP) database. The initial discovery cohort comprised 6,036 patients; the replication cohort, 9,000. These patients had a mean age of 60 years and were relatively healthy, with low rates of congestive obstructive pulmonary disease, renal failure, cancer, bleeding disorders, and ascites. About half were taking antihypertensive medications and 5%, steroids.
Using multivariable regression, the authors developed a scoring system as follows:
• 6 points for each level of preoperative functional status (1 – independent, 2 – partially dependent, 3 – totally dependent)
• 6 points for each level of ASA classification (1 – no disturbance, 2 – mild disturbance, 3 – severe disturbance, 4 – life-threatening disturbance, and 5 – moribund state)
• 4 points for each level of perioperative sepsis (1 – systemic inflammatory response syndrome [SIRS], 2 – sepsis, 3 – septic shock)
In the discovery cohort, the three-item FAS tool was just as accurate as the Margenthaler tool, with an odds ratio of 1.11 vs 1.10 for any complication. The areas under the curve were 0.69 vs. 0.68. These results were virtually identical in the replication cohort.
With a combined total score of 32 as the cutoff, FAS yielded a specificity of 93% for predicting any complication and 92% for any of the six most common complications (ventilator dependence greater than 48 hours, pneumonia, superficial surgical site infection, postoperative sepsis, urinary tract infection, or unplanned intubation) in the replication cohort. The positive predictive value was 50% for any complication and 45% for the six most common complications, and the negative predictive values were 81% and nearly 85%, respectively.
“We are very pleased with how this performs,” Dr. Asuzu said in an interview. “It’s apparent that these three parameters are sufficient to tell us with a high level of specificity which patients could benefit from a more conservative approach. The next step is to prospectively validate it in a single center dataset.”
He said discriminating the most meaningful risk factors plainly showed that preoperative physical status is the best indicator of how well a patient will handle the surgery.
“It turns out that the biggest predictor of you how do after surgery is how you are doing before surgery. We can look at it as the how big the hit is, and the patient’s ability to take that hit. If their ability is already compromised, it’s a sign they might not do well.”
The “functional status” parameter may seem overly simplistic at first glance, he said. “But it really takes into account everything: the gout, the hypertension, the smoking, heart and respiratory and kidney function. All of this plays a role in functional status. I think this is why some of these more complex scores suffer. They’re not clear because there is so much overlap there.”
Dr. Asuzu had no financial disclosures.
[email protected]
On Twitter @Alz_Gal
HOLLYWOOD, FLA. – A three-parameter scoring system predicts which patients are likely to experience complications from surgery for a small bowel obstruction.
The new tool – dubbed FAS (Functional status, American Society of Anesthesiologists [ASA] classification, and Sepsis) – focuses mostly on preoperative functional status and the presence of preoperative sepsis. It’s as accurate as a time-consuming 10-item Margenthaler system published in 2006, which requires data on blood chemistry, neurologic status, and cardiac and lung function as well as age, sepsis, and preoperative functional measures.
Small bowel obstruction is a common problem, said Dr. Asuzu, who is also a medical student at Yale University, New Haven, Conn. Whether to treat conservatively or surgically can be a complex decision. “Conservative treatment avoids postoperative complications, but there is a higher risk of occurrence and a quicker time to recurrence than with surgery. But surgery carries its own risks. If we could identify patients at high risk for complications, then perhaps we could push those patients more toward conservative treatment.”
The Margenthaler scoring system attempted to do just that. It was retrospectively validated in 2,000 patients included in the Veterans Affairs Surgical Quality Improvement Program database (VASQIP) who underwent surgery for small bowel obstruction. The authors examined about 60 clinical factors associated with postsurgical morbidity and mortality, finally settling on 10 that, when scored, accurately predicted 30-day morbidity and mortality.
These factors were:
• History of congestive heart failure
• Neurological deficit or stroke
• Chronic obstructive pulmonary disease
• Elevated white cell count
• Preoperative functional health status
• Surgery type
• Preoperative creatinine
• Wound classification
• ASA class
• Age
Dr. Asuzu and his mentor, Kevin Y. Pei, MD, FACS, wanted to come up with a more user-friendly risk assessment tool for patients undergoing open small bowel adhesiolysis. They focused on two measures of preoperative functional status: dependent vs. independent and ASA classification. Another measure – preoperative sepsis – estimated the impact of the patient’s current medical problem.
The tool was tested retrospectively in two independent cohorts extracted from the ACS National Surgery Quality Improvement Project (NSQIP) database. The initial discovery cohort comprised 6,036 patients; the replication cohort, 9,000. These patients had a mean age of 60 years and were relatively healthy, with low rates of congestive obstructive pulmonary disease, renal failure, cancer, bleeding disorders, and ascites. About half were taking antihypertensive medications and 5%, steroids.
Using multivariable regression, the authors developed a scoring system as follows:
• 6 points for each level of preoperative functional status (1 – independent, 2 – partially dependent, 3 – totally dependent)
• 6 points for each level of ASA classification (1 – no disturbance, 2 – mild disturbance, 3 – severe disturbance, 4 – life-threatening disturbance, and 5 – moribund state)
• 4 points for each level of perioperative sepsis (1 – systemic inflammatory response syndrome [SIRS], 2 – sepsis, 3 – septic shock)
In the discovery cohort, the three-item FAS tool was just as accurate as the Margenthaler tool, with an odds ratio of 1.11 vs 1.10 for any complication. The areas under the curve were 0.69 vs. 0.68. These results were virtually identical in the replication cohort.
With a combined total score of 32 as the cutoff, FAS yielded a specificity of 93% for predicting any complication and 92% for any of the six most common complications (ventilator dependence greater than 48 hours, pneumonia, superficial surgical site infection, postoperative sepsis, urinary tract infection, or unplanned intubation) in the replication cohort. The positive predictive value was 50% for any complication and 45% for the six most common complications, and the negative predictive values were 81% and nearly 85%, respectively.
“We are very pleased with how this performs,” Dr. Asuzu said in an interview. “It’s apparent that these three parameters are sufficient to tell us with a high level of specificity which patients could benefit from a more conservative approach. The next step is to prospectively validate it in a single center dataset.”
He said discriminating the most meaningful risk factors plainly showed that preoperative physical status is the best indicator of how well a patient will handle the surgery.
“It turns out that the biggest predictor of you how do after surgery is how you are doing before surgery. We can look at it as the how big the hit is, and the patient’s ability to take that hit. If their ability is already compromised, it’s a sign they might not do well.”
The “functional status” parameter may seem overly simplistic at first glance, he said. “But it really takes into account everything: the gout, the hypertension, the smoking, heart and respiratory and kidney function. All of this plays a role in functional status. I think this is why some of these more complex scores suffer. They’re not clear because there is so much overlap there.”
Dr. Asuzu had no financial disclosures.
[email protected]
On Twitter @Alz_Gal
AT THE EAST ANNUAL SCIENTIFIC ASSEMBLY
Key clinical point: A simple, three-item assessment tool predicted complications from small bowel obstruction surgery just as well as a more complex 10-item system.
Major finding: The FAS tool had a specificity of 93% for any complication and 92% for the six most common complications.
Data source: The tool was retrospectively validated in two cohorts comprising more than 15,000 patients.
Disclosures: Dr. Asuzu had no financial disclosures.
Proposed Alzheimer’s classification system relies solely on biomarkers
A proposed Alzheimer’s disease classification system eschews neurocognitive testing and relies instead on the presence or absence of known biomarkers.
These markers of Alzheimer’s pathophysiology fall into three distinct categories: amyloid, tau, and neuronal injury (A/T/N). By rating patients as positive or negative for each category, the criteria aim to allow researchers to differentiate true Alzheimer’s patients from those with suspected non-Alzheimer’s pathology (SNAP), a diverse group that experiences neurocognitive decline in the absence of amyloid (Neurology. 2016 Aug 2;87[5]:539-47).
The A/T/N system could be employed in three clinical groups: clinically normal patients, those who meet the clinical criteria for mild cognitive impairment (MCI), and patients with a probable Alzheimer’s disease diagnosis based on the 2011 criteria established by the National Institute on Aging–Alzheimer’s Association (NIA-AA) staging system (Alzheimers Dement. 2011 May;7[3]:257-62).
Both the NIA-AA and IWG systems comprise five biomarkers (low cerebrospinal fluid [CSF] amyloid-beta42; positive PET amyloid imaging; elevated CSF tau; hypometabolism in the temporoparietal cortex on 18F-fluorodeoxyglucose PET imaging; and atrophy in specific brain regions) plus cognitive testing.
The NIA-AA system defines three clinical stages of Alzheimer’s, each with separate classification criteria: stage 1, preclinical; stage 2, MCI; and stage 3, Alzheimer’s disease (AD) dementia. The IWG system is more complex than the NIA-AA system and takes into account biomarkers, cognition, and other clinical manifestations.
The A/T/N system doesn’t require cognitive testing, and includes additional biomarkers that should allow for a much more nuanced classification of patients. It also reflects the field’s growing confidence in objective markers that measure the pathophysiology of the disease, rather than the way it manifests symptomatically, said Dr. Jack, professor of radiology at the Mayo Clinic, Rochester, Minn.
He was the lead author on the August 2016 paper that provided a first look at the proposal. He presented a more mature version of the system at the Clinical Trials on Alzheimer’s Disease meeting in San Diego last fall. The committee is refining the document now, and intends to present a final draft at the Alzheimer’s Association International Conference in London this summer.
Would the A/T/N system benefit clinical research?
Researchers desperately need a better classification system, Dr. Jack said in an interview. The vast majority of AD drug trials have enrolled clinical cohorts that, by most estimates, are only 70% amyloid positive. The other 30% are patients whose neurocognitive deficits are due to other disorders. Many in the field believe this cohort impurity is directly tied to the consistently negative findings on anti-amyloid drugs: Simply put, anti-amyloid drugs won’t work in patients who don’t have amyloid brain plaques to begin with.
With the A/T/N system, “We take the position that cognitive impairment is a late occurrence,” in the Alzheimer’s disease trajectory, Dr. Jack said. “Clinical symptoms are not a good way to diagnose AD. This system does not require clinical symptoms for a diagnosis. In fact, the term ‘Alzheimer’s disease’ should refer only to the pathology in the brain, as it can exist in the absence of clinical symptoms or in the presence of atypical symptoms [such as language dysfunction], as well as in patients with the classic phenotype.”
The classification system comprises seven CSF and imaging biomarkers:
• A (amyloid) may be measured by an amyloid PET scan or by cerebrospinal fluid level of amyloid-beta42.
• T (tau) may be measured by CSF level of phosphorylated or total tau, or by tau PET imaging. Although tau imaging is still in the early phase, with no approved imaging agents, research is moving quickly and the committee wanted to be well positioned to incorporate it into the model as soon as an agent is approved.
• N (neurodegeneration/neuronal injury) may be measured by CSF level of total tau, hypometabolism on 18F-fluorodeoxyglucose PET imaging, or MRI that shows brain atrophy in regions characteristic of AD.
Since each component can be measured with CSF or imaging, the A/T/N system can be globally adopted despite different preferences for how biomarkers are acquired, Dr. Jack said.
“In the U.S., it’s much more common to use imaging, while in the E.U., it’s more common to use CSF for biomarkers. This is the beauty of the A/T/N system. With a single lumbar puncture or a series of imaging tests you can classify every research participant.”
In any of the patient groups, amyloid positivity is a key finding that an individual is probably on the path to Alzheimer’s disease. The biomarker permutations can be compared to the NIA-AA and IWG classifications as follows.
For clinically normal patients:
• A+/T-/N- is analogous to NIA-AA preclinical AD stage 1 and IWG asymptomatic at risk for AD (if A+ is established by amyloid PET).
• A+/T+/N- and A+/T+/N+ are analogous to NIA-AA preclinical AD stage 2/3 and IWG asymptomatic at risk for AD.
For MCI patients:
• A+/T-/N-, A+/T+/N-, and A+/T-/N+ are all analogous to the NIA-AA MCI core clinical criteria and IWG typical AD.
• A+/T+/N+ is analogous to NIA-AA MCI probably due to AD and IWG typical AD.
The A/T/N system offers the most useful details for patients who meet clinical criteria for probable AD dementia. Here, clinical criteria can be considered to help clarify the diagnostic picture:
• A-/T-/N-, analogous to NIA-AA dementia unlikely due to AD and is undefined by IWG.
• A+/T-/N-, analogous to NIA-AA intermediate likelihood of probable AD dementia, based on clinical criteria, and IWG typical AD (if A+ is established by amyloid PET).
• A+/T+/N-, analogous to NIA-AA high likelihood of probable AD dementia, based on clinical criteria, and IWG typical AD.
• A+/T-/N+, analogous to NIA-AA high likelihood of probable AD dementia, based on clinical criteria, and IWG typical AD (if A+ is established by amyloid PET).
• A+/T+/N+, analogous to NIA-AA high likelihood of AD pathophysiology and IWG typical AD.
• A-/T+/N+, analogous to NIA-AA probable AD dementia, based on clinical criteria and is undefined by IWG.
• A-/T-/N+, analogous to NIA-AA intermediate likelihood of probable AD dementia, based on clinical criteria, and is undefined by IWG.
• A-/T+/N+, analogous to NIA-AA intermediate likelihood of probable AD dementia, based on clinical criteria, and is undefined by IWG.
Would the A/T/N system benefit diagnostic accuracy?
The August paper sheds some additional light on how the system could hone diagnostic accuracy.
“For example, an A-/T-/N+ profile would be expected with pathologies such as ischemic cerebrovascular disease or hippocampal sclerosis, whereas an A-/T+/N+ profile would be expected with primary age-related tauopathy. An A+/T-/N+ profile might indicate an individual in the earliest stage of preclinical AD (accounting for the A+/T- status), who also has a non-AD pathology such as hippocampal sclerosis (accounting for the N+ status).”
Other typical profiles will certainly emerge as the A/T/N system is applied in large cohorts, the paper noted.
While the system is now aimed at building stronger research cohorts, it may eventually be adopted – and adapted – by clinicians.
“Right now, the reality is that most clinical practices don’t have access to getting these biomarkers,” Dr. Jack said. “Having said that, we also know that clinicians will vote with their feet. If they think this is useful they’ll end up adopting it, at least in the highly specialized centers that have access to these tests. The ultimate outcome someday will be a clinical practice guideline where people don’t get the label of AD unless they really have positive biomarkers.”
Dr. Jack has been a consultant for Eli Lilly.
[email protected]
On Twitter @alz_gal
A proposed Alzheimer’s disease classification system eschews neurocognitive testing and relies instead on the presence or absence of known biomarkers.
These markers of Alzheimer’s pathophysiology fall into three distinct categories: amyloid, tau, and neuronal injury (A/T/N). By rating patients as positive or negative for each category, the criteria aim to allow researchers to differentiate true Alzheimer’s patients from those with suspected non-Alzheimer’s pathology (SNAP), a diverse group that experiences neurocognitive decline in the absence of amyloid (Neurology. 2016 Aug 2;87[5]:539-47).
The A/T/N system could be employed in three clinical groups: clinically normal patients, those who meet the clinical criteria for mild cognitive impairment (MCI), and patients with a probable Alzheimer’s disease diagnosis based on the 2011 criteria established by the National Institute on Aging–Alzheimer’s Association (NIA-AA) staging system (Alzheimers Dement. 2011 May;7[3]:257-62).
Both the NIA-AA and IWG systems comprise five biomarkers (low cerebrospinal fluid [CSF] amyloid-beta42; positive PET amyloid imaging; elevated CSF tau; hypometabolism in the temporoparietal cortex on 18F-fluorodeoxyglucose PET imaging; and atrophy in specific brain regions) plus cognitive testing.
The NIA-AA system defines three clinical stages of Alzheimer’s, each with separate classification criteria: stage 1, preclinical; stage 2, MCI; and stage 3, Alzheimer’s disease (AD) dementia. The IWG system is more complex than the NIA-AA system and takes into account biomarkers, cognition, and other clinical manifestations.
The A/T/N system doesn’t require cognitive testing, and includes additional biomarkers that should allow for a much more nuanced classification of patients. It also reflects the field’s growing confidence in objective markers that measure the pathophysiology of the disease, rather than the way it manifests symptomatically, said Dr. Jack, professor of radiology at the Mayo Clinic, Rochester, Minn.
He was the lead author on the August 2016 paper that provided a first look at the proposal. He presented a more mature version of the system at the Clinical Trials on Alzheimer’s Disease meeting in San Diego last fall. The committee is refining the document now, and intends to present a final draft at the Alzheimer’s Association International Conference in London this summer.
Would the A/T/N system benefit clinical research?
Researchers desperately need a better classification system, Dr. Jack said in an interview. The vast majority of AD drug trials have enrolled clinical cohorts that, by most estimates, are only 70% amyloid positive. The other 30% are patients whose neurocognitive deficits are due to other disorders. Many in the field believe this cohort impurity is directly tied to the consistently negative findings on anti-amyloid drugs: Simply put, anti-amyloid drugs won’t work in patients who don’t have amyloid brain plaques to begin with.
With the A/T/N system, “We take the position that cognitive impairment is a late occurrence,” in the Alzheimer’s disease trajectory, Dr. Jack said. “Clinical symptoms are not a good way to diagnose AD. This system does not require clinical symptoms for a diagnosis. In fact, the term ‘Alzheimer’s disease’ should refer only to the pathology in the brain, as it can exist in the absence of clinical symptoms or in the presence of atypical symptoms [such as language dysfunction], as well as in patients with the classic phenotype.”
The classification system comprises seven CSF and imaging biomarkers:
• A (amyloid) may be measured by an amyloid PET scan or by cerebrospinal fluid level of amyloid-beta42.
• T (tau) may be measured by CSF level of phosphorylated or total tau, or by tau PET imaging. Although tau imaging is still in the early phase, with no approved imaging agents, research is moving quickly and the committee wanted to be well positioned to incorporate it into the model as soon as an agent is approved.
• N (neurodegeneration/neuronal injury) may be measured by CSF level of total tau, hypometabolism on 18F-fluorodeoxyglucose PET imaging, or MRI that shows brain atrophy in regions characteristic of AD.
Since each component can be measured with CSF or imaging, the A/T/N system can be globally adopted despite different preferences for how biomarkers are acquired, Dr. Jack said.
“In the U.S., it’s much more common to use imaging, while in the E.U., it’s more common to use CSF for biomarkers. This is the beauty of the A/T/N system. With a single lumbar puncture or a series of imaging tests you can classify every research participant.”
In any of the patient groups, amyloid positivity is a key finding that an individual is probably on the path to Alzheimer’s disease. The biomarker permutations can be compared to the NIA-AA and IWG classifications as follows.
For clinically normal patients:
• A+/T-/N- is analogous to NIA-AA preclinical AD stage 1 and IWG asymptomatic at risk for AD (if A+ is established by amyloid PET).
• A+/T+/N- and A+/T+/N+ are analogous to NIA-AA preclinical AD stage 2/3 and IWG asymptomatic at risk for AD.
For MCI patients:
• A+/T-/N-, A+/T+/N-, and A+/T-/N+ are all analogous to the NIA-AA MCI core clinical criteria and IWG typical AD.
• A+/T+/N+ is analogous to NIA-AA MCI probably due to AD and IWG typical AD.
The A/T/N system offers the most useful details for patients who meet clinical criteria for probable AD dementia. Here, clinical criteria can be considered to help clarify the diagnostic picture:
• A-/T-/N-, analogous to NIA-AA dementia unlikely due to AD and is undefined by IWG.
• A+/T-/N-, analogous to NIA-AA intermediate likelihood of probable AD dementia, based on clinical criteria, and IWG typical AD (if A+ is established by amyloid PET).
• A+/T+/N-, analogous to NIA-AA high likelihood of probable AD dementia, based on clinical criteria, and IWG typical AD.
• A+/T-/N+, analogous to NIA-AA high likelihood of probable AD dementia, based on clinical criteria, and IWG typical AD (if A+ is established by amyloid PET).
• A+/T+/N+, analogous to NIA-AA high likelihood of AD pathophysiology and IWG typical AD.
• A-/T+/N+, analogous to NIA-AA probable AD dementia, based on clinical criteria and is undefined by IWG.
• A-/T-/N+, analogous to NIA-AA intermediate likelihood of probable AD dementia, based on clinical criteria, and is undefined by IWG.
• A-/T+/N+, analogous to NIA-AA intermediate likelihood of probable AD dementia, based on clinical criteria, and is undefined by IWG.
Would the A/T/N system benefit diagnostic accuracy?
The August paper sheds some additional light on how the system could hone diagnostic accuracy.
“For example, an A-/T-/N+ profile would be expected with pathologies such as ischemic cerebrovascular disease or hippocampal sclerosis, whereas an A-/T+/N+ profile would be expected with primary age-related tauopathy. An A+/T-/N+ profile might indicate an individual in the earliest stage of preclinical AD (accounting for the A+/T- status), who also has a non-AD pathology such as hippocampal sclerosis (accounting for the N+ status).”
Other typical profiles will certainly emerge as the A/T/N system is applied in large cohorts, the paper noted.
While the system is now aimed at building stronger research cohorts, it may eventually be adopted – and adapted – by clinicians.
“Right now, the reality is that most clinical practices don’t have access to getting these biomarkers,” Dr. Jack said. “Having said that, we also know that clinicians will vote with their feet. If they think this is useful they’ll end up adopting it, at least in the highly specialized centers that have access to these tests. The ultimate outcome someday will be a clinical practice guideline where people don’t get the label of AD unless they really have positive biomarkers.”
Dr. Jack has been a consultant for Eli Lilly.
[email protected]
On Twitter @alz_gal
A proposed Alzheimer’s disease classification system eschews neurocognitive testing and relies instead on the presence or absence of known biomarkers.
These markers of Alzheimer’s pathophysiology fall into three distinct categories: amyloid, tau, and neuronal injury (A/T/N). By rating patients as positive or negative for each category, the criteria aim to allow researchers to differentiate true Alzheimer’s patients from those with suspected non-Alzheimer’s pathology (SNAP), a diverse group that experiences neurocognitive decline in the absence of amyloid (Neurology. 2016 Aug 2;87[5]:539-47).
The A/T/N system could be employed in three clinical groups: clinically normal patients, those who meet the clinical criteria for mild cognitive impairment (MCI), and patients with a probable Alzheimer’s disease diagnosis based on the 2011 criteria established by the National Institute on Aging–Alzheimer’s Association (NIA-AA) staging system (Alzheimers Dement. 2011 May;7[3]:257-62).
Both the NIA-AA and IWG systems comprise five biomarkers (low cerebrospinal fluid [CSF] amyloid-beta42; positive PET amyloid imaging; elevated CSF tau; hypometabolism in the temporoparietal cortex on 18F-fluorodeoxyglucose PET imaging; and atrophy in specific brain regions) plus cognitive testing.
The NIA-AA system defines three clinical stages of Alzheimer’s, each with separate classification criteria: stage 1, preclinical; stage 2, MCI; and stage 3, Alzheimer’s disease (AD) dementia. The IWG system is more complex than the NIA-AA system and takes into account biomarkers, cognition, and other clinical manifestations.
The A/T/N system doesn’t require cognitive testing, and includes additional biomarkers that should allow for a much more nuanced classification of patients. It also reflects the field’s growing confidence in objective markers that measure the pathophysiology of the disease, rather than the way it manifests symptomatically, said Dr. Jack, professor of radiology at the Mayo Clinic, Rochester, Minn.
He was the lead author on the August 2016 paper that provided a first look at the proposal. He presented a more mature version of the system at the Clinical Trials on Alzheimer’s Disease meeting in San Diego last fall. The committee is refining the document now, and intends to present a final draft at the Alzheimer’s Association International Conference in London this summer.
Would the A/T/N system benefit clinical research?
Researchers desperately need a better classification system, Dr. Jack said in an interview. The vast majority of AD drug trials have enrolled clinical cohorts that, by most estimates, are only 70% amyloid positive. The other 30% are patients whose neurocognitive deficits are due to other disorders. Many in the field believe this cohort impurity is directly tied to the consistently negative findings on anti-amyloid drugs: Simply put, anti-amyloid drugs won’t work in patients who don’t have amyloid brain plaques to begin with.
With the A/T/N system, “We take the position that cognitive impairment is a late occurrence,” in the Alzheimer’s disease trajectory, Dr. Jack said. “Clinical symptoms are not a good way to diagnose AD. This system does not require clinical symptoms for a diagnosis. In fact, the term ‘Alzheimer’s disease’ should refer only to the pathology in the brain, as it can exist in the absence of clinical symptoms or in the presence of atypical symptoms [such as language dysfunction], as well as in patients with the classic phenotype.”
The classification system comprises seven CSF and imaging biomarkers:
• A (amyloid) may be measured by an amyloid PET scan or by cerebrospinal fluid level of amyloid-beta42.
• T (tau) may be measured by CSF level of phosphorylated or total tau, or by tau PET imaging. Although tau imaging is still in the early phase, with no approved imaging agents, research is moving quickly and the committee wanted to be well positioned to incorporate it into the model as soon as an agent is approved.
• N (neurodegeneration/neuronal injury) may be measured by CSF level of total tau, hypometabolism on 18F-fluorodeoxyglucose PET imaging, or MRI that shows brain atrophy in regions characteristic of AD.
Since each component can be measured with CSF or imaging, the A/T/N system can be globally adopted despite different preferences for how biomarkers are acquired, Dr. Jack said.
“In the U.S., it’s much more common to use imaging, while in the E.U., it’s more common to use CSF for biomarkers. This is the beauty of the A/T/N system. With a single lumbar puncture or a series of imaging tests you can classify every research participant.”
In any of the patient groups, amyloid positivity is a key finding that an individual is probably on the path to Alzheimer’s disease. The biomarker permutations can be compared to the NIA-AA and IWG classifications as follows.
For clinically normal patients:
• A+/T-/N- is analogous to NIA-AA preclinical AD stage 1 and IWG asymptomatic at risk for AD (if A+ is established by amyloid PET).
• A+/T+/N- and A+/T+/N+ are analogous to NIA-AA preclinical AD stage 2/3 and IWG asymptomatic at risk for AD.
For MCI patients:
• A+/T-/N-, A+/T+/N-, and A+/T-/N+ are all analogous to the NIA-AA MCI core clinical criteria and IWG typical AD.
• A+/T+/N+ is analogous to NIA-AA MCI probably due to AD and IWG typical AD.
The A/T/N system offers the most useful details for patients who meet clinical criteria for probable AD dementia. Here, clinical criteria can be considered to help clarify the diagnostic picture:
• A-/T-/N-, analogous to NIA-AA dementia unlikely due to AD and is undefined by IWG.
• A+/T-/N-, analogous to NIA-AA intermediate likelihood of probable AD dementia, based on clinical criteria, and IWG typical AD (if A+ is established by amyloid PET).
• A+/T+/N-, analogous to NIA-AA high likelihood of probable AD dementia, based on clinical criteria, and IWG typical AD.
• A+/T-/N+, analogous to NIA-AA high likelihood of probable AD dementia, based on clinical criteria, and IWG typical AD (if A+ is established by amyloid PET).
• A+/T+/N+, analogous to NIA-AA high likelihood of AD pathophysiology and IWG typical AD.
• A-/T+/N+, analogous to NIA-AA probable AD dementia, based on clinical criteria and is undefined by IWG.
• A-/T-/N+, analogous to NIA-AA intermediate likelihood of probable AD dementia, based on clinical criteria, and is undefined by IWG.
• A-/T+/N+, analogous to NIA-AA intermediate likelihood of probable AD dementia, based on clinical criteria, and is undefined by IWG.
Would the A/T/N system benefit diagnostic accuracy?
The August paper sheds some additional light on how the system could hone diagnostic accuracy.
“For example, an A-/T-/N+ profile would be expected with pathologies such as ischemic cerebrovascular disease or hippocampal sclerosis, whereas an A-/T+/N+ profile would be expected with primary age-related tauopathy. An A+/T-/N+ profile might indicate an individual in the earliest stage of preclinical AD (accounting for the A+/T- status), who also has a non-AD pathology such as hippocampal sclerosis (accounting for the N+ status).”
Other typical profiles will certainly emerge as the A/T/N system is applied in large cohorts, the paper noted.
While the system is now aimed at building stronger research cohorts, it may eventually be adopted – and adapted – by clinicians.
“Right now, the reality is that most clinical practices don’t have access to getting these biomarkers,” Dr. Jack said. “Having said that, we also know that clinicians will vote with their feet. If they think this is useful they’ll end up adopting it, at least in the highly specialized centers that have access to these tests. The ultimate outcome someday will be a clinical practice guideline where people don’t get the label of AD unless they really have positive biomarkers.”
Dr. Jack has been a consultant for Eli Lilly.
[email protected]
On Twitter @alz_gal