Poorer-performing hospitals have higher readmission rates than better-performing hospitals for patients with similar diagnoses, a study shows.

Lead author Harlan M. Krumholz, MD, of Yale University, New Haven, Conn., and his colleagues analyzed Centers for Medicare and Medicaid Services hospital-wide readmission data and divided data from July 2014 through June 2015 into two random samples. Researchers used the first sample to calculate the risk-standardized readmission rate within 30 days for each hospital and classified hospitals into performance quartiles, with a lower readmission rate indicating better performance. The second study sample included patients who had two admissions for similar diagnoses at different hospitals that occurred more than 1 month and less than 1 year apart. Researchers compared the observed readmission rates among patients who had been admitted to hospitals in different performance quartiles. The analysis included all discharges occurring from July 1, 2014, through June 30, 2015, from short-term acute care or critical access hospitals in the United States involving Medicare patients who were aged 65 years or older.

Copyright Kimberly Pack/Thinkstock

“This study addresses a persistent concern that national readmission measures may reflect differences in unmeasured factors rather than in hospital performance,” study authors noted in the study. “The findings suggest that hospital quality contributes at least in part to readmission rates, independent of patient factors. By studying patients who were admitted twice within 1 year with similar diagnoses to different hospitals, this study design was able to isolate hospital signals of performance while minimizing differences among the patients. In these cases, because the same patients had similar admissions at two hospitals, the characteristics of the patients, including their level of social disadvantage, level of education, or degree of underlying illness, were broadly the same. The alignment of the differences that we observed with the results of the CMS hospital-wide readmission measure also adds to evidence that the readmission measure classifies true differences in performance.”

Dr. Krumholz and seven coauthors reported receiving support from contracts with the Center for Medicare and Medicaid Services to develop and reevaluate performance measures that are used for public reporting.

[email protected]

On Twitter @legal_med

Poorer-performing hospitals have higher readmission rates than better-performing hospitals for patients with similar diagnoses, a study shows.

Lead author Harlan M. Krumholz, MD, of Yale University, New Haven, Conn., and his colleagues analyzed Centers for Medicare and Medicaid Services hospital-wide readmission data and divided data from July 2014 through June 2015 into two random samples. Researchers used the first sample to calculate the risk-standardized readmission rate within 30 days for each hospital and classified hospitals into performance quartiles, with a lower readmission rate indicating better performance. The second study sample included patients who had two admissions for similar diagnoses at different hospitals that occurred more than 1 month and less than 1 year apart. Researchers compared the observed readmission rates among patients who had been admitted to hospitals in different performance quartiles. The analysis included all discharges occurring from July 1, 2014, through June 30, 2015, from short-term acute care or critical access hospitals in the United States involving Medicare patients who were aged 65 years or older.

Copyright Kimberly Pack/Thinkstock

“This study addresses a persistent concern that national readmission measures may reflect differences in unmeasured factors rather than in hospital performance,” study authors noted in the study. “The findings suggest that hospital quality contributes at least in part to readmission rates, independent of patient factors. By studying patients who were admitted twice within 1 year with similar diagnoses to different hospitals, this study design was able to isolate hospital signals of performance while minimizing differences among the patients. In these cases, because the same patients had similar admissions at two hospitals, the characteristics of the patients, including their level of social disadvantage, level of education, or degree of underlying illness, were broadly the same. The alignment of the differences that we observed with the results of the CMS hospital-wide readmission measure also adds to evidence that the readmission measure classifies true differences in performance.”

Dr. Krumholz and seven coauthors reported receiving support from contracts with the Center for Medicare and Medicaid Services to develop and reevaluate performance measures that are used for public reporting.

[email protected]

On Twitter @legal_med

Poorer-performing hospitals have higher readmission rates than better-performing hospitals for patients with similar diagnoses, a study shows.

Lead author Harlan M. Krumholz, MD, of Yale University, New Haven, Conn., and his colleagues analyzed Centers for Medicare and Medicaid Services hospital-wide readmission data and divided data from July 2014 through June 2015 into two random samples. Researchers used the first sample to calculate the risk-standardized readmission rate within 30 days for each hospital and classified hospitals into performance quartiles, with a lower readmission rate indicating better performance. The second study sample included patients who had two admissions for similar diagnoses at different hospitals that occurred more than 1 month and less than 1 year apart. Researchers compared the observed readmission rates among patients who had been admitted to hospitals in different performance quartiles. The analysis included all discharges occurring from July 1, 2014, through June 30, 2015, from short-term acute care or critical access hospitals in the United States involving Medicare patients who were aged 65 years or older.

Copyright Kimberly Pack/Thinkstock

“This study addresses a persistent concern that national readmission measures may reflect differences in unmeasured factors rather than in hospital performance,” study authors noted in the study. “The findings suggest that hospital quality contributes at least in part to readmission rates, independent of patient factors. By studying patients who were admitted twice within 1 year with similar diagnoses to different hospitals, this study design was able to isolate hospital signals of performance while minimizing differences among the patients. In these cases, because the same patients had similar admissions at two hospitals, the characteristics of the patients, including their level of social disadvantage, level of education, or degree of underlying illness, were broadly the same. The alignment of the differences that we observed with the results of the CMS hospital-wide readmission measure also adds to evidence that the readmission measure classifies true differences in performance.”

Dr. Krumholz and seven coauthors reported receiving support from contracts with the Center for Medicare and Medicaid Services to develop and reevaluate performance measures that are used for public reporting.

[email protected]

On Twitter @legal_med

Free flap autologous breast reconstruction is an excellent surgical option for breast reconstruction in select patients. A free flap involves moving skin, fat, and/or muscle from a distant part of the body, based on a named blood supply (pedicle), and attaching it to another blood supply adjacent to the acquired defect. This procedure is particularly useful in areas where local tissue supply is lacking in volume or is damaged due to trauma or radiation. These reconstructions are performed largely in high-volume centers outside the VA because of the required specialized level of surgical training, manpower, and nursing support.¹ The Malcom Randall VAMC in Gainesville, Florida, started offering autologous free flap breast reconstruction as an option to select patients in October 2012.

The Malcom Randall VAMC operating room (OR) does not operate 24/7, and the system has limited available OR time and surgical staff compared with the volume of patients requesting care.² Operative planning for free flap autologous breast reconstruction must occur months ahead of surgery to balance the system limitations with the ability to offer the highest level of care. Planning includes strict patient selection, preoperative imaging, practice runs with OR staff, use of venous couplers, and frequent intensive care unit (ICU) staff in-services. Planning also includes the need to keep surgeries within the allocated OR time to avoid shift changes during critical periods. Frequent and early communication occurs between the surgical scheduler, OR nurses, and the anesthesia and critical care teams.

Studies have found that the best chance of flap salvage in the event of a thrombotic event is a rapid return to the OR.³ It is essential to minimize the risk of emergent returns to the OR because it is not staffed throughout the night. Patient risk factors for perioperative vascular complications include hypercoagulable disorders, peripheral vascular disease, use of the superficial epigastric system, and smoking.^4-7

A PubMed search for free flap reconstruction solely within the VA over the past 20 years found 1 article discussing the use of free flaps in head and neck reconstruction which demonstrated an impressive success rate of 93%.⁸

The object of this study was to assess free flap breast reconstruction results at the Malcolm Randall VAMC to determine whether it is a realistic treatment to offer in the federal system.

Methods

The Malcolm Randall Institutional Review Board approved a retrospective chart review of all autologous free flap breast reconstructions using CPT code 19364, performed from October 2012 to June 2016. Medical records of patients who had a free flap breast reconstruction were queried during that period. Patient age; comorbidities listed on the electronic medical record “problem list;” body mass index (BMI); type of reconstruction (delayed vs immediate); length of surgery; length of stay; and complications over a 30-day period were recorded (Table). The authors looked for documentation of preoperative imaging and unplanned returns to the OR within the 30-day period.

Of 3 full-time VA plastic surgeons on staff during the study period, 2 surgeons had advanced fellowship training in either microsurgery or hand and microsurgery. Plastic surgery fellows and general surgery interns participated in the surgeries and postoperative care. The service had 1 dedicated advanced practice registered nurse involved in the surgical scheduling and perioperative care.

Results

A total of 11 abdominally based free flap breast reconstructions—6 muscle-sparing transverse rectus abdominus musculocutaneous (TRAM) and 5 deep inferior epigastric perforator (DIEP) flaps—were performed in 8 patients during the study period (Figures 1A, 1B, 1C, and 1D). Patient ages ranged from 31 to 58 years with a mean of 45.6 years. Six patients had preoperative computer tomography angiography (CTA) to define the location of the abdominal wall perforators. One muscle-sparing free flap was performed immediately after mastectomy; the other free flaps were performed as delayed reconstructions. Body mass index ranged from 24 to 35, with a mean of 30. All patients reported no tobacco use during the consultation; however, 1 patient later admitted to chewing tobacco. No urinary cotinine confirmation was requested. Two patients had 1 free flap reconstruction and 1 pedicle TRAM. This bilateral combination has been recently described in the literature and was chosen as a reasonable option to balance limited resources with abdominal wall morbidity.⁹ Operating room time ranged from 7 hours 50 minutes to 13 hours 3 minutes. All patients went to the ICU for hourly flap monitoring.

Length of stay ranged from 4 to 7 days, with a mean of 4.5 days. The longest stay was for a patient who had immediate reconstruction using a pedicle TRAM and muscle-sparing free TRAM. She was not a DIEP candidate because poor perforator quality had been noted during preoperative imaging.

Six patients had documentation of postoperative wound complications. One patient returned to the OR on the elective schedule 3 weeks postoperatively for a partial flap debridement. Her tissue transfer was > 1,000 g, and she required a matching reduction on the other side. There were no complete flap losses or postoperative thrombotic events; no cases went back to the OR emergently.

Discussion

With the number of women veterans steadily increasing, the number of patients in need of breast cancer surgery, including reconstruction, will rise in the VA.¹⁰ Fortunately, breast reconstruction is an elective procedure. Immediate breast reconstruction is a popular option because patients can combine surgeries and potentially avoid 2 recovery periods, and a better aesthetic outcome is possible because the skin does not have time to contract. Although immediate reconstruction has been increasing in popularity, it is associated with a higher complication rate.¹¹ Further, reconstruction can be jeopardized if the oncologic plan is changed in the early postoperative period.

Positive margins found after an autologous reconstruction result in a more complicated postoperative course and a higher rate of wound complications.¹² Unexpected radiation therapy after autologous reconstruction can severely distort a tissue flap because of fat necrosis, fibrosis, and contraction.^13,14 From a practical perspective in the federal system, it is very difficult to coordinate 2 surgeons’ schedules when the system is already struggling to keep up with demand. Splitting the ablative and reconstructive surgery allows the urgent problem (cancer) to be addressed first, ensuring clear margins and allowing the patient to recover and consider all reconstructive options without feeling time pressure.

A large tertiary care center will have staff and equipment redundancy, but this study had to consider limitations in resources. The preoperative lead time allows the ICU to arrange a bed for hourly flap checks and for in-servicing new nursing staff on free flap monitoring. This was well received, and patients gave positive feedback on the staff. The OR schedulers can schedule nurses and techs who are familiar with the microscope and microsurgery instruments. The micro sets were opened, and the microscope powered on for practice runs a week before the procedures to insure no broken or missing instruments.

High-procedure volume would logically improve efficiency. Although the VA is not likely to become a tertiary center for breast reconstruction, the findings of other high-volume microsurgeons can be applied to improve speed and limit complications. Efforts to limit the OR time included use of preoperative imaging and intraoperative venous couplers. Venous couplers can result in shorter OR time, fewer returns to the OR, and excellent patency rates.^15,16 One microsurgeon performed his surgery using only loupe-assisted vision (x 3.5), without use of the microscope. Pannucci and colleagues have recommended this as a way to improve access and OR efficiency.¹⁷ Use of the CTA has been found to decrease the rate of partial flap necrosis and improve speed of surgery.^18-20

Careful patient selection allowed a hospital stay that averaged 4.5 days and minimized risks for return to the OR. Only patients who were nonsmokers were offered the surgery. Average BMI was 30 to prevent the known operative risks in breast surgery patients who are morbidly obese.^21-23 No patients had a history of thromboembolic disease. Most patients were discharged home from the ICU. They eventually returned for elective revisions, second stages, and balancing procedures.

Conclusion

Free flap breast reconstruction can be offered as a treatment option with appropriate patient selection and planning. The most efficient way to provide this procedure within the federal system and to minimize the risk of flap loss and complications is by offering delayed reconstruction, obtaining preoperative CTA imaging, utilizing venous couplers, and frequently communicating with all involved practitioners from the OR to the ICU. This small study provides a good starting point to illustrate that tertiary-care reconstructive surgery can be offered to veterans within the federal system.

Acknowledgments
This material is the result of work supported with resources and the use of facilities at the North Florida/South Georgia Veterans Health System, Gainesville, Florida.

Free flap autologous breast reconstruction is an excellent surgical option for breast reconstruction in select patients. A free flap involves moving skin, fat, and/or muscle from a distant part of the body, based on a named blood supply (pedicle), and attaching it to another blood supply adjacent to the acquired defect. This procedure is particularly useful in areas where local tissue supply is lacking in volume or is damaged due to trauma or radiation. These reconstructions are performed largely in high-volume centers outside the VA because of the required specialized level of surgical training, manpower, and nursing support.¹ The Malcom Randall VAMC in Gainesville, Florida, started offering autologous free flap breast reconstruction as an option to select patients in October 2012.

The Malcom Randall VAMC operating room (OR) does not operate 24/7, and the system has limited available OR time and surgical staff compared with the volume of patients requesting care.² Operative planning for free flap autologous breast reconstruction must occur months ahead of surgery to balance the system limitations with the ability to offer the highest level of care. Planning includes strict patient selection, preoperative imaging, practice runs with OR staff, use of venous couplers, and frequent intensive care unit (ICU) staff in-services. Planning also includes the need to keep surgeries within the allocated OR time to avoid shift changes during critical periods. Frequent and early communication occurs between the surgical scheduler, OR nurses, and the anesthesia and critical care teams.

Studies have found that the best chance of flap salvage in the event of a thrombotic event is a rapid return to the OR.³ It is essential to minimize the risk of emergent returns to the OR because it is not staffed throughout the night. Patient risk factors for perioperative vascular complications include hypercoagulable disorders, peripheral vascular disease, use of the superficial epigastric system, and smoking.^4-7

A PubMed search for free flap reconstruction solely within the VA over the past 20 years found 1 article discussing the use of free flaps in head and neck reconstruction which demonstrated an impressive success rate of 93%.⁸

The object of this study was to assess free flap breast reconstruction results at the Malcolm Randall VAMC to determine whether it is a realistic treatment to offer in the federal system.

Methods

The Malcolm Randall Institutional Review Board approved a retrospective chart review of all autologous free flap breast reconstructions using CPT code 19364, performed from October 2012 to June 2016. Medical records of patients who had a free flap breast reconstruction were queried during that period. Patient age; comorbidities listed on the electronic medical record “problem list;” body mass index (BMI); type of reconstruction (delayed vs immediate); length of surgery; length of stay; and complications over a 30-day period were recorded (Table). The authors looked for documentation of preoperative imaging and unplanned returns to the OR within the 30-day period.

Of 3 full-time VA plastic surgeons on staff during the study period, 2 surgeons had advanced fellowship training in either microsurgery or hand and microsurgery. Plastic surgery fellows and general surgery interns participated in the surgeries and postoperative care. The service had 1 dedicated advanced practice registered nurse involved in the surgical scheduling and perioperative care.

Results

A total of 11 abdominally based free flap breast reconstructions—6 muscle-sparing transverse rectus abdominus musculocutaneous (TRAM) and 5 deep inferior epigastric perforator (DIEP) flaps—were performed in 8 patients during the study period (Figures 1A, 1B, 1C, and 1D). Patient ages ranged from 31 to 58 years with a mean of 45.6 years. Six patients had preoperative computer tomography angiography (CTA) to define the location of the abdominal wall perforators. One muscle-sparing free flap was performed immediately after mastectomy; the other free flaps were performed as delayed reconstructions. Body mass index ranged from 24 to 35, with a mean of 30. All patients reported no tobacco use during the consultation; however, 1 patient later admitted to chewing tobacco. No urinary cotinine confirmation was requested. Two patients had 1 free flap reconstruction and 1 pedicle TRAM. This bilateral combination has been recently described in the literature and was chosen as a reasonable option to balance limited resources with abdominal wall morbidity.⁹ Operating room time ranged from 7 hours 50 minutes to 13 hours 3 minutes. All patients went to the ICU for hourly flap monitoring.

Length of stay ranged from 4 to 7 days, with a mean of 4.5 days. The longest stay was for a patient who had immediate reconstruction using a pedicle TRAM and muscle-sparing free TRAM. She was not a DIEP candidate because poor perforator quality had been noted during preoperative imaging.

Six patients had documentation of postoperative wound complications. One patient returned to the OR on the elective schedule 3 weeks postoperatively for a partial flap debridement. Her tissue transfer was > 1,000 g, and she required a matching reduction on the other side. There were no complete flap losses or postoperative thrombotic events; no cases went back to the OR emergently.

Discussion

With the number of women veterans steadily increasing, the number of patients in need of breast cancer surgery, including reconstruction, will rise in the VA.¹⁰ Fortunately, breast reconstruction is an elective procedure. Immediate breast reconstruction is a popular option because patients can combine surgeries and potentially avoid 2 recovery periods, and a better aesthetic outcome is possible because the skin does not have time to contract. Although immediate reconstruction has been increasing in popularity, it is associated with a higher complication rate.¹¹ Further, reconstruction can be jeopardized if the oncologic plan is changed in the early postoperative period.

Positive margins found after an autologous reconstruction result in a more complicated postoperative course and a higher rate of wound complications.¹² Unexpected radiation therapy after autologous reconstruction can severely distort a tissue flap because of fat necrosis, fibrosis, and contraction.^13,14 From a practical perspective in the federal system, it is very difficult to coordinate 2 surgeons’ schedules when the system is already struggling to keep up with demand. Splitting the ablative and reconstructive surgery allows the urgent problem (cancer) to be addressed first, ensuring clear margins and allowing the patient to recover and consider all reconstructive options without feeling time pressure.

A large tertiary care center will have staff and equipment redundancy, but this study had to consider limitations in resources. The preoperative lead time allows the ICU to arrange a bed for hourly flap checks and for in-servicing new nursing staff on free flap monitoring. This was well received, and patients gave positive feedback on the staff. The OR schedulers can schedule nurses and techs who are familiar with the microscope and microsurgery instruments. The micro sets were opened, and the microscope powered on for practice runs a week before the procedures to insure no broken or missing instruments.

High-procedure volume would logically improve efficiency. Although the VA is not likely to become a tertiary center for breast reconstruction, the findings of other high-volume microsurgeons can be applied to improve speed and limit complications. Efforts to limit the OR time included use of preoperative imaging and intraoperative venous couplers. Venous couplers can result in shorter OR time, fewer returns to the OR, and excellent patency rates.^15,16 One microsurgeon performed his surgery using only loupe-assisted vision (x 3.5), without use of the microscope. Pannucci and colleagues have recommended this as a way to improve access and OR efficiency.¹⁷ Use of the CTA has been found to decrease the rate of partial flap necrosis and improve speed of surgery.^18-20

Careful patient selection allowed a hospital stay that averaged 4.5 days and minimized risks for return to the OR. Only patients who were nonsmokers were offered the surgery. Average BMI was 30 to prevent the known operative risks in breast surgery patients who are morbidly obese.^21-23 No patients had a history of thromboembolic disease. Most patients were discharged home from the ICU. They eventually returned for elective revisions, second stages, and balancing procedures.

Conclusion

Free flap breast reconstruction can be offered as a treatment option with appropriate patient selection and planning. The most efficient way to provide this procedure within the federal system and to minimize the risk of flap loss and complications is by offering delayed reconstruction, obtaining preoperative CTA imaging, utilizing venous couplers, and frequently communicating with all involved practitioners from the OR to the ICU. This small study provides a good starting point to illustrate that tertiary-care reconstructive surgery can be offered to veterans within the federal system.

Acknowledgments
This material is the result of work supported with resources and the use of facilities at the North Florida/South Georgia Veterans Health System, Gainesville, Florida.

Free flap autologous breast reconstruction is an excellent surgical option for breast reconstruction in select patients. A free flap involves moving skin, fat, and/or muscle from a distant part of the body, based on a named blood supply (pedicle), and attaching it to another blood supply adjacent to the acquired defect. This procedure is particularly useful in areas where local tissue supply is lacking in volume or is damaged due to trauma or radiation. These reconstructions are performed largely in high-volume centers outside the VA because of the required specialized level of surgical training, manpower, and nursing support.¹ The Malcom Randall VAMC in Gainesville, Florida, started offering autologous free flap breast reconstruction as an option to select patients in October 2012.

The Malcom Randall VAMC operating room (OR) does not operate 24/7, and the system has limited available OR time and surgical staff compared with the volume of patients requesting care.² Operative planning for free flap autologous breast reconstruction must occur months ahead of surgery to balance the system limitations with the ability to offer the highest level of care. Planning includes strict patient selection, preoperative imaging, practice runs with OR staff, use of venous couplers, and frequent intensive care unit (ICU) staff in-services. Planning also includes the need to keep surgeries within the allocated OR time to avoid shift changes during critical periods. Frequent and early communication occurs between the surgical scheduler, OR nurses, and the anesthesia and critical care teams.

Studies have found that the best chance of flap salvage in the event of a thrombotic event is a rapid return to the OR.³ It is essential to minimize the risk of emergent returns to the OR because it is not staffed throughout the night. Patient risk factors for perioperative vascular complications include hypercoagulable disorders, peripheral vascular disease, use of the superficial epigastric system, and smoking.^4-7

A PubMed search for free flap reconstruction solely within the VA over the past 20 years found 1 article discussing the use of free flaps in head and neck reconstruction which demonstrated an impressive success rate of 93%.⁸

The object of this study was to assess free flap breast reconstruction results at the Malcolm Randall VAMC to determine whether it is a realistic treatment to offer in the federal system.

Methods

The Malcolm Randall Institutional Review Board approved a retrospective chart review of all autologous free flap breast reconstructions using CPT code 19364, performed from October 2012 to June 2016. Medical records of patients who had a free flap breast reconstruction were queried during that period. Patient age; comorbidities listed on the electronic medical record “problem list;” body mass index (BMI); type of reconstruction (delayed vs immediate); length of surgery; length of stay; and complications over a 30-day period were recorded (Table). The authors looked for documentation of preoperative imaging and unplanned returns to the OR within the 30-day period.

Of 3 full-time VA plastic surgeons on staff during the study period, 2 surgeons had advanced fellowship training in either microsurgery or hand and microsurgery. Plastic surgery fellows and general surgery interns participated in the surgeries and postoperative care. The service had 1 dedicated advanced practice registered nurse involved in the surgical scheduling and perioperative care.

Results

A total of 11 abdominally based free flap breast reconstructions—6 muscle-sparing transverse rectus abdominus musculocutaneous (TRAM) and 5 deep inferior epigastric perforator (DIEP) flaps—were performed in 8 patients during the study period (Figures 1A, 1B, 1C, and 1D). Patient ages ranged from 31 to 58 years with a mean of 45.6 years. Six patients had preoperative computer tomography angiography (CTA) to define the location of the abdominal wall perforators. One muscle-sparing free flap was performed immediately after mastectomy; the other free flaps were performed as delayed reconstructions. Body mass index ranged from 24 to 35, with a mean of 30. All patients reported no tobacco use during the consultation; however, 1 patient later admitted to chewing tobacco. No urinary cotinine confirmation was requested. Two patients had 1 free flap reconstruction and 1 pedicle TRAM. This bilateral combination has been recently described in the literature and was chosen as a reasonable option to balance limited resources with abdominal wall morbidity.⁹ Operating room time ranged from 7 hours 50 minutes to 13 hours 3 minutes. All patients went to the ICU for hourly flap monitoring.

Length of stay ranged from 4 to 7 days, with a mean of 4.5 days. The longest stay was for a patient who had immediate reconstruction using a pedicle TRAM and muscle-sparing free TRAM. She was not a DIEP candidate because poor perforator quality had been noted during preoperative imaging.

Six patients had documentation of postoperative wound complications. One patient returned to the OR on the elective schedule 3 weeks postoperatively for a partial flap debridement. Her tissue transfer was > 1,000 g, and she required a matching reduction on the other side. There were no complete flap losses or postoperative thrombotic events; no cases went back to the OR emergently.

Discussion

With the number of women veterans steadily increasing, the number of patients in need of breast cancer surgery, including reconstruction, will rise in the VA.¹⁰ Fortunately, breast reconstruction is an elective procedure. Immediate breast reconstruction is a popular option because patients can combine surgeries and potentially avoid 2 recovery periods, and a better aesthetic outcome is possible because the skin does not have time to contract. Although immediate reconstruction has been increasing in popularity, it is associated with a higher complication rate.¹¹ Further, reconstruction can be jeopardized if the oncologic plan is changed in the early postoperative period.

Positive margins found after an autologous reconstruction result in a more complicated postoperative course and a higher rate of wound complications.¹² Unexpected radiation therapy after autologous reconstruction can severely distort a tissue flap because of fat necrosis, fibrosis, and contraction.^13,14 From a practical perspective in the federal system, it is very difficult to coordinate 2 surgeons’ schedules when the system is already struggling to keep up with demand. Splitting the ablative and reconstructive surgery allows the urgent problem (cancer) to be addressed first, ensuring clear margins and allowing the patient to recover and consider all reconstructive options without feeling time pressure.

A large tertiary care center will have staff and equipment redundancy, but this study had to consider limitations in resources. The preoperative lead time allows the ICU to arrange a bed for hourly flap checks and for in-servicing new nursing staff on free flap monitoring. This was well received, and patients gave positive feedback on the staff. The OR schedulers can schedule nurses and techs who are familiar with the microscope and microsurgery instruments. The micro sets were opened, and the microscope powered on for practice runs a week before the procedures to insure no broken or missing instruments.

High-procedure volume would logically improve efficiency. Although the VA is not likely to become a tertiary center for breast reconstruction, the findings of other high-volume microsurgeons can be applied to improve speed and limit complications. Efforts to limit the OR time included use of preoperative imaging and intraoperative venous couplers. Venous couplers can result in shorter OR time, fewer returns to the OR, and excellent patency rates.^15,16 One microsurgeon performed his surgery using only loupe-assisted vision (x 3.5), without use of the microscope. Pannucci and colleagues have recommended this as a way to improve access and OR efficiency.¹⁷ Use of the CTA has been found to decrease the rate of partial flap necrosis and improve speed of surgery.^18-20

Careful patient selection allowed a hospital stay that averaged 4.5 days and minimized risks for return to the OR. Only patients who were nonsmokers were offered the surgery. Average BMI was 30 to prevent the known operative risks in breast surgery patients who are morbidly obese.^21-23 No patients had a history of thromboembolic disease. Most patients were discharged home from the ICU. They eventually returned for elective revisions, second stages, and balancing procedures.

Conclusion

Free flap breast reconstruction can be offered as a treatment option with appropriate patient selection and planning. The most efficient way to provide this procedure within the federal system and to minimize the risk of flap loss and complications is by offering delayed reconstruction, obtaining preoperative CTA imaging, utilizing venous couplers, and frequently communicating with all involved practitioners from the OR to the ICU. This small study provides a good starting point to illustrate that tertiary-care reconstructive surgery can be offered to veterans within the federal system.

Acknowledgments
This material is the result of work supported with resources and the use of facilities at the North Florida/South Georgia Veterans Health System, Gainesville, Florida.

Gastroenterologists, female physicians, and physicians who were less than a decade out of residency had significantly higher adenoma detection rates (ADRs) than their counterparts in a retrospective cohort study of colonoscopists.

“Efforts to target physicians with lower-quality performance are needed,” wrote Ateev Mehrotra, MD, MPH, of Harvard Medical School in Boston, with his associates. The study, one of the first to use natural language processing to compare electronic health data from geographically diverse health care systems, was published online 30 in Gastrointestinal Endoscopy (2017 Aug 30. doi: 10.1016/j.gie.2017.08.023).

Eraxion/Thinkstock

These associations persisted among patients who received only screening colonoscopies, who had complete colonoscopies with adequate bowel preparation, or who were younger than 80 years, the researchers said. The findings on sex reflect recent studies in which treatment by female hospitalists slightly decreased the risk of 30-day mortality when compared with treatment by a male hospitalist, they added. “A deliberate and meticulous approach to colonoscopy may facilitate achievement of a high ADR, and this method may be more common among female physicians,” they wrote. “This is supported by research showing that female physicians are more likely to adhere to clinical guidelines and to provide preventive care.” Studies of men in other fields have found them more likely to take risks, which contradicts the methodical approach needed for a high ADR, they emphasized. “Sex differences in color perception [also] may make it easier for female physicians to identify adenomas.”

Likewise, research outside gastroenterology has linked fewer years in practice with better quality of care. Improvements in fellowship training, better access to new equipment, “or simply decay of performance with age” all could explain the findings, the researchers wrote. They also cited five prior studies in which nongastroenterologists had lower ADRs. They called for studies that would further explore the reasons why specific physician traits affect performance.

Physicians in the study tended to have practiced fewer years than gastroenterologists in general in the United States, the investigators noted. “We also could not measure some other physician factors that might explain some of the variation we observed, such as type of endoscopes used.”

The National Cancer Institute provided funding. The researchers did not report having conflicts of interest.

Gastroenterologists, female physicians, and physicians who were less than a decade out of residency had significantly higher adenoma detection rates (ADRs) than their counterparts in a retrospective cohort study of colonoscopists.

“Efforts to target physicians with lower-quality performance are needed,” wrote Ateev Mehrotra, MD, MPH, of Harvard Medical School in Boston, with his associates. The study, one of the first to use natural language processing to compare electronic health data from geographically diverse health care systems, was published online 30 in Gastrointestinal Endoscopy (2017 Aug 30. doi: 10.1016/j.gie.2017.08.023).

Eraxion/Thinkstock

These associations persisted among patients who received only screening colonoscopies, who had complete colonoscopies with adequate bowel preparation, or who were younger than 80 years, the researchers said. The findings on sex reflect recent studies in which treatment by female hospitalists slightly decreased the risk of 30-day mortality when compared with treatment by a male hospitalist, they added. “A deliberate and meticulous approach to colonoscopy may facilitate achievement of a high ADR, and this method may be more common among female physicians,” they wrote. “This is supported by research showing that female physicians are more likely to adhere to clinical guidelines and to provide preventive care.” Studies of men in other fields have found them more likely to take risks, which contradicts the methodical approach needed for a high ADR, they emphasized. “Sex differences in color perception [also] may make it easier for female physicians to identify adenomas.”

Likewise, research outside gastroenterology has linked fewer years in practice with better quality of care. Improvements in fellowship training, better access to new equipment, “or simply decay of performance with age” all could explain the findings, the researchers wrote. They also cited five prior studies in which nongastroenterologists had lower ADRs. They called for studies that would further explore the reasons why specific physician traits affect performance.

Physicians in the study tended to have practiced fewer years than gastroenterologists in general in the United States, the investigators noted. “We also could not measure some other physician factors that might explain some of the variation we observed, such as type of endoscopes used.”

The National Cancer Institute provided funding. The researchers did not report having conflicts of interest.

Gastroenterologists, female physicians, and physicians who were less than a decade out of residency had significantly higher adenoma detection rates (ADRs) than their counterparts in a retrospective cohort study of colonoscopists.

“Efforts to target physicians with lower-quality performance are needed,” wrote Ateev Mehrotra, MD, MPH, of Harvard Medical School in Boston, with his associates. The study, one of the first to use natural language processing to compare electronic health data from geographically diverse health care systems, was published online 30 in Gastrointestinal Endoscopy (2017 Aug 30. doi: 10.1016/j.gie.2017.08.023).

Eraxion/Thinkstock

These associations persisted among patients who received only screening colonoscopies, who had complete colonoscopies with adequate bowel preparation, or who were younger than 80 years, the researchers said. The findings on sex reflect recent studies in which treatment by female hospitalists slightly decreased the risk of 30-day mortality when compared with treatment by a male hospitalist, they added. “A deliberate and meticulous approach to colonoscopy may facilitate achievement of a high ADR, and this method may be more common among female physicians,” they wrote. “This is supported by research showing that female physicians are more likely to adhere to clinical guidelines and to provide preventive care.” Studies of men in other fields have found them more likely to take risks, which contradicts the methodical approach needed for a high ADR, they emphasized. “Sex differences in color perception [also] may make it easier for female physicians to identify adenomas.”

Likewise, research outside gastroenterology has linked fewer years in practice with better quality of care. Improvements in fellowship training, better access to new equipment, “or simply decay of performance with age” all could explain the findings, the researchers wrote. They also cited five prior studies in which nongastroenterologists had lower ADRs. They called for studies that would further explore the reasons why specific physician traits affect performance.

Physicians in the study tended to have practiced fewer years than gastroenterologists in general in the United States, the investigators noted. “We also could not measure some other physician factors that might explain some of the variation we observed, such as type of endoscopes used.”

The National Cancer Institute provided funding. The researchers did not report having conflicts of interest.

Previous clinical recommendations on caring for transgender individuals have advised that hormone treatment begin no earlier than age 16 years, but a new guideline from the Endocrine Society suggests that there are compelling reasons to consider treating transgender adolescents even earlier.

“Sixteen is the typical age cutoff in many areas of the world for some decision-making capacity from a legal perspective, but when you think about hormones and puberty, 16 is pretty late,” Joshua D. Safer, MD, one of the task force members who authored the guideline, said in an interview. “If we’re going to use biology for guidance, then hormone interventions for transgender kids should begin occurring earlier, when puberty really happens, like around age 12, 13, or 14. However, we’re in a situation where we lack a test. We can’t diagnose anybody as transgender with excellent confidence, outside of talking to those kids. When we start talking about hormone therapies, we talk about some things that will be irreversible. That’s a fraught place to go, but we recognize that people are going to treat kids under 16 in many instances.”

• All individuals seeking gender-affirming medical treatment should receive information and counsel on options for fertility preservation prior to initiating puberty suppression in adolescents and prior to treating with hormonal therapy of the affirmed gender in both adolescents and adults.
• Removal of gonads may be considered when high doses of sex steroids are required to suppress the body’s secretion of hormones and/or to reduce steroid levels in advanced age.
• During sex-steroid treatment, clinicians should monitor, in both transgender males (female to male) and transgender females (male to female), prolactin, metabolic disorders, and bone loss, as well as cancer risks in individuals who have not undergone surgical treatment.

Concurrent with the release of the new guideline, the Endocrine Society issued a position statement that calls on federal and private insurers to cover medical interventions for transgender individuals as prescribed by a physician. “I live in Massachusetts, where our insurance commissioner deemed insurance coverage obligatory for transgender individuals as of 2015,” said Dr. Safer, who is also director of the endocrinology fellowship training program at Boston University. “I’ve spoken to the medical directors of our large insurers, like Blue Cross/Blue Shield. What’s notable is that there has been no push back [on coverage for transgender individuals] from the insurance companies. These services are not expensive: the primary care, the mental health care, and the hormones. Many of the patients are not opting for surgeries. The theme of their concern was to get their [health insurance] policies right as quickly as possible so that they could stop wasting time talking about it, and they could focus their energy on other, more expensive health care concerns.”

In the guideline, Dr. Safer and the other task force members called for more rigorous evaluations of the effectiveness and safety of endocrine and surgical protocols in the future. “Specifically, endocrine treatment protocols for GD/gender incongruence should include the careful assessment of the following: (1) the effects of prolonged delay of puberty in adolescents on bone health, gonadal function, and the brain (including effects on cognitive, emotional, social, and sexual development); (2) the effects of treatment in adults on sex hormone levels; (3) the requirement for and the effects of progestins and other agents used to suppress endogenous sex steroids during treatment; and (4) the risks and benefits of gender-affirming hormone treatment in older transgender people.”

Dr. Safer reported having no financial disclosures.

[email protected]

Previous clinical recommendations on caring for transgender individuals have advised that hormone treatment begin no earlier than age 16 years, but a new guideline from the Endocrine Society suggests that there are compelling reasons to consider treating transgender adolescents even earlier.

“Sixteen is the typical age cutoff in many areas of the world for some decision-making capacity from a legal perspective, but when you think about hormones and puberty, 16 is pretty late,” Joshua D. Safer, MD, one of the task force members who authored the guideline, said in an interview. “If we’re going to use biology for guidance, then hormone interventions for transgender kids should begin occurring earlier, when puberty really happens, like around age 12, 13, or 14. However, we’re in a situation where we lack a test. We can’t diagnose anybody as transgender with excellent confidence, outside of talking to those kids. When we start talking about hormone therapies, we talk about some things that will be irreversible. That’s a fraught place to go, but we recognize that people are going to treat kids under 16 in many instances.”

• All individuals seeking gender-affirming medical treatment should receive information and counsel on options for fertility preservation prior to initiating puberty suppression in adolescents and prior to treating with hormonal therapy of the affirmed gender in both adolescents and adults.
• Removal of gonads may be considered when high doses of sex steroids are required to suppress the body’s secretion of hormones and/or to reduce steroid levels in advanced age.
• During sex-steroid treatment, clinicians should monitor, in both transgender males (female to male) and transgender females (male to female), prolactin, metabolic disorders, and bone loss, as well as cancer risks in individuals who have not undergone surgical treatment.

Concurrent with the release of the new guideline, the Endocrine Society issued a position statement that calls on federal and private insurers to cover medical interventions for transgender individuals as prescribed by a physician. “I live in Massachusetts, where our insurance commissioner deemed insurance coverage obligatory for transgender individuals as of 2015,” said Dr. Safer, who is also director of the endocrinology fellowship training program at Boston University. “I’ve spoken to the medical directors of our large insurers, like Blue Cross/Blue Shield. What’s notable is that there has been no push back [on coverage for transgender individuals] from the insurance companies. These services are not expensive: the primary care, the mental health care, and the hormones. Many of the patients are not opting for surgeries. The theme of their concern was to get their [health insurance] policies right as quickly as possible so that they could stop wasting time talking about it, and they could focus their energy on other, more expensive health care concerns.”

In the guideline, Dr. Safer and the other task force members called for more rigorous evaluations of the effectiveness and safety of endocrine and surgical protocols in the future. “Specifically, endocrine treatment protocols for GD/gender incongruence should include the careful assessment of the following: (1) the effects of prolonged delay of puberty in adolescents on bone health, gonadal function, and the brain (including effects on cognitive, emotional, social, and sexual development); (2) the effects of treatment in adults on sex hormone levels; (3) the requirement for and the effects of progestins and other agents used to suppress endogenous sex steroids during treatment; and (4) the risks and benefits of gender-affirming hormone treatment in older transgender people.”

Dr. Safer reported having no financial disclosures.

[email protected]

Previous clinical recommendations on caring for transgender individuals have advised that hormone treatment begin no earlier than age 16 years, but a new guideline from the Endocrine Society suggests that there are compelling reasons to consider treating transgender adolescents even earlier.

“Sixteen is the typical age cutoff in many areas of the world for some decision-making capacity from a legal perspective, but when you think about hormones and puberty, 16 is pretty late,” Joshua D. Safer, MD, one of the task force members who authored the guideline, said in an interview. “If we’re going to use biology for guidance, then hormone interventions for transgender kids should begin occurring earlier, when puberty really happens, like around age 12, 13, or 14. However, we’re in a situation where we lack a test. We can’t diagnose anybody as transgender with excellent confidence, outside of talking to those kids. When we start talking about hormone therapies, we talk about some things that will be irreversible. That’s a fraught place to go, but we recognize that people are going to treat kids under 16 in many instances.”

• All individuals seeking gender-affirming medical treatment should receive information and counsel on options for fertility preservation prior to initiating puberty suppression in adolescents and prior to treating with hormonal therapy of the affirmed gender in both adolescents and adults.
• Removal of gonads may be considered when high doses of sex steroids are required to suppress the body’s secretion of hormones and/or to reduce steroid levels in advanced age.
• During sex-steroid treatment, clinicians should monitor, in both transgender males (female to male) and transgender females (male to female), prolactin, metabolic disorders, and bone loss, as well as cancer risks in individuals who have not undergone surgical treatment.

Concurrent with the release of the new guideline, the Endocrine Society issued a position statement that calls on federal and private insurers to cover medical interventions for transgender individuals as prescribed by a physician. “I live in Massachusetts, where our insurance commissioner deemed insurance coverage obligatory for transgender individuals as of 2015,” said Dr. Safer, who is also director of the endocrinology fellowship training program at Boston University. “I’ve spoken to the medical directors of our large insurers, like Blue Cross/Blue Shield. What’s notable is that there has been no push back [on coverage for transgender individuals] from the insurance companies. These services are not expensive: the primary care, the mental health care, and the hormones. Many of the patients are not opting for surgeries. The theme of their concern was to get their [health insurance] policies right as quickly as possible so that they could stop wasting time talking about it, and they could focus their energy on other, more expensive health care concerns.”

In the guideline, Dr. Safer and the other task force members called for more rigorous evaluations of the effectiveness and safety of endocrine and surgical protocols in the future. “Specifically, endocrine treatment protocols for GD/gender incongruence should include the careful assessment of the following: (1) the effects of prolonged delay of puberty in adolescents on bone health, gonadal function, and the brain (including effects on cognitive, emotional, social, and sexual development); (2) the effects of treatment in adults on sex hormone levels; (3) the requirement for and the effects of progestins and other agents used to suppress endogenous sex steroids during treatment; and (4) the risks and benefits of gender-affirming hormone treatment in older transgender people.”

Dr. Safer reported having no financial disclosures.

[email protected]

CHICAGO – A baseline C-reactive protein (CRP) level above 50 mg/L independently predicted worse overall survival after immunotherapy in patients with advanced non–small cell lung cancer and small cell lung cancer in a retrospective study.

In 99 patients treated with nivolumab after a first-line platinum doublet, the median baseline CRP level was 22 mg/L. After a median follow-up of 8.5 months, 50% of patients were alive, and, based on univariate and multivariate analysis, both liver involvement and having a CRP level greater than 50 mg/L were significantly associated with inferior overall survival after immunotherapy.

The median overall survival after immunotherapy was 9.3 months versus 2.7 months with a CRP level of 50 mg/L or less versus above 50 mg/L, Abdul Rafeh Naqash, MD, of East Carolina University, Greenville, N.C., reported at the Chicago Multidisciplinary Symposium in Thoracic Oncology.

Notably, significant increases in CRP level, compared with baseline, were seen at the time of grade 2 to grade 4 immune-related adverse events, which occurred in 38.4% of patients. This is a hypothesis-generating finding in that it suggests there is dysregulation of the immune system, in the context of immune checkpoint blockade, that leads to a more proinflammatory state, which ultimately leads to immune-related adverse events, Dr. Naqash said.

Study subjects were adults with a median age of 65 years who were treated during April 2015-March 2017. Most were white (64.7%), were male (64.6%), and had non–small cell lung cancer (88%). Most had stage IV disease (70.7%), and the most common site for metastases was the bones (35.4%) and the liver (24.2%). Patients’ CRP levels were measured at anti-PD-1–treatment initiation and serially with subsequent doses.

The findings are important because the identification of predictive biomarkers in patients treated with anti-PD-1 therapy could provide valuable insights into underlying mechanisms regulating patient responses, elucidate resistance mechanisms, and help with optimal selection of patients for treatment with and development of patient-tailored treatment, Dr. Naqash said, noting that identifying such biomarkers has thus far been a challenge.

However, this study is limited by its retrospective design and limited follow-up; the findings require validation in prospective lung cancer trials, he concluded.

Dr. Naqash reported having no disclosures.

[email protected]
 

CHICAGO – A baseline C-reactive protein (CRP) level above 50 mg/L independently predicted worse overall survival after immunotherapy in patients with advanced non–small cell lung cancer and small cell lung cancer in a retrospective study.

In 99 patients treated with nivolumab after a first-line platinum doublet, the median baseline CRP level was 22 mg/L. After a median follow-up of 8.5 months, 50% of patients were alive, and, based on univariate and multivariate analysis, both liver involvement and having a CRP level greater than 50 mg/L were significantly associated with inferior overall survival after immunotherapy.

The median overall survival after immunotherapy was 9.3 months versus 2.7 months with a CRP level of 50 mg/L or less versus above 50 mg/L, Abdul Rafeh Naqash, MD, of East Carolina University, Greenville, N.C., reported at the Chicago Multidisciplinary Symposium in Thoracic Oncology.

Notably, significant increases in CRP level, compared with baseline, were seen at the time of grade 2 to grade 4 immune-related adverse events, which occurred in 38.4% of patients. This is a hypothesis-generating finding in that it suggests there is dysregulation of the immune system, in the context of immune checkpoint blockade, that leads to a more proinflammatory state, which ultimately leads to immune-related adverse events, Dr. Naqash said.

Study subjects were adults with a median age of 65 years who were treated during April 2015-March 2017. Most were white (64.7%), were male (64.6%), and had non–small cell lung cancer (88%). Most had stage IV disease (70.7%), and the most common site for metastases was the bones (35.4%) and the liver (24.2%). Patients’ CRP levels were measured at anti-PD-1–treatment initiation and serially with subsequent doses.

The findings are important because the identification of predictive biomarkers in patients treated with anti-PD-1 therapy could provide valuable insights into underlying mechanisms regulating patient responses, elucidate resistance mechanisms, and help with optimal selection of patients for treatment with and development of patient-tailored treatment, Dr. Naqash said, noting that identifying such biomarkers has thus far been a challenge.

However, this study is limited by its retrospective design and limited follow-up; the findings require validation in prospective lung cancer trials, he concluded.

Dr. Naqash reported having no disclosures.

[email protected]
 

CHICAGO – A baseline C-reactive protein (CRP) level above 50 mg/L independently predicted worse overall survival after immunotherapy in patients with advanced non–small cell lung cancer and small cell lung cancer in a retrospective study.

In 99 patients treated with nivolumab after a first-line platinum doublet, the median baseline CRP level was 22 mg/L. After a median follow-up of 8.5 months, 50% of patients were alive, and, based on univariate and multivariate analysis, both liver involvement and having a CRP level greater than 50 mg/L were significantly associated with inferior overall survival after immunotherapy.

The median overall survival after immunotherapy was 9.3 months versus 2.7 months with a CRP level of 50 mg/L or less versus above 50 mg/L, Abdul Rafeh Naqash, MD, of East Carolina University, Greenville, N.C., reported at the Chicago Multidisciplinary Symposium in Thoracic Oncology.

Notably, significant increases in CRP level, compared with baseline, were seen at the time of grade 2 to grade 4 immune-related adverse events, which occurred in 38.4% of patients. This is a hypothesis-generating finding in that it suggests there is dysregulation of the immune system, in the context of immune checkpoint blockade, that leads to a more proinflammatory state, which ultimately leads to immune-related adverse events, Dr. Naqash said.

Study subjects were adults with a median age of 65 years who were treated during April 2015-March 2017. Most were white (64.7%), were male (64.6%), and had non–small cell lung cancer (88%). Most had stage IV disease (70.7%), and the most common site for metastases was the bones (35.4%) and the liver (24.2%). Patients’ CRP levels were measured at anti-PD-1–treatment initiation and serially with subsequent doses.

The findings are important because the identification of predictive biomarkers in patients treated with anti-PD-1 therapy could provide valuable insights into underlying mechanisms regulating patient responses, elucidate resistance mechanisms, and help with optimal selection of patients for treatment with and development of patient-tailored treatment, Dr. Naqash said, noting that identifying such biomarkers has thus far been a challenge.

However, this study is limited by its retrospective design and limited follow-up; the findings require validation in prospective lung cancer trials, he concluded.

Dr. Naqash reported having no disclosures.

[email protected]
 

A 48-hour course of postoperative cephalexin and metronidazole, plus typical preoperative antibiotics, cut surgical site infections by 59% in obese women who had a cesarean delivery.

The benefit of the additional postoperative treatment was driven by a significant, 69% risk reduction among women who had ruptured membranes, Amy M. Valent, DO, and her colleagues reported (JAMA. 2017;318[11]:1026-34). However, the authors noted, “tests for interaction between the intact membranes and [ruptured] subgroups and postpartum cephalexin-metronidazole were not statistically different and should not be interpreted as showing a difference in significance or effect size among the subgroups with and without [rupture].”

AngelIce/Thinkstock

[email protected]

A 48-hour course of postoperative cephalexin and metronidazole, plus typical preoperative antibiotics, cut surgical site infections by 59% in obese women who had a cesarean delivery.

The benefit of the additional postoperative treatment was driven by a significant, 69% risk reduction among women who had ruptured membranes, Amy M. Valent, DO, and her colleagues reported (JAMA. 2017;318[11]:1026-34). However, the authors noted, “tests for interaction between the intact membranes and [ruptured] subgroups and postpartum cephalexin-metronidazole were not statistically different and should not be interpreted as showing a difference in significance or effect size among the subgroups with and without [rupture].”

AngelIce/Thinkstock

[email protected]

A 48-hour course of postoperative cephalexin and metronidazole, plus typical preoperative antibiotics, cut surgical site infections by 59% in obese women who had a cesarean delivery.

The benefit of the additional postoperative treatment was driven by a significant, 69% risk reduction among women who had ruptured membranes, Amy M. Valent, DO, and her colleagues reported (JAMA. 2017;318[11]:1026-34). However, the authors noted, “tests for interaction between the intact membranes and [ruptured] subgroups and postpartum cephalexin-metronidazole were not statistically different and should not be interpreted as showing a difference in significance or effect size among the subgroups with and without [rupture].”

AngelIce/Thinkstock

[email protected]

Session

Career Development (K Award) grants: What are they, why should I apply, and how do I get funded?

Presenters

Christopher Bonafide, MD, MSCE; Patrick Brady, MD, MS; Kavita Parikh, MD, MSHS; Raj Srivastava, MD, MPH, SFHM; Derek Williams, MD, MPH

Session Summary

Pediatric hospital medicine, in its relative infancy, is attracting a cohort of academicians dedicated to advancing the care of hospitalized children. While other pediatric subspecialties have long reserved a significant proportion of fellowship training for research, pediatric hospitalist research has instead developed from the work of scholarly pioneers in the industry.

Who should apply for an NIH Career Development Award?

Competitive applicants for a Career Development Award are ideally interested in embarking on a career dedicated to research of some type, although exactly what that entails can and certainly may change over time.

What does the NIH Career Development Award provide?

The award funds a significant portion of your salary to provide protected time dedicated to your research and career development. Removing this financial barrier allows the investigator to become fully immersed in maturation as an independent investigator. The presenters were quick to caution that applicants (along with department and division chairs) should be aware that the award does not cover your entire salary; early-career investigators truly need dedication from their department and/or division to be successful.

Why apply for an NIH Career Development Award?

Clinical, translational, and basic science research takes time to complete, and the skills needed to be a successful investigator are not intuitive. Rather, they require close mentorship and practice. A career development award organizes and prioritizes an early-career investigator’s approach to obtaining research independence. Applying for an NIH Career Development Award helps identify the applicant’s experiential and knowledge gaps and, more importantly, develops a plan for how these deficits will be addressed over the course of the research project. This formative process ideally allows the early-career investigator to be more competitive in seeking larger grant funding.

Interested in pursuing a career development award? Dr. Bonafide and Dr. Srivastava offered the valuable advice that an applicant’s proposed research is only part of the equation for funding success. Equally important is your ability to identify your weaknesses as they pertain to research (and how you will address these weaknesses) as well as to find your mentorship team. You and your fellow awardees should surround yourselves with mentors who will address specific needs, which, in some circumstances, may require creativity and collaboration to augment the experience gained from others.
 

Key takeaway for PHM

As we recognize the growing complexities of caring for the hospitalized child, opportunities for clinical, translational, and basic science are expanding rapidly. Embracing the benefits of formalizing your research training early can lead to a successful and satisfying academic career in the long term.

Dr. Morrison is a Pediatric Hospital Medicine Fellow at Johns Hopkins All Children’s Hospital, St. Petersburg, Fla.

Session

Career Development (K Award) grants: What are they, why should I apply, and how do I get funded?

Presenters

Christopher Bonafide, MD, MSCE; Patrick Brady, MD, MS; Kavita Parikh, MD, MSHS; Raj Srivastava, MD, MPH, SFHM; Derek Williams, MD, MPH

Session Summary

Pediatric hospital medicine, in its relative infancy, is attracting a cohort of academicians dedicated to advancing the care of hospitalized children. While other pediatric subspecialties have long reserved a significant proportion of fellowship training for research, pediatric hospitalist research has instead developed from the work of scholarly pioneers in the industry.

Who should apply for an NIH Career Development Award?

Competitive applicants for a Career Development Award are ideally interested in embarking on a career dedicated to research of some type, although exactly what that entails can and certainly may change over time.

What does the NIH Career Development Award provide?

The award funds a significant portion of your salary to provide protected time dedicated to your research and career development. Removing this financial barrier allows the investigator to become fully immersed in maturation as an independent investigator. The presenters were quick to caution that applicants (along with department and division chairs) should be aware that the award does not cover your entire salary; early-career investigators truly need dedication from their department and/or division to be successful.

Why apply for an NIH Career Development Award?

Clinical, translational, and basic science research takes time to complete, and the skills needed to be a successful investigator are not intuitive. Rather, they require close mentorship and practice. A career development award organizes and prioritizes an early-career investigator’s approach to obtaining research independence. Applying for an NIH Career Development Award helps identify the applicant’s experiential and knowledge gaps and, more importantly, develops a plan for how these deficits will be addressed over the course of the research project. This formative process ideally allows the early-career investigator to be more competitive in seeking larger grant funding.

Interested in pursuing a career development award? Dr. Bonafide and Dr. Srivastava offered the valuable advice that an applicant’s proposed research is only part of the equation for funding success. Equally important is your ability to identify your weaknesses as they pertain to research (and how you will address these weaknesses) as well as to find your mentorship team. You and your fellow awardees should surround yourselves with mentors who will address specific needs, which, in some circumstances, may require creativity and collaboration to augment the experience gained from others.
 

Key takeaway for PHM

As we recognize the growing complexities of caring for the hospitalized child, opportunities for clinical, translational, and basic science are expanding rapidly. Embracing the benefits of formalizing your research training early can lead to a successful and satisfying academic career in the long term.

Dr. Morrison is a Pediatric Hospital Medicine Fellow at Johns Hopkins All Children’s Hospital, St. Petersburg, Fla.

Session

Career Development (K Award) grants: What are they, why should I apply, and how do I get funded?

Presenters

Christopher Bonafide, MD, MSCE; Patrick Brady, MD, MS; Kavita Parikh, MD, MSHS; Raj Srivastava, MD, MPH, SFHM; Derek Williams, MD, MPH

Session Summary

Pediatric hospital medicine, in its relative infancy, is attracting a cohort of academicians dedicated to advancing the care of hospitalized children. While other pediatric subspecialties have long reserved a significant proportion of fellowship training for research, pediatric hospitalist research has instead developed from the work of scholarly pioneers in the industry.

Who should apply for an NIH Career Development Award?

Competitive applicants for a Career Development Award are ideally interested in embarking on a career dedicated to research of some type, although exactly what that entails can and certainly may change over time.

What does the NIH Career Development Award provide?

The award funds a significant portion of your salary to provide protected time dedicated to your research and career development. Removing this financial barrier allows the investigator to become fully immersed in maturation as an independent investigator. The presenters were quick to caution that applicants (along with department and division chairs) should be aware that the award does not cover your entire salary; early-career investigators truly need dedication from their department and/or division to be successful.

Why apply for an NIH Career Development Award?

Clinical, translational, and basic science research takes time to complete, and the skills needed to be a successful investigator are not intuitive. Rather, they require close mentorship and practice. A career development award organizes and prioritizes an early-career investigator’s approach to obtaining research independence. Applying for an NIH Career Development Award helps identify the applicant’s experiential and knowledge gaps and, more importantly, develops a plan for how these deficits will be addressed over the course of the research project. This formative process ideally allows the early-career investigator to be more competitive in seeking larger grant funding.

Interested in pursuing a career development award? Dr. Bonafide and Dr. Srivastava offered the valuable advice that an applicant’s proposed research is only part of the equation for funding success. Equally important is your ability to identify your weaknesses as they pertain to research (and how you will address these weaknesses) as well as to find your mentorship team. You and your fellow awardees should surround yourselves with mentors who will address specific needs, which, in some circumstances, may require creativity and collaboration to augment the experience gained from others.
 

Key takeaway for PHM

As we recognize the growing complexities of caring for the hospitalized child, opportunities for clinical, translational, and basic science are expanding rapidly. Embracing the benefits of formalizing your research training early can lead to a successful and satisfying academic career in the long term.

Dr. Morrison is a Pediatric Hospital Medicine Fellow at Johns Hopkins All Children’s Hospital, St. Petersburg, Fla.

The Food and Drug Administration has granted accelerated approval to copanlisib (Aliqopa) for the treatment of adults with relapsed follicular lymphoma who have received at least two prior treatments.

Approval of the kinase inhibitor was based on an overall response rate of 59% in a single-arm trial of 104 patients with follicular B-cell non-Hodgkin lymphoma who had relapsed disease following at least two prior treatments. These patients had a complete or partial response for a median 12.2 months.

[email protected]

The Food and Drug Administration has granted accelerated approval to copanlisib (Aliqopa) for the treatment of adults with relapsed follicular lymphoma who have received at least two prior treatments.

Approval of the kinase inhibitor was based on an overall response rate of 59% in a single-arm trial of 104 patients with follicular B-cell non-Hodgkin lymphoma who had relapsed disease following at least two prior treatments. These patients had a complete or partial response for a median 12.2 months.

[email protected]

The Food and Drug Administration has granted accelerated approval to copanlisib (Aliqopa) for the treatment of adults with relapsed follicular lymphoma who have received at least two prior treatments.

Approval of the kinase inhibitor was based on an overall response rate of 59% in a single-arm trial of 104 patients with follicular B-cell non-Hodgkin lymphoma who had relapsed disease following at least two prior treatments. These patients had a complete or partial response for a median 12.2 months.

[email protected]

Nearly one-third of cardiovascular events in patients with rheumatoid arthritis can be attributed to their rheumatoid arthritis characteristics, such as Disease Activity Score and rheumatoid factor or anticitrullinated protein antibody positivity, research suggests.

A prospective, international cohort study published in Annals of the Rheumatic Diseases followed 5,638 patients with rheumatoid arthritis (RA) and no history of cardiovascular disease for a mean of 5.8 years to look at their risk of myocardial infarction, angina, revascularization, stroke, peripheral vascular disease, and death from cardiovascular disease.

Nearly one-third of cardiovascular events in patients with rheumatoid arthritis can be attributed to their rheumatoid arthritis characteristics, such as Disease Activity Score and rheumatoid factor or anticitrullinated protein antibody positivity, research suggests.

A prospective, international cohort study published in Annals of the Rheumatic Diseases followed 5,638 patients with rheumatoid arthritis (RA) and no history of cardiovascular disease for a mean of 5.8 years to look at their risk of myocardial infarction, angina, revascularization, stroke, peripheral vascular disease, and death from cardiovascular disease.

Nearly one-third of cardiovascular events in patients with rheumatoid arthritis can be attributed to their rheumatoid arthritis characteristics, such as Disease Activity Score and rheumatoid factor or anticitrullinated protein antibody positivity, research suggests.

A prospective, international cohort study published in Annals of the Rheumatic Diseases followed 5,638 patients with rheumatoid arthritis (RA) and no history of cardiovascular disease for a mean of 5.8 years to look at their risk of myocardial infarction, angina, revascularization, stroke, peripheral vascular disease, and death from cardiovascular disease.

Ultrasound evaluations to look for subclinical inflammation in joints of patients with arthralgia appear best at ruling out inflammatory arthritis (IA) 1 year in the future rather than ruling it in, according to findings from a multicenter cohort study published online in Arthritis Research and Therapy.

The imaging modality’s ability to identify those who will not go on to develop IA complemented the serologic and clinical factors that help to discriminate the individuals with arthralgia who are most at risk of the condition.

Remains/Thinkstock

[email protected]

Ultrasound evaluations to look for subclinical inflammation in joints of patients with arthralgia appear best at ruling out inflammatory arthritis (IA) 1 year in the future rather than ruling it in, according to findings from a multicenter cohort study published online in Arthritis Research and Therapy.

The imaging modality’s ability to identify those who will not go on to develop IA complemented the serologic and clinical factors that help to discriminate the individuals with arthralgia who are most at risk of the condition.

Remains/Thinkstock

[email protected]

Ultrasound evaluations to look for subclinical inflammation in joints of patients with arthralgia appear best at ruling out inflammatory arthritis (IA) 1 year in the future rather than ruling it in, according to findings from a multicenter cohort study published online in Arthritis Research and Therapy.

The imaging modality’s ability to identify those who will not go on to develop IA complemented the serologic and clinical factors that help to discriminate the individuals with arthralgia who are most at risk of the condition.

Remains/Thinkstock

[email protected]