In young children, hepatitis A is usually asymptomatic. So a childcare facility (CCF) in Ireland surprised by an outbreak of hepatitis A that infected 7 adults and 5 children, hospitalizing 6 of the adults. By the time the investigation and interventions were over, > 554 contacts had been followed up, and it had all cost > €45,000 ($53,000).

The outbreak was traced to a man with hepatitis A whose child had been unwell for 3 weeks with fever, fatigue, abdominal pain, diarrhea, pale stools, and possible jaundice. The child (and an infected cousin) attended a local CCF but because several other cases seemed to be limited to the family and their friends, no one immediately considered the CCF as a possible source of infection. However, approximately 10 days after the first 2 cases were reported, an outbreak was officially declared.

At the time, 93 children were attending the CCF. All 7 adults were household contacts of children in the CCF. None of the 23-member CCF staff developed symptoms of hepatitis A.

As many as 70% of infections are asymptomatic in children under age 6, the researchers note, but that group is often a source of transmission due to suboptimal hygiene. Transmission is usually fecal-oral and person-to-person. Although the initial source of outbreak was not identified, the subsequent transmission suggested person-to-person spread. The researchers say the distribution of cases suggests that the transmission probably happened in the school, with asymptomatic children infecting their families, highlighting the fact that symptomatic cases of hepatitis A only represent a portion of the cases in an outbreak.

A preschool inspection report that preceded the outbreak highlighted deficiencies in the staff’s handwashing practices. An infection control audit undertaken because of the outbreak found a number of deficits, including lack of foot-operated bins and the use of cloth covers on furnishings rather than waterproof material. Medical expenses, including hospitalization, serology, and vaccine, cost between €43,400 - €47, 400 ($51,000 - $56,000).

The researchers say the delayed notification to public health of the first case probably contributed to the extent of the outbreak. Medical professionals, they note, should be aware that although uncommon, hepatitis A still occurs. Prompt recognition and notification can mitigate the significant morbidity associated with the infection.

Source:
O'Connor L, McGovern E, O'Meara M, et al. Epidemiol Infect. 2018;146(6):705-711.

In young children, hepatitis A is usually asymptomatic. So a childcare facility (CCF) in Ireland surprised by an outbreak of hepatitis A that infected 7 adults and 5 children, hospitalizing 6 of the adults. By the time the investigation and interventions were over, > 554 contacts had been followed up, and it had all cost > €45,000 ($53,000).

The outbreak was traced to a man with hepatitis A whose child had been unwell for 3 weeks with fever, fatigue, abdominal pain, diarrhea, pale stools, and possible jaundice. The child (and an infected cousin) attended a local CCF but because several other cases seemed to be limited to the family and their friends, no one immediately considered the CCF as a possible source of infection. However, approximately 10 days after the first 2 cases were reported, an outbreak was officially declared.

At the time, 93 children were attending the CCF. All 7 adults were household contacts of children in the CCF. None of the 23-member CCF staff developed symptoms of hepatitis A.

As many as 70% of infections are asymptomatic in children under age 6, the researchers note, but that group is often a source of transmission due to suboptimal hygiene. Transmission is usually fecal-oral and person-to-person. Although the initial source of outbreak was not identified, the subsequent transmission suggested person-to-person spread. The researchers say the distribution of cases suggests that the transmission probably happened in the school, with asymptomatic children infecting their families, highlighting the fact that symptomatic cases of hepatitis A only represent a portion of the cases in an outbreak.

A preschool inspection report that preceded the outbreak highlighted deficiencies in the staff’s handwashing practices. An infection control audit undertaken because of the outbreak found a number of deficits, including lack of foot-operated bins and the use of cloth covers on furnishings rather than waterproof material. Medical expenses, including hospitalization, serology, and vaccine, cost between €43,400 - €47, 400 ($51,000 - $56,000).

The researchers say the delayed notification to public health of the first case probably contributed to the extent of the outbreak. Medical professionals, they note, should be aware that although uncommon, hepatitis A still occurs. Prompt recognition and notification can mitigate the significant morbidity associated with the infection.

Source:
O'Connor L, McGovern E, O'Meara M, et al. Epidemiol Infect. 2018;146(6):705-711.

In young children, hepatitis A is usually asymptomatic. So a childcare facility (CCF) in Ireland surprised by an outbreak of hepatitis A that infected 7 adults and 5 children, hospitalizing 6 of the adults. By the time the investigation and interventions were over, > 554 contacts had been followed up, and it had all cost > €45,000 ($53,000).

The outbreak was traced to a man with hepatitis A whose child had been unwell for 3 weeks with fever, fatigue, abdominal pain, diarrhea, pale stools, and possible jaundice. The child (and an infected cousin) attended a local CCF but because several other cases seemed to be limited to the family and their friends, no one immediately considered the CCF as a possible source of infection. However, approximately 10 days after the first 2 cases were reported, an outbreak was officially declared.

At the time, 93 children were attending the CCF. All 7 adults were household contacts of children in the CCF. None of the 23-member CCF staff developed symptoms of hepatitis A.

As many as 70% of infections are asymptomatic in children under age 6, the researchers note, but that group is often a source of transmission due to suboptimal hygiene. Transmission is usually fecal-oral and person-to-person. Although the initial source of outbreak was not identified, the subsequent transmission suggested person-to-person spread. The researchers say the distribution of cases suggests that the transmission probably happened in the school, with asymptomatic children infecting their families, highlighting the fact that symptomatic cases of hepatitis A only represent a portion of the cases in an outbreak.

A preschool inspection report that preceded the outbreak highlighted deficiencies in the staff’s handwashing practices. An infection control audit undertaken because of the outbreak found a number of deficits, including lack of foot-operated bins and the use of cloth covers on furnishings rather than waterproof material. Medical expenses, including hospitalization, serology, and vaccine, cost between €43,400 - €47, 400 ($51,000 - $56,000).

The researchers say the delayed notification to public health of the first case probably contributed to the extent of the outbreak. Medical professionals, they note, should be aware that although uncommon, hepatitis A still occurs. Prompt recognition and notification can mitigate the significant morbidity associated with the infection.

Source:
O'Connor L, McGovern E, O'Meara M, et al. Epidemiol Infect. 2018;146(6):705-711.

©ASCO/Scott Morgan 2018

CHICAGO—A chemotherapy-free combination of lenalidomide plus rituximab shows similar efficacy and a different safety profile to chemotherapy plus rituximab (R-chemo) followed by rituximab maintenance in patients with previously untreated follicular lymphoma (FL).

According to investigators, the multicenter, international phase 3 RELEVANCE trial is the first to evaluate the chemo-free combination against the standard of care, R-chemo with rituximab maintenance.

“These results show that lenalidomide plus rituximab, a novel immunomodulatory approach, is a potential first-line option for patients with FL requiring treatment,” said investigator Nathan H. Fowler, MD, of the University of Texas MD Anderson Cancer Center in Houston.

Dr Fowler presented the results of the study at the 2018 ASCO Annual Meeting (abstract 7500).

The current standard of care in previously untreated symptomatic FL is immunochemotherapy induction followed by rituximab maintenance.

The immunomodulatory agent lenalidomide has complementary mechanisms with rituximab. Phase 2 studies of combined immunotherapy with lenalidomide and rituximab demonstrated 3-year progression-free survival (PFS) of 79%-81% in previously untreated FL, Dr Fowler said.

Phase 3 RELEVANCE trial (NCT01650701)

Investigators evaluated 1030 previously untreated grade 1-3a FL patients who required therapy.

Patients in the lenalidomide-rituximab group (n=513) received lenalidomide doses of 20 mg per day on days 2 to 22 and 28 for 6 to 12 cycles. Responders continued on therapy at 10 mg per day for a total of 18 cycles.

The rituximab dose was 375 mg/m² weekly in cycle 1 and day 1 in cycles 2 to 6 and continued in responders for 12 additional cycles.

Patients in the R-chemo arm (n=517) received the investigator’s choice of standard rituximab-CHOP, rituximab-bendamustine, or rituximab-CVP, followed by 12 cycles of rituximab.

Most patients (72%) in the R-chemo arm received R-CHOP.

Baseline characteristics were similar in both groups, Dr Fowler said.

Co-primary endpoints were complete remission/complete remission unconfirmed (CR/Cru) at 120 weeks and PFS.

Results

At a median follow-up of 37.9 months, the superiority for lenalidomide and rituximab over rituximab-chemotherapy was not established.

For the lenalidomide-rituximab patients, the CR/Cru was 48% and 3-year PFS was 77% as compared to 53% and 78%, respectively, for rituximab-chemotherapy patients, as assessed by an independent review committee.

Overall survival was 94% in both groups.

Safety

“Important differences in safety profiles were observed between the arms,” Dr Fowler said.

Rituximab-chemotherapy patients had more frequent neutropenia, febrile neutropenia, growth factor usage, nausea, vomiting, neuropathy, and alopecia.

Lenalidomide and rituximab showed more cutaneous reactions, tumor flare, and diarrhea.

Toxicity profiles differed, with higher grade 4 neutropenia (31% vs 8%) and febrile neutropenia (7% vs 2%) with rituximab-chemotherapy compared with lenalidomide-rituximab, respectively.

More patients experienced grade 3/4 cutaneous events (7% vs 1%) with lenalidomide-rituximab.

Second primary malignancies were slightly higher with rituximab-chemotherapy (10%) than with lenalidomide-rituximab (7%). Grade 5 adverse events were 1% in both groups.

About 70% of patients completed treatment in both groups.

“Lenalidomide and rituximab was not superior to rituximab-chemotherapy based on mature CR/Cru at 120 weeks and interim PFS,” Dr Fowler said. “Both treatments showed similar efficacy results. Treatment effects on PFS were consistent across pre-specified subgroups.”

Dr Fowler presented data as of May 31, 2017. Continued follow-up on PFS and OS is ongoing.

The study is sponsored by Celgene Corporation and the Lymphoma Academic Research Organisation (LYSARC). 

©ASCO/Scott Morgan 2018

CHICAGO—A chemotherapy-free combination of lenalidomide plus rituximab shows similar efficacy and a different safety profile to chemotherapy plus rituximab (R-chemo) followed by rituximab maintenance in patients with previously untreated follicular lymphoma (FL).

According to investigators, the multicenter, international phase 3 RELEVANCE trial is the first to evaluate the chemo-free combination against the standard of care, R-chemo with rituximab maintenance.

“These results show that lenalidomide plus rituximab, a novel immunomodulatory approach, is a potential first-line option for patients with FL requiring treatment,” said investigator Nathan H. Fowler, MD, of the University of Texas MD Anderson Cancer Center in Houston.

Dr Fowler presented the results of the study at the 2018 ASCO Annual Meeting (abstract 7500).

The current standard of care in previously untreated symptomatic FL is immunochemotherapy induction followed by rituximab maintenance.

The immunomodulatory agent lenalidomide has complementary mechanisms with rituximab. Phase 2 studies of combined immunotherapy with lenalidomide and rituximab demonstrated 3-year progression-free survival (PFS) of 79%-81% in previously untreated FL, Dr Fowler said.

Phase 3 RELEVANCE trial (NCT01650701)

Investigators evaluated 1030 previously untreated grade 1-3a FL patients who required therapy.

Patients in the lenalidomide-rituximab group (n=513) received lenalidomide doses of 20 mg per day on days 2 to 22 and 28 for 6 to 12 cycles. Responders continued on therapy at 10 mg per day for a total of 18 cycles.

The rituximab dose was 375 mg/m² weekly in cycle 1 and day 1 in cycles 2 to 6 and continued in responders for 12 additional cycles.

Patients in the R-chemo arm (n=517) received the investigator’s choice of standard rituximab-CHOP, rituximab-bendamustine, or rituximab-CVP, followed by 12 cycles of rituximab.

Most patients (72%) in the R-chemo arm received R-CHOP.

Baseline characteristics were similar in both groups, Dr Fowler said.

Co-primary endpoints were complete remission/complete remission unconfirmed (CR/Cru) at 120 weeks and PFS.

Results

At a median follow-up of 37.9 months, the superiority for lenalidomide and rituximab over rituximab-chemotherapy was not established.

For the lenalidomide-rituximab patients, the CR/Cru was 48% and 3-year PFS was 77% as compared to 53% and 78%, respectively, for rituximab-chemotherapy patients, as assessed by an independent review committee.

Overall survival was 94% in both groups.

Safety

“Important differences in safety profiles were observed between the arms,” Dr Fowler said.

Rituximab-chemotherapy patients had more frequent neutropenia, febrile neutropenia, growth factor usage, nausea, vomiting, neuropathy, and alopecia.

Lenalidomide and rituximab showed more cutaneous reactions, tumor flare, and diarrhea.

Toxicity profiles differed, with higher grade 4 neutropenia (31% vs 8%) and febrile neutropenia (7% vs 2%) with rituximab-chemotherapy compared with lenalidomide-rituximab, respectively.

More patients experienced grade 3/4 cutaneous events (7% vs 1%) with lenalidomide-rituximab.

Second primary malignancies were slightly higher with rituximab-chemotherapy (10%) than with lenalidomide-rituximab (7%). Grade 5 adverse events were 1% in both groups.

About 70% of patients completed treatment in both groups.

“Lenalidomide and rituximab was not superior to rituximab-chemotherapy based on mature CR/Cru at 120 weeks and interim PFS,” Dr Fowler said. “Both treatments showed similar efficacy results. Treatment effects on PFS were consistent across pre-specified subgroups.”

Dr Fowler presented data as of May 31, 2017. Continued follow-up on PFS and OS is ongoing.

The study is sponsored by Celgene Corporation and the Lymphoma Academic Research Organisation (LYSARC). 

©ASCO/Scott Morgan 2018

CHICAGO—A chemotherapy-free combination of lenalidomide plus rituximab shows similar efficacy and a different safety profile to chemotherapy plus rituximab (R-chemo) followed by rituximab maintenance in patients with previously untreated follicular lymphoma (FL).

According to investigators, the multicenter, international phase 3 RELEVANCE trial is the first to evaluate the chemo-free combination against the standard of care, R-chemo with rituximab maintenance.

“These results show that lenalidomide plus rituximab, a novel immunomodulatory approach, is a potential first-line option for patients with FL requiring treatment,” said investigator Nathan H. Fowler, MD, of the University of Texas MD Anderson Cancer Center in Houston.

Dr Fowler presented the results of the study at the 2018 ASCO Annual Meeting (abstract 7500).

The current standard of care in previously untreated symptomatic FL is immunochemotherapy induction followed by rituximab maintenance.

The immunomodulatory agent lenalidomide has complementary mechanisms with rituximab. Phase 2 studies of combined immunotherapy with lenalidomide and rituximab demonstrated 3-year progression-free survival (PFS) of 79%-81% in previously untreated FL, Dr Fowler said.

Phase 3 RELEVANCE trial (NCT01650701)

Investigators evaluated 1030 previously untreated grade 1-3a FL patients who required therapy.

Patients in the lenalidomide-rituximab group (n=513) received lenalidomide doses of 20 mg per day on days 2 to 22 and 28 for 6 to 12 cycles. Responders continued on therapy at 10 mg per day for a total of 18 cycles.

The rituximab dose was 375 mg/m² weekly in cycle 1 and day 1 in cycles 2 to 6 and continued in responders for 12 additional cycles.

Patients in the R-chemo arm (n=517) received the investigator’s choice of standard rituximab-CHOP, rituximab-bendamustine, or rituximab-CVP, followed by 12 cycles of rituximab.

Most patients (72%) in the R-chemo arm received R-CHOP.

Baseline characteristics were similar in both groups, Dr Fowler said.

Co-primary endpoints were complete remission/complete remission unconfirmed (CR/Cru) at 120 weeks and PFS.

Results

At a median follow-up of 37.9 months, the superiority for lenalidomide and rituximab over rituximab-chemotherapy was not established.

For the lenalidomide-rituximab patients, the CR/Cru was 48% and 3-year PFS was 77% as compared to 53% and 78%, respectively, for rituximab-chemotherapy patients, as assessed by an independent review committee.

Overall survival was 94% in both groups.

Safety

“Important differences in safety profiles were observed between the arms,” Dr Fowler said.

Rituximab-chemotherapy patients had more frequent neutropenia, febrile neutropenia, growth factor usage, nausea, vomiting, neuropathy, and alopecia.

Lenalidomide and rituximab showed more cutaneous reactions, tumor flare, and diarrhea.

Toxicity profiles differed, with higher grade 4 neutropenia (31% vs 8%) and febrile neutropenia (7% vs 2%) with rituximab-chemotherapy compared with lenalidomide-rituximab, respectively.

More patients experienced grade 3/4 cutaneous events (7% vs 1%) with lenalidomide-rituximab.

Second primary malignancies were slightly higher with rituximab-chemotherapy (10%) than with lenalidomide-rituximab (7%). Grade 5 adverse events were 1% in both groups.

About 70% of patients completed treatment in both groups.

“Lenalidomide and rituximab was not superior to rituximab-chemotherapy based on mature CR/Cru at 120 weeks and interim PFS,” Dr Fowler said. “Both treatments showed similar efficacy results. Treatment effects on PFS were consistent across pre-specified subgroups.”

Dr Fowler presented data as of May 31, 2017. Continued follow-up on PFS and OS is ongoing.

The study is sponsored by Celgene Corporation and the Lymphoma Academic Research Organisation (LYSARC). 

ANSWER

The image reveals a hypodense extra-axial fluid collection in the right frontoparietal region, measuring 8 to 10 mm in diameter. There is some mass effect and evidence of right-to-left shift. These findings are consistent with a subacute subdural hematoma, possibly secondary to the patient’s anticoagulant use. (The patient later recalled bumping his head a couple of months prior—but that may have been incidental.)

Arrangements were made for him at a local hospital where neurosurgical services were available. He underwent successful evacuation and was subsequently symptom free.

ANSWER

The image reveals a hypodense extra-axial fluid collection in the right frontoparietal region, measuring 8 to 10 mm in diameter. There is some mass effect and evidence of right-to-left shift. These findings are consistent with a subacute subdural hematoma, possibly secondary to the patient’s anticoagulant use. (The patient later recalled bumping his head a couple of months prior—but that may have been incidental.)

Arrangements were made for him at a local hospital where neurosurgical services were available. He underwent successful evacuation and was subsequently symptom free.

ANSWER

The image reveals a hypodense extra-axial fluid collection in the right frontoparietal region, measuring 8 to 10 mm in diameter. There is some mass effect and evidence of right-to-left shift. These findings are consistent with a subacute subdural hematoma, possibly secondary to the patient’s anticoagulant use. (The patient later recalled bumping his head a couple of months prior—but that may have been incidental.)

Arrangements were made for him at a local hospital where neurosurgical services were available. He underwent successful evacuation and was subsequently symptom free.

WASHINGTON – Mortality after revisional bariatric procedures remains rare but may be more common than the literature suggests, and appears to be rising in recent years, according to two studies presented at the annual Digestive Disease Week^®.

Violeta B. Popov, MD, of New York University, and a team of researchers used the Nationwide Inpatient Sample (NIS) to look at mortality risk, costs, and risk factors for complications in revisional bariatric procedures.

In one presentation, Dr. Popov noted that revision after bariatric surgery occurred in approximately 8% of cases for a variety of reasons including lap band adjustment, weight regain, gastric reflux problems, and rarely, because of staple-line leaks. Referring to findings based on the Bariatric Outcomes Longitudinal Database (BOLD), Dr. Popov said that mortality after primary bariatric surgery is estimated at around 0.2% and revisional procedures carry nearly the same low level of mortality risk. BOLD was developed by the American Society of Metabolic and Bariatric Surgery and reflects outcomes from certified Bariatric Centers of Excellence from 2007 to 2012. However, Dr. Popov noted, the outcomes derived from BOLD may well be better than those from noncertified centers (Gastrointest Surg. 2015 Jan;19[1]:171-8).

Dr. Popov reported that the number of revisional procedures has doubled over recent years, from 6% of all bariatric procedures in 2011 to 13% in 2015. The reasons behind the increase could be related to the number of patients switching to a different bariatric approach, the removal of lap bands, and possibly the increase in the number of primary bariatric surgeries performed by less-skilled operators, Dr. Popov said.

The investigators aimed to determine the mortality trends for these procedures in addition to evaluating costs and risk factors for complications. They conducted a retrospective cohort study using the 2014 NIS, comprising 14,280 patients who underwent revisional bariatric surgery. The primary outcome was postoperative in-hospital mortality, with secondary outcomes of cost, length of hospital stay (LOS), and ICU stay. The variables included a variety of comorbidities, alcohol use, smoking, income, and insurance status.

The mean age of this sample was 68 years and 58.8% were female. Outcomes for revisional bariatric surgery were worse in several categories than were found in the BOLD study in terms of LOS, costs, and mortality, and postoperative in-hospital mortality was unexpectedly high at 2.1% (290 patients). A total of 3.3% of the patients had an ICU stay, one-quarter of whom died.

On univariate analysis, comorbidities (age, coagulopathy, chronic kidney disease, anemia, and chronic heart failure) and the combined number of chronic conditions were all significant predictors of mortality. Multivariate analysis identified age (odds ratio, 1.08; 95% confidence interval, 1.04-1.20; P less than .001), alcohol use (OR, 4.0; 95% CI, 1.3-11.7; P = .01), coagulopathy (OR, 5.4; 95% CI, 2.2-13.3; P less than .001), and insurance status (Medicaid vs. private; OR, 4.0; 95% CI, 1.7-9.9; P = .002) as the most significant predictors of mortality after a revisional bariatric procedure.

[email protected]

SOURCE: Popov VB et al. DDW 2018, Abstract 324.

WASHINGTON – Mortality after revisional bariatric procedures remains rare but may be more common than the literature suggests, and appears to be rising in recent years, according to two studies presented at the annual Digestive Disease Week^®.

Violeta B. Popov, MD, of New York University, and a team of researchers used the Nationwide Inpatient Sample (NIS) to look at mortality risk, costs, and risk factors for complications in revisional bariatric procedures.

In one presentation, Dr. Popov noted that revision after bariatric surgery occurred in approximately 8% of cases for a variety of reasons including lap band adjustment, weight regain, gastric reflux problems, and rarely, because of staple-line leaks. Referring to findings based on the Bariatric Outcomes Longitudinal Database (BOLD), Dr. Popov said that mortality after primary bariatric surgery is estimated at around 0.2% and revisional procedures carry nearly the same low level of mortality risk. BOLD was developed by the American Society of Metabolic and Bariatric Surgery and reflects outcomes from certified Bariatric Centers of Excellence from 2007 to 2012. However, Dr. Popov noted, the outcomes derived from BOLD may well be better than those from noncertified centers (Gastrointest Surg. 2015 Jan;19[1]:171-8).

Dr. Popov reported that the number of revisional procedures has doubled over recent years, from 6% of all bariatric procedures in 2011 to 13% in 2015. The reasons behind the increase could be related to the number of patients switching to a different bariatric approach, the removal of lap bands, and possibly the increase in the number of primary bariatric surgeries performed by less-skilled operators, Dr. Popov said.

The investigators aimed to determine the mortality trends for these procedures in addition to evaluating costs and risk factors for complications. They conducted a retrospective cohort study using the 2014 NIS, comprising 14,280 patients who underwent revisional bariatric surgery. The primary outcome was postoperative in-hospital mortality, with secondary outcomes of cost, length of hospital stay (LOS), and ICU stay. The variables included a variety of comorbidities, alcohol use, smoking, income, and insurance status.

The mean age of this sample was 68 years and 58.8% were female. Outcomes for revisional bariatric surgery were worse in several categories than were found in the BOLD study in terms of LOS, costs, and mortality, and postoperative in-hospital mortality was unexpectedly high at 2.1% (290 patients). A total of 3.3% of the patients had an ICU stay, one-quarter of whom died.

On univariate analysis, comorbidities (age, coagulopathy, chronic kidney disease, anemia, and chronic heart failure) and the combined number of chronic conditions were all significant predictors of mortality. Multivariate analysis identified age (odds ratio, 1.08; 95% confidence interval, 1.04-1.20; P less than .001), alcohol use (OR, 4.0; 95% CI, 1.3-11.7; P = .01), coagulopathy (OR, 5.4; 95% CI, 2.2-13.3; P less than .001), and insurance status (Medicaid vs. private; OR, 4.0; 95% CI, 1.7-9.9; P = .002) as the most significant predictors of mortality after a revisional bariatric procedure.

[email protected]

SOURCE: Popov VB et al. DDW 2018, Abstract 324.

WASHINGTON – Mortality after revisional bariatric procedures remains rare but may be more common than the literature suggests, and appears to be rising in recent years, according to two studies presented at the annual Digestive Disease Week^®.

Violeta B. Popov, MD, of New York University, and a team of researchers used the Nationwide Inpatient Sample (NIS) to look at mortality risk, costs, and risk factors for complications in revisional bariatric procedures.

In one presentation, Dr. Popov noted that revision after bariatric surgery occurred in approximately 8% of cases for a variety of reasons including lap band adjustment, weight regain, gastric reflux problems, and rarely, because of staple-line leaks. Referring to findings based on the Bariatric Outcomes Longitudinal Database (BOLD), Dr. Popov said that mortality after primary bariatric surgery is estimated at around 0.2% and revisional procedures carry nearly the same low level of mortality risk. BOLD was developed by the American Society of Metabolic and Bariatric Surgery and reflects outcomes from certified Bariatric Centers of Excellence from 2007 to 2012. However, Dr. Popov noted, the outcomes derived from BOLD may well be better than those from noncertified centers (Gastrointest Surg. 2015 Jan;19[1]:171-8).

Dr. Popov reported that the number of revisional procedures has doubled over recent years, from 6% of all bariatric procedures in 2011 to 13% in 2015. The reasons behind the increase could be related to the number of patients switching to a different bariatric approach, the removal of lap bands, and possibly the increase in the number of primary bariatric surgeries performed by less-skilled operators, Dr. Popov said.

The investigators aimed to determine the mortality trends for these procedures in addition to evaluating costs and risk factors for complications. They conducted a retrospective cohort study using the 2014 NIS, comprising 14,280 patients who underwent revisional bariatric surgery. The primary outcome was postoperative in-hospital mortality, with secondary outcomes of cost, length of hospital stay (LOS), and ICU stay. The variables included a variety of comorbidities, alcohol use, smoking, income, and insurance status.

The mean age of this sample was 68 years and 58.8% were female. Outcomes for revisional bariatric surgery were worse in several categories than were found in the BOLD study in terms of LOS, costs, and mortality, and postoperative in-hospital mortality was unexpectedly high at 2.1% (290 patients). A total of 3.3% of the patients had an ICU stay, one-quarter of whom died.

On univariate analysis, comorbidities (age, coagulopathy, chronic kidney disease, anemia, and chronic heart failure) and the combined number of chronic conditions were all significant predictors of mortality. Multivariate analysis identified age (odds ratio, 1.08; 95% confidence interval, 1.04-1.20; P less than .001), alcohol use (OR, 4.0; 95% CI, 1.3-11.7; P = .01), coagulopathy (OR, 5.4; 95% CI, 2.2-13.3; P less than .001), and insurance status (Medicaid vs. private; OR, 4.0; 95% CI, 1.7-9.9; P = .002) as the most significant predictors of mortality after a revisional bariatric procedure.

[email protected]

SOURCE: Popov VB et al. DDW 2018, Abstract 324.

NASHVILLE, TENN. – With much unknown about the risks of cancer and vaccination associated with immunosuppressants used in multiple sclerosis treatment, a neurologist advised colleagues to be aware of the potential dangers and take appropriate precautions.

For example, Eric Williamson, MD, of the University of Pennsylvania and Philadelphia Veterans Administration Hospital, said he goes a step further than recommending that adult female patients with MS who take ocrelizumab (Ocrevus) get regular mammograms. Per policy, he also double-checks to make sure that patients actually get screened.

“I know two women who were diagnosed with breast cancer before they began on their treatment because we asked about mammograms,” said Dr. Williamson, who spoke in a presentation about the risks of immunosuppressants in MS at the annual meeting of the Consortium of Multiple Sclerosis Centers.

In regard to cancer as a whole, he said, “it’s unclear if there is any true increased risk in MS patients.” But this doesn’t mean there is no danger, he said, since research into immunosuppressants in other contexts show that they can boost the risk of cancer by three times to as much as several hundred times.

In transplant patients, he said, immunosuppressants are linked to higher rates of lymphoproliferative tumors (such as those linked to Epstein-Barr virus), Kaposi sarcoma, and cutaneous, renal, hepatobiliary, and anogenital tumors.

Research is also hazy in regard to specific immunosuppressants used to treat MS. Two reports published about a decade ago raised the possibility that natalizumab (Tysabri) may have sparked a slightly higher risk cancer in patients taking the drug for Crohn’s disease and MS, respectively; the latter report hinted at a higher risk of melanoma specifically. However, Dr. Williamson said postmarketing surveillance has not detected any further sign of trouble (N Engl J Med. 2006;354:899‐910; N Engl J Med. 2008;358;647‐8).

Another drug, ocrelizumab (Ocrevus), has sparked questions about a possible breast cancer risk. As Genentech, its manufacturer, notes: “breast cancer occurred in 6 of 781 females treated with Ocrevus and none of 668 females treated with Rebif [interferon beta-1a] or placebo.”

Guidance on vaccinations

On the vaccination front, Dr. Williamson said vaccines are a good idea for MS patients – as long as they’re “relatively safe” – because some infectious diseases appear to be more severe in this population.

Flu is a special danger, Dr. Williamson said. He recommends the flu vaccine to patients “because people with MS are at higher risk of influenza-related complications or hospitalizations.”

With guidance from a report led by Dr. Williamson, the National Multiple Sclerosis Society offers recommendations about whether patients with MS should use various vaccines (Curr Neurol Neurosci Rep. 2016;16:36).

Dr. Williamson cautioned that patients with MS who take dimethyl fumarate (Tecfidera), ocrelizumab (Ocrevus), and fingolimod (Gilenya) should not use live vaccines. The drugs can pose issues in regard to other vaccines, too, he said (Plos ONE 2013; 8:e78532; Neurol Res 2012;34:730-3; Neurology. 2013;81:552-8).

Autoimmune risk with alemtuzumab

Alemtuzumab (Lemtrada) has been linked to autoimmune thyroid disorders, especially Graves’ disease, Dr. Williamson said. It’s estimated to affect 17%-41% of patients (Front Endocrinol [Lausanne]. 2017;8:254).

Potentially life-threatening idiopathic thrombocytopenic purpura occurs in 2% of patients on Lemtrada, he said, and anti-GMB nephropathy/Goodpasture’s syndrome has been reported in 0.1%.

Dr. Williamson also noted case reports of autoimmune hemolytic anemia and hepatitis. Earlier this year, three reports in Neurology noted acute coronary syndrome in one patient, hemophagocytic lymphohistiocytosis (HLH) in two patients, and acute acalculous cholecystitis in eight patients (Neurology. 2018 Mar 30. doi: 10.1212/WNL.0000000000005422, doi: 10.1212/WNL.0000000000005420, doi: 10.1212/WNL.0000000000005417).

Dr. Williamson disclosed past consulting for Bayer, Biogen, Celgene, Genentech, EMD Serono, Teva, and Novartis, and current research support from Actelion and Alexion.

NASHVILLE, TENN. – With much unknown about the risks of cancer and vaccination associated with immunosuppressants used in multiple sclerosis treatment, a neurologist advised colleagues to be aware of the potential dangers and take appropriate precautions.

For example, Eric Williamson, MD, of the University of Pennsylvania and Philadelphia Veterans Administration Hospital, said he goes a step further than recommending that adult female patients with MS who take ocrelizumab (Ocrevus) get regular mammograms. Per policy, he also double-checks to make sure that patients actually get screened.

“I know two women who were diagnosed with breast cancer before they began on their treatment because we asked about mammograms,” said Dr. Williamson, who spoke in a presentation about the risks of immunosuppressants in MS at the annual meeting of the Consortium of Multiple Sclerosis Centers.

In regard to cancer as a whole, he said, “it’s unclear if there is any true increased risk in MS patients.” But this doesn’t mean there is no danger, he said, since research into immunosuppressants in other contexts show that they can boost the risk of cancer by three times to as much as several hundred times.

In transplant patients, he said, immunosuppressants are linked to higher rates of lymphoproliferative tumors (such as those linked to Epstein-Barr virus), Kaposi sarcoma, and cutaneous, renal, hepatobiliary, and anogenital tumors.

Research is also hazy in regard to specific immunosuppressants used to treat MS. Two reports published about a decade ago raised the possibility that natalizumab (Tysabri) may have sparked a slightly higher risk cancer in patients taking the drug for Crohn’s disease and MS, respectively; the latter report hinted at a higher risk of melanoma specifically. However, Dr. Williamson said postmarketing surveillance has not detected any further sign of trouble (N Engl J Med. 2006;354:899‐910; N Engl J Med. 2008;358;647‐8).

Another drug, ocrelizumab (Ocrevus), has sparked questions about a possible breast cancer risk. As Genentech, its manufacturer, notes: “breast cancer occurred in 6 of 781 females treated with Ocrevus and none of 668 females treated with Rebif [interferon beta-1a] or placebo.”

Guidance on vaccinations

On the vaccination front, Dr. Williamson said vaccines are a good idea for MS patients – as long as they’re “relatively safe” – because some infectious diseases appear to be more severe in this population.

Flu is a special danger, Dr. Williamson said. He recommends the flu vaccine to patients “because people with MS are at higher risk of influenza-related complications or hospitalizations.”

With guidance from a report led by Dr. Williamson, the National Multiple Sclerosis Society offers recommendations about whether patients with MS should use various vaccines (Curr Neurol Neurosci Rep. 2016;16:36).

Dr. Williamson cautioned that patients with MS who take dimethyl fumarate (Tecfidera), ocrelizumab (Ocrevus), and fingolimod (Gilenya) should not use live vaccines. The drugs can pose issues in regard to other vaccines, too, he said (Plos ONE 2013; 8:e78532; Neurol Res 2012;34:730-3; Neurology. 2013;81:552-8).

Autoimmune risk with alemtuzumab

Alemtuzumab (Lemtrada) has been linked to autoimmune thyroid disorders, especially Graves’ disease, Dr. Williamson said. It’s estimated to affect 17%-41% of patients (Front Endocrinol [Lausanne]. 2017;8:254).

Potentially life-threatening idiopathic thrombocytopenic purpura occurs in 2% of patients on Lemtrada, he said, and anti-GMB nephropathy/Goodpasture’s syndrome has been reported in 0.1%.

Dr. Williamson also noted case reports of autoimmune hemolytic anemia and hepatitis. Earlier this year, three reports in Neurology noted acute coronary syndrome in one patient, hemophagocytic lymphohistiocytosis (HLH) in two patients, and acute acalculous cholecystitis in eight patients (Neurology. 2018 Mar 30. doi: 10.1212/WNL.0000000000005422, doi: 10.1212/WNL.0000000000005420, doi: 10.1212/WNL.0000000000005417).

Dr. Williamson disclosed past consulting for Bayer, Biogen, Celgene, Genentech, EMD Serono, Teva, and Novartis, and current research support from Actelion and Alexion.

NASHVILLE, TENN. – With much unknown about the risks of cancer and vaccination associated with immunosuppressants used in multiple sclerosis treatment, a neurologist advised colleagues to be aware of the potential dangers and take appropriate precautions.

For example, Eric Williamson, MD, of the University of Pennsylvania and Philadelphia Veterans Administration Hospital, said he goes a step further than recommending that adult female patients with MS who take ocrelizumab (Ocrevus) get regular mammograms. Per policy, he also double-checks to make sure that patients actually get screened.

“I know two women who were diagnosed with breast cancer before they began on their treatment because we asked about mammograms,” said Dr. Williamson, who spoke in a presentation about the risks of immunosuppressants in MS at the annual meeting of the Consortium of Multiple Sclerosis Centers.

In regard to cancer as a whole, he said, “it’s unclear if there is any true increased risk in MS patients.” But this doesn’t mean there is no danger, he said, since research into immunosuppressants in other contexts show that they can boost the risk of cancer by three times to as much as several hundred times.

In transplant patients, he said, immunosuppressants are linked to higher rates of lymphoproliferative tumors (such as those linked to Epstein-Barr virus), Kaposi sarcoma, and cutaneous, renal, hepatobiliary, and anogenital tumors.

Research is also hazy in regard to specific immunosuppressants used to treat MS. Two reports published about a decade ago raised the possibility that natalizumab (Tysabri) may have sparked a slightly higher risk cancer in patients taking the drug for Crohn’s disease and MS, respectively; the latter report hinted at a higher risk of melanoma specifically. However, Dr. Williamson said postmarketing surveillance has not detected any further sign of trouble (N Engl J Med. 2006;354:899‐910; N Engl J Med. 2008;358;647‐8).

Another drug, ocrelizumab (Ocrevus), has sparked questions about a possible breast cancer risk. As Genentech, its manufacturer, notes: “breast cancer occurred in 6 of 781 females treated with Ocrevus and none of 668 females treated with Rebif [interferon beta-1a] or placebo.”

Guidance on vaccinations

On the vaccination front, Dr. Williamson said vaccines are a good idea for MS patients – as long as they’re “relatively safe” – because some infectious diseases appear to be more severe in this population.

Flu is a special danger, Dr. Williamson said. He recommends the flu vaccine to patients “because people with MS are at higher risk of influenza-related complications or hospitalizations.”

With guidance from a report led by Dr. Williamson, the National Multiple Sclerosis Society offers recommendations about whether patients with MS should use various vaccines (Curr Neurol Neurosci Rep. 2016;16:36).

Dr. Williamson cautioned that patients with MS who take dimethyl fumarate (Tecfidera), ocrelizumab (Ocrevus), and fingolimod (Gilenya) should not use live vaccines. The drugs can pose issues in regard to other vaccines, too, he said (Plos ONE 2013; 8:e78532; Neurol Res 2012;34:730-3; Neurology. 2013;81:552-8).

Autoimmune risk with alemtuzumab

Alemtuzumab (Lemtrada) has been linked to autoimmune thyroid disorders, especially Graves’ disease, Dr. Williamson said. It’s estimated to affect 17%-41% of patients (Front Endocrinol [Lausanne]. 2017;8:254).

Potentially life-threatening idiopathic thrombocytopenic purpura occurs in 2% of patients on Lemtrada, he said, and anti-GMB nephropathy/Goodpasture’s syndrome has been reported in 0.1%.

Dr. Williamson also noted case reports of autoimmune hemolytic anemia and hepatitis. Earlier this year, three reports in Neurology noted acute coronary syndrome in one patient, hemophagocytic lymphohistiocytosis (HLH) in two patients, and acute acalculous cholecystitis in eight patients (Neurology. 2018 Mar 30. doi: 10.1212/WNL.0000000000005422, doi: 10.1212/WNL.0000000000005420, doi: 10.1212/WNL.0000000000005417).

Dr. Williamson disclosed past consulting for Bayer, Biogen, Celgene, Genentech, EMD Serono, Teva, and Novartis, and current research support from Actelion and Alexion.

ABSTRACT

This study was performed to compare outcomes of open, arthroscopic, and percutaneous surgical techniques for lateral epicondylitis. We searched PubMed (MEDLINE) for literature published between January 1, 2004 and May 23, 2015 using these key words: lateral epicondylitis AND (surgery OR operative OR surgical OR open OR arthroscopic OR percutaneous). Meta-analyses were performed for outcomes reported in 3 studies using 2-sample and 2-proportion Z-tests. Thirty-five studies including 1640 elbows (1055 open, 401 arthroscopic, 184 percutaneous) met the inclusion criteria. There were no differences between groups regarding duration to return to work, complication rate, or patient satisfaction. A greater proportion of patients were pain free in the open group than in the arthroscopic group (70% vs 60%). Despite the absence of a difference among techniques regarding return to work and subjective function, we recommend open débridement as the technique most likely to achieve a pain-free outcome.

Continue to: Lateral epicondylitis affects...

Lateral epicondylitis affects 1% to 3% of adults each year. Although common, symptoms of lateral epicondylitis resolve spontaneously within a year of symptom onset in 80% of cases, and only 3% of patients who seek medical treatment ultimately require surgical intervention within 2 years of symptom onset.¹ Despite a relatively low percentage of patients who require surgery, Sanders and colleagues¹ noted a significant increase in the rate of surgical intervention from 1.1% to 3.2% of cases in the last 15 years. Surgical intervention is generally indicated when pain and functional disability persist after 6 to 12 months of nonsurgical treatment. Traditional surgical treatment involves open release/débridement of the extensor carpi radialis (ECRB) origin; however, with the increasing prevalence of surgical intervention, surgeons have demonstrated a rising interest in less invasive techniques like arthroscopic release/débridement and percutaneous tenotomy as alternatives to traditional open débridement. While favorable results have been reported for all 3 techniques, there is no current consensus regarding the optimal surgical technique. In 2007, Lo and Safran² reported no difference in the results of open, percutaneous, and arthroscopic techniques regarding any outcome measure in a systematic review of 33 papers. We conducted a repeat systematic review of the current literature to update Lo and Safran’s² review and to ascertain if more recent literature demonstrates superiority of 1 technique regarding pain relief, subjective questionnaire data, subjective satisfaction, restoration of strength, and return to work. We hypothesized that return to work would be accelerated, pain decreased, and function improved in the early postoperative period in the arthroscopic and percutaneous groups, but there would be no difference in ultimate pain, functional outcome, or subjective satisfaction.

METHODS

SEARCH STRATEGY AND STUDY SELECTION

We conducted a systematic review of the literature to update the topic of surgical intervention with lateral epicondylitis since the publication of the most recent review by Lo and Safran² in 2007, which included all relevant studies published up to 2004. To include all relevant studies published since that time, we searched PubMed (MEDLINE) for all literature published from January 1, 2004 to May 23, 2015 using the following key words: lateral epicondylitis AND (surgery OR operative OR surgical OR open OR arthroscopic OR percutaneous). General search terms were utilized to avoid unintentional exclusion of relevant studies. Two authors reviewed the abstracts of all resultant citations. Table 1 outlines the inclusion and exclusion criteria for the search. References from all included studies were reviewed for applicable articles that were not captured by the initial broad search strategy. A Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) trial flow chart shows the study selection algorithm (Figure 1).

Table 1. Inclusion and Exclusion Criteria for the Analyzed Studies

DATA EXTRACTION AND ANALYSIS

Data were extracted from the included studies by 2 reviewers using data abstraction forms. All study, subject, and surgery parameters were collected. The study and subject demographic parameters analyzed included year of publication, level of evidence, presence of study financial conflict of interest, number of subjects and elbows, gender, age, proportion in whom the dominant extremity was involved, proportion who were laborers, proportion who had a workman’s compensation claim, duration of symptoms prior to surgical intervention, and surgical technique employed (open, arthroscopic, or percutaneous). We recorded the following clinical outcomes: proportion of patients with complete pain relief, proportion who were partially or completely satisfied, proportion who were improved, duration to return to work, grip strength, Disabilities of the Arm, Shoulder, and Hand (DASH) score, visual analog scale (VAS) pain score, and complication rate.

Continue to: Statistical analysis...

STATISTICAL ANALYSIS

Data from all studies were pooled and descriptive statistics were reported as weighted mean ± weighted standard deviation for continuous variables and frequency with percentage for categorical variables. A meta-analysis was performed for all outcome measures that were reported in 3 or more studies within a specific treatment cohort. Data were analyzed using 2-sample and 2-proportion Z-tests. Results were considered statistically significant at P < .05.

RESULTS

LITERATURE RESEARCH

Using the aforementioned search strategy, 154 studies were identified. Following application of the inclusion and exclusion criteria, 35 studies were included in the analysis (Figure 1). One study compared open and percutaneous techniques, and another compared arthroscopic and percutaneous techniques, rendering a total of 19 studies examining open surgical techniques for treatment of lateral epicondylitis,^3-21 12 studies examining arthroscopic techniques,^14,22-32 and 6 studies reporting percutaneous surgical treatment of lateral epicondylitis^29,33-37 (Table 2). There was1 level I study (3%), 6 level III studies (17%), and 28 level IV studies (80%).

Table 2. Study Demographic Data for Open, Arthroscopic, and Percutaneous Lateral Epicondylectomy

Abbreviations: AJO, The American Journal of Orthopedics; AJSM, American Journal of Sports Medicine; Arthroscopy, The Journal of Arthroscopy and Related Surgery; CORR, Clinical Orthopaedics & Related Research; JHS, Journal of Hand Surgery; JOS, Journal of Orthopaedic Surgery; JSES, Journal of Shoulder and Elbow Surgery; KSSTA, Knee Surgery, Sports Traumatology, and Arthroscopy.

SUBJECT DEMOGRAPHICS

The 35 included studies comprised 1579 patients and 1640 elbows. Among these, 1055 (64%) elbows underwent open (O), 401 (25%) underwent arthroscopic (A), and 184 (11%) underwent percutaneous (P) treatment. The average age was 45.7 years, 47% of the patients were male, 43% were laborers, 31% had worker’s compensation claims, and the dominant extremity was involved in 62% of patients. The percutaneous cohort was older than the open cohort (P = 46.9, O = 45.4, A = 45.8; P = .036). The duration of symptoms was shorter in the percutaneous cohort than in the other 2 groups and shorter in the arthroscopic cohort than in the open cohort (P = 8 months, O = 23 months, A = 18 months; P < .001). There were no significant differences between groups regarding gender, occupation, worker’s compensation status, or involvement of the dominant extremity (Table 3).

Table 3. Subject Demographics for Open, Arthroscopic, and Percutaneous Groups

MATA-ANALYSIS CLINICAL OUTCOMES

Clinical outcome results were pooled for all studies reporting the same outcome measure for the same technique (open, arthroscopic, or percutaneous). A meta-analysis was performed for all outcome measures that were reported in a minimum of 3 studies utilizing the same surgical technique (Table 4).

PAIN RELIEF

Thirteen open studies,^{3,5,7,8,11-16,18,19,21} 7 arthroscopic studies^{14,22-24,26,27,31} and 0 percutaneous studies reported the proportion of patients who were pain free at final follow-up. The proportion of patients who were pain free following open débridement was greater than that in the arthroscopic cohort (O = 70%, A = 60%; P = .009) (Table 4).

Continue to: Subjective improvement and satisfaction...

SUBJECTIVE IMPROVEMENT AND SATISFACTION

Nine open studies, 6 arthroscopic studies, and 1 percutaneous study reported the proportion of patients who felt that their condition had been improved as a result of surgery. There was no difference in the proportion of patients who experienced improvement between the open and arthroscopic cohorts. Four open studies,^3,11,12 5 arthroscopic studies,^{22,26,28,29,32} and 2 percutaneous studies^29,36 reported the proportion of patients who were satisfied or partially satisfied with the results of the procedure. There was no difference between the open and arthroscopic groups in the proportion of patients who were satisfied or partially satisfied (Table 4).

RETURN TO WORK

The duration to return to work following surgery was reported in 5 open studies,^4,5,10,13,14 9 arthroscopic studies,^14,23-29,32 and 2 percutaneous studies.^29,36 There was no statistically significant difference between the open and arthroscopic groups with regard to duration to return to work (O = 6.5 weeks, A = 6 weeks; P = .601). The percutaneous technique could not be included in the meta-analysis due to the presence of only 2 studies, but the pooled mean duration to return to work in these 2 studies was 5.5 weeks (Table 4).

GRIP STRENGTH

Postoperative grip strength was reported in 2 open studies,^10,19 4 arthroscopic studies,^28,30,32 and 2 percutaneous studies.^35-36 A meta-analysis could not be performed on all the groups due to the presence of only 2 open and 2 percutaneous studies reporting grip strength. The pooled averages were O = 38.3 kg, A = 34.8 kg, and P = 27.1 kg (Table 4).

DASH SCORE

The postoperative DASH score was reported in 4 open studies,^{4,15,17,19,20} 5 arthroscopic studies,^28-31 and 3 percutaneous studies.^29,33,36 At final follow-up, the mean DASH score was higher in the arthroscopic group than in the open and percutaneous groups (A = 12.8, O = 19.5, P = 25.3; P < .001 for both comparisons), and the mean DASH score was significantly higher in the open group than in the percutaneous group (P = .029). The reporting of DASH scores in the early postoperative period was not sufficiently consistent to allow us to test our hypothesis that there would be early differences in function between groups (Table 4).

VAS PAIN SCORE

Postoperative VAS pain scores were reported in 11 open studies,^{6,8-10,12,15,19-21} 8 arthroscopic studies,^24-26,29-32 and 5 percutaneous studies.^29,33,35-37 At final follow-up, there was a lower mean VAS score in the arthroscopic group than in the open and percutaneous groups (A = 1.1, O = 1.9, and P = 2.5; P < .001 for both comparisons) and a lower mean VAS score in the open group than in the percutaneous group (P = .002) (Table 4). Reporting of VAS scores in the early postoperative period in the included studies wan not sufficiently consistent to allow us to test our hypothesis that there would be early differences in pain between groups.

COMPLICATIONS

The complication rate was reported in 15 open studies, 10 arthroscopic studies, and 3 percutaneous studies. There was no difference in the complication rate between the open and arthroscopic techniques (O = 2.4%, A = 1.9%; P = .629) (Table 4). Complications noted in the open cohort included superficial wound infection (6), hematoma (5), synovial fistula (2), seroma (2), and posterior interosseous nerve palsy (1). Complications noted in the arthroscopic cohort included superficial infection (3), hematoma (1), and transient paresthesia (1). Of note, there were no complications in the percutaneous group.

Continue to: Discussion...

DISCUSSION

The primary purpose of this review was to determine if definitive evidence suggests that any 1 of open, percutaneous, or arthroscopic surgical treatment is superior to the other 2 for relieving pain, improving functionality, restoring strength, or accelerating return to work. The most striking finding of this study was a significantly higher proportion of patients who were pain free at final follow-up in the open group than in the arthroscopic group (70% vs 60%, P = .009) (Table 4). At final follow-up, there were no significant differences between groups regarding duration to return to work, proportion who were improved, proportion who were satisfied or partially satisfied, and complication rate. Average VAS and DASH scores at final follow-up were lower in the arthroscopic group than in the open and percutaneous groups (Figure 2). However, although the difference between mean DASH scores in the arthroscopic and open groups (6.7 points) was statistically significant, it is likely not clinically significant, as the minimal clinically important difference (MCID) for the DASH score is 10 points, as demonstrated by Sorensen and colleagues.³⁸ Although it has not been specifically defined for lateral epicondylitis, the MCID for VAS pain has been reported in the literature to range from 1.0 to 1.4.^39-40 Therefore, as for the DASH score, the difference witnessed between the open and arthroscopic groups (0.8) is likely not clinically significant. Of note, the differences between values for arthroscopic and percutaneous techniques are greater than the MCID.

In light of a recent increase in the prevalence of surgical intervention for lateral epicondylitis, many authors have promoted arthroscopic and percutaneous techniques as alternatives to traditional open débridement with the goal of achieving the same results with decreased morbidity and accelerated return to work. Given the increased proportion of patients who were pain free at final follow-up in the open cohort, it is our contention that open release/débridement of the common extensor/ECRB origin allows the surgeon to fully appreciate the extent of tendinotic tissue that is contributing to the patient’s symptoms and to address the pathology in its entirety. Other authors have also questioned whether the full extent of extra-articular tendinosis can be accurately identified arthroscopically. Cummins⁴¹ demonstrated, in a series of 18 patients who underwent arthroscopic ECRB débridement, that 6 patients had residual tendinosis upon open evaluation and 10 had residual tendinosis on histologic assessment. Additionally, in the same series, residual tendinopathy was associated with poorer clinical outcomes.

The improved visualization associated with an open technique comes at minimal expense, as the incision was only 1.5 cm to 5 cm in 13 of 15 papers reporting incision length.^{3,4,6,8-11,13,15,18-20} This increased exposure may not translate into increased morbidity, as there was no increase in the duration to return to work nor the complication rate. As a result of the extensive instrumentation necessary for arthroscopic techniques, open techniques also appear to be less expensive. Analyses in the literature have suggested increased expenditures associated with arthroscopic treatment ranging from 23%⁴² to 100%⁴³ greater than those of open treatment.

Although obvious, it should be noted that a percutaneous tenotomy does not permit assessment of the extent of pathologic tendinosis. As a result of an inability to visualize and débride pathologic tissue, percutaneous tenotomy rendered inferior outcomes to open and arthroscopic techniques in terms of both postoperative VAS pain score and DASH score. Nonetheless, it is a relatively rapid and simple technique and resulted in zero complications in 184 elbows. Overall, percutaneous tenotomy appears to be an inferior technique to open and arthroscopic techniques in terms of achieving complete pain relief and optimal functional recovery; however, it may be useful in those who wish to avoid a more invasive intervention.

LIMITATIONS

The most significant limitation of this study was the heterogeneity in the techniques utilized in each group. Among the 19 papers in the open cohort, 11 used techniques aimed at lengthening or release of the extensor origin, 7 performed débridement of tendinotic tissue at the ECRB origin, and 1 compared these approaches. Exposures ranged from 1.5 cm to 8 cm in length, 3 techniques added tendon repair following débridement, and 2 utilized a radiofrequency device.

Among the 12 papers in the arthroscopic cohort, 8 performed arthroscopic (inside-out) débridement of the tendinotic tissue at the ECRB origin, 3 performed arthroscopic release of the ECRB tendon, and 1 performed endoscopic ECRB release in an outside-in fashion. Four techniques added posterior synovial plica excision and 4 added decortication of the lateral epicondyle débridement or release. Some authors advocate for arthroscopic intervention on the grounds that it permits evaluation and correction of other intra-articular pathology. With this in mind, some authors have suggested that a synovial fold (plica) adjacent to the radiocapitellar joint may contribute to lateral elbow pain.^27,44 Nevertheless, in the only comparative trial in the literature, Rhyou and Kim³⁰ demonstrated that excision of posterior synovial fold failed to enhance pain relief or function in a retrospective cohort study comparing arthroscopic débridement with and without plica excision.

Continue to: Some authors advocate...

Some authors advocate decorticating the non-articular, lateral epicondyle with a shaver to stimulate bleeding and promote a healing response. However, 1 study in our review compared arthroscopic ECRB release with and without decortication and found that decortication significantly increased pain up to 4 weeks postoperatively, increased duration to return to work, and did not improve the ultimate clinical result.²⁵ Of note, others have used a similar rationale to advocate drilling the lateral epicondyle when utilizing an open technique. However, Dunn and colleagues⁸ note that they have modified the Nirschl technique to eliminate drilling because they feel it increases postoperative pain and may damage the extensor digitorum communis origin.

Among the 6 papers in the percutaneous tenotomy cohort, 2 performed tenotomy with a hypodermic needle, 2 with a scalpel through a limited incision (0.5 cm-1 cm), 1 using a TX1 tissue removal system (Tenex Health), and 1 with a percutaneous radiofrequency probe. In 3 techniques, ultrasound was used to direct the tenotomy.

The quality of this review is also limited by the studies included for analysis, as with any systematic review. Because 28 of the 35 included studies were classified as evidence level IV, the likelihood of methodological bias is increased. The majority of studies contained ≥1 demonstrable biases, including selection, detection, attrition biases, or a combination. Selection bias is prevalent among predominantly level IV studies, in which the authors have selected their preferred surgical technique. There was heterogeneity in the reporting of preoperative variables and the outcome measures that were utilized. Scoring systems, such as the Nirschl Tennis Elbow Score and the Mayo Elbow Performance Index, would have been valuable in comparing the groups had they been more consistently reported. The heterogeneity in clinical outcome tools and the lack of reported outcome variance or standard deviations prevented a formal meta-analysis of some of these outcome measures. Due to inconsistent reporting, we were also unable to test our hypothesis that there would be less pain and improved function in the arthroscopic and/or percutaneous cohorts in the early postoperative period compared to the open cohort due to the less invasive techniques used. Although the differences in DASH and VAS scores at final follow-up likely did not meet the MCID threshold, these differences may have been greater and more clinically relevant in the early postoperative period.

CONCLUSION

We hypothesized that the arthroscopic and percutaneous groups would experience accelerated return to work and reduced pain in the early postoperative period but no difference in ultimate pain, functional outcome, or subjective satisfaction. There is no difference between open, arthroscopic, and percutaneous surgical treatment for lateral epicondylitis regarding return to work and subjective satisfaction; however, open treatment led to a greater percentage of patients being pain free at final follow-up. While arthroscopic treatment led to better pain and functional scores at final follow-up, the absolute differences were quite small and likely not clinically significant. In light of the available evidence, we recommend open débridement as the best means of minimizing cost and achieving a pain-free outcome in the long term. For future investigators, it would be useful to perform a randomized clinical study directly comparing open, arthroscopic, and percutaneous techniques, including assessment of pain and functional scores in the early postoperative period, and to further evaluate differences in cost among the various techniques.

This paper will be judged for the Resident Writer’s Award.

ABSTRACT

This study was performed to compare outcomes of open, arthroscopic, and percutaneous surgical techniques for lateral epicondylitis. We searched PubMed (MEDLINE) for literature published between January 1, 2004 and May 23, 2015 using these key words: lateral epicondylitis AND (surgery OR operative OR surgical OR open OR arthroscopic OR percutaneous). Meta-analyses were performed for outcomes reported in 3 studies using 2-sample and 2-proportion Z-tests. Thirty-five studies including 1640 elbows (1055 open, 401 arthroscopic, 184 percutaneous) met the inclusion criteria. There were no differences between groups regarding duration to return to work, complication rate, or patient satisfaction. A greater proportion of patients were pain free in the open group than in the arthroscopic group (70% vs 60%). Despite the absence of a difference among techniques regarding return to work and subjective function, we recommend open débridement as the technique most likely to achieve a pain-free outcome.

Continue to: Lateral epicondylitis affects...

Lateral epicondylitis affects 1% to 3% of adults each year. Although common, symptoms of lateral epicondylitis resolve spontaneously within a year of symptom onset in 80% of cases, and only 3% of patients who seek medical treatment ultimately require surgical intervention within 2 years of symptom onset.¹ Despite a relatively low percentage of patients who require surgery, Sanders and colleagues¹ noted a significant increase in the rate of surgical intervention from 1.1% to 3.2% of cases in the last 15 years. Surgical intervention is generally indicated when pain and functional disability persist after 6 to 12 months of nonsurgical treatment. Traditional surgical treatment involves open release/débridement of the extensor carpi radialis (ECRB) origin; however, with the increasing prevalence of surgical intervention, surgeons have demonstrated a rising interest in less invasive techniques like arthroscopic release/débridement and percutaneous tenotomy as alternatives to traditional open débridement. While favorable results have been reported for all 3 techniques, there is no current consensus regarding the optimal surgical technique. In 2007, Lo and Safran² reported no difference in the results of open, percutaneous, and arthroscopic techniques regarding any outcome measure in a systematic review of 33 papers. We conducted a repeat systematic review of the current literature to update Lo and Safran’s² review and to ascertain if more recent literature demonstrates superiority of 1 technique regarding pain relief, subjective questionnaire data, subjective satisfaction, restoration of strength, and return to work. We hypothesized that return to work would be accelerated, pain decreased, and function improved in the early postoperative period in the arthroscopic and percutaneous groups, but there would be no difference in ultimate pain, functional outcome, or subjective satisfaction.

METHODS

SEARCH STRATEGY AND STUDY SELECTION

We conducted a systematic review of the literature to update the topic of surgical intervention with lateral epicondylitis since the publication of the most recent review by Lo and Safran² in 2007, which included all relevant studies published up to 2004. To include all relevant studies published since that time, we searched PubMed (MEDLINE) for all literature published from January 1, 2004 to May 23, 2015 using the following key words: lateral epicondylitis AND (surgery OR operative OR surgical OR open OR arthroscopic OR percutaneous). General search terms were utilized to avoid unintentional exclusion of relevant studies. Two authors reviewed the abstracts of all resultant citations. Table 1 outlines the inclusion and exclusion criteria for the search. References from all included studies were reviewed for applicable articles that were not captured by the initial broad search strategy. A Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) trial flow chart shows the study selection algorithm (Figure 1).

Table 1. Inclusion and Exclusion Criteria for the Analyzed Studies

DATA EXTRACTION AND ANALYSIS

Data were extracted from the included studies by 2 reviewers using data abstraction forms. All study, subject, and surgery parameters were collected. The study and subject demographic parameters analyzed included year of publication, level of evidence, presence of study financial conflict of interest, number of subjects and elbows, gender, age, proportion in whom the dominant extremity was involved, proportion who were laborers, proportion who had a workman’s compensation claim, duration of symptoms prior to surgical intervention, and surgical technique employed (open, arthroscopic, or percutaneous). We recorded the following clinical outcomes: proportion of patients with complete pain relief, proportion who were partially or completely satisfied, proportion who were improved, duration to return to work, grip strength, Disabilities of the Arm, Shoulder, and Hand (DASH) score, visual analog scale (VAS) pain score, and complication rate.

Continue to: Statistical analysis...

STATISTICAL ANALYSIS

Data from all studies were pooled and descriptive statistics were reported as weighted mean ± weighted standard deviation for continuous variables and frequency with percentage for categorical variables. A meta-analysis was performed for all outcome measures that were reported in 3 or more studies within a specific treatment cohort. Data were analyzed using 2-sample and 2-proportion Z-tests. Results were considered statistically significant at P < .05.

RESULTS

LITERATURE RESEARCH

Using the aforementioned search strategy, 154 studies were identified. Following application of the inclusion and exclusion criteria, 35 studies were included in the analysis (Figure 1). One study compared open and percutaneous techniques, and another compared arthroscopic and percutaneous techniques, rendering a total of 19 studies examining open surgical techniques for treatment of lateral epicondylitis,^3-21 12 studies examining arthroscopic techniques,^14,22-32 and 6 studies reporting percutaneous surgical treatment of lateral epicondylitis^29,33-37 (Table 2). There was1 level I study (3%), 6 level III studies (17%), and 28 level IV studies (80%).

Table 2. Study Demographic Data for Open, Arthroscopic, and Percutaneous Lateral Epicondylectomy

Abbreviations: AJO, The American Journal of Orthopedics; AJSM, American Journal of Sports Medicine; Arthroscopy, The Journal of Arthroscopy and Related Surgery; CORR, Clinical Orthopaedics & Related Research; JHS, Journal of Hand Surgery; JOS, Journal of Orthopaedic Surgery; JSES, Journal of Shoulder and Elbow Surgery; KSSTA, Knee Surgery, Sports Traumatology, and Arthroscopy.

SUBJECT DEMOGRAPHICS

The 35 included studies comprised 1579 patients and 1640 elbows. Among these, 1055 (64%) elbows underwent open (O), 401 (25%) underwent arthroscopic (A), and 184 (11%) underwent percutaneous (P) treatment. The average age was 45.7 years, 47% of the patients were male, 43% were laborers, 31% had worker’s compensation claims, and the dominant extremity was involved in 62% of patients. The percutaneous cohort was older than the open cohort (P = 46.9, O = 45.4, A = 45.8; P = .036). The duration of symptoms was shorter in the percutaneous cohort than in the other 2 groups and shorter in the arthroscopic cohort than in the open cohort (P = 8 months, O = 23 months, A = 18 months; P < .001). There were no significant differences between groups regarding gender, occupation, worker’s compensation status, or involvement of the dominant extremity (Table 3).

Table 3. Subject Demographics for Open, Arthroscopic, and Percutaneous Groups

MATA-ANALYSIS CLINICAL OUTCOMES

Clinical outcome results were pooled for all studies reporting the same outcome measure for the same technique (open, arthroscopic, or percutaneous). A meta-analysis was performed for all outcome measures that were reported in a minimum of 3 studies utilizing the same surgical technique (Table 4).

PAIN RELIEF

Thirteen open studies,^{3,5,7,8,11-16,18,19,21} 7 arthroscopic studies^{14,22-24,26,27,31} and 0 percutaneous studies reported the proportion of patients who were pain free at final follow-up. The proportion of patients who were pain free following open débridement was greater than that in the arthroscopic cohort (O = 70%, A = 60%; P = .009) (Table 4).

Continue to: Subjective improvement and satisfaction...

SUBJECTIVE IMPROVEMENT AND SATISFACTION

Nine open studies, 6 arthroscopic studies, and 1 percutaneous study reported the proportion of patients who felt that their condition had been improved as a result of surgery. There was no difference in the proportion of patients who experienced improvement between the open and arthroscopic cohorts. Four open studies,^3,11,12 5 arthroscopic studies,^{22,26,28,29,32} and 2 percutaneous studies^29,36 reported the proportion of patients who were satisfied or partially satisfied with the results of the procedure. There was no difference between the open and arthroscopic groups in the proportion of patients who were satisfied or partially satisfied (Table 4).

RETURN TO WORK

The duration to return to work following surgery was reported in 5 open studies,^4,5,10,13,14 9 arthroscopic studies,^14,23-29,32 and 2 percutaneous studies.^29,36 There was no statistically significant difference between the open and arthroscopic groups with regard to duration to return to work (O = 6.5 weeks, A = 6 weeks; P = .601). The percutaneous technique could not be included in the meta-analysis due to the presence of only 2 studies, but the pooled mean duration to return to work in these 2 studies was 5.5 weeks (Table 4).

GRIP STRENGTH

Postoperative grip strength was reported in 2 open studies,^10,19 4 arthroscopic studies,^28,30,32 and 2 percutaneous studies.^35-36 A meta-analysis could not be performed on all the groups due to the presence of only 2 open and 2 percutaneous studies reporting grip strength. The pooled averages were O = 38.3 kg, A = 34.8 kg, and P = 27.1 kg (Table 4).

DASH SCORE

The postoperative DASH score was reported in 4 open studies,^{4,15,17,19,20} 5 arthroscopic studies,^28-31 and 3 percutaneous studies.^29,33,36 At final follow-up, the mean DASH score was higher in the arthroscopic group than in the open and percutaneous groups (A = 12.8, O = 19.5, P = 25.3; P < .001 for both comparisons), and the mean DASH score was significantly higher in the open group than in the percutaneous group (P = .029). The reporting of DASH scores in the early postoperative period was not sufficiently consistent to allow us to test our hypothesis that there would be early differences in function between groups (Table 4).

VAS PAIN SCORE

Postoperative VAS pain scores were reported in 11 open studies,^{6,8-10,12,15,19-21} 8 arthroscopic studies,^24-26,29-32 and 5 percutaneous studies.^29,33,35-37 At final follow-up, there was a lower mean VAS score in the arthroscopic group than in the open and percutaneous groups (A = 1.1, O = 1.9, and P = 2.5; P < .001 for both comparisons) and a lower mean VAS score in the open group than in the percutaneous group (P = .002) (Table 4). Reporting of VAS scores in the early postoperative period in the included studies wan not sufficiently consistent to allow us to test our hypothesis that there would be early differences in pain between groups.

COMPLICATIONS

The complication rate was reported in 15 open studies, 10 arthroscopic studies, and 3 percutaneous studies. There was no difference in the complication rate between the open and arthroscopic techniques (O = 2.4%, A = 1.9%; P = .629) (Table 4). Complications noted in the open cohort included superficial wound infection (6), hematoma (5), synovial fistula (2), seroma (2), and posterior interosseous nerve palsy (1). Complications noted in the arthroscopic cohort included superficial infection (3), hematoma (1), and transient paresthesia (1). Of note, there were no complications in the percutaneous group.

Continue to: Discussion...

DISCUSSION

The primary purpose of this review was to determine if definitive evidence suggests that any 1 of open, percutaneous, or arthroscopic surgical treatment is superior to the other 2 for relieving pain, improving functionality, restoring strength, or accelerating return to work. The most striking finding of this study was a significantly higher proportion of patients who were pain free at final follow-up in the open group than in the arthroscopic group (70% vs 60%, P = .009) (Table 4). At final follow-up, there were no significant differences between groups regarding duration to return to work, proportion who were improved, proportion who were satisfied or partially satisfied, and complication rate. Average VAS and DASH scores at final follow-up were lower in the arthroscopic group than in the open and percutaneous groups (Figure 2). However, although the difference between mean DASH scores in the arthroscopic and open groups (6.7 points) was statistically significant, it is likely not clinically significant, as the minimal clinically important difference (MCID) for the DASH score is 10 points, as demonstrated by Sorensen and colleagues.³⁸ Although it has not been specifically defined for lateral epicondylitis, the MCID for VAS pain has been reported in the literature to range from 1.0 to 1.4.^39-40 Therefore, as for the DASH score, the difference witnessed between the open and arthroscopic groups (0.8) is likely not clinically significant. Of note, the differences between values for arthroscopic and percutaneous techniques are greater than the MCID.

In light of a recent increase in the prevalence of surgical intervention for lateral epicondylitis, many authors have promoted arthroscopic and percutaneous techniques as alternatives to traditional open débridement with the goal of achieving the same results with decreased morbidity and accelerated return to work. Given the increased proportion of patients who were pain free at final follow-up in the open cohort, it is our contention that open release/débridement of the common extensor/ECRB origin allows the surgeon to fully appreciate the extent of tendinotic tissue that is contributing to the patient’s symptoms and to address the pathology in its entirety. Other authors have also questioned whether the full extent of extra-articular tendinosis can be accurately identified arthroscopically. Cummins⁴¹ demonstrated, in a series of 18 patients who underwent arthroscopic ECRB débridement, that 6 patients had residual tendinosis upon open evaluation and 10 had residual tendinosis on histologic assessment. Additionally, in the same series, residual tendinopathy was associated with poorer clinical outcomes.

The improved visualization associated with an open technique comes at minimal expense, as the incision was only 1.5 cm to 5 cm in 13 of 15 papers reporting incision length.^{3,4,6,8-11,13,15,18-20} This increased exposure may not translate into increased morbidity, as there was no increase in the duration to return to work nor the complication rate. As a result of the extensive instrumentation necessary for arthroscopic techniques, open techniques also appear to be less expensive. Analyses in the literature have suggested increased expenditures associated with arthroscopic treatment ranging from 23%⁴² to 100%⁴³ greater than those of open treatment.

Although obvious, it should be noted that a percutaneous tenotomy does not permit assessment of the extent of pathologic tendinosis. As a result of an inability to visualize and débride pathologic tissue, percutaneous tenotomy rendered inferior outcomes to open and arthroscopic techniques in terms of both postoperative VAS pain score and DASH score. Nonetheless, it is a relatively rapid and simple technique and resulted in zero complications in 184 elbows. Overall, percutaneous tenotomy appears to be an inferior technique to open and arthroscopic techniques in terms of achieving complete pain relief and optimal functional recovery; however, it may be useful in those who wish to avoid a more invasive intervention.

LIMITATIONS

The most significant limitation of this study was the heterogeneity in the techniques utilized in each group. Among the 19 papers in the open cohort, 11 used techniques aimed at lengthening or release of the extensor origin, 7 performed débridement of tendinotic tissue at the ECRB origin, and 1 compared these approaches. Exposures ranged from 1.5 cm to 8 cm in length, 3 techniques added tendon repair following débridement, and 2 utilized a radiofrequency device.

Among the 12 papers in the arthroscopic cohort, 8 performed arthroscopic (inside-out) débridement of the tendinotic tissue at the ECRB origin, 3 performed arthroscopic release of the ECRB tendon, and 1 performed endoscopic ECRB release in an outside-in fashion. Four techniques added posterior synovial plica excision and 4 added decortication of the lateral epicondyle débridement or release. Some authors advocate for arthroscopic intervention on the grounds that it permits evaluation and correction of other intra-articular pathology. With this in mind, some authors have suggested that a synovial fold (plica) adjacent to the radiocapitellar joint may contribute to lateral elbow pain.^27,44 Nevertheless, in the only comparative trial in the literature, Rhyou and Kim³⁰ demonstrated that excision of posterior synovial fold failed to enhance pain relief or function in a retrospective cohort study comparing arthroscopic débridement with and without plica excision.

Continue to: Some authors advocate...

Some authors advocate decorticating the non-articular, lateral epicondyle with a shaver to stimulate bleeding and promote a healing response. However, 1 study in our review compared arthroscopic ECRB release with and without decortication and found that decortication significantly increased pain up to 4 weeks postoperatively, increased duration to return to work, and did not improve the ultimate clinical result.²⁵ Of note, others have used a similar rationale to advocate drilling the lateral epicondyle when utilizing an open technique. However, Dunn and colleagues⁸ note that they have modified the Nirschl technique to eliminate drilling because they feel it increases postoperative pain and may damage the extensor digitorum communis origin.

Among the 6 papers in the percutaneous tenotomy cohort, 2 performed tenotomy with a hypodermic needle, 2 with a scalpel through a limited incision (0.5 cm-1 cm), 1 using a TX1 tissue removal system (Tenex Health), and 1 with a percutaneous radiofrequency probe. In 3 techniques, ultrasound was used to direct the tenotomy.

The quality of this review is also limited by the studies included for analysis, as with any systematic review. Because 28 of the 35 included studies were classified as evidence level IV, the likelihood of methodological bias is increased. The majority of studies contained ≥1 demonstrable biases, including selection, detection, attrition biases, or a combination. Selection bias is prevalent among predominantly level IV studies, in which the authors have selected their preferred surgical technique. There was heterogeneity in the reporting of preoperative variables and the outcome measures that were utilized. Scoring systems, such as the Nirschl Tennis Elbow Score and the Mayo Elbow Performance Index, would have been valuable in comparing the groups had they been more consistently reported. The heterogeneity in clinical outcome tools and the lack of reported outcome variance or standard deviations prevented a formal meta-analysis of some of these outcome measures. Due to inconsistent reporting, we were also unable to test our hypothesis that there would be less pain and improved function in the arthroscopic and/or percutaneous cohorts in the early postoperative period compared to the open cohort due to the less invasive techniques used. Although the differences in DASH and VAS scores at final follow-up likely did not meet the MCID threshold, these differences may have been greater and more clinically relevant in the early postoperative period.

CONCLUSION

We hypothesized that the arthroscopic and percutaneous groups would experience accelerated return to work and reduced pain in the early postoperative period but no difference in ultimate pain, functional outcome, or subjective satisfaction. There is no difference between open, arthroscopic, and percutaneous surgical treatment for lateral epicondylitis regarding return to work and subjective satisfaction; however, open treatment led to a greater percentage of patients being pain free at final follow-up. While arthroscopic treatment led to better pain and functional scores at final follow-up, the absolute differences were quite small and likely not clinically significant. In light of the available evidence, we recommend open débridement as the best means of minimizing cost and achieving a pain-free outcome in the long term. For future investigators, it would be useful to perform a randomized clinical study directly comparing open, arthroscopic, and percutaneous techniques, including assessment of pain and functional scores in the early postoperative period, and to further evaluate differences in cost among the various techniques.

This paper will be judged for the Resident Writer’s Award.

ABSTRACT

This study was performed to compare outcomes of open, arthroscopic, and percutaneous surgical techniques for lateral epicondylitis. We searched PubMed (MEDLINE) for literature published between January 1, 2004 and May 23, 2015 using these key words: lateral epicondylitis AND (surgery OR operative OR surgical OR open OR arthroscopic OR percutaneous). Meta-analyses were performed for outcomes reported in 3 studies using 2-sample and 2-proportion Z-tests. Thirty-five studies including 1640 elbows (1055 open, 401 arthroscopic, 184 percutaneous) met the inclusion criteria. There were no differences between groups regarding duration to return to work, complication rate, or patient satisfaction. A greater proportion of patients were pain free in the open group than in the arthroscopic group (70% vs 60%). Despite the absence of a difference among techniques regarding return to work and subjective function, we recommend open débridement as the technique most likely to achieve a pain-free outcome.

Continue to: Lateral epicondylitis affects...

Lateral epicondylitis affects 1% to 3% of adults each year. Although common, symptoms of lateral epicondylitis resolve spontaneously within a year of symptom onset in 80% of cases, and only 3% of patients who seek medical treatment ultimately require surgical intervention within 2 years of symptom onset.¹ Despite a relatively low percentage of patients who require surgery, Sanders and colleagues¹ noted a significant increase in the rate of surgical intervention from 1.1% to 3.2% of cases in the last 15 years. Surgical intervention is generally indicated when pain and functional disability persist after 6 to 12 months of nonsurgical treatment. Traditional surgical treatment involves open release/débridement of the extensor carpi radialis (ECRB) origin; however, with the increasing prevalence of surgical intervention, surgeons have demonstrated a rising interest in less invasive techniques like arthroscopic release/débridement and percutaneous tenotomy as alternatives to traditional open débridement. While favorable results have been reported for all 3 techniques, there is no current consensus regarding the optimal surgical technique. In 2007, Lo and Safran² reported no difference in the results of open, percutaneous, and arthroscopic techniques regarding any outcome measure in a systematic review of 33 papers. We conducted a repeat systematic review of the current literature to update Lo and Safran’s² review and to ascertain if more recent literature demonstrates superiority of 1 technique regarding pain relief, subjective questionnaire data, subjective satisfaction, restoration of strength, and return to work. We hypothesized that return to work would be accelerated, pain decreased, and function improved in the early postoperative period in the arthroscopic and percutaneous groups, but there would be no difference in ultimate pain, functional outcome, or subjective satisfaction.

METHODS

SEARCH STRATEGY AND STUDY SELECTION

We conducted a systematic review of the literature to update the topic of surgical intervention with lateral epicondylitis since the publication of the most recent review by Lo and Safran² in 2007, which included all relevant studies published up to 2004. To include all relevant studies published since that time, we searched PubMed (MEDLINE) for all literature published from January 1, 2004 to May 23, 2015 using the following key words: lateral epicondylitis AND (surgery OR operative OR surgical OR open OR arthroscopic OR percutaneous). General search terms were utilized to avoid unintentional exclusion of relevant studies. Two authors reviewed the abstracts of all resultant citations. Table 1 outlines the inclusion and exclusion criteria for the search. References from all included studies were reviewed for applicable articles that were not captured by the initial broad search strategy. A Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) trial flow chart shows the study selection algorithm (Figure 1).

Table 1. Inclusion and Exclusion Criteria for the Analyzed Studies

DATA EXTRACTION AND ANALYSIS

Data were extracted from the included studies by 2 reviewers using data abstraction forms. All study, subject, and surgery parameters were collected. The study and subject demographic parameters analyzed included year of publication, level of evidence, presence of study financial conflict of interest, number of subjects and elbows, gender, age, proportion in whom the dominant extremity was involved, proportion who were laborers, proportion who had a workman’s compensation claim, duration of symptoms prior to surgical intervention, and surgical technique employed (open, arthroscopic, or percutaneous). We recorded the following clinical outcomes: proportion of patients with complete pain relief, proportion who were partially or completely satisfied, proportion who were improved, duration to return to work, grip strength, Disabilities of the Arm, Shoulder, and Hand (DASH) score, visual analog scale (VAS) pain score, and complication rate.

Continue to: Statistical analysis...

STATISTICAL ANALYSIS

Data from all studies were pooled and descriptive statistics were reported as weighted mean ± weighted standard deviation for continuous variables and frequency with percentage for categorical variables. A meta-analysis was performed for all outcome measures that were reported in 3 or more studies within a specific treatment cohort. Data were analyzed using 2-sample and 2-proportion Z-tests. Results were considered statistically significant at P < .05.

RESULTS

LITERATURE RESEARCH

Using the aforementioned search strategy, 154 studies were identified. Following application of the inclusion and exclusion criteria, 35 studies were included in the analysis (Figure 1). One study compared open and percutaneous techniques, and another compared arthroscopic and percutaneous techniques, rendering a total of 19 studies examining open surgical techniques for treatment of lateral epicondylitis,^3-21 12 studies examining arthroscopic techniques,^14,22-32 and 6 studies reporting percutaneous surgical treatment of lateral epicondylitis^29,33-37 (Table 2). There was1 level I study (3%), 6 level III studies (17%), and 28 level IV studies (80%).

Table 2. Study Demographic Data for Open, Arthroscopic, and Percutaneous Lateral Epicondylectomy

Abbreviations: AJO, The American Journal of Orthopedics; AJSM, American Journal of Sports Medicine; Arthroscopy, The Journal of Arthroscopy and Related Surgery; CORR, Clinical Orthopaedics & Related Research; JHS, Journal of Hand Surgery; JOS, Journal of Orthopaedic Surgery; JSES, Journal of Shoulder and Elbow Surgery; KSSTA, Knee Surgery, Sports Traumatology, and Arthroscopy.

SUBJECT DEMOGRAPHICS

The 35 included studies comprised 1579 patients and 1640 elbows. Among these, 1055 (64%) elbows underwent open (O), 401 (25%) underwent arthroscopic (A), and 184 (11%) underwent percutaneous (P) treatment. The average age was 45.7 years, 47% of the patients were male, 43% were laborers, 31% had worker’s compensation claims, and the dominant extremity was involved in 62% of patients. The percutaneous cohort was older than the open cohort (P = 46.9, O = 45.4, A = 45.8; P = .036). The duration of symptoms was shorter in the percutaneous cohort than in the other 2 groups and shorter in the arthroscopic cohort than in the open cohort (P = 8 months, O = 23 months, A = 18 months; P < .001). There were no significant differences between groups regarding gender, occupation, worker’s compensation status, or involvement of the dominant extremity (Table 3).

Table 3. Subject Demographics for Open, Arthroscopic, and Percutaneous Groups

MATA-ANALYSIS CLINICAL OUTCOMES

Clinical outcome results were pooled for all studies reporting the same outcome measure for the same technique (open, arthroscopic, or percutaneous). A meta-analysis was performed for all outcome measures that were reported in a minimum of 3 studies utilizing the same surgical technique (Table 4).

PAIN RELIEF

Thirteen open studies,^{3,5,7,8,11-16,18,19,21} 7 arthroscopic studies^{14,22-24,26,27,31} and 0 percutaneous studies reported the proportion of patients who were pain free at final follow-up. The proportion of patients who were pain free following open débridement was greater than that in the arthroscopic cohort (O = 70%, A = 60%; P = .009) (Table 4).

Continue to: Subjective improvement and satisfaction...

SUBJECTIVE IMPROVEMENT AND SATISFACTION

Nine open studies, 6 arthroscopic studies, and 1 percutaneous study reported the proportion of patients who felt that their condition had been improved as a result of surgery. There was no difference in the proportion of patients who experienced improvement between the open and arthroscopic cohorts. Four open studies,^3,11,12 5 arthroscopic studies,^{22,26,28,29,32} and 2 percutaneous studies^29,36 reported the proportion of patients who were satisfied or partially satisfied with the results of the procedure. There was no difference between the open and arthroscopic groups in the proportion of patients who were satisfied or partially satisfied (Table 4).

RETURN TO WORK

The duration to return to work following surgery was reported in 5 open studies,^4,5,10,13,14 9 arthroscopic studies,^14,23-29,32 and 2 percutaneous studies.^29,36 There was no statistically significant difference between the open and arthroscopic groups with regard to duration to return to work (O = 6.5 weeks, A = 6 weeks; P = .601). The percutaneous technique could not be included in the meta-analysis due to the presence of only 2 studies, but the pooled mean duration to return to work in these 2 studies was 5.5 weeks (Table 4).

GRIP STRENGTH

Postoperative grip strength was reported in 2 open studies,^10,19 4 arthroscopic studies,^28,30,32 and 2 percutaneous studies.^35-36 A meta-analysis could not be performed on all the groups due to the presence of only 2 open and 2 percutaneous studies reporting grip strength. The pooled averages were O = 38.3 kg, A = 34.8 kg, and P = 27.1 kg (Table 4).

DASH SCORE

The postoperative DASH score was reported in 4 open studies,^{4,15,17,19,20} 5 arthroscopic studies,^28-31 and 3 percutaneous studies.^29,33,36 At final follow-up, the mean DASH score was higher in the arthroscopic group than in the open and percutaneous groups (A = 12.8, O = 19.5, P = 25.3; P < .001 for both comparisons), and the mean DASH score was significantly higher in the open group than in the percutaneous group (P = .029). The reporting of DASH scores in the early postoperative period was not sufficiently consistent to allow us to test our hypothesis that there would be early differences in function between groups (Table 4).

VAS PAIN SCORE

Postoperative VAS pain scores were reported in 11 open studies,^{6,8-10,12,15,19-21} 8 arthroscopic studies,^24-26,29-32 and 5 percutaneous studies.^29,33,35-37 At final follow-up, there was a lower mean VAS score in the arthroscopic group than in the open and percutaneous groups (A = 1.1, O = 1.9, and P = 2.5; P < .001 for both comparisons) and a lower mean VAS score in the open group than in the percutaneous group (P = .002) (Table 4). Reporting of VAS scores in the early postoperative period in the included studies wan not sufficiently consistent to allow us to test our hypothesis that there would be early differences in pain between groups.

COMPLICATIONS

The complication rate was reported in 15 open studies, 10 arthroscopic studies, and 3 percutaneous studies. There was no difference in the complication rate between the open and arthroscopic techniques (O = 2.4%, A = 1.9%; P = .629) (Table 4). Complications noted in the open cohort included superficial wound infection (6), hematoma (5), synovial fistula (2), seroma (2), and posterior interosseous nerve palsy (1). Complications noted in the arthroscopic cohort included superficial infection (3), hematoma (1), and transient paresthesia (1). Of note, there were no complications in the percutaneous group.

Continue to: Discussion...

DISCUSSION

The primary purpose of this review was to determine if definitive evidence suggests that any 1 of open, percutaneous, or arthroscopic surgical treatment is superior to the other 2 for relieving pain, improving functionality, restoring strength, or accelerating return to work. The most striking finding of this study was a significantly higher proportion of patients who were pain free at final follow-up in the open group than in the arthroscopic group (70% vs 60%, P = .009) (Table 4). At final follow-up, there were no significant differences between groups regarding duration to return to work, proportion who were improved, proportion who were satisfied or partially satisfied, and complication rate. Average VAS and DASH scores at final follow-up were lower in the arthroscopic group than in the open and percutaneous groups (Figure 2). However, although the difference between mean DASH scores in the arthroscopic and open groups (6.7 points) was statistically significant, it is likely not clinically significant, as the minimal clinically important difference (MCID) for the DASH score is 10 points, as demonstrated by Sorensen and colleagues.³⁸ Although it has not been specifically defined for lateral epicondylitis, the MCID for VAS pain has been reported in the literature to range from 1.0 to 1.4.^39-40 Therefore, as for the DASH score, the difference witnessed between the open and arthroscopic groups (0.8) is likely not clinically significant. Of note, the differences between values for arthroscopic and percutaneous techniques are greater than the MCID.

In light of a recent increase in the prevalence of surgical intervention for lateral epicondylitis, many authors have promoted arthroscopic and percutaneous techniques as alternatives to traditional open débridement with the goal of achieving the same results with decreased morbidity and accelerated return to work. Given the increased proportion of patients who were pain free at final follow-up in the open cohort, it is our contention that open release/débridement of the common extensor/ECRB origin allows the surgeon to fully appreciate the extent of tendinotic tissue that is contributing to the patient’s symptoms and to address the pathology in its entirety. Other authors have also questioned whether the full extent of extra-articular tendinosis can be accurately identified arthroscopically. Cummins⁴¹ demonstrated, in a series of 18 patients who underwent arthroscopic ECRB débridement, that 6 patients had residual tendinosis upon open evaluation and 10 had residual tendinosis on histologic assessment. Additionally, in the same series, residual tendinopathy was associated with poorer clinical outcomes.

The improved visualization associated with an open technique comes at minimal expense, as the incision was only 1.5 cm to 5 cm in 13 of 15 papers reporting incision length.^{3,4,6,8-11,13,15,18-20} This increased exposure may not translate into increased morbidity, as there was no increase in the duration to return to work nor the complication rate. As a result of the extensive instrumentation necessary for arthroscopic techniques, open techniques also appear to be less expensive. Analyses in the literature have suggested increased expenditures associated with arthroscopic treatment ranging from 23%⁴² to 100%⁴³ greater than those of open treatment.

Although obvious, it should be noted that a percutaneous tenotomy does not permit assessment of the extent of pathologic tendinosis. As a result of an inability to visualize and débride pathologic tissue, percutaneous tenotomy rendered inferior outcomes to open and arthroscopic techniques in terms of both postoperative VAS pain score and DASH score. Nonetheless, it is a relatively rapid and simple technique and resulted in zero complications in 184 elbows. Overall, percutaneous tenotomy appears to be an inferior technique to open and arthroscopic techniques in terms of achieving complete pain relief and optimal functional recovery; however, it may be useful in those who wish to avoid a more invasive intervention.

LIMITATIONS

The most significant limitation of this study was the heterogeneity in the techniques utilized in each group. Among the 19 papers in the open cohort, 11 used techniques aimed at lengthening or release of the extensor origin, 7 performed débridement of tendinotic tissue at the ECRB origin, and 1 compared these approaches. Exposures ranged from 1.5 cm to 8 cm in length, 3 techniques added tendon repair following débridement, and 2 utilized a radiofrequency device.

Among the 12 papers in the arthroscopic cohort, 8 performed arthroscopic (inside-out) débridement of the tendinotic tissue at the ECRB origin, 3 performed arthroscopic release of the ECRB tendon, and 1 performed endoscopic ECRB release in an outside-in fashion. Four techniques added posterior synovial plica excision and 4 added decortication of the lateral epicondyle débridement or release. Some authors advocate for arthroscopic intervention on the grounds that it permits evaluation and correction of other intra-articular pathology. With this in mind, some authors have suggested that a synovial fold (plica) adjacent to the radiocapitellar joint may contribute to lateral elbow pain.^27,44 Nevertheless, in the only comparative trial in the literature, Rhyou and Kim³⁰ demonstrated that excision of posterior synovial fold failed to enhance pain relief or function in a retrospective cohort study comparing arthroscopic débridement with and without plica excision.

Continue to: Some authors advocate...

Some authors advocate decorticating the non-articular, lateral epicondyle with a shaver to stimulate bleeding and promote a healing response. However, 1 study in our review compared arthroscopic ECRB release with and without decortication and found that decortication significantly increased pain up to 4 weeks postoperatively, increased duration to return to work, and did not improve the ultimate clinical result.²⁵ Of note, others have used a similar rationale to advocate drilling the lateral epicondyle when utilizing an open technique. However, Dunn and colleagues⁸ note that they have modified the Nirschl technique to eliminate drilling because they feel it increases postoperative pain and may damage the extensor digitorum communis origin.

Among the 6 papers in the percutaneous tenotomy cohort, 2 performed tenotomy with a hypodermic needle, 2 with a scalpel through a limited incision (0.5 cm-1 cm), 1 using a TX1 tissue removal system (Tenex Health), and 1 with a percutaneous radiofrequency probe. In 3 techniques, ultrasound was used to direct the tenotomy.

The quality of this review is also limited by the studies included for analysis, as with any systematic review. Because 28 of the 35 included studies were classified as evidence level IV, the likelihood of methodological bias is increased. The majority of studies contained ≥1 demonstrable biases, including selection, detection, attrition biases, or a combination. Selection bias is prevalent among predominantly level IV studies, in which the authors have selected their preferred surgical technique. There was heterogeneity in the reporting of preoperative variables and the outcome measures that were utilized. Scoring systems, such as the Nirschl Tennis Elbow Score and the Mayo Elbow Performance Index, would have been valuable in comparing the groups had they been more consistently reported. The heterogeneity in clinical outcome tools and the lack of reported outcome variance or standard deviations prevented a formal meta-analysis of some of these outcome measures. Due to inconsistent reporting, we were also unable to test our hypothesis that there would be less pain and improved function in the arthroscopic and/or percutaneous cohorts in the early postoperative period compared to the open cohort due to the less invasive techniques used. Although the differences in DASH and VAS scores at final follow-up likely did not meet the MCID threshold, these differences may have been greater and more clinically relevant in the early postoperative period.

CONCLUSION

We hypothesized that the arthroscopic and percutaneous groups would experience accelerated return to work and reduced pain in the early postoperative period but no difference in ultimate pain, functional outcome, or subjective satisfaction. There is no difference between open, arthroscopic, and percutaneous surgical treatment for lateral epicondylitis regarding return to work and subjective satisfaction; however, open treatment led to a greater percentage of patients being pain free at final follow-up. While arthroscopic treatment led to better pain and functional scores at final follow-up, the absolute differences were quite small and likely not clinically significant. In light of the available evidence, we recommend open débridement as the best means of minimizing cost and achieving a pain-free outcome in the long term. For future investigators, it would be useful to perform a randomized clinical study directly comparing open, arthroscopic, and percutaneous techniques, including assessment of pain and functional scores in the early postoperative period, and to further evaluate differences in cost among the various techniques.

This paper will be judged for the Resident Writer’s Award.

CHICAGO – Six months of maintenance chemotherapy prolongs overall survival in youth with high-risk rhabdomyosarcoma, finds a phase 3 randomized controlled trial of the European Paediatric Soft Tissue Sarcoma Study Group (EpSSG).

Rhabdomyosarcoma is a rare but very aggressive tumor, lead study author Gianni Bisogno, MD, PhD, a professor at the University Hospital of Padova, Italy, and chair of the EpSSG, noted in a press briefing at the annual meeting of the American Society of Clinical Oncology, where the findings were reported. Among pediatric patients who achieve complete response to standard therapy, “we know that after 1 or 2 years, one-third of these children relapse, and most of them die,” he said.

The EpSSG trial, which took about 10 years to conduct, enrolled 371 patients aged 0-21 years with high-risk rhabdomyosarcoma who had had a complete response to standard intensive therapy. They were randomized evenly to stop treatment or to receive 6 months of maintenance treatment consisting of low-dose vinorelbine and cyclophosphamide.

Results reported in the meeting’s plenary session showed that giving maintenance chemotherapy improved the 5-year overall survival rate by an absolute 12.8%, which translated to a near halving of the risk of death. And the maintenance regimen used was generally well tolerated.

“At the end of this long, not-easy study, we concluded that maintenance chemotherapy is an effective and well tolerated treatment for children with high-risk rhabdomyosarcoma,” Dr. Bisogno said.

Susan London/MDedge News

Susan London/MDedge News

Study details

Patients enrolled in the EpSSG trial had had a complete response to the standard intensive therapy used in Europe: high-dose chemotherapy (ifosfamide, vincristine, and actinomycin D, with or without doxorubicin), radiation therapy, and surgery.

The maintenance chemotherapy consisted of a combination of low-dose intravenous vinorelbine given weekly and oral cyclophosphamide given daily. The 6-month duration was somewhat arbitrary, according to Dr. Bisogno. “We had to start somewhere. So when we started, we decided to use 6 months because there was some evidence in the past for regimens that long. In our next European trial, we are going to test different kinds and durations of maintenance because this is very important.”

SOURCE: Bisogno et al. ASCO 2018 Abstract LBA2.

CHICAGO – Six months of maintenance chemotherapy prolongs overall survival in youth with high-risk rhabdomyosarcoma, finds a phase 3 randomized controlled trial of the European Paediatric Soft Tissue Sarcoma Study Group (EpSSG).

Rhabdomyosarcoma is a rare but very aggressive tumor, lead study author Gianni Bisogno, MD, PhD, a professor at the University Hospital of Padova, Italy, and chair of the EpSSG, noted in a press briefing at the annual meeting of the American Society of Clinical Oncology, where the findings were reported. Among pediatric patients who achieve complete response to standard therapy, “we know that after 1 or 2 years, one-third of these children relapse, and most of them die,” he said.

The EpSSG trial, which took about 10 years to conduct, enrolled 371 patients aged 0-21 years with high-risk rhabdomyosarcoma who had had a complete response to standard intensive therapy. They were randomized evenly to stop treatment or to receive 6 months of maintenance treatment consisting of low-dose vinorelbine and cyclophosphamide.

Results reported in the meeting’s plenary session showed that giving maintenance chemotherapy improved the 5-year overall survival rate by an absolute 12.8%, which translated to a near halving of the risk of death. And the maintenance regimen used was generally well tolerated.

“At the end of this long, not-easy study, we concluded that maintenance chemotherapy is an effective and well tolerated treatment for children with high-risk rhabdomyosarcoma,” Dr. Bisogno said.

Susan London/MDedge News

Susan London/MDedge News

Study details

Patients enrolled in the EpSSG trial had had a complete response to the standard intensive therapy used in Europe: high-dose chemotherapy (ifosfamide, vincristine, and actinomycin D, with or without doxorubicin), radiation therapy, and surgery.

The maintenance chemotherapy consisted of a combination of low-dose intravenous vinorelbine given weekly and oral cyclophosphamide given daily. The 6-month duration was somewhat arbitrary, according to Dr. Bisogno. “We had to start somewhere. So when we started, we decided to use 6 months because there was some evidence in the past for regimens that long. In our next European trial, we are going to test different kinds and durations of maintenance because this is very important.”

SOURCE: Bisogno et al. ASCO 2018 Abstract LBA2.

CHICAGO – Six months of maintenance chemotherapy prolongs overall survival in youth with high-risk rhabdomyosarcoma, finds a phase 3 randomized controlled trial of the European Paediatric Soft Tissue Sarcoma Study Group (EpSSG).

Rhabdomyosarcoma is a rare but very aggressive tumor, lead study author Gianni Bisogno, MD, PhD, a professor at the University Hospital of Padova, Italy, and chair of the EpSSG, noted in a press briefing at the annual meeting of the American Society of Clinical Oncology, where the findings were reported. Among pediatric patients who achieve complete response to standard therapy, “we know that after 1 or 2 years, one-third of these children relapse, and most of them die,” he said.

The EpSSG trial, which took about 10 years to conduct, enrolled 371 patients aged 0-21 years with high-risk rhabdomyosarcoma who had had a complete response to standard intensive therapy. They were randomized evenly to stop treatment or to receive 6 months of maintenance treatment consisting of low-dose vinorelbine and cyclophosphamide.

Results reported in the meeting’s plenary session showed that giving maintenance chemotherapy improved the 5-year overall survival rate by an absolute 12.8%, which translated to a near halving of the risk of death. And the maintenance regimen used was generally well tolerated.

“At the end of this long, not-easy study, we concluded that maintenance chemotherapy is an effective and well tolerated treatment for children with high-risk rhabdomyosarcoma,” Dr. Bisogno said.

Susan London/MDedge News

Susan London/MDedge News

Study details

Patients enrolled in the EpSSG trial had had a complete response to the standard intensive therapy used in Europe: high-dose chemotherapy (ifosfamide, vincristine, and actinomycin D, with or without doxorubicin), radiation therapy, and surgery.

The maintenance chemotherapy consisted of a combination of low-dose intravenous vinorelbine given weekly and oral cyclophosphamide given daily. The 6-month duration was somewhat arbitrary, according to Dr. Bisogno. “We had to start somewhere. So when we started, we decided to use 6 months because there was some evidence in the past for regimens that long. In our next European trial, we are going to test different kinds and durations of maintenance because this is very important.”

SOURCE: Bisogno et al. ASCO 2018 Abstract LBA2.

In October 2015, the Centers for Medicare & Medicaid Services implemented its first meaningful policy to attempt for addressing sepsis.

The condition – one of the leading causes of mortality among hospitalized patients – afflicts more than a million people each year in the United States, and between 15% and 30% of them die. Sepsis is one of the leading drivers of hospital readmissions, sending more patients back to the hospital than heart failure, pneumonia, and chronic obstructive pulmonary disease.¹

However, while providers seem to agree that time to address sepsis is past due, not everyone has embraced the Sepsis CMS Core Measure program, or SEP-1, as the means to best achieve it. This is, in part, because of discrepancies in how sepsis is defined, the burden of reporting, and what some consider to be arbitrary clinical requirements that may not correlate with better patient outcomes.

“Sepsis is indeed a critical public health problem, and it’s appropriate and valuable that Medicare and other policy makers are focusing on sepsis,” said Jeremy Kahn, MD, professor of critical care medicine and health policy and management at the University of Pittsburgh. “This was really the first approach at that … but at 85-pages long, it really is an enormous effort for hospitals to adhere to this measure.”

This is because of the tension between the “intense desire to improve sepsis outcomes” and the “incredible burden” of keeping up with the necessary documentation while also providing quality care, Dr. Kahn said.

In December 2017, Dr. Kahn helped lead a study published in the Journal of Hospital Medicine aimed at trying to understand hospital perceptions of SEP-1. Over the course of 29 interviews with randomly selected hospital quality leaders across the United States, including physicians and nurses, the results came as a surprise.²

Some, like emergency medicine physician Annahieta Kalantari, DO (who did not participate in the survey), feel that SEP-1 forces providers to practice “check-box” medicine and undermines successful efforts that don’t necessarily align with the CMS policy.

She arrived at her institution, Aria-Jefferson Health in Philadelphia, before CMS adopted SEP-1; at that time, she took note of the fact that the rate of sepsis mortalities in her hospital was, in her words, not great when compared with that at similar institutions. And then she helped do something about it.

“I thought, ‘We’re a Premier reporting hospital,’ so we did a gap analysis as to why and put together protocols for the hospital to follow with our sepsis patients, including a sepsis alert and a lot of education,” said Dr. Kalantari, associate program director for the emergency medicine residency program at Aria-Jefferson and a former chair of its sepsis management committee. “Before you knew it, mortalities were below benchmark.”

But once SEP-1 began, she said, the hospital was unable to check all of the boxes all of the time.

“We kept track, but we weren’t hitting all the bundles exactly within the periods of time recommended, but our mortalities were still amazing,” she said. “CMS basically picked definitions [for sepsis], and most of us don’t know what they’re basing them on because no one can agree on a definition anyway. Now they’re penalizing hospitals if they don’t hit the check marks in time, but we’d already demonstrated that our mortality and patient care was exceptional.”
She added: “I am extremely dissatisfied, as someone who provides frontline patient care, with how CMS is choosing to measure us.”

Dr. Kalantari wrote a piece in the Western Journal of Emergency Medicine in July 2017 in which she and coauthors outline the issues they take with SEP-1. They lay out the tension among the varied definitions of what sepsis is – and isn’t – and they also illuminate the apparent conflict between what CMS has officially defined and what evidence-based studies conducted since 2001 have suggested.³

In particular, CMS defines severe sepsis as an initial lactate above 2 mmol/L and septic shock as an initial lactate presentation of greater than 4 mmol/L. However, Dr. Kalantari and here coauthors argue in the paper that there is no standard definition of sepsis and that decades of attempts to achieve one have failed to reach consensus among providers. CMS, she said, fails to acknowledge this.

Defining sepsis

In fact, in 2016, another new definition of sepsis emerged by way of a 19-member task-force of experts: The Third International Consensus Definitions for Sepsis and Septic Shock, also called Sepsis-3.⁴ In March 2017, the Surviving Sepsis Campaign adopted this definition, which defined sepsis as a “life-threatening organ dysfunction caused by a dysregulated host response to infection.”⁵

“I think the definition has always been a challenging part of sepsis,” said Kencee Graves, MD, a hospitalist at the University of Utah, Salt Lake City. “The definitions came about for research purposes, so … they are not perfectly sensitive nor specific.”

However, Dr. Graves believes SEP-1 is a step in the right direction in that it brings awareness to sepsis and holds providers accountable. Several years ago, she and her colleague Devin Horton, MD, also a hospitalist at the University of Utah, embarked on a massive undertaking to address sepsis in their hospital. It was, at the time, lacking in “sepsis culture,” Dr. Horton said.

“One of the big things that motivated both of us was that we started doing chart review together and – it’s always easier with 20/20 hindsight – we were noticing that residents were missing the signs of sepsis,” Dr. Horton explained. “The clinical criteria would be there, but no one would say the word.” This is important, he said, because sepsis is time critical.

So the pair set out to create a cultural change by sharing data and collecting input from each service and unit, which relied heavily on nursing staff to perpetuate change. They created an early warning system in the medical record and worked with units to achieve flexibility in their criteria.

While the early warning system seemed helpful on the floor, SEP-1 adherence rates changed little in the emergency department. So Dr. Graves and Dr. Horton worked out an ED-specific process map that started at triage and was modeled after myocardial infarction STEMI protocols. From April through December 2016, the ED achieved between 29.5% adherence to the SEP-1 bundles, they said according to CMS abstractor data. After the change, between January and March 2017, the ED saw 52.2% adherence.

Dr. Kalantari would like to see CMS allow hospitals to evaluate and alter their processes more individually, with the required result being lower sepsis mortality. Hospitalists, said Dr. Kahn, are well poised to champion these sepsis improvement efforts.

“Hospitalists are uniquely positioned to lead in this area because they are a visible presence and a link between providers doing multidisciplinary acute care,” he said. “The other thing hospitalists can do is insist on rolling out approaches that are evidence based and not likely to cause harm by leading to over resuscitation, or ensuring patients are receiving central-line insertions only when needed.”

This is currently a moment for hospitals to innovate and provide meaningful feedback to CMS, which, he said, is listening.

“It’s a myth that CMS rolls out policy without listening to the clinical community, but what they want is constructive criticism, not just to hear ‘We’re not ready and we have to push this down the road,’ ” Dr. Kahn said. “The time is now in the era of accountability in health care.”

References

1. Sepsis. National Institute of General Medical Sciences. https://www.nigms.nih.gov/education/pages/factsheet_sepsis.aspx. Updated Sept 2017. Accessed Jan 4, 2018.

2. Barbash I et al. Hospital perceptions of Medicare’s sepsis quality reporting initiative. J Hosp Med. 2017;12;963-8.

3. Kalantari A et al. Sepsis Definitions: The search for gold and what CMS got wrong. West J Emerg Med. 2017 Aug;18(5):951-6.

4. Singer M et. al. The Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3). JAMA. 2016 Feb 23;315(8):801-10.

5. Rhodes A et al. Surviving Sepsis Campaign: International Guidelines for Management of Sepsis and Septic Shock: 2016. Intensive Care Med. 2017;43:304.

In October 2015, the Centers for Medicare & Medicaid Services implemented its first meaningful policy to attempt for addressing sepsis.

The condition – one of the leading causes of mortality among hospitalized patients – afflicts more than a million people each year in the United States, and between 15% and 30% of them die. Sepsis is one of the leading drivers of hospital readmissions, sending more patients back to the hospital than heart failure, pneumonia, and chronic obstructive pulmonary disease.¹

However, while providers seem to agree that time to address sepsis is past due, not everyone has embraced the Sepsis CMS Core Measure program, or SEP-1, as the means to best achieve it. This is, in part, because of discrepancies in how sepsis is defined, the burden of reporting, and what some consider to be arbitrary clinical requirements that may not correlate with better patient outcomes.

“Sepsis is indeed a critical public health problem, and it’s appropriate and valuable that Medicare and other policy makers are focusing on sepsis,” said Jeremy Kahn, MD, professor of critical care medicine and health policy and management at the University of Pittsburgh. “This was really the first approach at that … but at 85-pages long, it really is an enormous effort for hospitals to adhere to this measure.”

This is because of the tension between the “intense desire to improve sepsis outcomes” and the “incredible burden” of keeping up with the necessary documentation while also providing quality care, Dr. Kahn said.

In December 2017, Dr. Kahn helped lead a study published in the Journal of Hospital Medicine aimed at trying to understand hospital perceptions of SEP-1. Over the course of 29 interviews with randomly selected hospital quality leaders across the United States, including physicians and nurses, the results came as a surprise.²

Some, like emergency medicine physician Annahieta Kalantari, DO (who did not participate in the survey), feel that SEP-1 forces providers to practice “check-box” medicine and undermines successful efforts that don’t necessarily align with the CMS policy.

She arrived at her institution, Aria-Jefferson Health in Philadelphia, before CMS adopted SEP-1; at that time, she took note of the fact that the rate of sepsis mortalities in her hospital was, in her words, not great when compared with that at similar institutions. And then she helped do something about it.

“I thought, ‘We’re a Premier reporting hospital,’ so we did a gap analysis as to why and put together protocols for the hospital to follow with our sepsis patients, including a sepsis alert and a lot of education,” said Dr. Kalantari, associate program director for the emergency medicine residency program at Aria-Jefferson and a former chair of its sepsis management committee. “Before you knew it, mortalities were below benchmark.”

But once SEP-1 began, she said, the hospital was unable to check all of the boxes all of the time.

“We kept track, but we weren’t hitting all the bundles exactly within the periods of time recommended, but our mortalities were still amazing,” she said. “CMS basically picked definitions [for sepsis], and most of us don’t know what they’re basing them on because no one can agree on a definition anyway. Now they’re penalizing hospitals if they don’t hit the check marks in time, but we’d already demonstrated that our mortality and patient care was exceptional.”
She added: “I am extremely dissatisfied, as someone who provides frontline patient care, with how CMS is choosing to measure us.”

Dr. Kalantari wrote a piece in the Western Journal of Emergency Medicine in July 2017 in which she and coauthors outline the issues they take with SEP-1. They lay out the tension among the varied definitions of what sepsis is – and isn’t – and they also illuminate the apparent conflict between what CMS has officially defined and what evidence-based studies conducted since 2001 have suggested.³

In particular, CMS defines severe sepsis as an initial lactate above 2 mmol/L and septic shock as an initial lactate presentation of greater than 4 mmol/L. However, Dr. Kalantari and here coauthors argue in the paper that there is no standard definition of sepsis and that decades of attempts to achieve one have failed to reach consensus among providers. CMS, she said, fails to acknowledge this.

Defining sepsis

In fact, in 2016, another new definition of sepsis emerged by way of a 19-member task-force of experts: The Third International Consensus Definitions for Sepsis and Septic Shock, also called Sepsis-3.⁴ In March 2017, the Surviving Sepsis Campaign adopted this definition, which defined sepsis as a “life-threatening organ dysfunction caused by a dysregulated host response to infection.”⁵

“I think the definition has always been a challenging part of sepsis,” said Kencee Graves, MD, a hospitalist at the University of Utah, Salt Lake City. “The definitions came about for research purposes, so … they are not perfectly sensitive nor specific.”

However, Dr. Graves believes SEP-1 is a step in the right direction in that it brings awareness to sepsis and holds providers accountable. Several years ago, she and her colleague Devin Horton, MD, also a hospitalist at the University of Utah, embarked on a massive undertaking to address sepsis in their hospital. It was, at the time, lacking in “sepsis culture,” Dr. Horton said.

“One of the big things that motivated both of us was that we started doing chart review together and – it’s always easier with 20/20 hindsight – we were noticing that residents were missing the signs of sepsis,” Dr. Horton explained. “The clinical criteria would be there, but no one would say the word.” This is important, he said, because sepsis is time critical.

So the pair set out to create a cultural change by sharing data and collecting input from each service and unit, which relied heavily on nursing staff to perpetuate change. They created an early warning system in the medical record and worked with units to achieve flexibility in their criteria.

While the early warning system seemed helpful on the floor, SEP-1 adherence rates changed little in the emergency department. So Dr. Graves and Dr. Horton worked out an ED-specific process map that started at triage and was modeled after myocardial infarction STEMI protocols. From April through December 2016, the ED achieved between 29.5% adherence to the SEP-1 bundles, they said according to CMS abstractor data. After the change, between January and March 2017, the ED saw 52.2% adherence.

Dr. Kalantari would like to see CMS allow hospitals to evaluate and alter their processes more individually, with the required result being lower sepsis mortality. Hospitalists, said Dr. Kahn, are well poised to champion these sepsis improvement efforts.

“Hospitalists are uniquely positioned to lead in this area because they are a visible presence and a link between providers doing multidisciplinary acute care,” he said. “The other thing hospitalists can do is insist on rolling out approaches that are evidence based and not likely to cause harm by leading to over resuscitation, or ensuring patients are receiving central-line insertions only when needed.”

This is currently a moment for hospitals to innovate and provide meaningful feedback to CMS, which, he said, is listening.

“It’s a myth that CMS rolls out policy without listening to the clinical community, but what they want is constructive criticism, not just to hear ‘We’re not ready and we have to push this down the road,’ ” Dr. Kahn said. “The time is now in the era of accountability in health care.”

References

1. Sepsis. National Institute of General Medical Sciences. https://www.nigms.nih.gov/education/pages/factsheet_sepsis.aspx. Updated Sept 2017. Accessed Jan 4, 2018.

2. Barbash I et al. Hospital perceptions of Medicare’s sepsis quality reporting initiative. J Hosp Med. 2017;12;963-8.

3. Kalantari A et al. Sepsis Definitions: The search for gold and what CMS got wrong. West J Emerg Med. 2017 Aug;18(5):951-6.

4. Singer M et. al. The Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3). JAMA. 2016 Feb 23;315(8):801-10.

5. Rhodes A et al. Surviving Sepsis Campaign: International Guidelines for Management of Sepsis and Septic Shock: 2016. Intensive Care Med. 2017;43:304.

In October 2015, the Centers for Medicare & Medicaid Services implemented its first meaningful policy to attempt for addressing sepsis.

The condition – one of the leading causes of mortality among hospitalized patients – afflicts more than a million people each year in the United States, and between 15% and 30% of them die. Sepsis is one of the leading drivers of hospital readmissions, sending more patients back to the hospital than heart failure, pneumonia, and chronic obstructive pulmonary disease.¹

However, while providers seem to agree that time to address sepsis is past due, not everyone has embraced the Sepsis CMS Core Measure program, or SEP-1, as the means to best achieve it. This is, in part, because of discrepancies in how sepsis is defined, the burden of reporting, and what some consider to be arbitrary clinical requirements that may not correlate with better patient outcomes.

“Sepsis is indeed a critical public health problem, and it’s appropriate and valuable that Medicare and other policy makers are focusing on sepsis,” said Jeremy Kahn, MD, professor of critical care medicine and health policy and management at the University of Pittsburgh. “This was really the first approach at that … but at 85-pages long, it really is an enormous effort for hospitals to adhere to this measure.”

This is because of the tension between the “intense desire to improve sepsis outcomes” and the “incredible burden” of keeping up with the necessary documentation while also providing quality care, Dr. Kahn said.

In December 2017, Dr. Kahn helped lead a study published in the Journal of Hospital Medicine aimed at trying to understand hospital perceptions of SEP-1. Over the course of 29 interviews with randomly selected hospital quality leaders across the United States, including physicians and nurses, the results came as a surprise.²

Some, like emergency medicine physician Annahieta Kalantari, DO (who did not participate in the survey), feel that SEP-1 forces providers to practice “check-box” medicine and undermines successful efforts that don’t necessarily align with the CMS policy.

She arrived at her institution, Aria-Jefferson Health in Philadelphia, before CMS adopted SEP-1; at that time, she took note of the fact that the rate of sepsis mortalities in her hospital was, in her words, not great when compared with that at similar institutions. And then she helped do something about it.

“I thought, ‘We’re a Premier reporting hospital,’ so we did a gap analysis as to why and put together protocols for the hospital to follow with our sepsis patients, including a sepsis alert and a lot of education,” said Dr. Kalantari, associate program director for the emergency medicine residency program at Aria-Jefferson and a former chair of its sepsis management committee. “Before you knew it, mortalities were below benchmark.”

But once SEP-1 began, she said, the hospital was unable to check all of the boxes all of the time.

“We kept track, but we weren’t hitting all the bundles exactly within the periods of time recommended, but our mortalities were still amazing,” she said. “CMS basically picked definitions [for sepsis], and most of us don’t know what they’re basing them on because no one can agree on a definition anyway. Now they’re penalizing hospitals if they don’t hit the check marks in time, but we’d already demonstrated that our mortality and patient care was exceptional.”
She added: “I am extremely dissatisfied, as someone who provides frontline patient care, with how CMS is choosing to measure us.”

Dr. Kalantari wrote a piece in the Western Journal of Emergency Medicine in July 2017 in which she and coauthors outline the issues they take with SEP-1. They lay out the tension among the varied definitions of what sepsis is – and isn’t – and they also illuminate the apparent conflict between what CMS has officially defined and what evidence-based studies conducted since 2001 have suggested.³

In particular, CMS defines severe sepsis as an initial lactate above 2 mmol/L and septic shock as an initial lactate presentation of greater than 4 mmol/L. However, Dr. Kalantari and here coauthors argue in the paper that there is no standard definition of sepsis and that decades of attempts to achieve one have failed to reach consensus among providers. CMS, she said, fails to acknowledge this.

Defining sepsis

In fact, in 2016, another new definition of sepsis emerged by way of a 19-member task-force of experts: The Third International Consensus Definitions for Sepsis and Septic Shock, also called Sepsis-3.⁴ In March 2017, the Surviving Sepsis Campaign adopted this definition, which defined sepsis as a “life-threatening organ dysfunction caused by a dysregulated host response to infection.”⁵

“I think the definition has always been a challenging part of sepsis,” said Kencee Graves, MD, a hospitalist at the University of Utah, Salt Lake City. “The definitions came about for research purposes, so … they are not perfectly sensitive nor specific.”

However, Dr. Graves believes SEP-1 is a step in the right direction in that it brings awareness to sepsis and holds providers accountable. Several years ago, she and her colleague Devin Horton, MD, also a hospitalist at the University of Utah, embarked on a massive undertaking to address sepsis in their hospital. It was, at the time, lacking in “sepsis culture,” Dr. Horton said.

“One of the big things that motivated both of us was that we started doing chart review together and – it’s always easier with 20/20 hindsight – we were noticing that residents were missing the signs of sepsis,” Dr. Horton explained. “The clinical criteria would be there, but no one would say the word.” This is important, he said, because sepsis is time critical.

So the pair set out to create a cultural change by sharing data and collecting input from each service and unit, which relied heavily on nursing staff to perpetuate change. They created an early warning system in the medical record and worked with units to achieve flexibility in their criteria.

While the early warning system seemed helpful on the floor, SEP-1 adherence rates changed little in the emergency department. So Dr. Graves and Dr. Horton worked out an ED-specific process map that started at triage and was modeled after myocardial infarction STEMI protocols. From April through December 2016, the ED achieved between 29.5% adherence to the SEP-1 bundles, they said according to CMS abstractor data. After the change, between January and March 2017, the ED saw 52.2% adherence.

Dr. Kalantari would like to see CMS allow hospitals to evaluate and alter their processes more individually, with the required result being lower sepsis mortality. Hospitalists, said Dr. Kahn, are well poised to champion these sepsis improvement efforts.

“Hospitalists are uniquely positioned to lead in this area because they are a visible presence and a link between providers doing multidisciplinary acute care,” he said. “The other thing hospitalists can do is insist on rolling out approaches that are evidence based and not likely to cause harm by leading to over resuscitation, or ensuring patients are receiving central-line insertions only when needed.”

This is currently a moment for hospitals to innovate and provide meaningful feedback to CMS, which, he said, is listening.

“It’s a myth that CMS rolls out policy without listening to the clinical community, but what they want is constructive criticism, not just to hear ‘We’re not ready and we have to push this down the road,’ ” Dr. Kahn said. “The time is now in the era of accountability in health care.”

References

1. Sepsis. National Institute of General Medical Sciences. https://www.nigms.nih.gov/education/pages/factsheet_sepsis.aspx. Updated Sept 2017. Accessed Jan 4, 2018.

2. Barbash I et al. Hospital perceptions of Medicare’s sepsis quality reporting initiative. J Hosp Med. 2017;12;963-8.

3. Kalantari A et al. Sepsis Definitions: The search for gold and what CMS got wrong. West J Emerg Med. 2017 Aug;18(5):951-6.

4. Singer M et. al. The Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3). JAMA. 2016 Feb 23;315(8):801-10.

5. Rhodes A et al. Surviving Sepsis Campaign: International Guidelines for Management of Sepsis and Septic Shock: 2016. Intensive Care Med. 2017;43:304.

The Centers for Disease Control and Prevents has issued a Health Advisory regarding hepatitis A outbreaks within the United States among injection drug users.

From January 2017 to April 2018, more than 2,500 cases of hepatitis A infection associated with person-to-person transmission were reported to the CDC; of the 1,900 cases where risk factors are known, 68% were related to drug use, homelessness, or both. Various state responses caused a shortage in hepatitis A vaccine during this time, however, because of improvements in controlling outbreaks and an increased vaccine supply, the vaccine has become more available.

[email protected]

The Centers for Disease Control and Prevents has issued a Health Advisory regarding hepatitis A outbreaks within the United States among injection drug users.

From January 2017 to April 2018, more than 2,500 cases of hepatitis A infection associated with person-to-person transmission were reported to the CDC; of the 1,900 cases where risk factors are known, 68% were related to drug use, homelessness, or both. Various state responses caused a shortage in hepatitis A vaccine during this time, however, because of improvements in controlling outbreaks and an increased vaccine supply, the vaccine has become more available.

[email protected]

The Centers for Disease Control and Prevents has issued a Health Advisory regarding hepatitis A outbreaks within the United States among injection drug users.

From January 2017 to April 2018, more than 2,500 cases of hepatitis A infection associated with person-to-person transmission were reported to the CDC; of the 1,900 cases where risk factors are known, 68% were related to drug use, homelessness, or both. Various state responses caused a shortage in hepatitis A vaccine during this time, however, because of improvements in controlling outbreaks and an increased vaccine supply, the vaccine has become more available.

[email protected]

EULAR 2018’s scientific program in Amsterdam is packed with lectures, clinical and basic science symposia, workshops, and special interest sessions covering the full spectrum of rheumatic diseases, said Dr. Robert Landewé, chair of the Scientific Program Committee.

“More than 5,000 scientific abstracts were submitted, which is an absolute, all-time record,” Dr. Landewé said. Four experts scored each abstract, and only the top 7% were invited for oral presentation during abstract sessions or symposia, he explained in an interview.

Wednesday, June 13

A high point of the 2018 scientific program is Wednesday’s opening plenary session, which will feature abstracts that were handpicked by Dr. Landewé and Dr. Thomas Dörner, professor of rheumatology at Charite Universitätsmedizin, Berlin. “This session includes highly scored abstracts, including late-breakers, on current advances in therapeutics and disease classification,” said Dr. Dörner, who chaired this year’s Abstract Selection Committee.

The plenary abstract session will cover new findings on gout and cardiovascular disease from CANTOS (Canakinumab Anti-inflammatory Thrombosis Outcome Study), long-term mortality in patients with early RA from the COBRA (Combinatietherapie Bij Reumatoide Artritis) study, the use of zoledronic acid to treat knee osteoarthritis with bone lesions, and the relationship between bisphosphonate drug holidays and hip fracture risk. Researchers also will discuss baricitinib in systemic lupus erythematosus (SLE), the value of MRI when treating remitted RA to target, the validation of SLE classification criteria, and draft classification criteria for ANCA-associated vasculitides.

A notable clinical science session on Wednesday will cover cancer and inflammation, Dr. Landewé said. “This is a topic of increasing interest because cancer and inflammation share mutual pathways.”

Novel cancer therapies such as immune checkpoint inhibitors have improved outcomes across a range of tumor types, but also can induce rheumatic disease, he added. Accordingly, presenters will discuss inflammation as “friend” versus “foe” in cancer treatment, the role of tumor necrosis factor in cancer, and risk of malignancy among patients with RA.

Thursday, June 14

Topics in this session will include the use of estrogens and other hormonal therapies in patients with rheumatic disease, registry studies of rheumatologic conditions during pregnancy, and how clinicians can best discuss sexual concerns with their rheumatology patients.

Friday, June 15

For the first time, the scientific program also will include a clinical science session held jointly with the European Society of Musculoskeletal Radiology (ESSR). Dr. Joachim Sieper of Germany and ESSR President Dr. Monique Reijnierse of the Netherlands will cochair the Friday afternoon session on the role of MRI in rheumatology. Attendees from both organizations will learn when to use MRI in early and established RA and spondyloarthritis, and how to interpret the results, with abundant time built in for questions and answers. Dr. Landewé called the joint session “a test case” for exciting web-based interactions between EULAR and ESSR.

Another clinical science session on Friday afternoon will dive into the diagnosis of spondyloarthritis, which Dr. Landewé called “a matter of recognizing patterns, not ticking boxes on a list of criteria. This symposium leads you through the art of pattern recognition.”

Later on Friday afternoon, a session will explore advances in biologic therapy of small-vessel vasculitis, he added. “Biologic disease-modifying antirheumatic drugs [bDMARDs] are becoming more and more important in this area of expanding interest.” Experts will address complement inhibition in ANCA-associated vasculitis (AAV), the use of induction and maintenance rituximab in AAV, the evolving role of mepolizumab in eosinophilic granulomatosis with polyangiitis, survival in AAV, and the use of rituximab for treating children with granulomatosis with polyangiitis and microscopic polyangiitis.

Saturday, June 16

On Saturday, a bench-to-bedside session will cover gout and kidney function. “This is an area with important new insights,” Dr. Dörner said. Presenters will discuss the genetics of hyperuricemia, renal urate transporters, and the pros and cons of using xanthine oxidase inhibitors to treat chronic kidney disease. Researchers will also cover studies of impaired neutrophil chemotaxis in patients with chronic kidney disease and hyperuricemia, and the relationship between renal medullar hyperechogenicity and gout severity.

Also on Saturday, a clinical science session titled, “Rheumatoid arthritis: Is it all in your head?” will explore emerging data on the relationship between inflammation and depression. Patients with RA often face both clinical depression and social isolation, and these complex psychosocial conditions can worsen one another. “In addition to proper drug choice, treating RA effectively depends on how concomitant problems, such as nonspecific pain, depression, and social isolation, are coped with in a broad context,” Dr. Landewé said. “When it comes to optimal management, rheumatologists need to communicate and prescribe, not just prescribe.”

Christian Apfelbacher, PhD, of Germany will discuss prevention and treatment strategies and Dr. Jonathan Cavanagh of the United Kingdom will cover neuroimaging in RA. Researchers also will discuss new findings on pain, depression, and anxiety in patients recently diagnosed with RA.

Also on Saturday, a special session will cover EULAR’s initiatives to improve clinical approaches (ESSCA), Dr. Dörner noted. This effort has produced new or updated recommendations on topics such as vaccination, Sjögren’s syndrome, glucocorticoid therapy, and management of hand osteoarthritis, he said. “These recommendations follow a number of others and are expected to impact clinical science as well as clinical practice.”

EULAR 2018’s scientific program in Amsterdam is packed with lectures, clinical and basic science symposia, workshops, and special interest sessions covering the full spectrum of rheumatic diseases, said Dr. Robert Landewé, chair of the Scientific Program Committee.

“More than 5,000 scientific abstracts were submitted, which is an absolute, all-time record,” Dr. Landewé said. Four experts scored each abstract, and only the top 7% were invited for oral presentation during abstract sessions or symposia, he explained in an interview.

Wednesday, June 13

A high point of the 2018 scientific program is Wednesday’s opening plenary session, which will feature abstracts that were handpicked by Dr. Landewé and Dr. Thomas Dörner, professor of rheumatology at Charite Universitätsmedizin, Berlin. “This session includes highly scored abstracts, including late-breakers, on current advances in therapeutics and disease classification,” said Dr. Dörner, who chaired this year’s Abstract Selection Committee.

The plenary abstract session will cover new findings on gout and cardiovascular disease from CANTOS (Canakinumab Anti-inflammatory Thrombosis Outcome Study), long-term mortality in patients with early RA from the COBRA (Combinatietherapie Bij Reumatoide Artritis) study, the use of zoledronic acid to treat knee osteoarthritis with bone lesions, and the relationship between bisphosphonate drug holidays and hip fracture risk. Researchers also will discuss baricitinib in systemic lupus erythematosus (SLE), the value of MRI when treating remitted RA to target, the validation of SLE classification criteria, and draft classification criteria for ANCA-associated vasculitides.

A notable clinical science session on Wednesday will cover cancer and inflammation, Dr. Landewé said. “This is a topic of increasing interest because cancer and inflammation share mutual pathways.”

Novel cancer therapies such as immune checkpoint inhibitors have improved outcomes across a range of tumor types, but also can induce rheumatic disease, he added. Accordingly, presenters will discuss inflammation as “friend” versus “foe” in cancer treatment, the role of tumor necrosis factor in cancer, and risk of malignancy among patients with RA.

Thursday, June 14

Topics in this session will include the use of estrogens and other hormonal therapies in patients with rheumatic disease, registry studies of rheumatologic conditions during pregnancy, and how clinicians can best discuss sexual concerns with their rheumatology patients.

Friday, June 15

For the first time, the scientific program also will include a clinical science session held jointly with the European Society of Musculoskeletal Radiology (ESSR). Dr. Joachim Sieper of Germany and ESSR President Dr. Monique Reijnierse of the Netherlands will cochair the Friday afternoon session on the role of MRI in rheumatology. Attendees from both organizations will learn when to use MRI in early and established RA and spondyloarthritis, and how to interpret the results, with abundant time built in for questions and answers. Dr. Landewé called the joint session “a test case” for exciting web-based interactions between EULAR and ESSR.

Another clinical science session on Friday afternoon will dive into the diagnosis of spondyloarthritis, which Dr. Landewé called “a matter of recognizing patterns, not ticking boxes on a list of criteria. This symposium leads you through the art of pattern recognition.”

Later on Friday afternoon, a session will explore advances in biologic therapy of small-vessel vasculitis, he added. “Biologic disease-modifying antirheumatic drugs [bDMARDs] are becoming more and more important in this area of expanding interest.” Experts will address complement inhibition in ANCA-associated vasculitis (AAV), the use of induction and maintenance rituximab in AAV, the evolving role of mepolizumab in eosinophilic granulomatosis with polyangiitis, survival in AAV, and the use of rituximab for treating children with granulomatosis with polyangiitis and microscopic polyangiitis.

Saturday, June 16

On Saturday, a bench-to-bedside session will cover gout and kidney function. “This is an area with important new insights,” Dr. Dörner said. Presenters will discuss the genetics of hyperuricemia, renal urate transporters, and the pros and cons of using xanthine oxidase inhibitors to treat chronic kidney disease. Researchers will also cover studies of impaired neutrophil chemotaxis in patients with chronic kidney disease and hyperuricemia, and the relationship between renal medullar hyperechogenicity and gout severity.

Also on Saturday, a clinical science session titled, “Rheumatoid arthritis: Is it all in your head?” will explore emerging data on the relationship between inflammation and depression. Patients with RA often face both clinical depression and social isolation, and these complex psychosocial conditions can worsen one another. “In addition to proper drug choice, treating RA effectively depends on how concomitant problems, such as nonspecific pain, depression, and social isolation, are coped with in a broad context,” Dr. Landewé said. “When it comes to optimal management, rheumatologists need to communicate and prescribe, not just prescribe.”

Christian Apfelbacher, PhD, of Germany will discuss prevention and treatment strategies and Dr. Jonathan Cavanagh of the United Kingdom will cover neuroimaging in RA. Researchers also will discuss new findings on pain, depression, and anxiety in patients recently diagnosed with RA.

Also on Saturday, a special session will cover EULAR’s initiatives to improve clinical approaches (ESSCA), Dr. Dörner noted. This effort has produced new or updated recommendations on topics such as vaccination, Sjögren’s syndrome, glucocorticoid therapy, and management of hand osteoarthritis, he said. “These recommendations follow a number of others and are expected to impact clinical science as well as clinical practice.”

EULAR 2018’s scientific program in Amsterdam is packed with lectures, clinical and basic science symposia, workshops, and special interest sessions covering the full spectrum of rheumatic diseases, said Dr. Robert Landewé, chair of the Scientific Program Committee.

“More than 5,000 scientific abstracts were submitted, which is an absolute, all-time record,” Dr. Landewé said. Four experts scored each abstract, and only the top 7% were invited for oral presentation during abstract sessions or symposia, he explained in an interview.

Wednesday, June 13

A high point of the 2018 scientific program is Wednesday’s opening plenary session, which will feature abstracts that were handpicked by Dr. Landewé and Dr. Thomas Dörner, professor of rheumatology at Charite Universitätsmedizin, Berlin. “This session includes highly scored abstracts, including late-breakers, on current advances in therapeutics and disease classification,” said Dr. Dörner, who chaired this year’s Abstract Selection Committee.

The plenary abstract session will cover new findings on gout and cardiovascular disease from CANTOS (Canakinumab Anti-inflammatory Thrombosis Outcome Study), long-term mortality in patients with early RA from the COBRA (Combinatietherapie Bij Reumatoide Artritis) study, the use of zoledronic acid to treat knee osteoarthritis with bone lesions, and the relationship between bisphosphonate drug holidays and hip fracture risk. Researchers also will discuss baricitinib in systemic lupus erythematosus (SLE), the value of MRI when treating remitted RA to target, the validation of SLE classification criteria, and draft classification criteria for ANCA-associated vasculitides.

A notable clinical science session on Wednesday will cover cancer and inflammation, Dr. Landewé said. “This is a topic of increasing interest because cancer and inflammation share mutual pathways.”

Novel cancer therapies such as immune checkpoint inhibitors have improved outcomes across a range of tumor types, but also can induce rheumatic disease, he added. Accordingly, presenters will discuss inflammation as “friend” versus “foe” in cancer treatment, the role of tumor necrosis factor in cancer, and risk of malignancy among patients with RA.

Thursday, June 14

Topics in this session will include the use of estrogens and other hormonal therapies in patients with rheumatic disease, registry studies of rheumatologic conditions during pregnancy, and how clinicians can best discuss sexual concerns with their rheumatology patients.

Friday, June 15

For the first time, the scientific program also will include a clinical science session held jointly with the European Society of Musculoskeletal Radiology (ESSR). Dr. Joachim Sieper of Germany and ESSR President Dr. Monique Reijnierse of the Netherlands will cochair the Friday afternoon session on the role of MRI in rheumatology. Attendees from both organizations will learn when to use MRI in early and established RA and spondyloarthritis, and how to interpret the results, with abundant time built in for questions and answers. Dr. Landewé called the joint session “a test case” for exciting web-based interactions between EULAR and ESSR.

Another clinical science session on Friday afternoon will dive into the diagnosis of spondyloarthritis, which Dr. Landewé called “a matter of recognizing patterns, not ticking boxes on a list of criteria. This symposium leads you through the art of pattern recognition.”

Later on Friday afternoon, a session will explore advances in biologic therapy of small-vessel vasculitis, he added. “Biologic disease-modifying antirheumatic drugs [bDMARDs] are becoming more and more important in this area of expanding interest.” Experts will address complement inhibition in ANCA-associated vasculitis (AAV), the use of induction and maintenance rituximab in AAV, the evolving role of mepolizumab in eosinophilic granulomatosis with polyangiitis, survival in AAV, and the use of rituximab for treating children with granulomatosis with polyangiitis and microscopic polyangiitis.

Saturday, June 16

On Saturday, a bench-to-bedside session will cover gout and kidney function. “This is an area with important new insights,” Dr. Dörner said. Presenters will discuss the genetics of hyperuricemia, renal urate transporters, and the pros and cons of using xanthine oxidase inhibitors to treat chronic kidney disease. Researchers will also cover studies of impaired neutrophil chemotaxis in patients with chronic kidney disease and hyperuricemia, and the relationship between renal medullar hyperechogenicity and gout severity.

Also on Saturday, a clinical science session titled, “Rheumatoid arthritis: Is it all in your head?” will explore emerging data on the relationship between inflammation and depression. Patients with RA often face both clinical depression and social isolation, and these complex psychosocial conditions can worsen one another. “In addition to proper drug choice, treating RA effectively depends on how concomitant problems, such as nonspecific pain, depression, and social isolation, are coped with in a broad context,” Dr. Landewé said. “When it comes to optimal management, rheumatologists need to communicate and prescribe, not just prescribe.”

Christian Apfelbacher, PhD, of Germany will discuss prevention and treatment strategies and Dr. Jonathan Cavanagh of the United Kingdom will cover neuroimaging in RA. Researchers also will discuss new findings on pain, depression, and anxiety in patients recently diagnosed with RA.

Also on Saturday, a special session will cover EULAR’s initiatives to improve clinical approaches (ESSCA), Dr. Dörner noted. This effort has produced new or updated recommendations on topics such as vaccination, Sjögren’s syndrome, glucocorticoid therapy, and management of hand osteoarthritis, he said. “These recommendations follow a number of others and are expected to impact clinical science as well as clinical practice.”