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Smokers face higher infection risk after hernia operations
Jonah Stulberg, MD, FACS, is stickler about requiring patients to stop smoking at least 3 months before hernia surgery. He even uses urine tests to confirm whether they actually quit. A study by Dr. Stulberg and his colleagues supports this approach: .
The finding held up even after the researchers controlled for various factors. “Our findings are in agreement with other findings in higher risk surgeries, and they provide evidence that low-risk surgeries are not exempt from the risks associated with smoking,” said Dr. Stulberg in an interview. “Our data would suggest that there is significant clinical benefit to encouraging smoking cessation before elective hernia repair.”
The researchers launched the study to better understand how smoking affects complication rates in light of the fact that “surgeons in the U.S. tend to offer low-risk elective surgical procedures to patients who are actively smoking despite overwhelming evidence that smoking increases surgical risks,” Dr. Stulberg said.
The researchers tracked 220,629 patients in the American College of Surgeons National Surgical Quality Improvement Project (NSQIP) database who underwent several types of elective hernia repair from 2011 to 2014.
Just over 18% of the patients said they’d smoked over the past year; they were more likely to be younger (median age, 50 for smokers vs. 57 for nonsmokers). Smokers also were more likely to be black, to be underweight, and to consume two or more alcoholic beverages per day (P less than .05).
The researchers tracked serious complications in the 30 days after surgery such as death, sepsis, and readmission.
Complications developed in 6.34% of smokers and 4.72% of nonsmokers (P less than .001). Numerous kinds of complications were more common in the smokers prior to adjustment: death, return to the operating room, readmission, and transfusion plus wound, pulmonary, thromboembolic and cardiac complications.
The researchers adjusted their statistics to account for factors such as ethnicity, sex, body mass index, preexisting comorbidities, and type of hernia operation. They found that risk of all complications was higher in smokers, compared with nonsmokers (odds ratio, 1.30) as were several other complications: death (OR, 1.53), return to operating room (OR, 1.23), readmission (OR, 1.24), wound complication (OR, 1.36), sepsis/septic shock (OR, 1.31), pulmonary complication (OR 1.77-2.30) and cardiac complication (OR, 1.27-1.43).
Only transfusion (OR, 0.90) and thromboembolic (OR, 0.87) complications were less likely in smokers.
The researchers noted that the statistics don’t allow them to analyze whether it makes any difference if smokers quit shortly before their procedures. Still, Dr. Stulberg stands by his you-must-quit-smoking-before-surgery edict. “I believe that their active smoking habit is a bigger health threat than their asymptomatic hernia, and therefore feel the right thing to do as their physician is support them through their smoking cessation,” he said. “I offer counseling and nicotine replacement if needed. I have very good quit rates and would encourage other surgeons to do the same.”
Dr. Stulberg noted that he can’t point to evidence supporting his requirement that patients quit at least 3 months before surgery. “Most data out there says the farther away from your last cigarette, the better,” he said. “But there isn’t any magic to 3 months, other than I believe it will lead to a higher likelihood of permanent cessation.”
Northwestern Memorial Hospital and Northwestern University funded the study. Four of the nine authors, including Dr. Stulberg, report various disclosures that are not directly related to the study, including funding from government agencies, physician organizations, Health Care Services Corporation and Blue Cross Blue Shield of Illinois, Mallinckrodt, and Northwestern University. The other authors report no disclosures.
SOURCE: DeLancey JO et al. Am J Surg. 2018 Mar 6. doi: 10.1016/j.amjsurg.2018.03.004.
Jonah Stulberg, MD, FACS, is stickler about requiring patients to stop smoking at least 3 months before hernia surgery. He even uses urine tests to confirm whether they actually quit. A study by Dr. Stulberg and his colleagues supports this approach: .
The finding held up even after the researchers controlled for various factors. “Our findings are in agreement with other findings in higher risk surgeries, and they provide evidence that low-risk surgeries are not exempt from the risks associated with smoking,” said Dr. Stulberg in an interview. “Our data would suggest that there is significant clinical benefit to encouraging smoking cessation before elective hernia repair.”
The researchers launched the study to better understand how smoking affects complication rates in light of the fact that “surgeons in the U.S. tend to offer low-risk elective surgical procedures to patients who are actively smoking despite overwhelming evidence that smoking increases surgical risks,” Dr. Stulberg said.
The researchers tracked 220,629 patients in the American College of Surgeons National Surgical Quality Improvement Project (NSQIP) database who underwent several types of elective hernia repair from 2011 to 2014.
Just over 18% of the patients said they’d smoked over the past year; they were more likely to be younger (median age, 50 for smokers vs. 57 for nonsmokers). Smokers also were more likely to be black, to be underweight, and to consume two or more alcoholic beverages per day (P less than .05).
The researchers tracked serious complications in the 30 days after surgery such as death, sepsis, and readmission.
Complications developed in 6.34% of smokers and 4.72% of nonsmokers (P less than .001). Numerous kinds of complications were more common in the smokers prior to adjustment: death, return to the operating room, readmission, and transfusion plus wound, pulmonary, thromboembolic and cardiac complications.
The researchers adjusted their statistics to account for factors such as ethnicity, sex, body mass index, preexisting comorbidities, and type of hernia operation. They found that risk of all complications was higher in smokers, compared with nonsmokers (odds ratio, 1.30) as were several other complications: death (OR, 1.53), return to operating room (OR, 1.23), readmission (OR, 1.24), wound complication (OR, 1.36), sepsis/septic shock (OR, 1.31), pulmonary complication (OR 1.77-2.30) and cardiac complication (OR, 1.27-1.43).
Only transfusion (OR, 0.90) and thromboembolic (OR, 0.87) complications were less likely in smokers.
The researchers noted that the statistics don’t allow them to analyze whether it makes any difference if smokers quit shortly before their procedures. Still, Dr. Stulberg stands by his you-must-quit-smoking-before-surgery edict. “I believe that their active smoking habit is a bigger health threat than their asymptomatic hernia, and therefore feel the right thing to do as their physician is support them through their smoking cessation,” he said. “I offer counseling and nicotine replacement if needed. I have very good quit rates and would encourage other surgeons to do the same.”
Dr. Stulberg noted that he can’t point to evidence supporting his requirement that patients quit at least 3 months before surgery. “Most data out there says the farther away from your last cigarette, the better,” he said. “But there isn’t any magic to 3 months, other than I believe it will lead to a higher likelihood of permanent cessation.”
Northwestern Memorial Hospital and Northwestern University funded the study. Four of the nine authors, including Dr. Stulberg, report various disclosures that are not directly related to the study, including funding from government agencies, physician organizations, Health Care Services Corporation and Blue Cross Blue Shield of Illinois, Mallinckrodt, and Northwestern University. The other authors report no disclosures.
SOURCE: DeLancey JO et al. Am J Surg. 2018 Mar 6. doi: 10.1016/j.amjsurg.2018.03.004.
Jonah Stulberg, MD, FACS, is stickler about requiring patients to stop smoking at least 3 months before hernia surgery. He even uses urine tests to confirm whether they actually quit. A study by Dr. Stulberg and his colleagues supports this approach: .
The finding held up even after the researchers controlled for various factors. “Our findings are in agreement with other findings in higher risk surgeries, and they provide evidence that low-risk surgeries are not exempt from the risks associated with smoking,” said Dr. Stulberg in an interview. “Our data would suggest that there is significant clinical benefit to encouraging smoking cessation before elective hernia repair.”
The researchers launched the study to better understand how smoking affects complication rates in light of the fact that “surgeons in the U.S. tend to offer low-risk elective surgical procedures to patients who are actively smoking despite overwhelming evidence that smoking increases surgical risks,” Dr. Stulberg said.
The researchers tracked 220,629 patients in the American College of Surgeons National Surgical Quality Improvement Project (NSQIP) database who underwent several types of elective hernia repair from 2011 to 2014.
Just over 18% of the patients said they’d smoked over the past year; they were more likely to be younger (median age, 50 for smokers vs. 57 for nonsmokers). Smokers also were more likely to be black, to be underweight, and to consume two or more alcoholic beverages per day (P less than .05).
The researchers tracked serious complications in the 30 days after surgery such as death, sepsis, and readmission.
Complications developed in 6.34% of smokers and 4.72% of nonsmokers (P less than .001). Numerous kinds of complications were more common in the smokers prior to adjustment: death, return to the operating room, readmission, and transfusion plus wound, pulmonary, thromboembolic and cardiac complications.
The researchers adjusted their statistics to account for factors such as ethnicity, sex, body mass index, preexisting comorbidities, and type of hernia operation. They found that risk of all complications was higher in smokers, compared with nonsmokers (odds ratio, 1.30) as were several other complications: death (OR, 1.53), return to operating room (OR, 1.23), readmission (OR, 1.24), wound complication (OR, 1.36), sepsis/septic shock (OR, 1.31), pulmonary complication (OR 1.77-2.30) and cardiac complication (OR, 1.27-1.43).
Only transfusion (OR, 0.90) and thromboembolic (OR, 0.87) complications were less likely in smokers.
The researchers noted that the statistics don’t allow them to analyze whether it makes any difference if smokers quit shortly before their procedures. Still, Dr. Stulberg stands by his you-must-quit-smoking-before-surgery edict. “I believe that their active smoking habit is a bigger health threat than their asymptomatic hernia, and therefore feel the right thing to do as their physician is support them through their smoking cessation,” he said. “I offer counseling and nicotine replacement if needed. I have very good quit rates and would encourage other surgeons to do the same.”
Dr. Stulberg noted that he can’t point to evidence supporting his requirement that patients quit at least 3 months before surgery. “Most data out there says the farther away from your last cigarette, the better,” he said. “But there isn’t any magic to 3 months, other than I believe it will lead to a higher likelihood of permanent cessation.”
Northwestern Memorial Hospital and Northwestern University funded the study. Four of the nine authors, including Dr. Stulberg, report various disclosures that are not directly related to the study, including funding from government agencies, physician organizations, Health Care Services Corporation and Blue Cross Blue Shield of Illinois, Mallinckrodt, and Northwestern University. The other authors report no disclosures.
SOURCE: DeLancey JO et al. Am J Surg. 2018 Mar 6. doi: 10.1016/j.amjsurg.2018.03.004.
FROM AMERICAN JOURNAL OF SURGERY
Key clinical point: Smokers are more likely than are nonsmokers to develop serious complications after elective hernia surgery.
Major finding: The adjusted risk of serious complications after elective hernia surgery is higher (odds ratio, 1.30) in smokers than nonsmokers.
Study details: Retrospective study of ACS NSQIP data on 220,629 patients in the United States (18% smokers) who underwent elective hernia operations during 2011-2014.
Disclosures: Northwestern Memorial Hospital and Northwestern University funded the study. Four of the nine authors reported various disclosures. The other authors report no disclosures.
Source: DeLancey JO et al. Am J Surg. 2018 Mar 6. doi: 10.1016/j.amjsurg.2018.03.004.
Model predicted Barrett’s esophagus progression
A scoring model encompassing just four traits accurately predicted which patients with Barrett’s esophagus were most likely to develop high-grade dysplasia or esophageal adenocarcinoma, researchers reported in the April issue of Gastroenterology (2017 Dec 19. doi: 10.1053/j.gastro.2017.12.009).
Those risk factors included sex, smoking, length of Barrett’s esophagus, and the presence of baseline low-grade dysplasia, said Sravanthi Parasa, MD, of Swedish Medical Center, Seattle, and her associates. For example, a male with a history of smoking found to have a 5-cm, nondysplastic Barrett’s esophagus on histology during his index endoscopy would fall into the model’s intermediate risk category, with a 0.7% annual risk of progression to high-grade dysplasia or esophageal adenocarcinoma, they explained. “This model has the potential to complement molecular biomarker panels currently in development,” they wrote.
Barrett’s esophagus increases the risk of esophageal adenocarcinoma by anywhere from 30 to 125 times, a range that reflects the multifactorial nature of progression and the hypothesis that not all patients with Barrett’s esophagus should undergo the same frequency of endoscopic surveillance, said the researchers. To incorporate predictors of progression into a single model, they analyzed prospective data from nearly 3,000 patients with Barrett’s esophagus who were followed for a median of 6 years at five centers in the United States and one center in the Netherlands. At baseline, patients were an average of 55 years old (standard deviation, 20 years), 84% were men, 88% were white, and the average Barrett’s esophagus length was 3.7 cm (SD, 3.2 cm).
The researchers created the model by starting with many demographic and clinical candidate variables and then using backward selection to eliminate those that did not predict progression with a P value of .05 or less. This is the same method used in the Framingham Heart Study, they noted. In all, 154 (6%) patients with Barrett’s esophagus developed high-grade dysplasia or esophageal adenocarcinoma, with an annual progression rate of about 1%. The significant predictors of progression included male sex, smoking, length of Barrett’s esophagus, and low-grade dysplasia at baseline. A model that included only these four variables distinguished progressors from nonprogressors with a c statistic of 0.76 (95% confidence interval, 0.72 to 0.80; P less than .001). Using 30% of patients as an internal validation cohort, the model’s calibration slope was 0.99 and its calibration intercept was -0.09 cohort (perfectly calibrated models have a slope of 1.0 and an intercept of 0.0).
Therefore, the model was well calibrated and did an appropriate job of identifying risk groups, the investigators concluded. Considering that the overall risk of Barrett’s esophagus progression is low, using this model could help avoid excess costs and burdens of unnecessary surveillance, they added. “We recognize that there is a key interest in contemporary medical research whether a marker (e.g. molecular, genetic) could add to incremental value of a risk progression score,” they wrote. “This can be an area of future research.”
There were no funding sources. Dr. Parasa had no disclosures. One coinvestigator disclosed ties to Cook Medical, CDx Diagnostics, and Cosmo Pharmaceuticals.
SOURCE: Parasa S et al. Gastroenterology. 2017 Dec 19. doi: 10.1053/j.gastro.2017.12.009.
Barrett’s esophagus (BE) is the only known precursor lesion to esophageal adenocarcinoma (EAC), a rapidly rising cancer in the Western world, which has a poor 5-year survival rate of less than 20%. Management strategies to affect EAC incidence include screening and surveillance, with current guidelines recommending surveillance for all patients with a diagnosis of BE.
However, there are several challenges associated with adopting BE surveillance for all patients: It is estimated that anywhere from 2 million to 5 million U.S. adults may harbor BE, and the overall risk of BE progression to EAC is low (approximately 0.2%-0.4% annually). Both of these factors influence the cost-effectiveness of a global BE surveillance program.
Hence, a risk-stratification score that can distinguish BE patients who are at high risk for progression to high-grade dysplasia (HGD) and/or EAC from those whose disease will not progress will be extremely useful. This concept would be similar to other risk-scoring mechanisms, such as the MELD score for progression in liver disease.
With use of a large multicenter cohort of patients with BE (more than 4,500 patients), this is the first risk-prediction score developed and validated using baseline demographic and endoscopy information to determine risk of progression. Readily available factors such as patient sex, smoking status, BE length, and confirmed histology were identified as risk factors for progression, which could then generate a score determining the individual patient’s risk of progression. Such a simple scoring system has the potential of tailoring management based on the risk factors. In the future, inclusion of molecular biomarkers along with this score may further enhance its potential for personalized medicine in BE patients.
Prateek Sharma, MD, is a professor of medicine of University of Kansas, Kansas City. He has no conflicts of interest.
Barrett’s esophagus (BE) is the only known precursor lesion to esophageal adenocarcinoma (EAC), a rapidly rising cancer in the Western world, which has a poor 5-year survival rate of less than 20%. Management strategies to affect EAC incidence include screening and surveillance, with current guidelines recommending surveillance for all patients with a diagnosis of BE.
However, there are several challenges associated with adopting BE surveillance for all patients: It is estimated that anywhere from 2 million to 5 million U.S. adults may harbor BE, and the overall risk of BE progression to EAC is low (approximately 0.2%-0.4% annually). Both of these factors influence the cost-effectiveness of a global BE surveillance program.
Hence, a risk-stratification score that can distinguish BE patients who are at high risk for progression to high-grade dysplasia (HGD) and/or EAC from those whose disease will not progress will be extremely useful. This concept would be similar to other risk-scoring mechanisms, such as the MELD score for progression in liver disease.
With use of a large multicenter cohort of patients with BE (more than 4,500 patients), this is the first risk-prediction score developed and validated using baseline demographic and endoscopy information to determine risk of progression. Readily available factors such as patient sex, smoking status, BE length, and confirmed histology were identified as risk factors for progression, which could then generate a score determining the individual patient’s risk of progression. Such a simple scoring system has the potential of tailoring management based on the risk factors. In the future, inclusion of molecular biomarkers along with this score may further enhance its potential for personalized medicine in BE patients.
Prateek Sharma, MD, is a professor of medicine of University of Kansas, Kansas City. He has no conflicts of interest.
Barrett’s esophagus (BE) is the only known precursor lesion to esophageal adenocarcinoma (EAC), a rapidly rising cancer in the Western world, which has a poor 5-year survival rate of less than 20%. Management strategies to affect EAC incidence include screening and surveillance, with current guidelines recommending surveillance for all patients with a diagnosis of BE.
However, there are several challenges associated with adopting BE surveillance for all patients: It is estimated that anywhere from 2 million to 5 million U.S. adults may harbor BE, and the overall risk of BE progression to EAC is low (approximately 0.2%-0.4% annually). Both of these factors influence the cost-effectiveness of a global BE surveillance program.
Hence, a risk-stratification score that can distinguish BE patients who are at high risk for progression to high-grade dysplasia (HGD) and/or EAC from those whose disease will not progress will be extremely useful. This concept would be similar to other risk-scoring mechanisms, such as the MELD score for progression in liver disease.
With use of a large multicenter cohort of patients with BE (more than 4,500 patients), this is the first risk-prediction score developed and validated using baseline demographic and endoscopy information to determine risk of progression. Readily available factors such as patient sex, smoking status, BE length, and confirmed histology were identified as risk factors for progression, which could then generate a score determining the individual patient’s risk of progression. Such a simple scoring system has the potential of tailoring management based on the risk factors. In the future, inclusion of molecular biomarkers along with this score may further enhance its potential for personalized medicine in BE patients.
Prateek Sharma, MD, is a professor of medicine of University of Kansas, Kansas City. He has no conflicts of interest.
A scoring model encompassing just four traits accurately predicted which patients with Barrett’s esophagus were most likely to develop high-grade dysplasia or esophageal adenocarcinoma, researchers reported in the April issue of Gastroenterology (2017 Dec 19. doi: 10.1053/j.gastro.2017.12.009).
Those risk factors included sex, smoking, length of Barrett’s esophagus, and the presence of baseline low-grade dysplasia, said Sravanthi Parasa, MD, of Swedish Medical Center, Seattle, and her associates. For example, a male with a history of smoking found to have a 5-cm, nondysplastic Barrett’s esophagus on histology during his index endoscopy would fall into the model’s intermediate risk category, with a 0.7% annual risk of progression to high-grade dysplasia or esophageal adenocarcinoma, they explained. “This model has the potential to complement molecular biomarker panels currently in development,” they wrote.
Barrett’s esophagus increases the risk of esophageal adenocarcinoma by anywhere from 30 to 125 times, a range that reflects the multifactorial nature of progression and the hypothesis that not all patients with Barrett’s esophagus should undergo the same frequency of endoscopic surveillance, said the researchers. To incorporate predictors of progression into a single model, they analyzed prospective data from nearly 3,000 patients with Barrett’s esophagus who were followed for a median of 6 years at five centers in the United States and one center in the Netherlands. At baseline, patients were an average of 55 years old (standard deviation, 20 years), 84% were men, 88% were white, and the average Barrett’s esophagus length was 3.7 cm (SD, 3.2 cm).
The researchers created the model by starting with many demographic and clinical candidate variables and then using backward selection to eliminate those that did not predict progression with a P value of .05 or less. This is the same method used in the Framingham Heart Study, they noted. In all, 154 (6%) patients with Barrett’s esophagus developed high-grade dysplasia or esophageal adenocarcinoma, with an annual progression rate of about 1%. The significant predictors of progression included male sex, smoking, length of Barrett’s esophagus, and low-grade dysplasia at baseline. A model that included only these four variables distinguished progressors from nonprogressors with a c statistic of 0.76 (95% confidence interval, 0.72 to 0.80; P less than .001). Using 30% of patients as an internal validation cohort, the model’s calibration slope was 0.99 and its calibration intercept was -0.09 cohort (perfectly calibrated models have a slope of 1.0 and an intercept of 0.0).
Therefore, the model was well calibrated and did an appropriate job of identifying risk groups, the investigators concluded. Considering that the overall risk of Barrett’s esophagus progression is low, using this model could help avoid excess costs and burdens of unnecessary surveillance, they added. “We recognize that there is a key interest in contemporary medical research whether a marker (e.g. molecular, genetic) could add to incremental value of a risk progression score,” they wrote. “This can be an area of future research.”
There were no funding sources. Dr. Parasa had no disclosures. One coinvestigator disclosed ties to Cook Medical, CDx Diagnostics, and Cosmo Pharmaceuticals.
SOURCE: Parasa S et al. Gastroenterology. 2017 Dec 19. doi: 10.1053/j.gastro.2017.12.009.
A scoring model encompassing just four traits accurately predicted which patients with Barrett’s esophagus were most likely to develop high-grade dysplasia or esophageal adenocarcinoma, researchers reported in the April issue of Gastroenterology (2017 Dec 19. doi: 10.1053/j.gastro.2017.12.009).
Those risk factors included sex, smoking, length of Barrett’s esophagus, and the presence of baseline low-grade dysplasia, said Sravanthi Parasa, MD, of Swedish Medical Center, Seattle, and her associates. For example, a male with a history of smoking found to have a 5-cm, nondysplastic Barrett’s esophagus on histology during his index endoscopy would fall into the model’s intermediate risk category, with a 0.7% annual risk of progression to high-grade dysplasia or esophageal adenocarcinoma, they explained. “This model has the potential to complement molecular biomarker panels currently in development,” they wrote.
Barrett’s esophagus increases the risk of esophageal adenocarcinoma by anywhere from 30 to 125 times, a range that reflects the multifactorial nature of progression and the hypothesis that not all patients with Barrett’s esophagus should undergo the same frequency of endoscopic surveillance, said the researchers. To incorporate predictors of progression into a single model, they analyzed prospective data from nearly 3,000 patients with Barrett’s esophagus who were followed for a median of 6 years at five centers in the United States and one center in the Netherlands. At baseline, patients were an average of 55 years old (standard deviation, 20 years), 84% were men, 88% were white, and the average Barrett’s esophagus length was 3.7 cm (SD, 3.2 cm).
The researchers created the model by starting with many demographic and clinical candidate variables and then using backward selection to eliminate those that did not predict progression with a P value of .05 or less. This is the same method used in the Framingham Heart Study, they noted. In all, 154 (6%) patients with Barrett’s esophagus developed high-grade dysplasia or esophageal adenocarcinoma, with an annual progression rate of about 1%. The significant predictors of progression included male sex, smoking, length of Barrett’s esophagus, and low-grade dysplasia at baseline. A model that included only these four variables distinguished progressors from nonprogressors with a c statistic of 0.76 (95% confidence interval, 0.72 to 0.80; P less than .001). Using 30% of patients as an internal validation cohort, the model’s calibration slope was 0.99 and its calibration intercept was -0.09 cohort (perfectly calibrated models have a slope of 1.0 and an intercept of 0.0).
Therefore, the model was well calibrated and did an appropriate job of identifying risk groups, the investigators concluded. Considering that the overall risk of Barrett’s esophagus progression is low, using this model could help avoid excess costs and burdens of unnecessary surveillance, they added. “We recognize that there is a key interest in contemporary medical research whether a marker (e.g. molecular, genetic) could add to incremental value of a risk progression score,” they wrote. “This can be an area of future research.”
There were no funding sources. Dr. Parasa had no disclosures. One coinvestigator disclosed ties to Cook Medical, CDx Diagnostics, and Cosmo Pharmaceuticals.
SOURCE: Parasa S et al. Gastroenterology. 2017 Dec 19. doi: 10.1053/j.gastro.2017.12.009.
FROM GASTROENTEROLOGY
Key clinical point: A model containing four risk factors identified patients with Barrett’s esophagus at significantly increased risk of progression to high-grade dysplasia or esophageal adenocarcinoma.
Major finding: Scores assigned identified patients with BE that progressed to HGD or EAC with a c statistic of 0.76 (95% CI, 0.72 to 0.80; P less than .001).
Data source: A multicenter, longitudinal study of 2,697 patients with Barrett’s esophagus.
Disclosures: There were no funding sources. Dr. Parasa had no disclosures. One coinvestigator disclosed ties to Cook Medical, CDx Diagnostics, and Cosmo Pharmaceuticals.
Source: Parasa S et al. Gastroenterology. 2017 Dec 19. doi: 10.1053/j.gastro.2017.12.009.
Sustaining the evolution of PAs in hospital medicine
Editor’s note: Each month, SHM puts the spotlight on some of our most active members who are making substantial contributions to hospital medicine. Visit www.hospitalmedicine.org for more information on how you can lend your expertise to help SHM improve the care of hospitalized patients.
This month, The Hospitalist spotlights Meredith K. Wold, PA-C, APC supervisor, Hospital Medicine and Critical Care, at Regions Hospital in St. Paul, Minn., and adjunct faculty, Augsburg University Physician Assistant Program. Ms. Wold is a long-time member of SHM and the recipient of this year’s Clinical Excellence Award for Nurse Practitioners and Physician Assistants.
How did you first hear of SHM and why did you decide to become a member?
I’ve always recognized the importance of engaging in a community beyond my daily practice. Shortly after starting my career in hospital medicine, I quickly recognized this was a belief shared and cultivated by my hospital medicine group as well. Our HM group at HealthPartners has a long history of SHM participation. As our advanced practice clinician (APC) group grew, I knew engagement at the national level was critical to ensure that our ongoing evolution was supported, sustained, and shared.
What does it mean to you to receive SHM’s Clinical Excellence Award for nurse practitioners and physician assistants?
Being awarded the SHM Clinical Excellence Award is remarkable. I work alongside really, really amazing people, and every day I strive toward the exceptionally high bar they set. I’m passionate and committed to hospital medicine, and I’m so very grateful this is appreciated.
Which SHM conferences have you attended? Tell us about some of the highlights from these courses.
The first SHM annual conference I attended was in 2008 in sunny San Diego. I’d been a physician assistant (PA) for barely a year. I remember being so energized by the passion and commitment of the speakers and attendees. I harnessed that energy and spent the next several years being part of a growing APC group at Regions Hospital in St. Paul, Minn., where our HM group holds partnership and innovation at its core. You can imagine my excitement when I was asked to speak about APC practice models at HM16. Fellow APC Emily Thornhill Davis and I spoke to a standing-room only audience! Emily and I partnered again as faculty at HM17. I look forward to being part of a panel discussion at HM18 in Orlando (alongside some SHM trailblazers!).
Closer to home, I’ve taken advantage of phenomenal opportunities hosted by our local chapter of SHM. My colleagues Benji Mathews, MD, and Kreegan Reierson, MD, have led Point-of-Care Ultrasound (POCUS) training courses regionally and nationally. Their comprehensive, hands-on course ensured that I had the foundation to incorporate portable ultrasound into my practice. Thank goodness for their refresher course as well; my skills were rusty after a long maternity leave!
Given the tremendous clinical growth I have absorbed through local and national SHM offerings, I look forward to my leadership and operations skills being bolstered at SHM’s Leadership Academy this fall in Vancouver. As APCs hold more and more vital roles within HM groups, it’s integral that, along the way, our leadership skills are recognized and honed as well.
As an SHM member of over 10 years, what has been most valuable for you as a physician assistant?
The relationships. Networking, sharing ideas, pushing the status quo with other like-minded clinicians from around the country is invigorating. Because of SHM, I have an APC network from coast to coast – a lattice of clinicians that are linked by dedication and enthusiasm to hospital medicine.
What advice do you have for early-career physician assistants looking to work in hospital medicine?
Find a hospital medicine group whose culture allows and supports your growth as an advanced practice clinician. In an exemplary HM model, the delegated autonomy of an APC should widen and deepen over time. Seek out a team that appreciates the importance of this evolution.
Ms. Steele is marketing communications specialist at the Society of Hospital Medicine.
Editor’s note: Each month, SHM puts the spotlight on some of our most active members who are making substantial contributions to hospital medicine. Visit www.hospitalmedicine.org for more information on how you can lend your expertise to help SHM improve the care of hospitalized patients.
This month, The Hospitalist spotlights Meredith K. Wold, PA-C, APC supervisor, Hospital Medicine and Critical Care, at Regions Hospital in St. Paul, Minn., and adjunct faculty, Augsburg University Physician Assistant Program. Ms. Wold is a long-time member of SHM and the recipient of this year’s Clinical Excellence Award for Nurse Practitioners and Physician Assistants.
How did you first hear of SHM and why did you decide to become a member?
I’ve always recognized the importance of engaging in a community beyond my daily practice. Shortly after starting my career in hospital medicine, I quickly recognized this was a belief shared and cultivated by my hospital medicine group as well. Our HM group at HealthPartners has a long history of SHM participation. As our advanced practice clinician (APC) group grew, I knew engagement at the national level was critical to ensure that our ongoing evolution was supported, sustained, and shared.
What does it mean to you to receive SHM’s Clinical Excellence Award for nurse practitioners and physician assistants?
Being awarded the SHM Clinical Excellence Award is remarkable. I work alongside really, really amazing people, and every day I strive toward the exceptionally high bar they set. I’m passionate and committed to hospital medicine, and I’m so very grateful this is appreciated.
Which SHM conferences have you attended? Tell us about some of the highlights from these courses.
The first SHM annual conference I attended was in 2008 in sunny San Diego. I’d been a physician assistant (PA) for barely a year. I remember being so energized by the passion and commitment of the speakers and attendees. I harnessed that energy and spent the next several years being part of a growing APC group at Regions Hospital in St. Paul, Minn., where our HM group holds partnership and innovation at its core. You can imagine my excitement when I was asked to speak about APC practice models at HM16. Fellow APC Emily Thornhill Davis and I spoke to a standing-room only audience! Emily and I partnered again as faculty at HM17. I look forward to being part of a panel discussion at HM18 in Orlando (alongside some SHM trailblazers!).
Closer to home, I’ve taken advantage of phenomenal opportunities hosted by our local chapter of SHM. My colleagues Benji Mathews, MD, and Kreegan Reierson, MD, have led Point-of-Care Ultrasound (POCUS) training courses regionally and nationally. Their comprehensive, hands-on course ensured that I had the foundation to incorporate portable ultrasound into my practice. Thank goodness for their refresher course as well; my skills were rusty after a long maternity leave!
Given the tremendous clinical growth I have absorbed through local and national SHM offerings, I look forward to my leadership and operations skills being bolstered at SHM’s Leadership Academy this fall in Vancouver. As APCs hold more and more vital roles within HM groups, it’s integral that, along the way, our leadership skills are recognized and honed as well.
As an SHM member of over 10 years, what has been most valuable for you as a physician assistant?
The relationships. Networking, sharing ideas, pushing the status quo with other like-minded clinicians from around the country is invigorating. Because of SHM, I have an APC network from coast to coast – a lattice of clinicians that are linked by dedication and enthusiasm to hospital medicine.
What advice do you have for early-career physician assistants looking to work in hospital medicine?
Find a hospital medicine group whose culture allows and supports your growth as an advanced practice clinician. In an exemplary HM model, the delegated autonomy of an APC should widen and deepen over time. Seek out a team that appreciates the importance of this evolution.
Ms. Steele is marketing communications specialist at the Society of Hospital Medicine.
Editor’s note: Each month, SHM puts the spotlight on some of our most active members who are making substantial contributions to hospital medicine. Visit www.hospitalmedicine.org for more information on how you can lend your expertise to help SHM improve the care of hospitalized patients.
This month, The Hospitalist spotlights Meredith K. Wold, PA-C, APC supervisor, Hospital Medicine and Critical Care, at Regions Hospital in St. Paul, Minn., and adjunct faculty, Augsburg University Physician Assistant Program. Ms. Wold is a long-time member of SHM and the recipient of this year’s Clinical Excellence Award for Nurse Practitioners and Physician Assistants.
How did you first hear of SHM and why did you decide to become a member?
I’ve always recognized the importance of engaging in a community beyond my daily practice. Shortly after starting my career in hospital medicine, I quickly recognized this was a belief shared and cultivated by my hospital medicine group as well. Our HM group at HealthPartners has a long history of SHM participation. As our advanced practice clinician (APC) group grew, I knew engagement at the national level was critical to ensure that our ongoing evolution was supported, sustained, and shared.
What does it mean to you to receive SHM’s Clinical Excellence Award for nurse practitioners and physician assistants?
Being awarded the SHM Clinical Excellence Award is remarkable. I work alongside really, really amazing people, and every day I strive toward the exceptionally high bar they set. I’m passionate and committed to hospital medicine, and I’m so very grateful this is appreciated.
Which SHM conferences have you attended? Tell us about some of the highlights from these courses.
The first SHM annual conference I attended was in 2008 in sunny San Diego. I’d been a physician assistant (PA) for barely a year. I remember being so energized by the passion and commitment of the speakers and attendees. I harnessed that energy and spent the next several years being part of a growing APC group at Regions Hospital in St. Paul, Minn., where our HM group holds partnership and innovation at its core. You can imagine my excitement when I was asked to speak about APC practice models at HM16. Fellow APC Emily Thornhill Davis and I spoke to a standing-room only audience! Emily and I partnered again as faculty at HM17. I look forward to being part of a panel discussion at HM18 in Orlando (alongside some SHM trailblazers!).
Closer to home, I’ve taken advantage of phenomenal opportunities hosted by our local chapter of SHM. My colleagues Benji Mathews, MD, and Kreegan Reierson, MD, have led Point-of-Care Ultrasound (POCUS) training courses regionally and nationally. Their comprehensive, hands-on course ensured that I had the foundation to incorporate portable ultrasound into my practice. Thank goodness for their refresher course as well; my skills were rusty after a long maternity leave!
Given the tremendous clinical growth I have absorbed through local and national SHM offerings, I look forward to my leadership and operations skills being bolstered at SHM’s Leadership Academy this fall in Vancouver. As APCs hold more and more vital roles within HM groups, it’s integral that, along the way, our leadership skills are recognized and honed as well.
As an SHM member of over 10 years, what has been most valuable for you as a physician assistant?
The relationships. Networking, sharing ideas, pushing the status quo with other like-minded clinicians from around the country is invigorating. Because of SHM, I have an APC network from coast to coast – a lattice of clinicians that are linked by dedication and enthusiasm to hospital medicine.
What advice do you have for early-career physician assistants looking to work in hospital medicine?
Find a hospital medicine group whose culture allows and supports your growth as an advanced practice clinician. In an exemplary HM model, the delegated autonomy of an APC should widen and deepen over time. Seek out a team that appreciates the importance of this evolution.
Ms. Steele is marketing communications specialist at the Society of Hospital Medicine.
VIDEO: Intestinal remodeling contributes to HbA1c drop after Roux-en-Y gastric bypass
CHICAGO – Of medical and surgical tactics to tackle long-term weight loss, , and gene expression in the Roux limb may hold the key to the surgery’s efficacy, according to an ongoing study.
“We know that Roux-en-Y gastric bypass surgery is highly effective as not only a weight-loss therapy, but more and more we’re appreciating its role as a diabetes therapy as well,” said Margaret Stefater, MD, PhD, speaking in an interview at the annual meeting of the Endocrine Society.
The study, she said, was designed to learn more about the intestine’s contribution to the salubrious effect that Roux-en-Y surgery has on diabetes.
“We used microarray in order to characterize gene expression in the intestine” to gain a broad understanding of the processes that are altered after surgery, said Dr. Stefater, a pediatric endocrinology fellow at Boston Children’s Hospital. More specifically, though, the study looked at an individual’s changes in gene expression over time and correlated those changes with that patient’s clinical picture.
The data reported by Dr. Stefater and shared in a press conference, represent part of an ongoing longitudinal prospective study of 32 patients.
“The study aims to characterize gene expression for the first postoperative year,” and findings from the first 6 postoperative months of 19 patients were shared at the meeting, said Dr. Stefater. “This is the first look at our cohort.”
So far, she and her colleagues have compared gene expression using microarray at 1 month and 6 months post-surgery, comparing change across time and change from baseline data.
From hundreds of candidate genes, Dr. Stefater and her colleagues have developed a smaller gene list that, even in the first postoperative month, is predictive of changes in hemoglobin A1c levels over time. “Remarkably, the changes in a select list of genes out to 1 month is actually able to predict hemoglobin A1c levels out to 1 year,” she said. “This speaks to the fact that biological reprogramming in the intestine is somehow related to glycemic response in patients.
“We hope that by understanding these processes, we can home in on those processes that are most likely to be mechanistically responsible for these changes, and then to reverse-engineer this surgery to identify processes or targets which may be good places to start when we think about creating better, or nonsurgical, therapies for people who have obesity and diabetes,” said Dr. Stefater.
Dr. Stefater reported no relevant financial disclosures.
SOURCE: Stefater MA et al. ENDO 2018, Abstract OR 12-6.
CHICAGO – Of medical and surgical tactics to tackle long-term weight loss, , and gene expression in the Roux limb may hold the key to the surgery’s efficacy, according to an ongoing study.
“We know that Roux-en-Y gastric bypass surgery is highly effective as not only a weight-loss therapy, but more and more we’re appreciating its role as a diabetes therapy as well,” said Margaret Stefater, MD, PhD, speaking in an interview at the annual meeting of the Endocrine Society.
The study, she said, was designed to learn more about the intestine’s contribution to the salubrious effect that Roux-en-Y surgery has on diabetes.
“We used microarray in order to characterize gene expression in the intestine” to gain a broad understanding of the processes that are altered after surgery, said Dr. Stefater, a pediatric endocrinology fellow at Boston Children’s Hospital. More specifically, though, the study looked at an individual’s changes in gene expression over time and correlated those changes with that patient’s clinical picture.
The data reported by Dr. Stefater and shared in a press conference, represent part of an ongoing longitudinal prospective study of 32 patients.
“The study aims to characterize gene expression for the first postoperative year,” and findings from the first 6 postoperative months of 19 patients were shared at the meeting, said Dr. Stefater. “This is the first look at our cohort.”
So far, she and her colleagues have compared gene expression using microarray at 1 month and 6 months post-surgery, comparing change across time and change from baseline data.
From hundreds of candidate genes, Dr. Stefater and her colleagues have developed a smaller gene list that, even in the first postoperative month, is predictive of changes in hemoglobin A1c levels over time. “Remarkably, the changes in a select list of genes out to 1 month is actually able to predict hemoglobin A1c levels out to 1 year,” she said. “This speaks to the fact that biological reprogramming in the intestine is somehow related to glycemic response in patients.
“We hope that by understanding these processes, we can home in on those processes that are most likely to be mechanistically responsible for these changes, and then to reverse-engineer this surgery to identify processes or targets which may be good places to start when we think about creating better, or nonsurgical, therapies for people who have obesity and diabetes,” said Dr. Stefater.
Dr. Stefater reported no relevant financial disclosures.
SOURCE: Stefater MA et al. ENDO 2018, Abstract OR 12-6.
CHICAGO – Of medical and surgical tactics to tackle long-term weight loss, , and gene expression in the Roux limb may hold the key to the surgery’s efficacy, according to an ongoing study.
“We know that Roux-en-Y gastric bypass surgery is highly effective as not only a weight-loss therapy, but more and more we’re appreciating its role as a diabetes therapy as well,” said Margaret Stefater, MD, PhD, speaking in an interview at the annual meeting of the Endocrine Society.
The study, she said, was designed to learn more about the intestine’s contribution to the salubrious effect that Roux-en-Y surgery has on diabetes.
“We used microarray in order to characterize gene expression in the intestine” to gain a broad understanding of the processes that are altered after surgery, said Dr. Stefater, a pediatric endocrinology fellow at Boston Children’s Hospital. More specifically, though, the study looked at an individual’s changes in gene expression over time and correlated those changes with that patient’s clinical picture.
The data reported by Dr. Stefater and shared in a press conference, represent part of an ongoing longitudinal prospective study of 32 patients.
“The study aims to characterize gene expression for the first postoperative year,” and findings from the first 6 postoperative months of 19 patients were shared at the meeting, said Dr. Stefater. “This is the first look at our cohort.”
So far, she and her colleagues have compared gene expression using microarray at 1 month and 6 months post-surgery, comparing change across time and change from baseline data.
From hundreds of candidate genes, Dr. Stefater and her colleagues have developed a smaller gene list that, even in the first postoperative month, is predictive of changes in hemoglobin A1c levels over time. “Remarkably, the changes in a select list of genes out to 1 month is actually able to predict hemoglobin A1c levels out to 1 year,” she said. “This speaks to the fact that biological reprogramming in the intestine is somehow related to glycemic response in patients.
“We hope that by understanding these processes, we can home in on those processes that are most likely to be mechanistically responsible for these changes, and then to reverse-engineer this surgery to identify processes or targets which may be good places to start when we think about creating better, or nonsurgical, therapies for people who have obesity and diabetes,” said Dr. Stefater.
Dr. Stefater reported no relevant financial disclosures.
SOURCE: Stefater MA et al. ENDO 2018, Abstract OR 12-6.
REPORTING FROM ENDO 2018
Protocol helped identify hospitalized children at risk for VTE
SAN DIEGO – Following simple institutional care guidelines helped clinicians identify pediatric patients at moderate-to-severe risk of venous thromboembolism (VTE), results from a single-center study showed.
“Hospital-acquired VTE is on the rise in the pediatric population,” lead study author Emily Southard, MD, said at the biennial summit of the Thrombosis & Hemostasis Societies of North America. “This consists of a DVT or [pulmonary embolism] 48 hours or more after admission, or any time at the site of a central venous catheter.”
One published study found a 70% increased incidence in the pediatric population from 2001-2007 (Pediatrics 2009;124[4]:1001-8). More than half of the children in that study (63%) had at least one coexisting complex medical condition, with malignancy being the most common.
Hospital-acquired VTE cases tend to harbor a number of complications, said Dr. Southard, who is a pediatric hematology/oncology fellow at Children’s Hospital Colorado, Aurora. For example, 15%-20% of patients with a DVT will have a pulmonary embolism (PE) as well, 26% of patients with upper or lower extremity DVT develop post-thrombotic syndrome, and 3% of patients with PE develop chronic pulmonary hypertension.
“Medical costs are also impacted,” she said. “The cost for a hospital-acquired VTE in pediatrics increased the length of stay by about 8 days and increased the cost of hospital admission by more than $27,000.”
Known risk factors for VTE in this patient population include ICU admission (Odds Ratio, 2.14), presence of a central venous catheter (OR, 2.12), mechanical ventilation (OR, 1.56), and prolonged admission (OR, 1.03 for each day).
Risk factors in pediatric trauma patients include ICU admission (OR, 6.25), transfusion of blood products (OR, 2.1), lower extremity fracture (OR, 1.8), and neurosurgery (OR, 2.13). She and her associates hypothesized that understanding the relative contributions of clinical, biological, and genetic risk factors for pediatric VTE would help appropriately risk-stratify patients and allow better prophylactic approaches.
In 2012, Children’s Hospital Colorado implemented a VTE risk assessment tool as part of a hospital-wide patient safety initiative. The assessment is triggered via an Epic Best Practice Advisory to complete in certain higher-risk patients, including ICU patients, hematology/oncology floor patients, any patients with a central line catheter, and those who are over age 12 and obese.
Clinicians also assess for risk factors such as significant infection, recent surgery, and personal or family history of thrombophilia. Next, they classify each patient’s risk of hospital-acquired VTE as high, moderate, or low risk.
In a pilot study, Dr. Southard and her associates set out to validate the accuracy of the institution’s VTE risk assessment tool since it was implemented in 2012. She presented findings from 215 hospital-acquired VTE cases in patients younger than age 18, compared with age-matched inpatient controls. Data from patients under 6 months of age is available after October 2016, coinciding with a change in definition of pediatric hospital-acquired VTE.
Most hospital-acquired VTE patients (77.2%) ranged in age from 1-17 years. The number of patients admitted for a trauma diagnosis was similar between VTE cases and controls (7.4% vs. 7.9%, respectively). However, compared with controls, a significantly greater number of VTE cases were immobile (41.8% vs. 10.3%, respectively), required ICU admission (86.4% vs. 26.5%), had a central venous catheter (80.4% vs. 10.9%), had a positive blood culture (16.7% vs. 1.9%), required surgery or a medical procedure (57.7% vs. 36.7%), and had a longer procedure time (a mean of 151 vs. 133 minutes).
The researchers also found that upon initial admission, 7.9% of VTE cases were identified as high risk and another 21.9% were identified as moderate risk, compared with 1.2% and 3.7% in the controls, respectively.
“Patients identified as moderate or high risk for VTE were generally more medically complex patients,” Dr. Southard said.
Future directions of this project include expanding the patient population that has a risk assessment performed.
Dr. Southard reported having no financial disclosures.
SOURCE: Southard E et al. THSNA 2018.
SAN DIEGO – Following simple institutional care guidelines helped clinicians identify pediatric patients at moderate-to-severe risk of venous thromboembolism (VTE), results from a single-center study showed.
“Hospital-acquired VTE is on the rise in the pediatric population,” lead study author Emily Southard, MD, said at the biennial summit of the Thrombosis & Hemostasis Societies of North America. “This consists of a DVT or [pulmonary embolism] 48 hours or more after admission, or any time at the site of a central venous catheter.”
One published study found a 70% increased incidence in the pediatric population from 2001-2007 (Pediatrics 2009;124[4]:1001-8). More than half of the children in that study (63%) had at least one coexisting complex medical condition, with malignancy being the most common.
Hospital-acquired VTE cases tend to harbor a number of complications, said Dr. Southard, who is a pediatric hematology/oncology fellow at Children’s Hospital Colorado, Aurora. For example, 15%-20% of patients with a DVT will have a pulmonary embolism (PE) as well, 26% of patients with upper or lower extremity DVT develop post-thrombotic syndrome, and 3% of patients with PE develop chronic pulmonary hypertension.
“Medical costs are also impacted,” she said. “The cost for a hospital-acquired VTE in pediatrics increased the length of stay by about 8 days and increased the cost of hospital admission by more than $27,000.”
Known risk factors for VTE in this patient population include ICU admission (Odds Ratio, 2.14), presence of a central venous catheter (OR, 2.12), mechanical ventilation (OR, 1.56), and prolonged admission (OR, 1.03 for each day).
Risk factors in pediatric trauma patients include ICU admission (OR, 6.25), transfusion of blood products (OR, 2.1), lower extremity fracture (OR, 1.8), and neurosurgery (OR, 2.13). She and her associates hypothesized that understanding the relative contributions of clinical, biological, and genetic risk factors for pediatric VTE would help appropriately risk-stratify patients and allow better prophylactic approaches.
In 2012, Children’s Hospital Colorado implemented a VTE risk assessment tool as part of a hospital-wide patient safety initiative. The assessment is triggered via an Epic Best Practice Advisory to complete in certain higher-risk patients, including ICU patients, hematology/oncology floor patients, any patients with a central line catheter, and those who are over age 12 and obese.
Clinicians also assess for risk factors such as significant infection, recent surgery, and personal or family history of thrombophilia. Next, they classify each patient’s risk of hospital-acquired VTE as high, moderate, or low risk.
In a pilot study, Dr. Southard and her associates set out to validate the accuracy of the institution’s VTE risk assessment tool since it was implemented in 2012. She presented findings from 215 hospital-acquired VTE cases in patients younger than age 18, compared with age-matched inpatient controls. Data from patients under 6 months of age is available after October 2016, coinciding with a change in definition of pediatric hospital-acquired VTE.
Most hospital-acquired VTE patients (77.2%) ranged in age from 1-17 years. The number of patients admitted for a trauma diagnosis was similar between VTE cases and controls (7.4% vs. 7.9%, respectively). However, compared with controls, a significantly greater number of VTE cases were immobile (41.8% vs. 10.3%, respectively), required ICU admission (86.4% vs. 26.5%), had a central venous catheter (80.4% vs. 10.9%), had a positive blood culture (16.7% vs. 1.9%), required surgery or a medical procedure (57.7% vs. 36.7%), and had a longer procedure time (a mean of 151 vs. 133 minutes).
The researchers also found that upon initial admission, 7.9% of VTE cases were identified as high risk and another 21.9% were identified as moderate risk, compared with 1.2% and 3.7% in the controls, respectively.
“Patients identified as moderate or high risk for VTE were generally more medically complex patients,” Dr. Southard said.
Future directions of this project include expanding the patient population that has a risk assessment performed.
Dr. Southard reported having no financial disclosures.
SOURCE: Southard E et al. THSNA 2018.
SAN DIEGO – Following simple institutional care guidelines helped clinicians identify pediatric patients at moderate-to-severe risk of venous thromboembolism (VTE), results from a single-center study showed.
“Hospital-acquired VTE is on the rise in the pediatric population,” lead study author Emily Southard, MD, said at the biennial summit of the Thrombosis & Hemostasis Societies of North America. “This consists of a DVT or [pulmonary embolism] 48 hours or more after admission, or any time at the site of a central venous catheter.”
One published study found a 70% increased incidence in the pediatric population from 2001-2007 (Pediatrics 2009;124[4]:1001-8). More than half of the children in that study (63%) had at least one coexisting complex medical condition, with malignancy being the most common.
Hospital-acquired VTE cases tend to harbor a number of complications, said Dr. Southard, who is a pediatric hematology/oncology fellow at Children’s Hospital Colorado, Aurora. For example, 15%-20% of patients with a DVT will have a pulmonary embolism (PE) as well, 26% of patients with upper or lower extremity DVT develop post-thrombotic syndrome, and 3% of patients with PE develop chronic pulmonary hypertension.
“Medical costs are also impacted,” she said. “The cost for a hospital-acquired VTE in pediatrics increased the length of stay by about 8 days and increased the cost of hospital admission by more than $27,000.”
Known risk factors for VTE in this patient population include ICU admission (Odds Ratio, 2.14), presence of a central venous catheter (OR, 2.12), mechanical ventilation (OR, 1.56), and prolonged admission (OR, 1.03 for each day).
Risk factors in pediatric trauma patients include ICU admission (OR, 6.25), transfusion of blood products (OR, 2.1), lower extremity fracture (OR, 1.8), and neurosurgery (OR, 2.13). She and her associates hypothesized that understanding the relative contributions of clinical, biological, and genetic risk factors for pediatric VTE would help appropriately risk-stratify patients and allow better prophylactic approaches.
In 2012, Children’s Hospital Colorado implemented a VTE risk assessment tool as part of a hospital-wide patient safety initiative. The assessment is triggered via an Epic Best Practice Advisory to complete in certain higher-risk patients, including ICU patients, hematology/oncology floor patients, any patients with a central line catheter, and those who are over age 12 and obese.
Clinicians also assess for risk factors such as significant infection, recent surgery, and personal or family history of thrombophilia. Next, they classify each patient’s risk of hospital-acquired VTE as high, moderate, or low risk.
In a pilot study, Dr. Southard and her associates set out to validate the accuracy of the institution’s VTE risk assessment tool since it was implemented in 2012. She presented findings from 215 hospital-acquired VTE cases in patients younger than age 18, compared with age-matched inpatient controls. Data from patients under 6 months of age is available after October 2016, coinciding with a change in definition of pediatric hospital-acquired VTE.
Most hospital-acquired VTE patients (77.2%) ranged in age from 1-17 years. The number of patients admitted for a trauma diagnosis was similar between VTE cases and controls (7.4% vs. 7.9%, respectively). However, compared with controls, a significantly greater number of VTE cases were immobile (41.8% vs. 10.3%, respectively), required ICU admission (86.4% vs. 26.5%), had a central venous catheter (80.4% vs. 10.9%), had a positive blood culture (16.7% vs. 1.9%), required surgery or a medical procedure (57.7% vs. 36.7%), and had a longer procedure time (a mean of 151 vs. 133 minutes).
The researchers also found that upon initial admission, 7.9% of VTE cases were identified as high risk and another 21.9% were identified as moderate risk, compared with 1.2% and 3.7% in the controls, respectively.
“Patients identified as moderate or high risk for VTE were generally more medically complex patients,” Dr. Southard said.
Future directions of this project include expanding the patient population that has a risk assessment performed.
Dr. Southard reported having no financial disclosures.
SOURCE: Southard E et al. THSNA 2018.
REPORTING FROM THSNA 2018
Key clinical point:
Major finding: A significantly greater number of VTE patients were immobile (41.8% vs. 10.3%, respectively), required ICU admission (86.4% vs. 26.5%), and had a central venous catheter (80.4% vs. 10.9%), compared with controls.
Study details: A retrospective analysis of 215 hospital-acquired VTE cases in patients younger than age 18.
Disclosures: Dr. Southard reported having no financial disclosures.
Source: Southard E et al. THSNA 2018.
Certifications, training to increase addiction medicine specialists
Two new workforce developments aim to increase the number of addiction medicine specialists and provide new training opportunities in the subspecialty.
The American Board of Medical Specialties (ABMS) recently certified its first formal wave of addiction medicine physicians, adding 1,200 specialists to the field. Addiction medicine was first recognized as a subspecialty by ABMS in 2015, followed by the first certification exam in 2017.
The two developments “will change the landscape in substance use prevention, early intervention, and in addiction treatment and management,” said Lon R. Hays, MD, president of The Addiction Medicine Foundation, in Chevy Chase, Md., and director of the addiction medicine fellowship program at the University of Kentucky, Lexington.
“Many more trained physicians will be available to address the opioid crisis and other addictions,” Dr. Hays said in a statement. “They will also be able to help prevent and intervene early with unhealthy substance use in all its forms. For the first time, when aspiring physicians consider a career path, they will now have as an available choice an addiction medicine specialty that meets the highest standards of medicine.”
“When the American Board of Medical Specialties welcomed addiction medicine as its newest subspecialty, it in a lot of ways, legitimized our discipline,” Dr. Brennan said in an interview. “The American Board of Medical Specialties really represents the ‘House of Medicine.’ Being able to enter into that, it gives us a measure of credibility in the eyes of the public, and it basically codifies that these physicians who have passed this board exam have achieved a level of competency and knowledge that makes them trustworthy and safe to provide care to folks suffering from addiction.”
While the 1,200 additional addiction medicine specialists are an improvement, many more are needed, Dr. Brennan said, adding that he is optimistic that the new addiction medicine training opportunities provided by ACGME will help achieve higher numbers.
“For addiction medicine, we’ve had fellowships for about 10 years, but the funding for those fellowships was really challenging,” Dr. Brennan said. “Once you get ACGME-accredited, it gives you the ability to partake of [Centers for Medicare & Medicaid Services] funding that funds most of the graduate medical education residency fellowship spots in the United States. ACGME is the gold standard. I think that makes us much more potentially attractive for graduating physicians who are finishing their residencies.”
The certification of new addiction specialists is welcome news, particularly in the midst of the current epidemic, added Clif Knight, MD, senior vice president for education for the American Academy of Family Physicians.
“This is really good news [especially considering], the difficulty that the country is having with so much addiction – of course opioids are in the forefront – but there are so many different types of addiction,” he said in an interview. “This is good news that the certification is available and that physicians are pursuing obtaining additional expertise and recognition in their ability to treat addictions.”
Dr. Knight expressed appreciation that the ACGME training opportunities in addiction medicine are open to doctors of various specialties, he said.
“A lot of times subspecialty fellowships are only available to one specialty,” said Dr. Knight. “In this case, it looks like they’ve been very deliberate to make this available to multiple specialties. I think that really sends an important message that this is not just one specialty that is focused on [addiction medicine], but really should be something that all specialties are engaged and involved in.”
*This article was updated on 4/2/2018.
Two new workforce developments aim to increase the number of addiction medicine specialists and provide new training opportunities in the subspecialty.
The American Board of Medical Specialties (ABMS) recently certified its first formal wave of addiction medicine physicians, adding 1,200 specialists to the field. Addiction medicine was first recognized as a subspecialty by ABMS in 2015, followed by the first certification exam in 2017.
The two developments “will change the landscape in substance use prevention, early intervention, and in addiction treatment and management,” said Lon R. Hays, MD, president of The Addiction Medicine Foundation, in Chevy Chase, Md., and director of the addiction medicine fellowship program at the University of Kentucky, Lexington.
“Many more trained physicians will be available to address the opioid crisis and other addictions,” Dr. Hays said in a statement. “They will also be able to help prevent and intervene early with unhealthy substance use in all its forms. For the first time, when aspiring physicians consider a career path, they will now have as an available choice an addiction medicine specialty that meets the highest standards of medicine.”
“When the American Board of Medical Specialties welcomed addiction medicine as its newest subspecialty, it in a lot of ways, legitimized our discipline,” Dr. Brennan said in an interview. “The American Board of Medical Specialties really represents the ‘House of Medicine.’ Being able to enter into that, it gives us a measure of credibility in the eyes of the public, and it basically codifies that these physicians who have passed this board exam have achieved a level of competency and knowledge that makes them trustworthy and safe to provide care to folks suffering from addiction.”
While the 1,200 additional addiction medicine specialists are an improvement, many more are needed, Dr. Brennan said, adding that he is optimistic that the new addiction medicine training opportunities provided by ACGME will help achieve higher numbers.
“For addiction medicine, we’ve had fellowships for about 10 years, but the funding for those fellowships was really challenging,” Dr. Brennan said. “Once you get ACGME-accredited, it gives you the ability to partake of [Centers for Medicare & Medicaid Services] funding that funds most of the graduate medical education residency fellowship spots in the United States. ACGME is the gold standard. I think that makes us much more potentially attractive for graduating physicians who are finishing their residencies.”
The certification of new addiction specialists is welcome news, particularly in the midst of the current epidemic, added Clif Knight, MD, senior vice president for education for the American Academy of Family Physicians.
“This is really good news [especially considering], the difficulty that the country is having with so much addiction – of course opioids are in the forefront – but there are so many different types of addiction,” he said in an interview. “This is good news that the certification is available and that physicians are pursuing obtaining additional expertise and recognition in their ability to treat addictions.”
Dr. Knight expressed appreciation that the ACGME training opportunities in addiction medicine are open to doctors of various specialties, he said.
“A lot of times subspecialty fellowships are only available to one specialty,” said Dr. Knight. “In this case, it looks like they’ve been very deliberate to make this available to multiple specialties. I think that really sends an important message that this is not just one specialty that is focused on [addiction medicine], but really should be something that all specialties are engaged and involved in.”
*This article was updated on 4/2/2018.
Two new workforce developments aim to increase the number of addiction medicine specialists and provide new training opportunities in the subspecialty.
The American Board of Medical Specialties (ABMS) recently certified its first formal wave of addiction medicine physicians, adding 1,200 specialists to the field. Addiction medicine was first recognized as a subspecialty by ABMS in 2015, followed by the first certification exam in 2017.
The two developments “will change the landscape in substance use prevention, early intervention, and in addiction treatment and management,” said Lon R. Hays, MD, president of The Addiction Medicine Foundation, in Chevy Chase, Md., and director of the addiction medicine fellowship program at the University of Kentucky, Lexington.
“Many more trained physicians will be available to address the opioid crisis and other addictions,” Dr. Hays said in a statement. “They will also be able to help prevent and intervene early with unhealthy substance use in all its forms. For the first time, when aspiring physicians consider a career path, they will now have as an available choice an addiction medicine specialty that meets the highest standards of medicine.”
“When the American Board of Medical Specialties welcomed addiction medicine as its newest subspecialty, it in a lot of ways, legitimized our discipline,” Dr. Brennan said in an interview. “The American Board of Medical Specialties really represents the ‘House of Medicine.’ Being able to enter into that, it gives us a measure of credibility in the eyes of the public, and it basically codifies that these physicians who have passed this board exam have achieved a level of competency and knowledge that makes them trustworthy and safe to provide care to folks suffering from addiction.”
While the 1,200 additional addiction medicine specialists are an improvement, many more are needed, Dr. Brennan said, adding that he is optimistic that the new addiction medicine training opportunities provided by ACGME will help achieve higher numbers.
“For addiction medicine, we’ve had fellowships for about 10 years, but the funding for those fellowships was really challenging,” Dr. Brennan said. “Once you get ACGME-accredited, it gives you the ability to partake of [Centers for Medicare & Medicaid Services] funding that funds most of the graduate medical education residency fellowship spots in the United States. ACGME is the gold standard. I think that makes us much more potentially attractive for graduating physicians who are finishing their residencies.”
The certification of new addiction specialists is welcome news, particularly in the midst of the current epidemic, added Clif Knight, MD, senior vice president for education for the American Academy of Family Physicians.
“This is really good news [especially considering], the difficulty that the country is having with so much addiction – of course opioids are in the forefront – but there are so many different types of addiction,” he said in an interview. “This is good news that the certification is available and that physicians are pursuing obtaining additional expertise and recognition in their ability to treat addictions.”
Dr. Knight expressed appreciation that the ACGME training opportunities in addiction medicine are open to doctors of various specialties, he said.
“A lot of times subspecialty fellowships are only available to one specialty,” said Dr. Knight. “In this case, it looks like they’ve been very deliberate to make this available to multiple specialties. I think that really sends an important message that this is not just one specialty that is focused on [addiction medicine], but really should be something that all specialties are engaged and involved in.”
*This article was updated on 4/2/2018.
Single screening for Lynch syndrome beats sequential tests in CRC
Physicians could more accurately test patients with colon cancer for Lynch syndrome by using a single tumor sequencing test instead of the current protocol of up to six sequential tests, a new study suggests. The process may also be faster in some cases.
“We found that up-front tumor testing is actually more sensitive and more specific for detecting Lynch syndrome than the old, multiple-test model,” study coauthor Rachel Pearlman, MS, a genetic counselor at Ohio State University Wexner Medical Center, said in an interview. “Tumor sequencing resulted in a 10% improvement in Lynch syndrome detection rates while also providing important information about treatment options for the patients.”
According to Ms. Pearlman, screening for Lynch syndrome is recommended for all patients with colon cancer and can require multiple sequential tests. It affects an estimated 3% of these patients, putting them at higher risk of several kinds of cancers including endometrial, ovarian, and gastric.
“Identifying the condition at the time of diagnosis can potentially impact treatment options and also help to facilitate intensive surveillance for other types of cancer,” Ms. Pearlman said. “In addition, we’ll know that the patients’ family members are at risk and will benefit from genetic counseling and testing.”
However, “traditional sequential testing is complex and confusing to patients and clinicians and occurs over a prolonged period, incurring risk for loss to follow-up,” the investigators wrote in JAMA Oncology.
For the new study, the researchers sought to confirm whether tumor sequencing, a form of genetic testing, would be faster and more accurate than the current sequential testing approach.
In a multicenter study, they prospectively tested tumor DNA in 2015 and 2016. They also tested another 46 patients who had been previously confirmed to have Lynch syndrome.
The average age of the patients was 60 years, 52% were women, 89% were white. Hispanics and Asians made up just 1% each of the total. Most of the cancers were stage II (26%) or stage III (40%).
Tumor sequencing identified all of the 46 confirmed cases of Lynch syndrome and turned up 12 more in the larger group, the researchers found.
Sensitivity of tumor sequencing was better (100%; 95% confidence interval, 93.8%-100%) than immunohistochemical testing plus BRAF (89.7%; 95% CI, 78.8%-96.1%; P = .04) and microsatellite instability testing plus BRAF (91.4%; 95% CI, 81.0%-97.1%; P = .07), and its specificity was equal to the other approaches, Ms. Pearlman and her associates reported.
Researchers also reported that tumor sequencing identified nearly 300 cases of tumors with genetic mutations that could impact therapy.
Eesults from tumor sequencing are available in a median of 2 weeks, which may be longer than some other tests, but “it requires less time overall by eliminating multiple follow-up tests in a subset of cases,” the study authors wrote.
“While this new test is currently more expensive than traditional step-wise testing, it will eliminate many other tests for a subset of patients so that it may be more cost-effective overall. If it is not now, it will certainly be in the future as the costs of tumor sequencing continue to decline,” Ms. Pearlman said. “However, formal cost-analysis studies will be necessary to determine if this is a cost-effective approach.”
The study was funded by a grant from Pelotonia, an annual cycling event that supports cancer research, and the National Cancer Institute. Myriad Genetics donated the sequence testing used for some patients.
SOURCE: Hampel H et al. JAMA Oncol. 2018 Mar 29. doi: 10.1001/jamaoncol.2018.0104.
Physicians could more accurately test patients with colon cancer for Lynch syndrome by using a single tumor sequencing test instead of the current protocol of up to six sequential tests, a new study suggests. The process may also be faster in some cases.
“We found that up-front tumor testing is actually more sensitive and more specific for detecting Lynch syndrome than the old, multiple-test model,” study coauthor Rachel Pearlman, MS, a genetic counselor at Ohio State University Wexner Medical Center, said in an interview. “Tumor sequencing resulted in a 10% improvement in Lynch syndrome detection rates while also providing important information about treatment options for the patients.”
According to Ms. Pearlman, screening for Lynch syndrome is recommended for all patients with colon cancer and can require multiple sequential tests. It affects an estimated 3% of these patients, putting them at higher risk of several kinds of cancers including endometrial, ovarian, and gastric.
“Identifying the condition at the time of diagnosis can potentially impact treatment options and also help to facilitate intensive surveillance for other types of cancer,” Ms. Pearlman said. “In addition, we’ll know that the patients’ family members are at risk and will benefit from genetic counseling and testing.”
However, “traditional sequential testing is complex and confusing to patients and clinicians and occurs over a prolonged period, incurring risk for loss to follow-up,” the investigators wrote in JAMA Oncology.
For the new study, the researchers sought to confirm whether tumor sequencing, a form of genetic testing, would be faster and more accurate than the current sequential testing approach.
In a multicenter study, they prospectively tested tumor DNA in 2015 and 2016. They also tested another 46 patients who had been previously confirmed to have Lynch syndrome.
The average age of the patients was 60 years, 52% were women, 89% were white. Hispanics and Asians made up just 1% each of the total. Most of the cancers were stage II (26%) or stage III (40%).
Tumor sequencing identified all of the 46 confirmed cases of Lynch syndrome and turned up 12 more in the larger group, the researchers found.
Sensitivity of tumor sequencing was better (100%; 95% confidence interval, 93.8%-100%) than immunohistochemical testing plus BRAF (89.7%; 95% CI, 78.8%-96.1%; P = .04) and microsatellite instability testing plus BRAF (91.4%; 95% CI, 81.0%-97.1%; P = .07), and its specificity was equal to the other approaches, Ms. Pearlman and her associates reported.
Researchers also reported that tumor sequencing identified nearly 300 cases of tumors with genetic mutations that could impact therapy.
Eesults from tumor sequencing are available in a median of 2 weeks, which may be longer than some other tests, but “it requires less time overall by eliminating multiple follow-up tests in a subset of cases,” the study authors wrote.
“While this new test is currently more expensive than traditional step-wise testing, it will eliminate many other tests for a subset of patients so that it may be more cost-effective overall. If it is not now, it will certainly be in the future as the costs of tumor sequencing continue to decline,” Ms. Pearlman said. “However, formal cost-analysis studies will be necessary to determine if this is a cost-effective approach.”
The study was funded by a grant from Pelotonia, an annual cycling event that supports cancer research, and the National Cancer Institute. Myriad Genetics donated the sequence testing used for some patients.
SOURCE: Hampel H et al. JAMA Oncol. 2018 Mar 29. doi: 10.1001/jamaoncol.2018.0104.
Physicians could more accurately test patients with colon cancer for Lynch syndrome by using a single tumor sequencing test instead of the current protocol of up to six sequential tests, a new study suggests. The process may also be faster in some cases.
“We found that up-front tumor testing is actually more sensitive and more specific for detecting Lynch syndrome than the old, multiple-test model,” study coauthor Rachel Pearlman, MS, a genetic counselor at Ohio State University Wexner Medical Center, said in an interview. “Tumor sequencing resulted in a 10% improvement in Lynch syndrome detection rates while also providing important information about treatment options for the patients.”
According to Ms. Pearlman, screening for Lynch syndrome is recommended for all patients with colon cancer and can require multiple sequential tests. It affects an estimated 3% of these patients, putting them at higher risk of several kinds of cancers including endometrial, ovarian, and gastric.
“Identifying the condition at the time of diagnosis can potentially impact treatment options and also help to facilitate intensive surveillance for other types of cancer,” Ms. Pearlman said. “In addition, we’ll know that the patients’ family members are at risk and will benefit from genetic counseling and testing.”
However, “traditional sequential testing is complex and confusing to patients and clinicians and occurs over a prolonged period, incurring risk for loss to follow-up,” the investigators wrote in JAMA Oncology.
For the new study, the researchers sought to confirm whether tumor sequencing, a form of genetic testing, would be faster and more accurate than the current sequential testing approach.
In a multicenter study, they prospectively tested tumor DNA in 2015 and 2016. They also tested another 46 patients who had been previously confirmed to have Lynch syndrome.
The average age of the patients was 60 years, 52% were women, 89% were white. Hispanics and Asians made up just 1% each of the total. Most of the cancers were stage II (26%) or stage III (40%).
Tumor sequencing identified all of the 46 confirmed cases of Lynch syndrome and turned up 12 more in the larger group, the researchers found.
Sensitivity of tumor sequencing was better (100%; 95% confidence interval, 93.8%-100%) than immunohistochemical testing plus BRAF (89.7%; 95% CI, 78.8%-96.1%; P = .04) and microsatellite instability testing plus BRAF (91.4%; 95% CI, 81.0%-97.1%; P = .07), and its specificity was equal to the other approaches, Ms. Pearlman and her associates reported.
Researchers also reported that tumor sequencing identified nearly 300 cases of tumors with genetic mutations that could impact therapy.
Eesults from tumor sequencing are available in a median of 2 weeks, which may be longer than some other tests, but “it requires less time overall by eliminating multiple follow-up tests in a subset of cases,” the study authors wrote.
“While this new test is currently more expensive than traditional step-wise testing, it will eliminate many other tests for a subset of patients so that it may be more cost-effective overall. If it is not now, it will certainly be in the future as the costs of tumor sequencing continue to decline,” Ms. Pearlman said. “However, formal cost-analysis studies will be necessary to determine if this is a cost-effective approach.”
The study was funded by a grant from Pelotonia, an annual cycling event that supports cancer research, and the National Cancer Institute. Myriad Genetics donated the sequence testing used for some patients.
SOURCE: Hampel H et al. JAMA Oncol. 2018 Mar 29. doi: 10.1001/jamaoncol.2018.0104.
FROM JAMA ONCOLOGY
Key clinical point: Tumor sequencing provides more accurate Lynch syndrome testing in colon cancer.
Major finding: Sensitivity of tumor sequencing was better (100%) than immunohistochemical testing plus BRAF (89.7%) and microsatellite instability testing plus BRAF (91.4%). Specificity was the same.
Study details: Prospective testing of 419 consecutive patients with colon cancer plus analysis of samples from 46 patients with confirmed Lynch syndrome.
Disclosures: The study was funded by a grant from Pelotonia, an annual cycling event that supports cancer research, and the National Cancer Institute. Myriad Genetics provided the sequence testing used for some of the patients.
Source: Hampel H et al. JAMA Oncol. 2018 Mar 29. doi: 10.1001/jamaoncol.2018.0104.
Warfarin dose capping avoided supratherapeutic INRs in hospitalized elderly
SAN DIEGO – A simple intervention of initial warfarin dose capping in hospitalized patients aged 85 years and older led to significant reductions in supratherapeutic INRs without a significant change in length of stay, a single-center study showed.
“We’re excited to see if these results are reproducible,” Jonathan Falsetta, PharmD, said at the biennial summit of the Thrombosis & Hemostasis Societies of North America. “We do feel that it may represent an important step forward in warfarin safety in a vulnerable patient population.”
“From this we gathered that we had an issue with dosing,” said Dr. Falsetta, who is assistant director of pharmacy clinical educational services at Plainview Hospital. “These patients were spiking dangerously high INRs, and we needed to do something about it.”
A review of current medical literature revealed a lack of well-validated recommendations regarding warfarin initiation in older patients, so Dr. Falsetta and his associates set out to create their own dose-capping recommendation. This involved limiting the initial dose of warfarin to 2.5 mg or less for hospitalized patients aged 85 years and older.
“We wanted this to be applicable to patients regardless if they were warfarin naïve or if they had been on warfarin prior to admission,” he said.
Before the roll out, clinical pharmacists and pharmacy residents conducted provider education on the initial dose capping protocol. Providers could order initial doses that exceeded 2.5 mg with valid clinical reasoning. Outcomes of interest were dosing protocol compliance and post-intervention analysis of INRs in this patient population. The pre-intervention period spanned from Nov. 1, 2014 through Oct. 31, 2015, while the post-intervention period spanned from Nov. 1, 2015 through Oct. 31, 2017. Dr. Falsetta reported data from 768 patients.
Between the pre-intervention and post-intervention periods, compliance with dose capping rose from 38.5% to 64.2% (P less than .001), the supratherapeutic INR rate dropped from 20.9% to 13.3% (P= .004), and the length of hospital stay in hours rose from a mean of 145.8 to a mean of 155.8, which was not statistically significant (P= .13).
Following the post-intervention period, the number of peak INRs in the 1 to 2 range rose by 15% and the number of peak INRs in the 2 to 3 range rose by 6%. At the same time, the number of peak INRs in the 3 to 4 range fell by 6%, the number of peak INRs in the 4 to 5 range fell by 36%, and the number of peak INRs in the 5 and greater range fell by 53%. These INR percentages represent relative increases and/or decreases.
“This was a relatively simple intervention that resulted in significant reductions in supratherapeutic INRs,” Dr. Falsetta said.
The researchers also observed that there was less IV vitamin K use after the dose capping intervention. “We can’t say for sure that this was tied to the intervention, but it was interesting, and it is something for us to take a look at, as well as roll this out in future iterations,” he said. “We are on the cusp of rolling this out at some of the tertiary sites within our health care system, and some of the community sites as well.”
He acknowledged certain limitations of the study, including its single-center design, relatively small sample size, and lack of clinical endpoints. “I’d like to be able to tie this to something like reduced bleeding events,” Dr. Falsetta said. “I think that’s something we need to explore in the future.”
Dr. Falsetta reported having no financial disclosures.
SOURCE: Falsetta J et al. THSNA 2018.
SAN DIEGO – A simple intervention of initial warfarin dose capping in hospitalized patients aged 85 years and older led to significant reductions in supratherapeutic INRs without a significant change in length of stay, a single-center study showed.
“We’re excited to see if these results are reproducible,” Jonathan Falsetta, PharmD, said at the biennial summit of the Thrombosis & Hemostasis Societies of North America. “We do feel that it may represent an important step forward in warfarin safety in a vulnerable patient population.”
“From this we gathered that we had an issue with dosing,” said Dr. Falsetta, who is assistant director of pharmacy clinical educational services at Plainview Hospital. “These patients were spiking dangerously high INRs, and we needed to do something about it.”
A review of current medical literature revealed a lack of well-validated recommendations regarding warfarin initiation in older patients, so Dr. Falsetta and his associates set out to create their own dose-capping recommendation. This involved limiting the initial dose of warfarin to 2.5 mg or less for hospitalized patients aged 85 years and older.
“We wanted this to be applicable to patients regardless if they were warfarin naïve or if they had been on warfarin prior to admission,” he said.
Before the roll out, clinical pharmacists and pharmacy residents conducted provider education on the initial dose capping protocol. Providers could order initial doses that exceeded 2.5 mg with valid clinical reasoning. Outcomes of interest were dosing protocol compliance and post-intervention analysis of INRs in this patient population. The pre-intervention period spanned from Nov. 1, 2014 through Oct. 31, 2015, while the post-intervention period spanned from Nov. 1, 2015 through Oct. 31, 2017. Dr. Falsetta reported data from 768 patients.
Between the pre-intervention and post-intervention periods, compliance with dose capping rose from 38.5% to 64.2% (P less than .001), the supratherapeutic INR rate dropped from 20.9% to 13.3% (P= .004), and the length of hospital stay in hours rose from a mean of 145.8 to a mean of 155.8, which was not statistically significant (P= .13).
Following the post-intervention period, the number of peak INRs in the 1 to 2 range rose by 15% and the number of peak INRs in the 2 to 3 range rose by 6%. At the same time, the number of peak INRs in the 3 to 4 range fell by 6%, the number of peak INRs in the 4 to 5 range fell by 36%, and the number of peak INRs in the 5 and greater range fell by 53%. These INR percentages represent relative increases and/or decreases.
“This was a relatively simple intervention that resulted in significant reductions in supratherapeutic INRs,” Dr. Falsetta said.
The researchers also observed that there was less IV vitamin K use after the dose capping intervention. “We can’t say for sure that this was tied to the intervention, but it was interesting, and it is something for us to take a look at, as well as roll this out in future iterations,” he said. “We are on the cusp of rolling this out at some of the tertiary sites within our health care system, and some of the community sites as well.”
He acknowledged certain limitations of the study, including its single-center design, relatively small sample size, and lack of clinical endpoints. “I’d like to be able to tie this to something like reduced bleeding events,” Dr. Falsetta said. “I think that’s something we need to explore in the future.”
Dr. Falsetta reported having no financial disclosures.
SOURCE: Falsetta J et al. THSNA 2018.
SAN DIEGO – A simple intervention of initial warfarin dose capping in hospitalized patients aged 85 years and older led to significant reductions in supratherapeutic INRs without a significant change in length of stay, a single-center study showed.
“We’re excited to see if these results are reproducible,” Jonathan Falsetta, PharmD, said at the biennial summit of the Thrombosis & Hemostasis Societies of North America. “We do feel that it may represent an important step forward in warfarin safety in a vulnerable patient population.”
“From this we gathered that we had an issue with dosing,” said Dr. Falsetta, who is assistant director of pharmacy clinical educational services at Plainview Hospital. “These patients were spiking dangerously high INRs, and we needed to do something about it.”
A review of current medical literature revealed a lack of well-validated recommendations regarding warfarin initiation in older patients, so Dr. Falsetta and his associates set out to create their own dose-capping recommendation. This involved limiting the initial dose of warfarin to 2.5 mg or less for hospitalized patients aged 85 years and older.
“We wanted this to be applicable to patients regardless if they were warfarin naïve or if they had been on warfarin prior to admission,” he said.
Before the roll out, clinical pharmacists and pharmacy residents conducted provider education on the initial dose capping protocol. Providers could order initial doses that exceeded 2.5 mg with valid clinical reasoning. Outcomes of interest were dosing protocol compliance and post-intervention analysis of INRs in this patient population. The pre-intervention period spanned from Nov. 1, 2014 through Oct. 31, 2015, while the post-intervention period spanned from Nov. 1, 2015 through Oct. 31, 2017. Dr. Falsetta reported data from 768 patients.
Between the pre-intervention and post-intervention periods, compliance with dose capping rose from 38.5% to 64.2% (P less than .001), the supratherapeutic INR rate dropped from 20.9% to 13.3% (P= .004), and the length of hospital stay in hours rose from a mean of 145.8 to a mean of 155.8, which was not statistically significant (P= .13).
Following the post-intervention period, the number of peak INRs in the 1 to 2 range rose by 15% and the number of peak INRs in the 2 to 3 range rose by 6%. At the same time, the number of peak INRs in the 3 to 4 range fell by 6%, the number of peak INRs in the 4 to 5 range fell by 36%, and the number of peak INRs in the 5 and greater range fell by 53%. These INR percentages represent relative increases and/or decreases.
“This was a relatively simple intervention that resulted in significant reductions in supratherapeutic INRs,” Dr. Falsetta said.
The researchers also observed that there was less IV vitamin K use after the dose capping intervention. “We can’t say for sure that this was tied to the intervention, but it was interesting, and it is something for us to take a look at, as well as roll this out in future iterations,” he said. “We are on the cusp of rolling this out at some of the tertiary sites within our health care system, and some of the community sites as well.”
He acknowledged certain limitations of the study, including its single-center design, relatively small sample size, and lack of clinical endpoints. “I’d like to be able to tie this to something like reduced bleeding events,” Dr. Falsetta said. “I think that’s something we need to explore in the future.”
Dr. Falsetta reported having no financial disclosures.
SOURCE: Falsetta J et al. THSNA 2018.
REPORTING FROM THSNA 2018
Key clinical point:
Major finding: The supratherapeutic INR rate dropped from 20.9% to 13.3% (P= .004) between the pre- and post-intervention period.
Study details: A single-center study of 768 hospitalized patients aged 85 years and older.
Disclosures: Dr. Falsetta reported having no financial disclosures.
Source: Falsetta J et al., THSNA 2018.
Think about breast cancer surveillance for transgender patients
CHICAGO – , said Christel de Blok, MD, sharing results of a Dutch national study.
The study included 3,078 transgender people (2,064 transgender women) who began hormone therapy (HT) at age 18 years or older. The mean age at which transgender women began HT was 33 years; for transgender men, the mean age was 25 years. In all, transgender women in the study had a total of 30,699 person-years of exposure to HT; for transgender men, the figure was 13,155 person-years.
Overall, there were 16 observed cases of breast cancer in transgender women and four in transgender men. After gender-affirming surgery, the transgender women were followed for a median of 146 months, and experienced a median of 193 months of HT. Transgender men who had mastectomies were followed for a median 93 months, and those who had a hysterectomy-oophorectomy were followed for a median 144 months. Transgender men received a median 176 months of HT.
“Breast cancer can still occur after mastectomy in [transgender] men,” Dr. de Blok said at the annual meeting of the Endocrine Society. “What is interesting is that three out of the four cases of breast cancer in [transgender] men happened after mastectomy.”
In the Netherlands, one in eight women and one in 1,000 men will develop cancer at some point during their lives. In patients who have had a subtotal mastectomy and who are BRCA-1/2 carriers, there is still an approximate 5% residual risk of breast cancer, said Dr. de Blok.
A literature review conducted by Dr. de Blok and her colleagues revealed 19 cases of breast cancer in transgender women and 13 in transgender men. However, a more general study of incidence and characteristics of breast cancer in transgender people receiving hormone treatment had not been done, said Dr. de Blok, of the VU University Medical Center, Amsterdam.
The investigators examined data for adult transgender people seen at their center from 1991 to 2017 and started on hormone treatment. This clinic, said Dr. de Blok, sees about 95% of the transgender individuals in the Netherlands.
The study was able to capitalize on comprehensive information from national databases and registries. Investigators drew from a national histopathology and cytopathology registry as well as from a national vital statistics database. A comprehensive cancer database was used to establish both reference incidence values for males and females and the number of expected cases within the study group.
In both transgender men and women, exactly 50% of cases were ductal carcinoma, compared to 85% in the group of reference women.
An additional 31% of the breast cancers in transgender women were lobular, 6% were ductal carcinoma in situ (DCIS), and the remainder were of other types. Of the cancers in transgender women, 82% were estrogen receptor positive, 64% were progesterone receptor positive, and 9% were Her2/neu positive.
For transgender men, there were no lobular carcinomas; 25% were DCIS, and 25% were of other types. Half of the cancers were estrogen receptor positive, and half were progesterone receptor positive; 25% were Her2/neu positive, and there was one case of androgen receptor positive breast cancer.
Dr. de Blok explained that their analysis compared the observed cases in both transgender men and women to the expected number of cases for the same number of males and females, yielding two standardized incidence ratios (SIRs) for each transgender group.
For transgender women, the SIR for breast cancer compared with males was 50.9 (95% confidence interval, 30.1-80.9). The SIR compared to females was 0.3 (95% CI, 0.2-0.4). This reflected the expected case number of 0.3 for males and the 58 expected cases for a matched group of females.
For transgender men, the SIR for breast cancer compared with males was 59.8 (95% CI, 19-144.3), while the SIR compared to females was 0.2 (95% CI, 0.1-0.5). The expected cases for a similar group of males would be 0.1, and for females, 18.
In many cases, whether a transgender person receives standardized screening mammogram reminders will depend on which sex is assigned to that individual in insurance and other administrative databases, Mr. de Blok noted. When electronic health records and other databases have a binary system, at-risk individuals may fall through the cracks.
Dr. de Blok reported no conflicts of interest.
SOURCE: de Blok C, et al. ENDO 2018, abstract OR 25-6.
CHICAGO – , said Christel de Blok, MD, sharing results of a Dutch national study.
The study included 3,078 transgender people (2,064 transgender women) who began hormone therapy (HT) at age 18 years or older. The mean age at which transgender women began HT was 33 years; for transgender men, the mean age was 25 years. In all, transgender women in the study had a total of 30,699 person-years of exposure to HT; for transgender men, the figure was 13,155 person-years.
Overall, there were 16 observed cases of breast cancer in transgender women and four in transgender men. After gender-affirming surgery, the transgender women were followed for a median of 146 months, and experienced a median of 193 months of HT. Transgender men who had mastectomies were followed for a median 93 months, and those who had a hysterectomy-oophorectomy were followed for a median 144 months. Transgender men received a median 176 months of HT.
“Breast cancer can still occur after mastectomy in [transgender] men,” Dr. de Blok said at the annual meeting of the Endocrine Society. “What is interesting is that three out of the four cases of breast cancer in [transgender] men happened after mastectomy.”
In the Netherlands, one in eight women and one in 1,000 men will develop cancer at some point during their lives. In patients who have had a subtotal mastectomy and who are BRCA-1/2 carriers, there is still an approximate 5% residual risk of breast cancer, said Dr. de Blok.
A literature review conducted by Dr. de Blok and her colleagues revealed 19 cases of breast cancer in transgender women and 13 in transgender men. However, a more general study of incidence and characteristics of breast cancer in transgender people receiving hormone treatment had not been done, said Dr. de Blok, of the VU University Medical Center, Amsterdam.
The investigators examined data for adult transgender people seen at their center from 1991 to 2017 and started on hormone treatment. This clinic, said Dr. de Blok, sees about 95% of the transgender individuals in the Netherlands.
The study was able to capitalize on comprehensive information from national databases and registries. Investigators drew from a national histopathology and cytopathology registry as well as from a national vital statistics database. A comprehensive cancer database was used to establish both reference incidence values for males and females and the number of expected cases within the study group.
In both transgender men and women, exactly 50% of cases were ductal carcinoma, compared to 85% in the group of reference women.
An additional 31% of the breast cancers in transgender women were lobular, 6% were ductal carcinoma in situ (DCIS), and the remainder were of other types. Of the cancers in transgender women, 82% were estrogen receptor positive, 64% were progesterone receptor positive, and 9% were Her2/neu positive.
For transgender men, there were no lobular carcinomas; 25% were DCIS, and 25% were of other types. Half of the cancers were estrogen receptor positive, and half were progesterone receptor positive; 25% were Her2/neu positive, and there was one case of androgen receptor positive breast cancer.
Dr. de Blok explained that their analysis compared the observed cases in both transgender men and women to the expected number of cases for the same number of males and females, yielding two standardized incidence ratios (SIRs) for each transgender group.
For transgender women, the SIR for breast cancer compared with males was 50.9 (95% confidence interval, 30.1-80.9). The SIR compared to females was 0.3 (95% CI, 0.2-0.4). This reflected the expected case number of 0.3 for males and the 58 expected cases for a matched group of females.
For transgender men, the SIR for breast cancer compared with males was 59.8 (95% CI, 19-144.3), while the SIR compared to females was 0.2 (95% CI, 0.1-0.5). The expected cases for a similar group of males would be 0.1, and for females, 18.
In many cases, whether a transgender person receives standardized screening mammogram reminders will depend on which sex is assigned to that individual in insurance and other administrative databases, Mr. de Blok noted. When electronic health records and other databases have a binary system, at-risk individuals may fall through the cracks.
Dr. de Blok reported no conflicts of interest.
SOURCE: de Blok C, et al. ENDO 2018, abstract OR 25-6.
CHICAGO – , said Christel de Blok, MD, sharing results of a Dutch national study.
The study included 3,078 transgender people (2,064 transgender women) who began hormone therapy (HT) at age 18 years or older. The mean age at which transgender women began HT was 33 years; for transgender men, the mean age was 25 years. In all, transgender women in the study had a total of 30,699 person-years of exposure to HT; for transgender men, the figure was 13,155 person-years.
Overall, there were 16 observed cases of breast cancer in transgender women and four in transgender men. After gender-affirming surgery, the transgender women were followed for a median of 146 months, and experienced a median of 193 months of HT. Transgender men who had mastectomies were followed for a median 93 months, and those who had a hysterectomy-oophorectomy were followed for a median 144 months. Transgender men received a median 176 months of HT.
“Breast cancer can still occur after mastectomy in [transgender] men,” Dr. de Blok said at the annual meeting of the Endocrine Society. “What is interesting is that three out of the four cases of breast cancer in [transgender] men happened after mastectomy.”
In the Netherlands, one in eight women and one in 1,000 men will develop cancer at some point during their lives. In patients who have had a subtotal mastectomy and who are BRCA-1/2 carriers, there is still an approximate 5% residual risk of breast cancer, said Dr. de Blok.
A literature review conducted by Dr. de Blok and her colleagues revealed 19 cases of breast cancer in transgender women and 13 in transgender men. However, a more general study of incidence and characteristics of breast cancer in transgender people receiving hormone treatment had not been done, said Dr. de Blok, of the VU University Medical Center, Amsterdam.
The investigators examined data for adult transgender people seen at their center from 1991 to 2017 and started on hormone treatment. This clinic, said Dr. de Blok, sees about 95% of the transgender individuals in the Netherlands.
The study was able to capitalize on comprehensive information from national databases and registries. Investigators drew from a national histopathology and cytopathology registry as well as from a national vital statistics database. A comprehensive cancer database was used to establish both reference incidence values for males and females and the number of expected cases within the study group.
In both transgender men and women, exactly 50% of cases were ductal carcinoma, compared to 85% in the group of reference women.
An additional 31% of the breast cancers in transgender women were lobular, 6% were ductal carcinoma in situ (DCIS), and the remainder were of other types. Of the cancers in transgender women, 82% were estrogen receptor positive, 64% were progesterone receptor positive, and 9% were Her2/neu positive.
For transgender men, there were no lobular carcinomas; 25% were DCIS, and 25% were of other types. Half of the cancers were estrogen receptor positive, and half were progesterone receptor positive; 25% were Her2/neu positive, and there was one case of androgen receptor positive breast cancer.
Dr. de Blok explained that their analysis compared the observed cases in both transgender men and women to the expected number of cases for the same number of males and females, yielding two standardized incidence ratios (SIRs) for each transgender group.
For transgender women, the SIR for breast cancer compared with males was 50.9 (95% confidence interval, 30.1-80.9). The SIR compared to females was 0.3 (95% CI, 0.2-0.4). This reflected the expected case number of 0.3 for males and the 58 expected cases for a matched group of females.
For transgender men, the SIR for breast cancer compared with males was 59.8 (95% CI, 19-144.3), while the SIR compared to females was 0.2 (95% CI, 0.1-0.5). The expected cases for a similar group of males would be 0.1, and for females, 18.
In many cases, whether a transgender person receives standardized screening mammogram reminders will depend on which sex is assigned to that individual in insurance and other administrative databases, Mr. de Blok noted. When electronic health records and other databases have a binary system, at-risk individuals may fall through the cracks.
Dr. de Blok reported no conflicts of interest.
SOURCE: de Blok C, et al. ENDO 2018, abstract OR 25-6.
REPORTING FROM ENDO 2018
Key clinical point: Transgender individuals had increased risk of breast cancer similar to a female reference population.
Major finding: Transgender men had a standardized incidence ratio of 59.8 compared to a male reference population.
Study details: Study of 3,078 transgender adults receiving hormone therapy.
Disclosures: Dr. de Blok reported no conflicts of interest.
Source: de Blok C, et al. ENDO 2018, abstract OR 25-6.
VIDEO: Biomarker accurately predicted primary nonfunction after liver transplant
, researchers reported in Gastroenterology.
SOURCE: AMERICAN GASTROENTEROLOGICAL ASSOCIATION
Glycomic alterations of immunoglobulin G “represent inflammatory disturbances in the liver that [mean it] will fail after transplantation,” wrote Xavier Verhelst, MD, of Ghent (Belgium) University Hospital, and his associates. The new glycomarker “could be a tool to safely select high-risk organs for liver transplantation that otherwise would be discarded from the donor pool based on a conventional clinical assessment,” and also could help prevent engraftment failures. “To our knowledge, not a single biomarker has demonstrated the same accuracy today,” they wrote in the April issue of Gastroenterology.
Chronic shortages of donor livers contribute to morbidity and death worldwide. However, relaxing donor criteria is controversial because of the increased risk of primary nonfunction, which affects some 2%-10% of liver transplantation patients, and early allograft dysfunction, which is even more common. Although no reliable scoring systems or biomarkers have been able to predict these outcomes prior to transplantation, clinical glycomics of serum has proven useful for diagnosing hepatic fibrosis, cirrhosis, and hepatocellular carcinoma, and for distinguishing hepatic steatosis from nonalcoholic steatohepatitis. “Perfusate biomarkers are an attractive alternative [to] liver biopsy or serum markers, because perfusate is believed to represent the condition of the entire liver parenchyma and is easy to collect in large volumes,” the researchers wrote.
Accordingly, they studied 66 patients who underwent liver transplantation at a single center in Belgium and a separate validation cohort of 56 transplantation recipients from two centers. The most common reason for liver transplantation was decompensated cirrhosis secondary to alcoholism, followed by chronic hepatitis C or B virus infection, acute liver failure, and polycystic liver disease. Donor grafts were transported using cold static storage (21° C), and hepatic veins were flushed to collect perfusate before transplantation. Protein-linked N-glycans was isolated from these perfusate samples and analyzed with a multicapillary electrophoresis-based ABI3130 sequencer.
The four patients in the primary study cohort who developed primary nonfunction resembled the others in terms of all clinical and demographic parameters except that they had a markedly increased concentration (P less than .0001) of a single-glycan, agalacto core-alpha-1,6-fucosylated biantennary glycan, dubbed NGA2F. The single patient in the validation cohort who developed primary nonfunction also had a significantly increased concentration of NGA2F (P = .037). There were no false positives in either cohort, and a 13% cutoff for perfusate NGA2F level identified primary nonfunction with 100% accuracy, the researchers said. In a multivariable model of donor risk index and perfusate markers, only NGA2F was prognostic for developing primary nonfunction (P less than .0001).
The researchers found no specific glycomic signature for early allograft dysfunction, perhaps because it is more complex and multifactorial, they wrote. Although electrophoresis testing took 48 hours, work is underway to shorten this to a “clinically acceptable time frame,” they added. They recommended multicenter studies to validate their findings.
Funders included the Research Fund – Flanders and Ghent University. The researchers reported having no conflicts of interest.
SOURCE: Verhelst X et al. Gastroenterology 2018 Jan 6. doi: 10.1053/j.gastro.2017.12.027.
, researchers reported in Gastroenterology.
SOURCE: AMERICAN GASTROENTEROLOGICAL ASSOCIATION
Glycomic alterations of immunoglobulin G “represent inflammatory disturbances in the liver that [mean it] will fail after transplantation,” wrote Xavier Verhelst, MD, of Ghent (Belgium) University Hospital, and his associates. The new glycomarker “could be a tool to safely select high-risk organs for liver transplantation that otherwise would be discarded from the donor pool based on a conventional clinical assessment,” and also could help prevent engraftment failures. “To our knowledge, not a single biomarker has demonstrated the same accuracy today,” they wrote in the April issue of Gastroenterology.
Chronic shortages of donor livers contribute to morbidity and death worldwide. However, relaxing donor criteria is controversial because of the increased risk of primary nonfunction, which affects some 2%-10% of liver transplantation patients, and early allograft dysfunction, which is even more common. Although no reliable scoring systems or biomarkers have been able to predict these outcomes prior to transplantation, clinical glycomics of serum has proven useful for diagnosing hepatic fibrosis, cirrhosis, and hepatocellular carcinoma, and for distinguishing hepatic steatosis from nonalcoholic steatohepatitis. “Perfusate biomarkers are an attractive alternative [to] liver biopsy or serum markers, because perfusate is believed to represent the condition of the entire liver parenchyma and is easy to collect in large volumes,” the researchers wrote.
Accordingly, they studied 66 patients who underwent liver transplantation at a single center in Belgium and a separate validation cohort of 56 transplantation recipients from two centers. The most common reason for liver transplantation was decompensated cirrhosis secondary to alcoholism, followed by chronic hepatitis C or B virus infection, acute liver failure, and polycystic liver disease. Donor grafts were transported using cold static storage (21° C), and hepatic veins were flushed to collect perfusate before transplantation. Protein-linked N-glycans was isolated from these perfusate samples and analyzed with a multicapillary electrophoresis-based ABI3130 sequencer.
The four patients in the primary study cohort who developed primary nonfunction resembled the others in terms of all clinical and demographic parameters except that they had a markedly increased concentration (P less than .0001) of a single-glycan, agalacto core-alpha-1,6-fucosylated biantennary glycan, dubbed NGA2F. The single patient in the validation cohort who developed primary nonfunction also had a significantly increased concentration of NGA2F (P = .037). There were no false positives in either cohort, and a 13% cutoff for perfusate NGA2F level identified primary nonfunction with 100% accuracy, the researchers said. In a multivariable model of donor risk index and perfusate markers, only NGA2F was prognostic for developing primary nonfunction (P less than .0001).
The researchers found no specific glycomic signature for early allograft dysfunction, perhaps because it is more complex and multifactorial, they wrote. Although electrophoresis testing took 48 hours, work is underway to shorten this to a “clinically acceptable time frame,” they added. They recommended multicenter studies to validate their findings.
Funders included the Research Fund – Flanders and Ghent University. The researchers reported having no conflicts of interest.
SOURCE: Verhelst X et al. Gastroenterology 2018 Jan 6. doi: 10.1053/j.gastro.2017.12.027.
, researchers reported in Gastroenterology.
SOURCE: AMERICAN GASTROENTEROLOGICAL ASSOCIATION
Glycomic alterations of immunoglobulin G “represent inflammatory disturbances in the liver that [mean it] will fail after transplantation,” wrote Xavier Verhelst, MD, of Ghent (Belgium) University Hospital, and his associates. The new glycomarker “could be a tool to safely select high-risk organs for liver transplantation that otherwise would be discarded from the donor pool based on a conventional clinical assessment,” and also could help prevent engraftment failures. “To our knowledge, not a single biomarker has demonstrated the same accuracy today,” they wrote in the April issue of Gastroenterology.
Chronic shortages of donor livers contribute to morbidity and death worldwide. However, relaxing donor criteria is controversial because of the increased risk of primary nonfunction, which affects some 2%-10% of liver transplantation patients, and early allograft dysfunction, which is even more common. Although no reliable scoring systems or biomarkers have been able to predict these outcomes prior to transplantation, clinical glycomics of serum has proven useful for diagnosing hepatic fibrosis, cirrhosis, and hepatocellular carcinoma, and for distinguishing hepatic steatosis from nonalcoholic steatohepatitis. “Perfusate biomarkers are an attractive alternative [to] liver biopsy or serum markers, because perfusate is believed to represent the condition of the entire liver parenchyma and is easy to collect in large volumes,” the researchers wrote.
Accordingly, they studied 66 patients who underwent liver transplantation at a single center in Belgium and a separate validation cohort of 56 transplantation recipients from two centers. The most common reason for liver transplantation was decompensated cirrhosis secondary to alcoholism, followed by chronic hepatitis C or B virus infection, acute liver failure, and polycystic liver disease. Donor grafts were transported using cold static storage (21° C), and hepatic veins were flushed to collect perfusate before transplantation. Protein-linked N-glycans was isolated from these perfusate samples and analyzed with a multicapillary electrophoresis-based ABI3130 sequencer.
The four patients in the primary study cohort who developed primary nonfunction resembled the others in terms of all clinical and demographic parameters except that they had a markedly increased concentration (P less than .0001) of a single-glycan, agalacto core-alpha-1,6-fucosylated biantennary glycan, dubbed NGA2F. The single patient in the validation cohort who developed primary nonfunction also had a significantly increased concentration of NGA2F (P = .037). There were no false positives in either cohort, and a 13% cutoff for perfusate NGA2F level identified primary nonfunction with 100% accuracy, the researchers said. In a multivariable model of donor risk index and perfusate markers, only NGA2F was prognostic for developing primary nonfunction (P less than .0001).
The researchers found no specific glycomic signature for early allograft dysfunction, perhaps because it is more complex and multifactorial, they wrote. Although electrophoresis testing took 48 hours, work is underway to shorten this to a “clinically acceptable time frame,” they added. They recommended multicenter studies to validate their findings.
Funders included the Research Fund – Flanders and Ghent University. The researchers reported having no conflicts of interest.
SOURCE: Verhelst X et al. Gastroenterology 2018 Jan 6. doi: 10.1053/j.gastro.2017.12.027.
FROM GASTROENTEROLOGY
Key clinical point: A glycomarker in donor liver perfusate was 100% accurate at predicting primary nonfunction after liver transplantation.
Major finding: In a multivariable model of donor risk index and perfusate markers, only the single-glycan, NGA2F was a significant predictor of primary nonfunction (P less than .0001).
Data source: A dual-center, prospective study of 66 liver transplant patients and a 55-member validation cohort.
Disclosures: Funders included the Research Fund – Flanders and Ghent University. The researchers reported having no conflicts of interest.
Source: Verhelst X et al. Gastroenterology 2018 Jan 6. doi: 10.1053/j.gastro.2017.12.027.
