User login
Poor health literacy raises readmission risk
JACKSONVILLE, FLA. – Low health literacy is a common problem in Veterans Affairs health systems, and patients with low health literacy scores are 50% more likely to return to the hospital within 30 days of discharge after surgery than patients with high health literacy, investigators found in a study of surgery patients at VA medical centers.
“Low health literacy is prevalent among VA surgery patients and is associated with surgical readmissions,” said Samantha Baker, MD, of the University of Alabama at Birmingham and the VA Birmingham Healthcare System. She presented the findings at the Association for Academic Surgery/Society of University Surgeons Academic Surgical Congress.
This study used an instrument developed by Lisa Chew, MD, at the University of Washington to determine health literacy scores (Fam Med. 2004;36:588-94). The instrument uses three questions: how often patients have someone else help them read hospital materials; whether they have problems learning about a medical condition because they have difficulty understanding written information; and how confident they are in filling out their own medical forms. Answers are given on a scale of 0-4, with 12 points being the highest score for poor health literacy. This study considered adequate health literacy to be a score of 0-3, and 4-12 as “possibly inadequate health literacy.”
“Of the 722 patients who took the survey, 39.2% had a score of 0; 33.2% had a score of 4 or more,” Dr. Baker said.
The adequate health literacy group had significantly lower rates of unplanned readmissions and a trend toward lower emergency department visits than the possibly inadequate health literacy group, 11.7% vs. 22.5% (P = .003) for the former and 18.7% vs. 24.2% (P = .08) for the latter, Dr. Baker said.
She noted that the ethnic makeup of the groups was similar and the differences in health literacy among the ethnic groups were not statistically significant.
She also mentioned that those with adequate health literacy tended to be younger – 64 vs. 66.9 years – and more likely to be women (“but our number is low for females in the VA,” Dr. Baker said). She added that married patients tended to have lower heath literacy than did single patients.”
The 30-day surgical readmission rate was 13.7% for patients with high health literacy and 22.5% for those with low health literacy. Patients with inadequate health literacy were 53% more likely to be readmitted to the hospital within 30 days of their index operation, she said. Each one-unit increase in health literacy scores – meaning an increase in inadequate health literacy – increased an individual’s risk of readmission by about 6% on an adjusted basis, Dr. Baker said.
“Future work is going to be focused on identifying these patients and developing the interventions to educate and empower this vulnerable population before they are discharged,” Dr. Baker said.
Dr. Baker and coauthors reported having no financial disclosures.
SOURCE: Baker S et al. Academic Surgical Congress.
JACKSONVILLE, FLA. – Low health literacy is a common problem in Veterans Affairs health systems, and patients with low health literacy scores are 50% more likely to return to the hospital within 30 days of discharge after surgery than patients with high health literacy, investigators found in a study of surgery patients at VA medical centers.
“Low health literacy is prevalent among VA surgery patients and is associated with surgical readmissions,” said Samantha Baker, MD, of the University of Alabama at Birmingham and the VA Birmingham Healthcare System. She presented the findings at the Association for Academic Surgery/Society of University Surgeons Academic Surgical Congress.
This study used an instrument developed by Lisa Chew, MD, at the University of Washington to determine health literacy scores (Fam Med. 2004;36:588-94). The instrument uses three questions: how often patients have someone else help them read hospital materials; whether they have problems learning about a medical condition because they have difficulty understanding written information; and how confident they are in filling out their own medical forms. Answers are given on a scale of 0-4, with 12 points being the highest score for poor health literacy. This study considered adequate health literacy to be a score of 0-3, and 4-12 as “possibly inadequate health literacy.”
“Of the 722 patients who took the survey, 39.2% had a score of 0; 33.2% had a score of 4 or more,” Dr. Baker said.
The adequate health literacy group had significantly lower rates of unplanned readmissions and a trend toward lower emergency department visits than the possibly inadequate health literacy group, 11.7% vs. 22.5% (P = .003) for the former and 18.7% vs. 24.2% (P = .08) for the latter, Dr. Baker said.
She noted that the ethnic makeup of the groups was similar and the differences in health literacy among the ethnic groups were not statistically significant.
She also mentioned that those with adequate health literacy tended to be younger – 64 vs. 66.9 years – and more likely to be women (“but our number is low for females in the VA,” Dr. Baker said). She added that married patients tended to have lower heath literacy than did single patients.”
The 30-day surgical readmission rate was 13.7% for patients with high health literacy and 22.5% for those with low health literacy. Patients with inadequate health literacy were 53% more likely to be readmitted to the hospital within 30 days of their index operation, she said. Each one-unit increase in health literacy scores – meaning an increase in inadequate health literacy – increased an individual’s risk of readmission by about 6% on an adjusted basis, Dr. Baker said.
“Future work is going to be focused on identifying these patients and developing the interventions to educate and empower this vulnerable population before they are discharged,” Dr. Baker said.
Dr. Baker and coauthors reported having no financial disclosures.
SOURCE: Baker S et al. Academic Surgical Congress.
JACKSONVILLE, FLA. – Low health literacy is a common problem in Veterans Affairs health systems, and patients with low health literacy scores are 50% more likely to return to the hospital within 30 days of discharge after surgery than patients with high health literacy, investigators found in a study of surgery patients at VA medical centers.
“Low health literacy is prevalent among VA surgery patients and is associated with surgical readmissions,” said Samantha Baker, MD, of the University of Alabama at Birmingham and the VA Birmingham Healthcare System. She presented the findings at the Association for Academic Surgery/Society of University Surgeons Academic Surgical Congress.
This study used an instrument developed by Lisa Chew, MD, at the University of Washington to determine health literacy scores (Fam Med. 2004;36:588-94). The instrument uses three questions: how often patients have someone else help them read hospital materials; whether they have problems learning about a medical condition because they have difficulty understanding written information; and how confident they are in filling out their own medical forms. Answers are given on a scale of 0-4, with 12 points being the highest score for poor health literacy. This study considered adequate health literacy to be a score of 0-3, and 4-12 as “possibly inadequate health literacy.”
“Of the 722 patients who took the survey, 39.2% had a score of 0; 33.2% had a score of 4 or more,” Dr. Baker said.
The adequate health literacy group had significantly lower rates of unplanned readmissions and a trend toward lower emergency department visits than the possibly inadequate health literacy group, 11.7% vs. 22.5% (P = .003) for the former and 18.7% vs. 24.2% (P = .08) for the latter, Dr. Baker said.
She noted that the ethnic makeup of the groups was similar and the differences in health literacy among the ethnic groups were not statistically significant.
She also mentioned that those with adequate health literacy tended to be younger – 64 vs. 66.9 years – and more likely to be women (“but our number is low for females in the VA,” Dr. Baker said). She added that married patients tended to have lower heath literacy than did single patients.”
The 30-day surgical readmission rate was 13.7% for patients with high health literacy and 22.5% for those with low health literacy. Patients with inadequate health literacy were 53% more likely to be readmitted to the hospital within 30 days of their index operation, she said. Each one-unit increase in health literacy scores – meaning an increase in inadequate health literacy – increased an individual’s risk of readmission by about 6% on an adjusted basis, Dr. Baker said.
“Future work is going to be focused on identifying these patients and developing the interventions to educate and empower this vulnerable population before they are discharged,” Dr. Baker said.
Dr. Baker and coauthors reported having no financial disclosures.
SOURCE: Baker S et al. Academic Surgical Congress.
REPORTING FROM THE ACADEMIC SURGICAL CONGRESS
Key clinical point:
Major finding: The 30-day surgical readmission rate was 13.7% for patients with high health literacy and 22.5% for those with low health literacy.
Data source: Analysis of 722 patients who had general, vascular, or thoracic surgery at four VA Medical Centers from August 2015 to June 2017.
Disclosures: Dr. Baker and coauthors reported having no financial disclosures.
Source: Baker S et al. Academic Surgical Congress.
Laparoscopic procedure safer for SBO in elderly patients
JACKSONVILLE, FLA. – Octogenarians with small-bowel obstruction are about seven times more likely to have open than laparoscopic surgery, but the minimally invasive approach in these patients has been found to reduce their hospital stays and risk of pneumonia afterward, according to results of an observational study of data from the American College of Surgeons National Surgical Quality Improvement Program database.
Dr. Chang said, “Our study was able to show that age and the presence of preoperative sepsis are associated with mortality rather than procedure type, and that there are procedure-type risks associated with open procedures.”
The observational study analyzed 103 laparoscopic and 692 open operations for small-bowel obstruction (SBO) in patients 80 and older from 2006 to 2014. Characteristics of the open and laparoscopic group – age, gender, body mass index, and race – were similar, although the open group had higher American Society of Anesthesiologists classification and incidence of preoperative sepsis, Dr. Chang said.
“Unadjusted outcomes showed longer length of stay [and] higher postoperative mortality and rates of postoperative pneumonia in the open cases vs. laparoscopic,” she said. “But after we made adjustments for preoperative risk variables, age and the presence of preoperative sepsis were associated with mortality, not the operative approach.” Length of stay was 4 days for the laparoscopic patients vs. 8 days for open (P less than .0001).
The researchers performed logistical regression analysis and found that mortality risk rose slightly with age (odds ratio, 1.11; P = .0311) but almost quadrupled with preoperative sepsis (OR, 3.77; P = .0287) regardless of open or laparoscopic approach. For postoperative pneumonia, risk factors were male gender (OR, 2.68; P = .0003) and open procedure (OR, 5.03; P = .0282).
“Our study elucidates that the octogenarian with small-bowel obstruction due to adhesive disease may benefit from an initial laparoscopic approach,” Dr. Change said. “Further prospective studies are warranted.”
Dr. Chang and coauthors reported having no financial disclosures.
SOURCE: Chang E et al. Academic Surgical Congress.
JACKSONVILLE, FLA. – Octogenarians with small-bowel obstruction are about seven times more likely to have open than laparoscopic surgery, but the minimally invasive approach in these patients has been found to reduce their hospital stays and risk of pneumonia afterward, according to results of an observational study of data from the American College of Surgeons National Surgical Quality Improvement Program database.
Dr. Chang said, “Our study was able to show that age and the presence of preoperative sepsis are associated with mortality rather than procedure type, and that there are procedure-type risks associated with open procedures.”
The observational study analyzed 103 laparoscopic and 692 open operations for small-bowel obstruction (SBO) in patients 80 and older from 2006 to 2014. Characteristics of the open and laparoscopic group – age, gender, body mass index, and race – were similar, although the open group had higher American Society of Anesthesiologists classification and incidence of preoperative sepsis, Dr. Chang said.
“Unadjusted outcomes showed longer length of stay [and] higher postoperative mortality and rates of postoperative pneumonia in the open cases vs. laparoscopic,” she said. “But after we made adjustments for preoperative risk variables, age and the presence of preoperative sepsis were associated with mortality, not the operative approach.” Length of stay was 4 days for the laparoscopic patients vs. 8 days for open (P less than .0001).
The researchers performed logistical regression analysis and found that mortality risk rose slightly with age (odds ratio, 1.11; P = .0311) but almost quadrupled with preoperative sepsis (OR, 3.77; P = .0287) regardless of open or laparoscopic approach. For postoperative pneumonia, risk factors were male gender (OR, 2.68; P = .0003) and open procedure (OR, 5.03; P = .0282).
“Our study elucidates that the octogenarian with small-bowel obstruction due to adhesive disease may benefit from an initial laparoscopic approach,” Dr. Change said. “Further prospective studies are warranted.”
Dr. Chang and coauthors reported having no financial disclosures.
SOURCE: Chang E et al. Academic Surgical Congress.
JACKSONVILLE, FLA. – Octogenarians with small-bowel obstruction are about seven times more likely to have open than laparoscopic surgery, but the minimally invasive approach in these patients has been found to reduce their hospital stays and risk of pneumonia afterward, according to results of an observational study of data from the American College of Surgeons National Surgical Quality Improvement Program database.
Dr. Chang said, “Our study was able to show that age and the presence of preoperative sepsis are associated with mortality rather than procedure type, and that there are procedure-type risks associated with open procedures.”
The observational study analyzed 103 laparoscopic and 692 open operations for small-bowel obstruction (SBO) in patients 80 and older from 2006 to 2014. Characteristics of the open and laparoscopic group – age, gender, body mass index, and race – were similar, although the open group had higher American Society of Anesthesiologists classification and incidence of preoperative sepsis, Dr. Chang said.
“Unadjusted outcomes showed longer length of stay [and] higher postoperative mortality and rates of postoperative pneumonia in the open cases vs. laparoscopic,” she said. “But after we made adjustments for preoperative risk variables, age and the presence of preoperative sepsis were associated with mortality, not the operative approach.” Length of stay was 4 days for the laparoscopic patients vs. 8 days for open (P less than .0001).
The researchers performed logistical regression analysis and found that mortality risk rose slightly with age (odds ratio, 1.11; P = .0311) but almost quadrupled with preoperative sepsis (OR, 3.77; P = .0287) regardless of open or laparoscopic approach. For postoperative pneumonia, risk factors were male gender (OR, 2.68; P = .0003) and open procedure (OR, 5.03; P = .0282).
“Our study elucidates that the octogenarian with small-bowel obstruction due to adhesive disease may benefit from an initial laparoscopic approach,” Dr. Change said. “Further prospective studies are warranted.”
Dr. Chang and coauthors reported having no financial disclosures.
SOURCE: Chang E et al. Academic Surgical Congress.
REPORTING FROM THE ACADEMIC SURGICAL CONGRESS
Key clinical point: and older.
Major finding: The open procedure had an odds ratio five times greater than laparoscopic surgery for risk of pneumonia after the operation in this age group (OR, 5.03; P =.0282).
Data source: Observational study of 103 laparoscopic and 692 open cases of surgery for SBO in the ACS NSQIP database from 2006 to 2014.
Disclosures: Dr. Chang and coauthors reported having no financial disclosures.
Source: Chang E et al. Academic Surgical Congress.
The case for closing robotic surgery port sites
JACKSONVILLE, FLA. – Findings from a retrospective chart review of robotic operations performed over 6 years has identified situations in which surgeons may consider closing 8-mm port sites after robotic surgery, according to a presentation at the Association for Academic Surgery/Society of University Surgeons Academic Surgical Congress.
“Although the incidence of hernia through the 8-mm port sites was low, it’s still important because it’s a significant cause of morbidity in these patients,” Dr. Diez-Barroso said. Two of the three 8-mm port-site hernias required emergency surgery for small bowel incarceration.
“Both of the hernias occurred in the left lower quadrant in the lateral most port, near the anterior superior iliac spine,” he said. “The nearest site of muscle insertions was where the abdominal wall muscle layers have a limited ability to slide over one another during insufflation and desufflation and therefore have a lack of ability to seal off the port site correctly.”
These results have caused surgeons in his group to take a closer look at their own practices, Dr. Diez-Barroso said. “In our practice, now we’re considering closure of the ports in that location in the presence of known risk factors for hernia formation,” he said.
Dr. Diez-Barroso noted other scenarios when surgeons might consider closing 8-mm port sites, for example, after a prolonged operation, when significant torque has been placed on the port site, and in obese patients. The two cases of emergency surgery for port-site hernias involved obese patients: a female with a body mass index of 33 kg/m2 who had an abdominoperineal resection and a male with a BMI of 34 kg/m2 who had a right-sided ventral hernia repair.
The study had a number of limitations, Dr. Diez-Barroso said: its small sample size, retrospective nature, and short follow-up. “Moving forward, to understand better the true incidence of port-site hernias, we want further investigation with longer follow-up times and a larger sample size,” he said.
During questions, moderator Lesly Ann Dossett, MD, FACS, of the University of Michigan, Ann Arbor, asked whether there were other steps surgeons could take, such as where to place the ports or how much torque they apply, besides closing the ports.
“We’ve always placed ports with the standard approach: inserting them perpendicular to the abdominal wall,” Dr. Diez-Barroso said. “Others have theorized that the lateral sites undergo more torque, but I think that also needs further investigation.”
Dr. Diez-Barroso and coauthors reported having no financial disclosures.
Source: Diez-Barroso R. Academic Surgical Congress 2018.
JACKSONVILLE, FLA. – Findings from a retrospective chart review of robotic operations performed over 6 years has identified situations in which surgeons may consider closing 8-mm port sites after robotic surgery, according to a presentation at the Association for Academic Surgery/Society of University Surgeons Academic Surgical Congress.
“Although the incidence of hernia through the 8-mm port sites was low, it’s still important because it’s a significant cause of morbidity in these patients,” Dr. Diez-Barroso said. Two of the three 8-mm port-site hernias required emergency surgery for small bowel incarceration.
“Both of the hernias occurred in the left lower quadrant in the lateral most port, near the anterior superior iliac spine,” he said. “The nearest site of muscle insertions was where the abdominal wall muscle layers have a limited ability to slide over one another during insufflation and desufflation and therefore have a lack of ability to seal off the port site correctly.”
These results have caused surgeons in his group to take a closer look at their own practices, Dr. Diez-Barroso said. “In our practice, now we’re considering closure of the ports in that location in the presence of known risk factors for hernia formation,” he said.
Dr. Diez-Barroso noted other scenarios when surgeons might consider closing 8-mm port sites, for example, after a prolonged operation, when significant torque has been placed on the port site, and in obese patients. The two cases of emergency surgery for port-site hernias involved obese patients: a female with a body mass index of 33 kg/m2 who had an abdominoperineal resection and a male with a BMI of 34 kg/m2 who had a right-sided ventral hernia repair.
The study had a number of limitations, Dr. Diez-Barroso said: its small sample size, retrospective nature, and short follow-up. “Moving forward, to understand better the true incidence of port-site hernias, we want further investigation with longer follow-up times and a larger sample size,” he said.
During questions, moderator Lesly Ann Dossett, MD, FACS, of the University of Michigan, Ann Arbor, asked whether there were other steps surgeons could take, such as where to place the ports or how much torque they apply, besides closing the ports.
“We’ve always placed ports with the standard approach: inserting them perpendicular to the abdominal wall,” Dr. Diez-Barroso said. “Others have theorized that the lateral sites undergo more torque, but I think that also needs further investigation.”
Dr. Diez-Barroso and coauthors reported having no financial disclosures.
Source: Diez-Barroso R. Academic Surgical Congress 2018.
JACKSONVILLE, FLA. – Findings from a retrospective chart review of robotic operations performed over 6 years has identified situations in which surgeons may consider closing 8-mm port sites after robotic surgery, according to a presentation at the Association for Academic Surgery/Society of University Surgeons Academic Surgical Congress.
“Although the incidence of hernia through the 8-mm port sites was low, it’s still important because it’s a significant cause of morbidity in these patients,” Dr. Diez-Barroso said. Two of the three 8-mm port-site hernias required emergency surgery for small bowel incarceration.
“Both of the hernias occurred in the left lower quadrant in the lateral most port, near the anterior superior iliac spine,” he said. “The nearest site of muscle insertions was where the abdominal wall muscle layers have a limited ability to slide over one another during insufflation and desufflation and therefore have a lack of ability to seal off the port site correctly.”
These results have caused surgeons in his group to take a closer look at their own practices, Dr. Diez-Barroso said. “In our practice, now we’re considering closure of the ports in that location in the presence of known risk factors for hernia formation,” he said.
Dr. Diez-Barroso noted other scenarios when surgeons might consider closing 8-mm port sites, for example, after a prolonged operation, when significant torque has been placed on the port site, and in obese patients. The two cases of emergency surgery for port-site hernias involved obese patients: a female with a body mass index of 33 kg/m2 who had an abdominoperineal resection and a male with a BMI of 34 kg/m2 who had a right-sided ventral hernia repair.
The study had a number of limitations, Dr. Diez-Barroso said: its small sample size, retrospective nature, and short follow-up. “Moving forward, to understand better the true incidence of port-site hernias, we want further investigation with longer follow-up times and a larger sample size,” he said.
During questions, moderator Lesly Ann Dossett, MD, FACS, of the University of Michigan, Ann Arbor, asked whether there were other steps surgeons could take, such as where to place the ports or how much torque they apply, besides closing the ports.
“We’ve always placed ports with the standard approach: inserting them perpendicular to the abdominal wall,” Dr. Diez-Barroso said. “Others have theorized that the lateral sites undergo more torque, but I think that also needs further investigation.”
Dr. Diez-Barroso and coauthors reported having no financial disclosures.
Source: Diez-Barroso R. Academic Surgical Congress 2018.
AT THE ACADEMIC SURGICAL CONGRESS
Key clinical point: Some 8-mm robotic port sites may warrant closure under certain circumstances.
Major finding: Of 178 patients, 3 had complications caused by 8-mm robotic port sites that were not closed, 2 of which required emergency reoperation for small bowel incarceration.
Data source: Retrospective chart review of 178 patients who had robotic general and oncologic surgical procedures between July 2010 and December 2016.
Disclosures: Dr. Diez-Barroso and coauthors reported having no financial disclosures.
Source: Diez-Barroso R. Academic Surgical Congress 2018.
No link found between OR skullcaps and infection
JACKSONVILLE, FLA. – Surgeons who choose to wear a skullcap in the OR can point to yet another study with evidence to bolster their preference.
Two major hospital and nursing credentialing organizations have recommended that hospitals ban skullcaps from the operating room as a practice to control surgical site infections, but a study of almost 2,000 operations at an academic medical center has found that strictly enforcing the ban had no impact on infection rates, according to results of a study presented at the Association for Academic Surgery/Society of University Surgeons Academic Surgical Congress.
The study, conducted at Thomas Jefferson University in Philadelphia, showed that rates of surgical site infections (SSIs) were almost identical in the year before and the year after the institution implemented the skullcap ban. “The overall surgical site infection rate was 5.4%, and there were no differences in surgical site infections before or after the headwear policy was adopted,” said Arturo J. Rios-Diaz, MD. The Joint Commission and the Association of periOperative Registered Nurses recommend against the use of skullcaps.
The study reviewed American College of Surgeons National Surgical Quality Improvement Program data on 1,901 patients who had 1,950 clean or clean-contaminated general surgery procedures in 2015, the year before the ban was implemented, and in 2016 (767 in 2015 and 1,183 in 2016). The most common procedures were colectomy (18.2%), pancreatectomy (13.5%), and ventral hernia repair (9.9%). The study excluded orthopedic and vascular operations and any cases with sepsis or an active infection at the time of surgery.
There were some differences between the pre- and postban patient groups. The preban group was younger (median age, 57.91 years vs. 59.75, P = .01) but had more patients who were obese, measured as body mass index above 30 kg/m2 (42.37% vs. 35.23%, P less than .01), and smokers (16.18% vs. 12.27%, P = .02). Wound classification also differed: clean, 38.55% before vs. 43.91% after; and clean-contaminated, 61.45% vs. 56.09% (P = .02). All other demographic and clinical characteristics were similar between the two groups.
“In multivariate logistic regression models controlling for these confounders, there was no association of the banning of skullcaps with decreased surgical site infection rates,” Dr. Rios-Diaz said.
“The adoption of guidelines targeted to optimize patient care should always be welcomed by surgeons,” he said. “However, if they’re going to be implemented on a national level, these policies must be based on higher levels of evidence, so further studies are warranted to assess the validity of the [Joint Commission] headwear guidelines.” According to Dr. Rios-Diaz, the recommendations from the Association of periOperative Registered Nurses are based on two case series from the 1960s and 1970s.
Thomas Jefferson University once again allows skullcaps in the OR, he said.
Dr. Rios-Diaz and his coauthors had no financial relationships to disclose.
SOURCE: Rios-Diaz AJ et al. Annual Academic Surgical Congress. Abstract 09.11.
JACKSONVILLE, FLA. – Surgeons who choose to wear a skullcap in the OR can point to yet another study with evidence to bolster their preference.
Two major hospital and nursing credentialing organizations have recommended that hospitals ban skullcaps from the operating room as a practice to control surgical site infections, but a study of almost 2,000 operations at an academic medical center has found that strictly enforcing the ban had no impact on infection rates, according to results of a study presented at the Association for Academic Surgery/Society of University Surgeons Academic Surgical Congress.
The study, conducted at Thomas Jefferson University in Philadelphia, showed that rates of surgical site infections (SSIs) were almost identical in the year before and the year after the institution implemented the skullcap ban. “The overall surgical site infection rate was 5.4%, and there were no differences in surgical site infections before or after the headwear policy was adopted,” said Arturo J. Rios-Diaz, MD. The Joint Commission and the Association of periOperative Registered Nurses recommend against the use of skullcaps.
The study reviewed American College of Surgeons National Surgical Quality Improvement Program data on 1,901 patients who had 1,950 clean or clean-contaminated general surgery procedures in 2015, the year before the ban was implemented, and in 2016 (767 in 2015 and 1,183 in 2016). The most common procedures were colectomy (18.2%), pancreatectomy (13.5%), and ventral hernia repair (9.9%). The study excluded orthopedic and vascular operations and any cases with sepsis or an active infection at the time of surgery.
There were some differences between the pre- and postban patient groups. The preban group was younger (median age, 57.91 years vs. 59.75, P = .01) but had more patients who were obese, measured as body mass index above 30 kg/m2 (42.37% vs. 35.23%, P less than .01), and smokers (16.18% vs. 12.27%, P = .02). Wound classification also differed: clean, 38.55% before vs. 43.91% after; and clean-contaminated, 61.45% vs. 56.09% (P = .02). All other demographic and clinical characteristics were similar between the two groups.
“In multivariate logistic regression models controlling for these confounders, there was no association of the banning of skullcaps with decreased surgical site infection rates,” Dr. Rios-Diaz said.
“The adoption of guidelines targeted to optimize patient care should always be welcomed by surgeons,” he said. “However, if they’re going to be implemented on a national level, these policies must be based on higher levels of evidence, so further studies are warranted to assess the validity of the [Joint Commission] headwear guidelines.” According to Dr. Rios-Diaz, the recommendations from the Association of periOperative Registered Nurses are based on two case series from the 1960s and 1970s.
Thomas Jefferson University once again allows skullcaps in the OR, he said.
Dr. Rios-Diaz and his coauthors had no financial relationships to disclose.
SOURCE: Rios-Diaz AJ et al. Annual Academic Surgical Congress. Abstract 09.11.
JACKSONVILLE, FLA. – Surgeons who choose to wear a skullcap in the OR can point to yet another study with evidence to bolster their preference.
Two major hospital and nursing credentialing organizations have recommended that hospitals ban skullcaps from the operating room as a practice to control surgical site infections, but a study of almost 2,000 operations at an academic medical center has found that strictly enforcing the ban had no impact on infection rates, according to results of a study presented at the Association for Academic Surgery/Society of University Surgeons Academic Surgical Congress.
The study, conducted at Thomas Jefferson University in Philadelphia, showed that rates of surgical site infections (SSIs) were almost identical in the year before and the year after the institution implemented the skullcap ban. “The overall surgical site infection rate was 5.4%, and there were no differences in surgical site infections before or after the headwear policy was adopted,” said Arturo J. Rios-Diaz, MD. The Joint Commission and the Association of periOperative Registered Nurses recommend against the use of skullcaps.
The study reviewed American College of Surgeons National Surgical Quality Improvement Program data on 1,901 patients who had 1,950 clean or clean-contaminated general surgery procedures in 2015, the year before the ban was implemented, and in 2016 (767 in 2015 and 1,183 in 2016). The most common procedures were colectomy (18.2%), pancreatectomy (13.5%), and ventral hernia repair (9.9%). The study excluded orthopedic and vascular operations and any cases with sepsis or an active infection at the time of surgery.
There were some differences between the pre- and postban patient groups. The preban group was younger (median age, 57.91 years vs. 59.75, P = .01) but had more patients who were obese, measured as body mass index above 30 kg/m2 (42.37% vs. 35.23%, P less than .01), and smokers (16.18% vs. 12.27%, P = .02). Wound classification also differed: clean, 38.55% before vs. 43.91% after; and clean-contaminated, 61.45% vs. 56.09% (P = .02). All other demographic and clinical characteristics were similar between the two groups.
“In multivariate logistic regression models controlling for these confounders, there was no association of the banning of skullcaps with decreased surgical site infection rates,” Dr. Rios-Diaz said.
“The adoption of guidelines targeted to optimize patient care should always be welcomed by surgeons,” he said. “However, if they’re going to be implemented on a national level, these policies must be based on higher levels of evidence, so further studies are warranted to assess the validity of the [Joint Commission] headwear guidelines.” According to Dr. Rios-Diaz, the recommendations from the Association of periOperative Registered Nurses are based on two case series from the 1960s and 1970s.
Thomas Jefferson University once again allows skullcaps in the OR, he said.
Dr. Rios-Diaz and his coauthors had no financial relationships to disclose.
SOURCE: Rios-Diaz AJ et al. Annual Academic Surgical Congress. Abstract 09.11.
REPORTING FROM THE ACADEMIC SURGICAL CONGRESS
Key clinical point: Findings of this study do not support the ban on surgical skullcaps.
Major finding: No association was found between the skullcap ban and decreased surgical site infection.
Study details: Analysis of ACS NSQIP data on 1,950 surgical cases from before and after the skullcap ban.
Disclosures: The investigators had no financial relationships to disclose.
Source: Rios-Diaz AJ et al. Annual Academic Surgical Congress. Abstract 09.11.
ERAS pathway can cut postdischarge opioid use
JACKSONVILLE, FLA. – An but also to reduce postdischarge opioid prescriptions.
The results of the enhanced recovery after surgery (ERAS) study were reported at the Association for Academic Surgical/Society of Academic Surgeons Academic Congress by Kathryn Hudak, a fourth-year medical student at the University of Alabama at Birmingham (UAB).
The researchers compared outcomes of 197 patients in the ERAS database at the institution who had colorectal surgery in 2015 with 198 patients who had surgery in 2013 and 2014 before the ERAS protocol was put in place.
Overall, the ERAS program had successes. “Using ERAS, we have shown a reduction in hospital length of stay and reduction in postoperative complications, [and] a reduction in hospital costs without any increase in readmissions or mortality,” Ms. Hudak said. Average length of stay decreased by 2 days and postoperative complications by 30%, study results showed.
“One purpose of ERAS is to control pain with as little need for opioids as possible,” she said. Pain management in the ERAS protocol used at UAB involved celecoxib, gabapentin, and acetaminophen before surgery; ketorolac and lidocaine during the operation; and alternating acetaminophen with other nonsteroidal anti-inflammatory drugs and oral oxycodone as needed after surgery. “If ERAS uses multimodal analgesia to avoid opioid use in the hospital, we wanted to know if we could see any effect in the use of opioids outside of the hospital,” Ms. Hudak said.
ERAS patients had more minimally invasive surgery (43.4% vs. 32.5%), more ostomies (38.9% vs. 25.9%), and lower rates of baseline opioid use (15.2% vs. 29.4%). So these patients would be expected to have a lower need for postdischarge pain medications.
For the study overall, 89.6% of patients in both groups were discharged with an opioid prescription but, Ms. Hudak said, “more of our ERAS patients were discharged without a prescription for an opioid – 14.1% vs. 7% in the pre-ERAS patients. “In our ERAS patients, we found a significantly different makeup in those discharge medications,” she said. “Many more patients were discharged on tramadol or a combination of tramadol and oxycodone or hydrocodone – again, using more of those low-potency opioids.”
The study revealed one unexpected finding, Ms. Hudak said. “We found that ERAS patients had a higher number of pills prescribed and OMEs [oral morphine equivalents], and we were surprised by this because we were expecting the opposite,” she said. Among those discharged with opioids, ERAS patients had an average oral morphine equivalent of 403 and 60.6 pills vs. 343 OMEs and 46.9 pills pre-ERAS (P less than .03). However, per-pill OME ratios were lower for the ERAS group: 6.9 vs. 7.6, Ms. Hudak said.
The study also followed up with patients a year after discharge, and found that 34% of ERAS patients needed an additional prescription while 44% of pre-ERAS patients required additional high-potency opioids, Hudak said.
“ERAS does seem to modify postdischarge opioid utilization, but we definitely need to work toward better standardization of opioid prescribing,” Ms. Hudak said. The UAB has since implemented a standardized protocol for residents to prescribe opioids after surgery based on a patient’s risk for postoperative pain, she said.
Ms. Hudak and her coauthors had no financial relationships to disclose.
JACKSONVILLE, FLA. – An but also to reduce postdischarge opioid prescriptions.
The results of the enhanced recovery after surgery (ERAS) study were reported at the Association for Academic Surgical/Society of Academic Surgeons Academic Congress by Kathryn Hudak, a fourth-year medical student at the University of Alabama at Birmingham (UAB).
The researchers compared outcomes of 197 patients in the ERAS database at the institution who had colorectal surgery in 2015 with 198 patients who had surgery in 2013 and 2014 before the ERAS protocol was put in place.
Overall, the ERAS program had successes. “Using ERAS, we have shown a reduction in hospital length of stay and reduction in postoperative complications, [and] a reduction in hospital costs without any increase in readmissions or mortality,” Ms. Hudak said. Average length of stay decreased by 2 days and postoperative complications by 30%, study results showed.
“One purpose of ERAS is to control pain with as little need for opioids as possible,” she said. Pain management in the ERAS protocol used at UAB involved celecoxib, gabapentin, and acetaminophen before surgery; ketorolac and lidocaine during the operation; and alternating acetaminophen with other nonsteroidal anti-inflammatory drugs and oral oxycodone as needed after surgery. “If ERAS uses multimodal analgesia to avoid opioid use in the hospital, we wanted to know if we could see any effect in the use of opioids outside of the hospital,” Ms. Hudak said.
ERAS patients had more minimally invasive surgery (43.4% vs. 32.5%), more ostomies (38.9% vs. 25.9%), and lower rates of baseline opioid use (15.2% vs. 29.4%). So these patients would be expected to have a lower need for postdischarge pain medications.
For the study overall, 89.6% of patients in both groups were discharged with an opioid prescription but, Ms. Hudak said, “more of our ERAS patients were discharged without a prescription for an opioid – 14.1% vs. 7% in the pre-ERAS patients. “In our ERAS patients, we found a significantly different makeup in those discharge medications,” she said. “Many more patients were discharged on tramadol or a combination of tramadol and oxycodone or hydrocodone – again, using more of those low-potency opioids.”
The study revealed one unexpected finding, Ms. Hudak said. “We found that ERAS patients had a higher number of pills prescribed and OMEs [oral morphine equivalents], and we were surprised by this because we were expecting the opposite,” she said. Among those discharged with opioids, ERAS patients had an average oral morphine equivalent of 403 and 60.6 pills vs. 343 OMEs and 46.9 pills pre-ERAS (P less than .03). However, per-pill OME ratios were lower for the ERAS group: 6.9 vs. 7.6, Ms. Hudak said.
The study also followed up with patients a year after discharge, and found that 34% of ERAS patients needed an additional prescription while 44% of pre-ERAS patients required additional high-potency opioids, Hudak said.
“ERAS does seem to modify postdischarge opioid utilization, but we definitely need to work toward better standardization of opioid prescribing,” Ms. Hudak said. The UAB has since implemented a standardized protocol for residents to prescribe opioids after surgery based on a patient’s risk for postoperative pain, she said.
Ms. Hudak and her coauthors had no financial relationships to disclose.
JACKSONVILLE, FLA. – An but also to reduce postdischarge opioid prescriptions.
The results of the enhanced recovery after surgery (ERAS) study were reported at the Association for Academic Surgical/Society of Academic Surgeons Academic Congress by Kathryn Hudak, a fourth-year medical student at the University of Alabama at Birmingham (UAB).
The researchers compared outcomes of 197 patients in the ERAS database at the institution who had colorectal surgery in 2015 with 198 patients who had surgery in 2013 and 2014 before the ERAS protocol was put in place.
Overall, the ERAS program had successes. “Using ERAS, we have shown a reduction in hospital length of stay and reduction in postoperative complications, [and] a reduction in hospital costs without any increase in readmissions or mortality,” Ms. Hudak said. Average length of stay decreased by 2 days and postoperative complications by 30%, study results showed.
“One purpose of ERAS is to control pain with as little need for opioids as possible,” she said. Pain management in the ERAS protocol used at UAB involved celecoxib, gabapentin, and acetaminophen before surgery; ketorolac and lidocaine during the operation; and alternating acetaminophen with other nonsteroidal anti-inflammatory drugs and oral oxycodone as needed after surgery. “If ERAS uses multimodal analgesia to avoid opioid use in the hospital, we wanted to know if we could see any effect in the use of opioids outside of the hospital,” Ms. Hudak said.
ERAS patients had more minimally invasive surgery (43.4% vs. 32.5%), more ostomies (38.9% vs. 25.9%), and lower rates of baseline opioid use (15.2% vs. 29.4%). So these patients would be expected to have a lower need for postdischarge pain medications.
For the study overall, 89.6% of patients in both groups were discharged with an opioid prescription but, Ms. Hudak said, “more of our ERAS patients were discharged without a prescription for an opioid – 14.1% vs. 7% in the pre-ERAS patients. “In our ERAS patients, we found a significantly different makeup in those discharge medications,” she said. “Many more patients were discharged on tramadol or a combination of tramadol and oxycodone or hydrocodone – again, using more of those low-potency opioids.”
The study revealed one unexpected finding, Ms. Hudak said. “We found that ERAS patients had a higher number of pills prescribed and OMEs [oral morphine equivalents], and we were surprised by this because we were expecting the opposite,” she said. Among those discharged with opioids, ERAS patients had an average oral morphine equivalent of 403 and 60.6 pills vs. 343 OMEs and 46.9 pills pre-ERAS (P less than .03). However, per-pill OME ratios were lower for the ERAS group: 6.9 vs. 7.6, Ms. Hudak said.
The study also followed up with patients a year after discharge, and found that 34% of ERAS patients needed an additional prescription while 44% of pre-ERAS patients required additional high-potency opioids, Hudak said.
“ERAS does seem to modify postdischarge opioid utilization, but we definitely need to work toward better standardization of opioid prescribing,” Ms. Hudak said. The UAB has since implemented a standardized protocol for residents to prescribe opioids after surgery based on a patient’s risk for postoperative pain, she said.
Ms. Hudak and her coauthors had no financial relationships to disclose.
REPORTING FROM THE ACADEMIC SURGICAL CONGRESS
Key clinical point: Use of the enhanced recovery after surgery (ERAS) pathway reduces discharge prescriptions for opioids after colorectal surgery.
Major finding: 14.2% of ERAS patients were discharged without an opioid prescription vs. 7% for pre-ERAS patients.
Data source: An analysis of a single-institution ERAS database of 197 ERAS patients, compared with 198 patients who did not follow the ERAS pathway.
Disclosures: Ms. Hudak reported having no relevant financial disclosures.
Patient instructions in surgery exceed recommended reading grade level
JACKSONVILLE, FLA. – The American Medical Association and National Institutes of Health recommend that patient instructions should be written at a sixth-grade level, and the Centers for Disease Control and Prevention recommend an eighth-grade level so patients and caregivers can easily understand them, but a study of education materials that patients get for surgery finds that they typically overshoot that mark – in some cases considerably.
A study of patient education materials distributed at the University of Alabama at Birmingham has revealed that the , second-year medical student Callie Perkins reported at the Association for Academic Surgery/Society of University Surgeons Academic Surgical Congress.
“Only 16% of our collected material actually met the standards for readability,” Ms. Perkins said. “As far as surgical subspecialties go, neurosurgery had the highest grade level and plastic surgery had the lowest.”
Nine of the 12 surgical disciplines had no materials at the sixth-grade level or below. Plastic surgery had the highest percentage of materials that met the recommended standard: 47%. Overall, plastic surgery education materials had the lowest FKGL score, at the equivalent of grade 6.34. Neurosurgery had the highest, at 9.83. Other disciplines with an FKGL of 9 or greater are thoracic surgery (9.61) and pancreatic surgery (9.18), while vascular surgery had a level of 8.95.
The study also looked at specific words commonly used in patient literature with FKGL scores that far exceed the recommended level, Ms. Perkins said. They include strenuous (21 FKGL), anesthesia (26.2 FKGL), narcotic (21.5 FKGL) and incision (16.8 FKGL).
The findings, Ms. Perkins said, “provide a clear opportunity for improvement of our patient materials at UAB.” She noted that Microsoft Word has a tool for evaluating the FKGL of text, although the software does not account for potentially more challenging anatomical terms.
Ms. Perkins suggested a way forward may be to hold focus groups with surgeons and nursing clinical care coordinators to educate them about more patient-friendly terminology. In the meantime, Ms. Perkins said, using the FKGL tool in Microsoft Word is the most accessible solution to gauge education materials that talk over the patient’s head.
Ms. Perkins reported having no financial relationships to disclose.
SOURCE: Perkins, C et al. Abstract 67.08
JACKSONVILLE, FLA. – The American Medical Association and National Institutes of Health recommend that patient instructions should be written at a sixth-grade level, and the Centers for Disease Control and Prevention recommend an eighth-grade level so patients and caregivers can easily understand them, but a study of education materials that patients get for surgery finds that they typically overshoot that mark – in some cases considerably.
A study of patient education materials distributed at the University of Alabama at Birmingham has revealed that the , second-year medical student Callie Perkins reported at the Association for Academic Surgery/Society of University Surgeons Academic Surgical Congress.
“Only 16% of our collected material actually met the standards for readability,” Ms. Perkins said. “As far as surgical subspecialties go, neurosurgery had the highest grade level and plastic surgery had the lowest.”
Nine of the 12 surgical disciplines had no materials at the sixth-grade level or below. Plastic surgery had the highest percentage of materials that met the recommended standard: 47%. Overall, plastic surgery education materials had the lowest FKGL score, at the equivalent of grade 6.34. Neurosurgery had the highest, at 9.83. Other disciplines with an FKGL of 9 or greater are thoracic surgery (9.61) and pancreatic surgery (9.18), while vascular surgery had a level of 8.95.
The study also looked at specific words commonly used in patient literature with FKGL scores that far exceed the recommended level, Ms. Perkins said. They include strenuous (21 FKGL), anesthesia (26.2 FKGL), narcotic (21.5 FKGL) and incision (16.8 FKGL).
The findings, Ms. Perkins said, “provide a clear opportunity for improvement of our patient materials at UAB.” She noted that Microsoft Word has a tool for evaluating the FKGL of text, although the software does not account for potentially more challenging anatomical terms.
Ms. Perkins suggested a way forward may be to hold focus groups with surgeons and nursing clinical care coordinators to educate them about more patient-friendly terminology. In the meantime, Ms. Perkins said, using the FKGL tool in Microsoft Word is the most accessible solution to gauge education materials that talk over the patient’s head.
Ms. Perkins reported having no financial relationships to disclose.
SOURCE: Perkins, C et al. Abstract 67.08
JACKSONVILLE, FLA. – The American Medical Association and National Institutes of Health recommend that patient instructions should be written at a sixth-grade level, and the Centers for Disease Control and Prevention recommend an eighth-grade level so patients and caregivers can easily understand them, but a study of education materials that patients get for surgery finds that they typically overshoot that mark – in some cases considerably.
A study of patient education materials distributed at the University of Alabama at Birmingham has revealed that the , second-year medical student Callie Perkins reported at the Association for Academic Surgery/Society of University Surgeons Academic Surgical Congress.
“Only 16% of our collected material actually met the standards for readability,” Ms. Perkins said. “As far as surgical subspecialties go, neurosurgery had the highest grade level and plastic surgery had the lowest.”
Nine of the 12 surgical disciplines had no materials at the sixth-grade level or below. Plastic surgery had the highest percentage of materials that met the recommended standard: 47%. Overall, plastic surgery education materials had the lowest FKGL score, at the equivalent of grade 6.34. Neurosurgery had the highest, at 9.83. Other disciplines with an FKGL of 9 or greater are thoracic surgery (9.61) and pancreatic surgery (9.18), while vascular surgery had a level of 8.95.
The study also looked at specific words commonly used in patient literature with FKGL scores that far exceed the recommended level, Ms. Perkins said. They include strenuous (21 FKGL), anesthesia (26.2 FKGL), narcotic (21.5 FKGL) and incision (16.8 FKGL).
The findings, Ms. Perkins said, “provide a clear opportunity for improvement of our patient materials at UAB.” She noted that Microsoft Word has a tool for evaluating the FKGL of text, although the software does not account for potentially more challenging anatomical terms.
Ms. Perkins suggested a way forward may be to hold focus groups with surgeons and nursing clinical care coordinators to educate them about more patient-friendly terminology. In the meantime, Ms. Perkins said, using the FKGL tool in Microsoft Word is the most accessible solution to gauge education materials that talk over the patient’s head.
Ms. Perkins reported having no financial relationships to disclose.
SOURCE: Perkins, C et al. Abstract 67.08
AT THE ACADEMIC SURGICAL CONGRESS
Key clinical point: Patient education materials in surgery typically exceed the recommended guidelines of being at a sixth-grade reading level.
Major finding: Only 16% of patient education materials from surgical specialties met the recommended guideline.
Data source: Flesch-Kincaid Grade Level analysis of 112 education materials collected from 12 different surgical specialties at the University of Alabama at Birmingham.
Disclosure: Ms. Perkins reported having no financial relationships to disclose.
Source: Perkins, C et al. Abstract 67.08.
Surgery team scorecard improved patient satisfaction
JACKSONVILLE, FLA. – A scorecard enables spectators at a baseball game to keep track of who the players are, and a scorecard of the surgery team can do the same for inpatients, researchers at Johns Hopkins University in Baltimore found.
They gave patients a “facesheet” that included photographs and biographies of all members of their surgery team, which helped patients to better understand the team members’ roles in their care and led to improvements in overall satisfaction scores, according to a study reported at the Association for Academic Surgery/Society of University Surgeons Academic Surgical Congress.
The study involved two intervals: a prefacesheet phase of 153 patients and a postfacesheet phase of 100 patients. The two groups, all gastrointestinal surgery inpatients, were administered preintervention discharge surveys to evaluate their level of patient satisfaction according to a 5-point Likert scale (1 = strongly disagree and 5 = strongly agree).
“We found that using these facesheets helped patients know the roles of their team members, and the patients felt that it was important to [have this information],” Dr. DiBrito said.
The share of patients answering 4 (agreed) or 5 (strongly agreed) for overall satisfaction rose from 83% before the facesheet intervention to 88% afterward (P = .5). The number of patients agreeing that they understood their providers’ roles increased from 72% to 83% (P = .05), and the number who agreed that it was important to know who their surgical team members were increased from 85% to 94% (P = .04). The latter finding somewhat surprised the researchers. Dr. DiBrito said, “That’s not exactly what we were anticipating.”
The study also revealed a trend in patients’ feeling more confident in their team overall after the facesheet intervention, rising from 89% to 95%, Dr. DiBrito said.
She said the Johns Hopkins team is not continuing the initiative currently but would like to roll it out more broadly to other hospital services. Other groups within the hospital, including nursing and clinical customer services, must get on board, she said. “We really need buy-in from higher levels in the hospital, and this was part of the proof that we needed,” Dr. DiBrito said.
The premise of the study was that patients need to identify a member of their care team as a point person, she added. “We’re trying to give the patients, and their family members as well, some people to look out for,” Dr. DiBrito said.
Dr. DiBrito and her coauthors had no financial relationships to disclose.
SOURCE: Dibrito SR et al. Academic Surgical Congress 2018, Abstract 09.04.
JACKSONVILLE, FLA. – A scorecard enables spectators at a baseball game to keep track of who the players are, and a scorecard of the surgery team can do the same for inpatients, researchers at Johns Hopkins University in Baltimore found.
They gave patients a “facesheet” that included photographs and biographies of all members of their surgery team, which helped patients to better understand the team members’ roles in their care and led to improvements in overall satisfaction scores, according to a study reported at the Association for Academic Surgery/Society of University Surgeons Academic Surgical Congress.
The study involved two intervals: a prefacesheet phase of 153 patients and a postfacesheet phase of 100 patients. The two groups, all gastrointestinal surgery inpatients, were administered preintervention discharge surveys to evaluate their level of patient satisfaction according to a 5-point Likert scale (1 = strongly disagree and 5 = strongly agree).
“We found that using these facesheets helped patients know the roles of their team members, and the patients felt that it was important to [have this information],” Dr. DiBrito said.
The share of patients answering 4 (agreed) or 5 (strongly agreed) for overall satisfaction rose from 83% before the facesheet intervention to 88% afterward (P = .5). The number of patients agreeing that they understood their providers’ roles increased from 72% to 83% (P = .05), and the number who agreed that it was important to know who their surgical team members were increased from 85% to 94% (P = .04). The latter finding somewhat surprised the researchers. Dr. DiBrito said, “That’s not exactly what we were anticipating.”
The study also revealed a trend in patients’ feeling more confident in their team overall after the facesheet intervention, rising from 89% to 95%, Dr. DiBrito said.
She said the Johns Hopkins team is not continuing the initiative currently but would like to roll it out more broadly to other hospital services. Other groups within the hospital, including nursing and clinical customer services, must get on board, she said. “We really need buy-in from higher levels in the hospital, and this was part of the proof that we needed,” Dr. DiBrito said.
The premise of the study was that patients need to identify a member of their care team as a point person, she added. “We’re trying to give the patients, and their family members as well, some people to look out for,” Dr. DiBrito said.
Dr. DiBrito and her coauthors had no financial relationships to disclose.
SOURCE: Dibrito SR et al. Academic Surgical Congress 2018, Abstract 09.04.
JACKSONVILLE, FLA. – A scorecard enables spectators at a baseball game to keep track of who the players are, and a scorecard of the surgery team can do the same for inpatients, researchers at Johns Hopkins University in Baltimore found.
They gave patients a “facesheet” that included photographs and biographies of all members of their surgery team, which helped patients to better understand the team members’ roles in their care and led to improvements in overall satisfaction scores, according to a study reported at the Association for Academic Surgery/Society of University Surgeons Academic Surgical Congress.
The study involved two intervals: a prefacesheet phase of 153 patients and a postfacesheet phase of 100 patients. The two groups, all gastrointestinal surgery inpatients, were administered preintervention discharge surveys to evaluate their level of patient satisfaction according to a 5-point Likert scale (1 = strongly disagree and 5 = strongly agree).
“We found that using these facesheets helped patients know the roles of their team members, and the patients felt that it was important to [have this information],” Dr. DiBrito said.
The share of patients answering 4 (agreed) or 5 (strongly agreed) for overall satisfaction rose from 83% before the facesheet intervention to 88% afterward (P = .5). The number of patients agreeing that they understood their providers’ roles increased from 72% to 83% (P = .05), and the number who agreed that it was important to know who their surgical team members were increased from 85% to 94% (P = .04). The latter finding somewhat surprised the researchers. Dr. DiBrito said, “That’s not exactly what we were anticipating.”
The study also revealed a trend in patients’ feeling more confident in their team overall after the facesheet intervention, rising from 89% to 95%, Dr. DiBrito said.
She said the Johns Hopkins team is not continuing the initiative currently but would like to roll it out more broadly to other hospital services. Other groups within the hospital, including nursing and clinical customer services, must get on board, she said. “We really need buy-in from higher levels in the hospital, and this was part of the proof that we needed,” Dr. DiBrito said.
The premise of the study was that patients need to identify a member of their care team as a point person, she added. “We’re trying to give the patients, and their family members as well, some people to look out for,” Dr. DiBrito said.
Dr. DiBrito and her coauthors had no financial relationships to disclose.
SOURCE: Dibrito SR et al. Academic Surgical Congress 2018, Abstract 09.04.
REPORTING FROM THE ACADEMIC SURGICAL CONGRESS
Key clinical point: A “facesheet” that includes photographs and biographies of the surgical care team improves patient satisfaction.
Major finding: Overall satisfaction scores increased from 83% preintervention to 88% postintervention.
Data source: Analysis of the survey responses from 253 gastrointestinal surgery patients pre- and postintervention from February 2017 to May 2017.
Disclosures: Dr. DiBrito and her coauthors had no financial relationships to disclose.
Source: Dibrito SR et al. Academic Surgical Congress 2018, Abstract 09.04.
Pain after breast surgery may not be caused by the operation
, according to a study of almost 2,000 women recruited from the Mastectomy Reconstructive Outcomes Consortium (MROC).
In the February issue of The Breast, investigators from the University of Michigan, Ann Arbor and Memorial Sloan Kettering Cancer Center, New York, wrote that almost half of the study subjects had some level of pain before their operations and that, at 2 years afterward, their pain had increased but not in a clinically meaningful way. This finding is consistent with earlier research, which investigators noted found that “one-fourth to one-half of women who undergo postmastectomy report persistent pain months and years after surgery.”
“Average clinical pain severity was strikingly similar for preoperative and postoperative assessments,” said lead author Randy S. Roth, PhD, of the University of Michigan, and his coauthors. “Postoperative levels of pain, acute postoperative pain and (marginally) level of depression held consistent relationship at 2-year follow-up with all outcome measures.”
The prospective, multicenter cohort study of 1,996 women was undertaken over 5 years. Most patients had immediate (92.7%) and bilateral (53.8%) reconstruction; 47.6% had sentinel lymph node biopsy and 25.9% had axillary lymph node dissection. Most had no adjuvant therapy: 70.3% received no radiation and 52.7% no chemotherapy.
At 2 years, the Numerical Pain Rating Scale (NPRS) measured what Dr. Roth and his coauthors called a “significant increase in pain intensity” – from an average rating of 1.1 to 1.2, an increase of 9%. However, the absolute change and standard deviation (1.7 for both intervals) “suggest that this was not a clinically meaningful change.” The researchers also recorded more complaints of bodily discomfort after 2 years, “but the statistical parameters again indicate little clinically meaningful differences from preoperative status.”
Pain ratings measured with the McGill Pain Questionnaire showed a significant decrease in the MPQ affective pain rating, from 1.6 preoperatively to 0.8 at 2 years (P less than .001), and virtually no change in the MPQ sensory rating, from 3.2 to 3.1.
The researchers drew some conclusions about demographic profiles and pain after breast reconstruction. Older age was associated with more severe pain on NPRS, and higher body mass index was linked with chronic postsurgical pain for the MPQ sensory rating, NPRS score, and body discomfort scores.
Treatment characteristics associated with chronic postsurgical pain (CPSP) include radiation therapy during or after reconstruction and chemotherapy before reconstruction. Chemotherapy during or after reconstruction was associated with higher MPQ affective rating scores at 2 years (P = .011), as was chemotherapy both before and during or after reconstruction (P = .001). The latter also was linked to higher NPRS scores (P = .0015).
The type of surgery also was a factor in CPSP, the researchers wrote. Both MPQ sensory and affective ratings were higher in women who had free transverse flap surgery, or deep or superficial inferior epigastric perforator surgery than in women who had tissue expander/implant reconstruction. Lymph node status and timing of surgery had no impact on chronic pain.
One noteworthy finding, Dr. Roth and his coauthors wrote, is that “careful examination of our data suggests that CPSP following breast reconstruction may be of less clinical concern as a direct consequence of breast reconstruction than suggested by previous investigations of major surgery, including mastectomy and breast reconstruction.” Future studies of chronic postsurgical pain in breast reconstruction “will require greater methodological rigor” to reach more sound conclusions to use in patient counseling.
Dr. Roth and his coauthors had no financial relationships to disclose.
SOURCE: Roth RS et al. Breast 2018;37:119-25.
, according to a study of almost 2,000 women recruited from the Mastectomy Reconstructive Outcomes Consortium (MROC).
In the February issue of The Breast, investigators from the University of Michigan, Ann Arbor and Memorial Sloan Kettering Cancer Center, New York, wrote that almost half of the study subjects had some level of pain before their operations and that, at 2 years afterward, their pain had increased but not in a clinically meaningful way. This finding is consistent with earlier research, which investigators noted found that “one-fourth to one-half of women who undergo postmastectomy report persistent pain months and years after surgery.”
“Average clinical pain severity was strikingly similar for preoperative and postoperative assessments,” said lead author Randy S. Roth, PhD, of the University of Michigan, and his coauthors. “Postoperative levels of pain, acute postoperative pain and (marginally) level of depression held consistent relationship at 2-year follow-up with all outcome measures.”
The prospective, multicenter cohort study of 1,996 women was undertaken over 5 years. Most patients had immediate (92.7%) and bilateral (53.8%) reconstruction; 47.6% had sentinel lymph node biopsy and 25.9% had axillary lymph node dissection. Most had no adjuvant therapy: 70.3% received no radiation and 52.7% no chemotherapy.
At 2 years, the Numerical Pain Rating Scale (NPRS) measured what Dr. Roth and his coauthors called a “significant increase in pain intensity” – from an average rating of 1.1 to 1.2, an increase of 9%. However, the absolute change and standard deviation (1.7 for both intervals) “suggest that this was not a clinically meaningful change.” The researchers also recorded more complaints of bodily discomfort after 2 years, “but the statistical parameters again indicate little clinically meaningful differences from preoperative status.”
Pain ratings measured with the McGill Pain Questionnaire showed a significant decrease in the MPQ affective pain rating, from 1.6 preoperatively to 0.8 at 2 years (P less than .001), and virtually no change in the MPQ sensory rating, from 3.2 to 3.1.
The researchers drew some conclusions about demographic profiles and pain after breast reconstruction. Older age was associated with more severe pain on NPRS, and higher body mass index was linked with chronic postsurgical pain for the MPQ sensory rating, NPRS score, and body discomfort scores.
Treatment characteristics associated with chronic postsurgical pain (CPSP) include radiation therapy during or after reconstruction and chemotherapy before reconstruction. Chemotherapy during or after reconstruction was associated with higher MPQ affective rating scores at 2 years (P = .011), as was chemotherapy both before and during or after reconstruction (P = .001). The latter also was linked to higher NPRS scores (P = .0015).
The type of surgery also was a factor in CPSP, the researchers wrote. Both MPQ sensory and affective ratings were higher in women who had free transverse flap surgery, or deep or superficial inferior epigastric perforator surgery than in women who had tissue expander/implant reconstruction. Lymph node status and timing of surgery had no impact on chronic pain.
One noteworthy finding, Dr. Roth and his coauthors wrote, is that “careful examination of our data suggests that CPSP following breast reconstruction may be of less clinical concern as a direct consequence of breast reconstruction than suggested by previous investigations of major surgery, including mastectomy and breast reconstruction.” Future studies of chronic postsurgical pain in breast reconstruction “will require greater methodological rigor” to reach more sound conclusions to use in patient counseling.
Dr. Roth and his coauthors had no financial relationships to disclose.
SOURCE: Roth RS et al. Breast 2018;37:119-25.
, according to a study of almost 2,000 women recruited from the Mastectomy Reconstructive Outcomes Consortium (MROC).
In the February issue of The Breast, investigators from the University of Michigan, Ann Arbor and Memorial Sloan Kettering Cancer Center, New York, wrote that almost half of the study subjects had some level of pain before their operations and that, at 2 years afterward, their pain had increased but not in a clinically meaningful way. This finding is consistent with earlier research, which investigators noted found that “one-fourth to one-half of women who undergo postmastectomy report persistent pain months and years after surgery.”
“Average clinical pain severity was strikingly similar for preoperative and postoperative assessments,” said lead author Randy S. Roth, PhD, of the University of Michigan, and his coauthors. “Postoperative levels of pain, acute postoperative pain and (marginally) level of depression held consistent relationship at 2-year follow-up with all outcome measures.”
The prospective, multicenter cohort study of 1,996 women was undertaken over 5 years. Most patients had immediate (92.7%) and bilateral (53.8%) reconstruction; 47.6% had sentinel lymph node biopsy and 25.9% had axillary lymph node dissection. Most had no adjuvant therapy: 70.3% received no radiation and 52.7% no chemotherapy.
At 2 years, the Numerical Pain Rating Scale (NPRS) measured what Dr. Roth and his coauthors called a “significant increase in pain intensity” – from an average rating of 1.1 to 1.2, an increase of 9%. However, the absolute change and standard deviation (1.7 for both intervals) “suggest that this was not a clinically meaningful change.” The researchers also recorded more complaints of bodily discomfort after 2 years, “but the statistical parameters again indicate little clinically meaningful differences from preoperative status.”
Pain ratings measured with the McGill Pain Questionnaire showed a significant decrease in the MPQ affective pain rating, from 1.6 preoperatively to 0.8 at 2 years (P less than .001), and virtually no change in the MPQ sensory rating, from 3.2 to 3.1.
The researchers drew some conclusions about demographic profiles and pain after breast reconstruction. Older age was associated with more severe pain on NPRS, and higher body mass index was linked with chronic postsurgical pain for the MPQ sensory rating, NPRS score, and body discomfort scores.
Treatment characteristics associated with chronic postsurgical pain (CPSP) include radiation therapy during or after reconstruction and chemotherapy before reconstruction. Chemotherapy during or after reconstruction was associated with higher MPQ affective rating scores at 2 years (P = .011), as was chemotherapy both before and during or after reconstruction (P = .001). The latter also was linked to higher NPRS scores (P = .0015).
The type of surgery also was a factor in CPSP, the researchers wrote. Both MPQ sensory and affective ratings were higher in women who had free transverse flap surgery, or deep or superficial inferior epigastric perforator surgery than in women who had tissue expander/implant reconstruction. Lymph node status and timing of surgery had no impact on chronic pain.
One noteworthy finding, Dr. Roth and his coauthors wrote, is that “careful examination of our data suggests that CPSP following breast reconstruction may be of less clinical concern as a direct consequence of breast reconstruction than suggested by previous investigations of major surgery, including mastectomy and breast reconstruction.” Future studies of chronic postsurgical pain in breast reconstruction “will require greater methodological rigor” to reach more sound conclusions to use in patient counseling.
Dr. Roth and his coauthors had no financial relationships to disclose.
SOURCE: Roth RS et al. Breast 2018;37:119-25.
FROM THE BREAST
Key clinical point: Breast reconstruction surgery may not be the cause of persistent pain afterward.
Major finding: McGill Pain Questionnaire affective pain rating decreased from 1.6 preoperatively to 0.8 at 2 years.
Data source: Five-year prospective multicenter cohort study of 1,966 women recruited for the Mastectomy Reconstruction Outcomes Consortium.
Disclosures: Dr. Roth and his coauthors reported having no financial disclosures.
Source: Roth RS et al. Breast 2018;37:119-25.
Model validates use of HCV+ livers for transplant
As the evidence supporting the idea of transplanting livers infected with hepatitis C into patients who do not have the disease continues to mount, a multi-institutional team of researchers has developed a mathematical model that shows when hepatitis C–positive-to-negative transplant may improve survival for patients who might otherwise die awaiting a disease-free liver.
In a report published in the journal Hepatology (doi: 10.1002/hep.29723), the researchers noted how direct-acting antivirals (DAAs) have changed the calculus of hepatitis C (HCV) status in liver transplant by reducing the number of HCV-positive patients on the wait list and providing treatment for HCV-negative patients who receive HCV-positive livers. “It is important that further research in this area continues, as we expect that the supply of HCV-positive organs may continue to increase in light of the growing opioid epidemic,” said lead author Jagpreet Chhatwal, PhD, of Massachusetts General Hospital Institute for Technology Assessment in Boston.
Dr. Chhatwal and coauthors claimed their study provides some of the first empirical data for transplanting livers from patients with HCV into patients who do not have the disease.
The researchers performed their analysis using a Markov-based mathematical model known as Simulation of Liver Transplant Candidates (SIM-LT). The model had been validated in previous studies that Dr. Chhatwal and some coauthors had published (Hepatology. 2017;65:777-88; Clin Gastroenterol Hepatol 2018;16:115-22). Dr. Chhatwal and coauthors revised the SIM-LT model to simulate a virtual trial of HCV-negative patients on the liver transplant waiting list to compare outcomes in patients willing to accept any liver to those willing to accept only HCV-negative livers.
The patients willing to receive HCV-positive livers were given 12 weeks of DAA therapy preemptively and had a higher risk of graft failure. The model incorporated data from published studies using the United Network for Organ Sharing (UNOS) and used reported outcomes of the Organ Procurement and Transplantation Network to validate the findings.
The study showed that the clinical benefits of an HCV-negative patient receiving an HCV-positive liver depend on the patient’s Model for End-Stage Liver Disease (MELD) score. Using the measured change in life-years, the researchers found that patients with a MELD score below 20 actually witnessed reduction in life-years when accepting any liver, but that the benefits of accepting any liver started to accrue at MELD score 20. The benefit topped out at MELD 28, with 0.172 life years gained, but even sustained at 0.06 life years gained at MELD 40.
The effectiveness of using HCV-positive livers may also depend on region. UNOS Region 1 – essentially New England minus western Vermont – has the highest rate of HCV-positive organs, and a patient there with MELD 28 would gain 0.36 life-years by accepting any liver regardless of HCV status. However, Region 7 – the Dakotas and upper Midwest plus Illinois – has the lowest HCV-positive organ rate, and a MELD 28 patient there would gain only 0.1 life-year accepting any liver.
“Transplanting HCV-positive livers into HCV-negative patients receiving preemptive DAA therapy could be a viable option for improving patient survival on the LT waiting list, especially in UNOS regions with high HCV-positive donor organ rates,” said Dr. Chhatwal and coauthors. They concluded that their analysis could help direct future clinical trials evaluating the effectiveness of DAA therapy in liver transplant by recognizing patients who could benefit most from accepting HCV-positive donor organs.
The study authors reported having no financial disclosures. The study was supported by grants from the American Cancer Society, Health Resources and Services Administration, National Institutes of Health, National Science Foundation, and Massachusetts General Hospital Research Scholars Program. Coauthor Fasiha Kanwal, MD, received support from the Veterans Administration Health Services, Research & Development Center for Innovations in Quality, Effectiveness and Safety and Public Health Service.
SOURCE: Chhatwal J et al. Hepatology. doi:10.1002/hep.29723.
As the evidence supporting the idea of transplanting livers infected with hepatitis C into patients who do not have the disease continues to mount, a multi-institutional team of researchers has developed a mathematical model that shows when hepatitis C–positive-to-negative transplant may improve survival for patients who might otherwise die awaiting a disease-free liver.
In a report published in the journal Hepatology (doi: 10.1002/hep.29723), the researchers noted how direct-acting antivirals (DAAs) have changed the calculus of hepatitis C (HCV) status in liver transplant by reducing the number of HCV-positive patients on the wait list and providing treatment for HCV-negative patients who receive HCV-positive livers. “It is important that further research in this area continues, as we expect that the supply of HCV-positive organs may continue to increase in light of the growing opioid epidemic,” said lead author Jagpreet Chhatwal, PhD, of Massachusetts General Hospital Institute for Technology Assessment in Boston.
Dr. Chhatwal and coauthors claimed their study provides some of the first empirical data for transplanting livers from patients with HCV into patients who do not have the disease.
The researchers performed their analysis using a Markov-based mathematical model known as Simulation of Liver Transplant Candidates (SIM-LT). The model had been validated in previous studies that Dr. Chhatwal and some coauthors had published (Hepatology. 2017;65:777-88; Clin Gastroenterol Hepatol 2018;16:115-22). Dr. Chhatwal and coauthors revised the SIM-LT model to simulate a virtual trial of HCV-negative patients on the liver transplant waiting list to compare outcomes in patients willing to accept any liver to those willing to accept only HCV-negative livers.
The patients willing to receive HCV-positive livers were given 12 weeks of DAA therapy preemptively and had a higher risk of graft failure. The model incorporated data from published studies using the United Network for Organ Sharing (UNOS) and used reported outcomes of the Organ Procurement and Transplantation Network to validate the findings.
The study showed that the clinical benefits of an HCV-negative patient receiving an HCV-positive liver depend on the patient’s Model for End-Stage Liver Disease (MELD) score. Using the measured change in life-years, the researchers found that patients with a MELD score below 20 actually witnessed reduction in life-years when accepting any liver, but that the benefits of accepting any liver started to accrue at MELD score 20. The benefit topped out at MELD 28, with 0.172 life years gained, but even sustained at 0.06 life years gained at MELD 40.
The effectiveness of using HCV-positive livers may also depend on region. UNOS Region 1 – essentially New England minus western Vermont – has the highest rate of HCV-positive organs, and a patient there with MELD 28 would gain 0.36 life-years by accepting any liver regardless of HCV status. However, Region 7 – the Dakotas and upper Midwest plus Illinois – has the lowest HCV-positive organ rate, and a MELD 28 patient there would gain only 0.1 life-year accepting any liver.
“Transplanting HCV-positive livers into HCV-negative patients receiving preemptive DAA therapy could be a viable option for improving patient survival on the LT waiting list, especially in UNOS regions with high HCV-positive donor organ rates,” said Dr. Chhatwal and coauthors. They concluded that their analysis could help direct future clinical trials evaluating the effectiveness of DAA therapy in liver transplant by recognizing patients who could benefit most from accepting HCV-positive donor organs.
The study authors reported having no financial disclosures. The study was supported by grants from the American Cancer Society, Health Resources and Services Administration, National Institutes of Health, National Science Foundation, and Massachusetts General Hospital Research Scholars Program. Coauthor Fasiha Kanwal, MD, received support from the Veterans Administration Health Services, Research & Development Center for Innovations in Quality, Effectiveness and Safety and Public Health Service.
SOURCE: Chhatwal J et al. Hepatology. doi:10.1002/hep.29723.
As the evidence supporting the idea of transplanting livers infected with hepatitis C into patients who do not have the disease continues to mount, a multi-institutional team of researchers has developed a mathematical model that shows when hepatitis C–positive-to-negative transplant may improve survival for patients who might otherwise die awaiting a disease-free liver.
In a report published in the journal Hepatology (doi: 10.1002/hep.29723), the researchers noted how direct-acting antivirals (DAAs) have changed the calculus of hepatitis C (HCV) status in liver transplant by reducing the number of HCV-positive patients on the wait list and providing treatment for HCV-negative patients who receive HCV-positive livers. “It is important that further research in this area continues, as we expect that the supply of HCV-positive organs may continue to increase in light of the growing opioid epidemic,” said lead author Jagpreet Chhatwal, PhD, of Massachusetts General Hospital Institute for Technology Assessment in Boston.
Dr. Chhatwal and coauthors claimed their study provides some of the first empirical data for transplanting livers from patients with HCV into patients who do not have the disease.
The researchers performed their analysis using a Markov-based mathematical model known as Simulation of Liver Transplant Candidates (SIM-LT). The model had been validated in previous studies that Dr. Chhatwal and some coauthors had published (Hepatology. 2017;65:777-88; Clin Gastroenterol Hepatol 2018;16:115-22). Dr. Chhatwal and coauthors revised the SIM-LT model to simulate a virtual trial of HCV-negative patients on the liver transplant waiting list to compare outcomes in patients willing to accept any liver to those willing to accept only HCV-negative livers.
The patients willing to receive HCV-positive livers were given 12 weeks of DAA therapy preemptively and had a higher risk of graft failure. The model incorporated data from published studies using the United Network for Organ Sharing (UNOS) and used reported outcomes of the Organ Procurement and Transplantation Network to validate the findings.
The study showed that the clinical benefits of an HCV-negative patient receiving an HCV-positive liver depend on the patient’s Model for End-Stage Liver Disease (MELD) score. Using the measured change in life-years, the researchers found that patients with a MELD score below 20 actually witnessed reduction in life-years when accepting any liver, but that the benefits of accepting any liver started to accrue at MELD score 20. The benefit topped out at MELD 28, with 0.172 life years gained, but even sustained at 0.06 life years gained at MELD 40.
The effectiveness of using HCV-positive livers may also depend on region. UNOS Region 1 – essentially New England minus western Vermont – has the highest rate of HCV-positive organs, and a patient there with MELD 28 would gain 0.36 life-years by accepting any liver regardless of HCV status. However, Region 7 – the Dakotas and upper Midwest plus Illinois – has the lowest HCV-positive organ rate, and a MELD 28 patient there would gain only 0.1 life-year accepting any liver.
“Transplanting HCV-positive livers into HCV-negative patients receiving preemptive DAA therapy could be a viable option for improving patient survival on the LT waiting list, especially in UNOS regions with high HCV-positive donor organ rates,” said Dr. Chhatwal and coauthors. They concluded that their analysis could help direct future clinical trials evaluating the effectiveness of DAA therapy in liver transplant by recognizing patients who could benefit most from accepting HCV-positive donor organs.
The study authors reported having no financial disclosures. The study was supported by grants from the American Cancer Society, Health Resources and Services Administration, National Institutes of Health, National Science Foundation, and Massachusetts General Hospital Research Scholars Program. Coauthor Fasiha Kanwal, MD, received support from the Veterans Administration Health Services, Research & Development Center for Innovations in Quality, Effectiveness and Safety and Public Health Service.
SOURCE: Chhatwal J et al. Hepatology. doi:10.1002/hep.29723.
FROM HEPATOLOGY
Key clinical point: Making hepatitis C virus–positive livers available to HCV-negative patients awaiting liver transplant could improve survival of patients on the liver transplant waiting list.
Major finding: Patients with a Model for End-Stage Liver Disease score of 28 willing to receive any liver gained 0.172 life-years.
Data source: Simulated trial using Markov-based mathematical model and data from published studies and the United Network for Organ Sharing.
Disclosures: Dr. Chhatwal and coauthors reported having no financial disclosures. The study was supported by grants from the American Cancer Society, Health Resources and Services Administration, National Institutes of Health, National Science Foundation, and Massachusetts General Hospital Research Scholars Program. Coauthor Fasiha Kanwal, MD, received support from the Veterans Administration Health Services, Research & Development Center for Innovations in Quality, Effectiveness and Safety and Public Health Service.
Source: Chhatwal J et al. Hepatology. doi:10.1002/hep.29723.
C7 nerve transfer shows promising results for spastic arm paralysis
Patients with spastic arm paralysis who received a contralateral C7 nerve graft from their nonparalyzed side to their paralyzed side led to greater improvement in arm function and reduction in spasticity after a year, compared with rehabilitation alone, investigators from Huashan Hospital in China reported online Jan. 3 in the New England Journal of Medicine.
The researchers randomly assigned 36 patients who had unilateral arm paralysis for at least 5 years to either surgical C7 nerve transfer plus rehabilitation or rehabilitation only. Results of the trial’s primary outcome – arm function using the Fugl-Meyer score – showed that those in the surgery group had an average increase of 17.7, while those in the rehabilitation-only group had an average increase of 2.6 (P less than .001). This 15.1-point difference had a 95% confidence interval ranging from 12.2 to 17.9.
To evaluate spasticity, the researchers used the Modified Ashworth Scale, which is a 0-5 scale to score spasticity; a higher score means more spasticity. Surgery patients saw improvement from baseline in all five areas measured across the board, and none saw worsening in scores. The smallest difference between the two groups was in thumb extension, with 15 surgery patients having a 1- and 2-unit improvement and 3 having no change, while 7 controls showed a 1- or 2-unit improvement, another 7 showed no improvement, and 4 had a 1-unit worsening in score (P less than .001). At 1 year, 16 (89%) of surgery patients could accomplish three or more of the functional tasks researchers gave them, whereas none of the controls could.
“The majority of clinical improvements coincided with physiological evidence of connectivity between the hemisphere on the side of the donor nerve and the paralyzed arm,” said lead author Mou-Xiong Zheng, MD, PhD, of the department of hand surgery at Huashan Hospital at Fudan University in Shanghai, and colleagues.
The research by Dr. Zheng and coauthors arises from what is known about hand paralysis after stroke, that damage to the contralateral cerebral hemisphere arises from interruption of the inhibitory activity of upper motor neurons, which causes spasticity, along with hand weakness and loss of fractionated fine motor control. Other studies have noted activity in the cerebral hemisphere on the same side of paralysis during recovery (Neuroimage. 2004;22:1775-83; J Neurophysiol. 2005;93:1209-22; J Neurosci. 2006;26:6096-102; Front Neurol. 2015;6:214), but Dr. Zheng and coauthors noted “sparse” connections between the hand and that part of the brain limit the body’s ability to compensate for spasticity and functional loss.
The latest study followed earlier studies, including one by Dr. Zheng’s coauthors (J Hand Surg Br. 1992;17:518-21), that reported the paralyzed hand could be connected to the unaffected hemisphere by transferring a cervical spine nerve from the nonparalyzed side, a treatment previously reported for injuries of the brachial plexus. Of the five nerves of the brachial plexus, Dr. Zheng and coauthors chose the C7 nerve because it accounts for about 20% of the nerve fibers in the brachial bundle and severing the nerve typically results in transient weakness and numbness in the arm or leg on the same side. Hence, when evaluating the hand on the side of the donor graft, the researchers found no significant changes in power, tactile threshold, or two-point discrimination as a result of surgery.
Their surgical approach was a modification of the C7 nerve transfer method that Dr. Zheng and coauthors had previously reported (Microsurgery. 2011;31:404-8; Neurosurgery. 2015;76:187-95). The operation involved making an incision at the superior aspect of the sternum, mobilizing the donor C7 nerve on the nonparalyzed side, and routing it between the spinal column and esophagus. Then, an anastomosis was performed directly with the C7 nerve on the paralyzed side.
Rehabilitation therapy for both the surgery group and controls was identical, administered four times weekly for 12 months at a single facility, although surgery patients wore an immobilizing cast after their operations.
The nature of the study population – men of varying ages with varying causes of the underlying cerebral lesions – makes it difficult to generalize the findings, Dr. Zheng and coauthors noted. “A larger cohort, followed for a longer period, would be necessary to determine whether cervical nerve transfer results in safe, consistent, and long-term improvements in the function of an arm that is chronically paralyzed as a result of a cerebral lesion,” the authors concluded.
Grants from the following supported the study: National Natural Science Foundation of China; Science and Technology Commission of Shanghai Municipality; Health and Family Planning Commission of Shanghai; and Shanghai Shen-Kang Hospital Development Center.
The results that Dr. Zheng and coauthors reported “are exciting,” said Robert J. Spinner, MD, Alexander Y. Shin, MD, and Allen T. Bishop, MD, in an accompanying editorial, “but need clarification and confirmation” (N Engl J Med. 2017 Dec 20. doi: 10.1056/NEJMe1713313).
Among questions Dr. Spinner and coauthors raised about the study is whether distal muscles can functionally reinnervate in a year, and if C7 neurotomy on the paralyzed side led to improvements in spasticity and function. “The C7 neurotomy itself, associated with an immediate reduction in spasticity, represents a major advance for some patients with brain injury who have poor function and spasticity,” the authors of the editorial noted. Improvement of the damaged motor cortex, which ongoing physical therapy may enhance, may also contribute to a reduction in spasticity.
Dr. Spinner and coauthors also cited a previous trial by some of Dr. Zheng’s coauthors that showed 49% of patients with brachial plexus injury had motor recovery within 7 years (Chin Med J [Engl]. 2013;126:3865-8). “The presence of physiological connectivity observed in the trials does not necessarily equate with functional recovery,” the authors stated.
Future studies of surgical C7 nerve transfer in patients with one-sided arm paralysis should include patients who have C7 neurotomy without nerve transfer, Dr. Spinner and coauthors said. They also noted that Dr. Zheng and coauthors perform a relatively high volume of these operations, so their results may not be easy to reproduce elsewhere.
“Factors other than technical ones, including differences in body-mass index and limb length across different populations, may lead to different surgical outcomes,” Dr. Spinner and coauthors said. Future research should focus on ways to enhance or speed up nerve regeneration, improve plasticity, and maximize rehabilitation, they added.
Dr. Spinner, Dr. Shin, and Dr. Bishop are with the departments of neurologic surgery and orthopedics, division of hand surgery, at the Mayo Clinic in Rochester, Minn.
The results that Dr. Zheng and coauthors reported “are exciting,” said Robert J. Spinner, MD, Alexander Y. Shin, MD, and Allen T. Bishop, MD, in an accompanying editorial, “but need clarification and confirmation” (N Engl J Med. 2017 Dec 20. doi: 10.1056/NEJMe1713313).
Among questions Dr. Spinner and coauthors raised about the study is whether distal muscles can functionally reinnervate in a year, and if C7 neurotomy on the paralyzed side led to improvements in spasticity and function. “The C7 neurotomy itself, associated with an immediate reduction in spasticity, represents a major advance for some patients with brain injury who have poor function and spasticity,” the authors of the editorial noted. Improvement of the damaged motor cortex, which ongoing physical therapy may enhance, may also contribute to a reduction in spasticity.
Dr. Spinner and coauthors also cited a previous trial by some of Dr. Zheng’s coauthors that showed 49% of patients with brachial plexus injury had motor recovery within 7 years (Chin Med J [Engl]. 2013;126:3865-8). “The presence of physiological connectivity observed in the trials does not necessarily equate with functional recovery,” the authors stated.
Future studies of surgical C7 nerve transfer in patients with one-sided arm paralysis should include patients who have C7 neurotomy without nerve transfer, Dr. Spinner and coauthors said. They also noted that Dr. Zheng and coauthors perform a relatively high volume of these operations, so their results may not be easy to reproduce elsewhere.
“Factors other than technical ones, including differences in body-mass index and limb length across different populations, may lead to different surgical outcomes,” Dr. Spinner and coauthors said. Future research should focus on ways to enhance or speed up nerve regeneration, improve plasticity, and maximize rehabilitation, they added.
Dr. Spinner, Dr. Shin, and Dr. Bishop are with the departments of neurologic surgery and orthopedics, division of hand surgery, at the Mayo Clinic in Rochester, Minn.
The results that Dr. Zheng and coauthors reported “are exciting,” said Robert J. Spinner, MD, Alexander Y. Shin, MD, and Allen T. Bishop, MD, in an accompanying editorial, “but need clarification and confirmation” (N Engl J Med. 2017 Dec 20. doi: 10.1056/NEJMe1713313).
Among questions Dr. Spinner and coauthors raised about the study is whether distal muscles can functionally reinnervate in a year, and if C7 neurotomy on the paralyzed side led to improvements in spasticity and function. “The C7 neurotomy itself, associated with an immediate reduction in spasticity, represents a major advance for some patients with brain injury who have poor function and spasticity,” the authors of the editorial noted. Improvement of the damaged motor cortex, which ongoing physical therapy may enhance, may also contribute to a reduction in spasticity.
Dr. Spinner and coauthors also cited a previous trial by some of Dr. Zheng’s coauthors that showed 49% of patients with brachial plexus injury had motor recovery within 7 years (Chin Med J [Engl]. 2013;126:3865-8). “The presence of physiological connectivity observed in the trials does not necessarily equate with functional recovery,” the authors stated.
Future studies of surgical C7 nerve transfer in patients with one-sided arm paralysis should include patients who have C7 neurotomy without nerve transfer, Dr. Spinner and coauthors said. They also noted that Dr. Zheng and coauthors perform a relatively high volume of these operations, so their results may not be easy to reproduce elsewhere.
“Factors other than technical ones, including differences in body-mass index and limb length across different populations, may lead to different surgical outcomes,” Dr. Spinner and coauthors said. Future research should focus on ways to enhance or speed up nerve regeneration, improve plasticity, and maximize rehabilitation, they added.
Dr. Spinner, Dr. Shin, and Dr. Bishop are with the departments of neurologic surgery and orthopedics, division of hand surgery, at the Mayo Clinic in Rochester, Minn.
Patients with spastic arm paralysis who received a contralateral C7 nerve graft from their nonparalyzed side to their paralyzed side led to greater improvement in arm function and reduction in spasticity after a year, compared with rehabilitation alone, investigators from Huashan Hospital in China reported online Jan. 3 in the New England Journal of Medicine.
The researchers randomly assigned 36 patients who had unilateral arm paralysis for at least 5 years to either surgical C7 nerve transfer plus rehabilitation or rehabilitation only. Results of the trial’s primary outcome – arm function using the Fugl-Meyer score – showed that those in the surgery group had an average increase of 17.7, while those in the rehabilitation-only group had an average increase of 2.6 (P less than .001). This 15.1-point difference had a 95% confidence interval ranging from 12.2 to 17.9.
To evaluate spasticity, the researchers used the Modified Ashworth Scale, which is a 0-5 scale to score spasticity; a higher score means more spasticity. Surgery patients saw improvement from baseline in all five areas measured across the board, and none saw worsening in scores. The smallest difference between the two groups was in thumb extension, with 15 surgery patients having a 1- and 2-unit improvement and 3 having no change, while 7 controls showed a 1- or 2-unit improvement, another 7 showed no improvement, and 4 had a 1-unit worsening in score (P less than .001). At 1 year, 16 (89%) of surgery patients could accomplish three or more of the functional tasks researchers gave them, whereas none of the controls could.
“The majority of clinical improvements coincided with physiological evidence of connectivity between the hemisphere on the side of the donor nerve and the paralyzed arm,” said lead author Mou-Xiong Zheng, MD, PhD, of the department of hand surgery at Huashan Hospital at Fudan University in Shanghai, and colleagues.
The research by Dr. Zheng and coauthors arises from what is known about hand paralysis after stroke, that damage to the contralateral cerebral hemisphere arises from interruption of the inhibitory activity of upper motor neurons, which causes spasticity, along with hand weakness and loss of fractionated fine motor control. Other studies have noted activity in the cerebral hemisphere on the same side of paralysis during recovery (Neuroimage. 2004;22:1775-83; J Neurophysiol. 2005;93:1209-22; J Neurosci. 2006;26:6096-102; Front Neurol. 2015;6:214), but Dr. Zheng and coauthors noted “sparse” connections between the hand and that part of the brain limit the body’s ability to compensate for spasticity and functional loss.
The latest study followed earlier studies, including one by Dr. Zheng’s coauthors (J Hand Surg Br. 1992;17:518-21), that reported the paralyzed hand could be connected to the unaffected hemisphere by transferring a cervical spine nerve from the nonparalyzed side, a treatment previously reported for injuries of the brachial plexus. Of the five nerves of the brachial plexus, Dr. Zheng and coauthors chose the C7 nerve because it accounts for about 20% of the nerve fibers in the brachial bundle and severing the nerve typically results in transient weakness and numbness in the arm or leg on the same side. Hence, when evaluating the hand on the side of the donor graft, the researchers found no significant changes in power, tactile threshold, or two-point discrimination as a result of surgery.
Their surgical approach was a modification of the C7 nerve transfer method that Dr. Zheng and coauthors had previously reported (Microsurgery. 2011;31:404-8; Neurosurgery. 2015;76:187-95). The operation involved making an incision at the superior aspect of the sternum, mobilizing the donor C7 nerve on the nonparalyzed side, and routing it between the spinal column and esophagus. Then, an anastomosis was performed directly with the C7 nerve on the paralyzed side.
Rehabilitation therapy for both the surgery group and controls was identical, administered four times weekly for 12 months at a single facility, although surgery patients wore an immobilizing cast after their operations.
The nature of the study population – men of varying ages with varying causes of the underlying cerebral lesions – makes it difficult to generalize the findings, Dr. Zheng and coauthors noted. “A larger cohort, followed for a longer period, would be necessary to determine whether cervical nerve transfer results in safe, consistent, and long-term improvements in the function of an arm that is chronically paralyzed as a result of a cerebral lesion,” the authors concluded.
Grants from the following supported the study: National Natural Science Foundation of China; Science and Technology Commission of Shanghai Municipality; Health and Family Planning Commission of Shanghai; and Shanghai Shen-Kang Hospital Development Center.
Patients with spastic arm paralysis who received a contralateral C7 nerve graft from their nonparalyzed side to their paralyzed side led to greater improvement in arm function and reduction in spasticity after a year, compared with rehabilitation alone, investigators from Huashan Hospital in China reported online Jan. 3 in the New England Journal of Medicine.
The researchers randomly assigned 36 patients who had unilateral arm paralysis for at least 5 years to either surgical C7 nerve transfer plus rehabilitation or rehabilitation only. Results of the trial’s primary outcome – arm function using the Fugl-Meyer score – showed that those in the surgery group had an average increase of 17.7, while those in the rehabilitation-only group had an average increase of 2.6 (P less than .001). This 15.1-point difference had a 95% confidence interval ranging from 12.2 to 17.9.
To evaluate spasticity, the researchers used the Modified Ashworth Scale, which is a 0-5 scale to score spasticity; a higher score means more spasticity. Surgery patients saw improvement from baseline in all five areas measured across the board, and none saw worsening in scores. The smallest difference between the two groups was in thumb extension, with 15 surgery patients having a 1- and 2-unit improvement and 3 having no change, while 7 controls showed a 1- or 2-unit improvement, another 7 showed no improvement, and 4 had a 1-unit worsening in score (P less than .001). At 1 year, 16 (89%) of surgery patients could accomplish three or more of the functional tasks researchers gave them, whereas none of the controls could.
“The majority of clinical improvements coincided with physiological evidence of connectivity between the hemisphere on the side of the donor nerve and the paralyzed arm,” said lead author Mou-Xiong Zheng, MD, PhD, of the department of hand surgery at Huashan Hospital at Fudan University in Shanghai, and colleagues.
The research by Dr. Zheng and coauthors arises from what is known about hand paralysis after stroke, that damage to the contralateral cerebral hemisphere arises from interruption of the inhibitory activity of upper motor neurons, which causes spasticity, along with hand weakness and loss of fractionated fine motor control. Other studies have noted activity in the cerebral hemisphere on the same side of paralysis during recovery (Neuroimage. 2004;22:1775-83; J Neurophysiol. 2005;93:1209-22; J Neurosci. 2006;26:6096-102; Front Neurol. 2015;6:214), but Dr. Zheng and coauthors noted “sparse” connections between the hand and that part of the brain limit the body’s ability to compensate for spasticity and functional loss.
The latest study followed earlier studies, including one by Dr. Zheng’s coauthors (J Hand Surg Br. 1992;17:518-21), that reported the paralyzed hand could be connected to the unaffected hemisphere by transferring a cervical spine nerve from the nonparalyzed side, a treatment previously reported for injuries of the brachial plexus. Of the five nerves of the brachial plexus, Dr. Zheng and coauthors chose the C7 nerve because it accounts for about 20% of the nerve fibers in the brachial bundle and severing the nerve typically results in transient weakness and numbness in the arm or leg on the same side. Hence, when evaluating the hand on the side of the donor graft, the researchers found no significant changes in power, tactile threshold, or two-point discrimination as a result of surgery.
Their surgical approach was a modification of the C7 nerve transfer method that Dr. Zheng and coauthors had previously reported (Microsurgery. 2011;31:404-8; Neurosurgery. 2015;76:187-95). The operation involved making an incision at the superior aspect of the sternum, mobilizing the donor C7 nerve on the nonparalyzed side, and routing it between the spinal column and esophagus. Then, an anastomosis was performed directly with the C7 nerve on the paralyzed side.
Rehabilitation therapy for both the surgery group and controls was identical, administered four times weekly for 12 months at a single facility, although surgery patients wore an immobilizing cast after their operations.
The nature of the study population – men of varying ages with varying causes of the underlying cerebral lesions – makes it difficult to generalize the findings, Dr. Zheng and coauthors noted. “A larger cohort, followed for a longer period, would be necessary to determine whether cervical nerve transfer results in safe, consistent, and long-term improvements in the function of an arm that is chronically paralyzed as a result of a cerebral lesion,” the authors concluded.
Grants from the following supported the study: National Natural Science Foundation of China; Science and Technology Commission of Shanghai Municipality; Health and Family Planning Commission of Shanghai; and Shanghai Shen-Kang Hospital Development Center.
FROM NEW ENGLAND JOURNAL OF MEDICINE
Key clinical point:
Major finding: Mean increase in Fugl-Meyer score in the paralyzed arm was 17.7 in the surgery group and 2.6 in the control group at 12 months (P less than .001).
Data source: Thirty-six patients with unilateral arm paralysis randomly assigned to C7 nerve transfer plus rehabilitation or rehabilitation alone.
Disclosures: The National Natural Science Foundation of China, the Science and Technology Commission of Shanghai Municipality, the Health and Family Planning Commission of Shanghai, and the Shanghai Shen-Kang Hospital Development Center provided funding for the study.
Source: Zheng M et al. N Engl J Med. 2018;378:22-34