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Antianginal agents underutilized after MI
WASHINGTON – Non–beta-blocker antianginal drugs are seriously underprescribed in patients with angina following percutaneous coronary intervention (PCI) for a myocardial infarction (MI), according to a large national study, Alexander C. Fanaroff, MD, said at the annual meeting of the American College of Cardiology.
Clinical practice in this regard appears to be largely out of touch with current evidence-based guidelines regarding angina management in patients with stable ischemic heart disease. Those ACC/American Heart Association guidelines recommend a stepwise approach beginning with a beta-blocker and sublingual nitroglycerin, adding a calcium channel blocker if the beta-blocker isn’t tolerated or effective, further adding a long-acting nitrate if symptoms persist, incorporating ranolazine (Ranexa) as needed, and finally turning to revascularization for symptomatic relief if multidrug therapy proves inadequate (J Am Coll Cardiol. 2012 Dec 18;60[24]:e44-e164).
“When you ask patients and physicians separately about the prevalence of angina, they tend to disagree, with physicians consistently thinking their patients have less angina than patients report themselves. Together, with our data, this indicates that strategies to improve clinician recognition and treatment of angina symptoms are needed,” he asserted.
TRANSLATE-ACS was a large, longitudinal, observational study of patients who underwent PCI at 233 U.S. hospitals during 2010-2012. Dr. Fanaroff focused on 12-month follow-up data on the 10,870 patients whose PCI was for treatment of an acute MI. In telephone interviews 6 weeks postdischarge which incorporated the validated Seattle Angina Questionnaire, 3,190 of these individuals (31%) with stable ischemic heart disease reported angina symptoms. Of those, 79% said their symptoms occurred at least monthly, 18% weekly, and 3% daily. Yet, only 1 in 5 patients with angina 6 weeks postdischarge were on a non–beta-blocker antianginal medication: 16% were on monotherapy with a calcium channel blocker or long-acting nitrate, 3% were on dual therapy, and less than 1% were on three non–beta-blockers for their angina.
The prevalence of angina dropped over time. At 6 months postdischarge, 40% of the original cohort of patients who had angina at 6 weeks still reported angina. At 12 months, it was 33%. Meanwhile, the use of non–beta-blocker antianginal agents crept up modestly over time, from 20% in patients with angina at 6 weeks postdischarge, to 22% in those with angina at 6 months, and 23% at 12 months.
On the other hand, 33% of patients with angina at 6 weeks had persistent angina through 12 months. Remarkably, 69% of these individuals never received a non–beta-blocker antianginal drug during all that time, including 61% of those who experienced daily or weekly angina.
The use of non–beta-blocker antianginal drugs was more frequent in patients with more severe angina: 25% of patients with daily or weekly angina at 6 weeks were on such medication, as were 34% at 6 months and 38% at 12 months, compared with 16%, 18%, and 22% of those with monthly angina. Still, most of these patients were on only a single non–beta-blocker antianginal agent.
Of patients with angina at 6 weeks, 12% subsequently underwent repeat PCI at some point during the first year postdischarge. Of these individuals, 19% were on a single non–beta-blocker antianginal drug at the time of their procedure, 6% were on two such drugs, and only 1% were on three.
Roughly 10% of patients with multivessel coronary disease who were identified angiographically at the time of their acute MI did not undergo multivessel PCI at that time. This was not predictive of angina 6 weeks post discharge, Dr. Fanaroff continued.
One audience member asked Dr. Fanaroff how he knows that the patients with self-reported angina didn’t actually have noncardiac chest pain, in which case their physicians’ decision not to prescribe second- and third-tier antianginal drugs would be appropriate.
Dr. Fanaroff responded that it’s possible, and even likely, that some patients with self-reported angina had a noncardiac source of their chest pain. However, they would be in the minority. The fact is that multiple studies have shown that patients who report experiencing angina after PCI for acute MI have about a 1.5-times increased risk of readmission and repeat revascularization, a 2-times increased risk of developing new depressive symptoms, and diminished quality of life scores.
The TRANSLATE-ACS study was sponsored by Eli Lilly. Dr. Fanaroff reported having no financial conflicts.
WASHINGTON – Non–beta-blocker antianginal drugs are seriously underprescribed in patients with angina following percutaneous coronary intervention (PCI) for a myocardial infarction (MI), according to a large national study, Alexander C. Fanaroff, MD, said at the annual meeting of the American College of Cardiology.
Clinical practice in this regard appears to be largely out of touch with current evidence-based guidelines regarding angina management in patients with stable ischemic heart disease. Those ACC/American Heart Association guidelines recommend a stepwise approach beginning with a beta-blocker and sublingual nitroglycerin, adding a calcium channel blocker if the beta-blocker isn’t tolerated or effective, further adding a long-acting nitrate if symptoms persist, incorporating ranolazine (Ranexa) as needed, and finally turning to revascularization for symptomatic relief if multidrug therapy proves inadequate (J Am Coll Cardiol. 2012 Dec 18;60[24]:e44-e164).
“When you ask patients and physicians separately about the prevalence of angina, they tend to disagree, with physicians consistently thinking their patients have less angina than patients report themselves. Together, with our data, this indicates that strategies to improve clinician recognition and treatment of angina symptoms are needed,” he asserted.
TRANSLATE-ACS was a large, longitudinal, observational study of patients who underwent PCI at 233 U.S. hospitals during 2010-2012. Dr. Fanaroff focused on 12-month follow-up data on the 10,870 patients whose PCI was for treatment of an acute MI. In telephone interviews 6 weeks postdischarge which incorporated the validated Seattle Angina Questionnaire, 3,190 of these individuals (31%) with stable ischemic heart disease reported angina symptoms. Of those, 79% said their symptoms occurred at least monthly, 18% weekly, and 3% daily. Yet, only 1 in 5 patients with angina 6 weeks postdischarge were on a non–beta-blocker antianginal medication: 16% were on monotherapy with a calcium channel blocker or long-acting nitrate, 3% were on dual therapy, and less than 1% were on three non–beta-blockers for their angina.
The prevalence of angina dropped over time. At 6 months postdischarge, 40% of the original cohort of patients who had angina at 6 weeks still reported angina. At 12 months, it was 33%. Meanwhile, the use of non–beta-blocker antianginal agents crept up modestly over time, from 20% in patients with angina at 6 weeks postdischarge, to 22% in those with angina at 6 months, and 23% at 12 months.
On the other hand, 33% of patients with angina at 6 weeks had persistent angina through 12 months. Remarkably, 69% of these individuals never received a non–beta-blocker antianginal drug during all that time, including 61% of those who experienced daily or weekly angina.
The use of non–beta-blocker antianginal drugs was more frequent in patients with more severe angina: 25% of patients with daily or weekly angina at 6 weeks were on such medication, as were 34% at 6 months and 38% at 12 months, compared with 16%, 18%, and 22% of those with monthly angina. Still, most of these patients were on only a single non–beta-blocker antianginal agent.
Of patients with angina at 6 weeks, 12% subsequently underwent repeat PCI at some point during the first year postdischarge. Of these individuals, 19% were on a single non–beta-blocker antianginal drug at the time of their procedure, 6% were on two such drugs, and only 1% were on three.
Roughly 10% of patients with multivessel coronary disease who were identified angiographically at the time of their acute MI did not undergo multivessel PCI at that time. This was not predictive of angina 6 weeks post discharge, Dr. Fanaroff continued.
One audience member asked Dr. Fanaroff how he knows that the patients with self-reported angina didn’t actually have noncardiac chest pain, in which case their physicians’ decision not to prescribe second- and third-tier antianginal drugs would be appropriate.
Dr. Fanaroff responded that it’s possible, and even likely, that some patients with self-reported angina had a noncardiac source of their chest pain. However, they would be in the minority. The fact is that multiple studies have shown that patients who report experiencing angina after PCI for acute MI have about a 1.5-times increased risk of readmission and repeat revascularization, a 2-times increased risk of developing new depressive symptoms, and diminished quality of life scores.
The TRANSLATE-ACS study was sponsored by Eli Lilly. Dr. Fanaroff reported having no financial conflicts.
WASHINGTON – Non–beta-blocker antianginal drugs are seriously underprescribed in patients with angina following percutaneous coronary intervention (PCI) for a myocardial infarction (MI), according to a large national study, Alexander C. Fanaroff, MD, said at the annual meeting of the American College of Cardiology.
Clinical practice in this regard appears to be largely out of touch with current evidence-based guidelines regarding angina management in patients with stable ischemic heart disease. Those ACC/American Heart Association guidelines recommend a stepwise approach beginning with a beta-blocker and sublingual nitroglycerin, adding a calcium channel blocker if the beta-blocker isn’t tolerated or effective, further adding a long-acting nitrate if symptoms persist, incorporating ranolazine (Ranexa) as needed, and finally turning to revascularization for symptomatic relief if multidrug therapy proves inadequate (J Am Coll Cardiol. 2012 Dec 18;60[24]:e44-e164).
“When you ask patients and physicians separately about the prevalence of angina, they tend to disagree, with physicians consistently thinking their patients have less angina than patients report themselves. Together, with our data, this indicates that strategies to improve clinician recognition and treatment of angina symptoms are needed,” he asserted.
TRANSLATE-ACS was a large, longitudinal, observational study of patients who underwent PCI at 233 U.S. hospitals during 2010-2012. Dr. Fanaroff focused on 12-month follow-up data on the 10,870 patients whose PCI was for treatment of an acute MI. In telephone interviews 6 weeks postdischarge which incorporated the validated Seattle Angina Questionnaire, 3,190 of these individuals (31%) with stable ischemic heart disease reported angina symptoms. Of those, 79% said their symptoms occurred at least monthly, 18% weekly, and 3% daily. Yet, only 1 in 5 patients with angina 6 weeks postdischarge were on a non–beta-blocker antianginal medication: 16% were on monotherapy with a calcium channel blocker or long-acting nitrate, 3% were on dual therapy, and less than 1% were on three non–beta-blockers for their angina.
The prevalence of angina dropped over time. At 6 months postdischarge, 40% of the original cohort of patients who had angina at 6 weeks still reported angina. At 12 months, it was 33%. Meanwhile, the use of non–beta-blocker antianginal agents crept up modestly over time, from 20% in patients with angina at 6 weeks postdischarge, to 22% in those with angina at 6 months, and 23% at 12 months.
On the other hand, 33% of patients with angina at 6 weeks had persistent angina through 12 months. Remarkably, 69% of these individuals never received a non–beta-blocker antianginal drug during all that time, including 61% of those who experienced daily or weekly angina.
The use of non–beta-blocker antianginal drugs was more frequent in patients with more severe angina: 25% of patients with daily or weekly angina at 6 weeks were on such medication, as were 34% at 6 months and 38% at 12 months, compared with 16%, 18%, and 22% of those with monthly angina. Still, most of these patients were on only a single non–beta-blocker antianginal agent.
Of patients with angina at 6 weeks, 12% subsequently underwent repeat PCI at some point during the first year postdischarge. Of these individuals, 19% were on a single non–beta-blocker antianginal drug at the time of their procedure, 6% were on two such drugs, and only 1% were on three.
Roughly 10% of patients with multivessel coronary disease who were identified angiographically at the time of their acute MI did not undergo multivessel PCI at that time. This was not predictive of angina 6 weeks post discharge, Dr. Fanaroff continued.
One audience member asked Dr. Fanaroff how he knows that the patients with self-reported angina didn’t actually have noncardiac chest pain, in which case their physicians’ decision not to prescribe second- and third-tier antianginal drugs would be appropriate.
Dr. Fanaroff responded that it’s possible, and even likely, that some patients with self-reported angina had a noncardiac source of their chest pain. However, they would be in the minority. The fact is that multiple studies have shown that patients who report experiencing angina after PCI for acute MI have about a 1.5-times increased risk of readmission and repeat revascularization, a 2-times increased risk of developing new depressive symptoms, and diminished quality of life scores.
The TRANSLATE-ACS study was sponsored by Eli Lilly. Dr. Fanaroff reported having no financial conflicts.
AT ACC 17
Key clinical point:
Major finding: Only 31% of patients who reported persistent angina for the first 12 months post PCI for acute MI reported taking any non–beta-blocker antianginal drugs during that period.
Data source: An analysis of nearly 11,000 patients who underwent PCI for an acute MI at 233 U.S. hospitals in the longitudinal observational TRANSLATE-ACS study.
Disclosures: The TRANSLATE-ACS study was sponsored by Eli Lilly. The presenter reported having no financial conflicts.
Maternal antidepressants unrelated to autism in offspring
Maternal use of antidepressants during pregnancy is unrelated to autism spectrum disorder in the offspring, according to two separate, population-level cohort studies that used sophisticated statistical techniques to account for numerous confounding factors.
Both studies were reported online April 18 in JAMA.
Some previous studies have reported a possible link between in utero exposure to antidepressants, particularly SSRIs, and autism. But they had limited ability to control for key confounders, notably the mother’s underlying depression.
Overall, 1.1% of these children were diagnosed as having autism spectrum disorder. This prevalence is consistent with current population estimates, indicating that few if any cases of the disorder were missed, said Dr. Brown of Women’s College Research Institute in Toronto and the division of epidemiology, University of Toronto, and her associates.
In initial, unadjusted analyses of the data, the risk of autism was higher in exposed than in nonexposed children. However, that association disappeared once the data were adjusted to account for numerous potential confounders.
Further analysis comparing the exposed children with their unexposed siblings also found that after adjusting for confounding factors, prenatal exposure to antidepressants did not affect the risk of developing autism. In addition, this lack of association also was found in the subgroup of children whose mothers took antidepressants shortly before but not during pregnancy.
Taken together, these findings “suggest that confounding by indication for the medication may explain previously observed associations between in utero serotonergic antidepressant exposure and autism spectrum disorder,” Dr. Brown and her associates said (JAMA. 2017 Apr 18. doi: 10.1001.jama.2017.3415). In the other study, Ayesha C. Sujan and her associates analyzed data in several nationwide Swedish registries to examine whether first trimester exposure to any antidepressants raised the risk of a range of neurodevelopmental problems, including autism. This study involved 1,580,629 offspring, including 22,544 (1.4%) whose mothers took antidepressants during the first trimester.
As with Dr. Brown’s study, the initial unadjusted analysis showed an association between antidepressant exposure and autism, but that association disappeared once the data were adjusted to account for confounding factors. In the final data analysis, first trimester exposure was associated with preterm birth (odds ratio, 1.34) but not with small-for-gestational-age size (OR, 1.01), autism spectrum disorder (hazard ratio, 0.83), or attention deficit/hyperactivity disorder (HR, 0.99), said Ms. Sujan of the department of psychological and brain sciences, Indiana University, Bloomington, and her associates.
“These results are consistent with the hypothesis that genetic factors, familial environmental factors, or both, account for the population-wide associations between first-trimester antidepressant exposure and these outcomes,” they noted (JAMA. 2017 Apr 18. doi: 10.1001/jama.2017.3413).
These two studies add to the growing literature suggesting that any association between prenatal antidepressant exposure and autism spectrum disorder may not be causal.
Both reports should reassure both parents and clinicians.
And regardless of whether any such association reflects antidepressant effects, the mother’s underlying mental health, or other factors, efforts should focus on promoting optimal child health in ways that harness the child’s inherent developmental plasticity.
Tim F. Oberlander, MD, is in the division of developmental pediatrics at the University of British Columbia and at the British Columbia Children’s Hospital Research Institute, both in Vancouver. Lonnie Zwaigenbaum, MD, is in the department of pediatrics at the University of Alberta, Edmonton. They reported having no relevant financial disclosures. These remarks were excerpted from an editorial accompanying the two reports (JAMA. 2017;317[15]:1533-4).
These two studies add to the growing literature suggesting that any association between prenatal antidepressant exposure and autism spectrum disorder may not be causal.
Both reports should reassure both parents and clinicians.
And regardless of whether any such association reflects antidepressant effects, the mother’s underlying mental health, or other factors, efforts should focus on promoting optimal child health in ways that harness the child’s inherent developmental plasticity.
Tim F. Oberlander, MD, is in the division of developmental pediatrics at the University of British Columbia and at the British Columbia Children’s Hospital Research Institute, both in Vancouver. Lonnie Zwaigenbaum, MD, is in the department of pediatrics at the University of Alberta, Edmonton. They reported having no relevant financial disclosures. These remarks were excerpted from an editorial accompanying the two reports (JAMA. 2017;317[15]:1533-4).
These two studies add to the growing literature suggesting that any association between prenatal antidepressant exposure and autism spectrum disorder may not be causal.
Both reports should reassure both parents and clinicians.
And regardless of whether any such association reflects antidepressant effects, the mother’s underlying mental health, or other factors, efforts should focus on promoting optimal child health in ways that harness the child’s inherent developmental plasticity.
Tim F. Oberlander, MD, is in the division of developmental pediatrics at the University of British Columbia and at the British Columbia Children’s Hospital Research Institute, both in Vancouver. Lonnie Zwaigenbaum, MD, is in the department of pediatrics at the University of Alberta, Edmonton. They reported having no relevant financial disclosures. These remarks were excerpted from an editorial accompanying the two reports (JAMA. 2017;317[15]:1533-4).
Maternal use of antidepressants during pregnancy is unrelated to autism spectrum disorder in the offspring, according to two separate, population-level cohort studies that used sophisticated statistical techniques to account for numerous confounding factors.
Both studies were reported online April 18 in JAMA.
Some previous studies have reported a possible link between in utero exposure to antidepressants, particularly SSRIs, and autism. But they had limited ability to control for key confounders, notably the mother’s underlying depression.
Overall, 1.1% of these children were diagnosed as having autism spectrum disorder. This prevalence is consistent with current population estimates, indicating that few if any cases of the disorder were missed, said Dr. Brown of Women’s College Research Institute in Toronto and the division of epidemiology, University of Toronto, and her associates.
In initial, unadjusted analyses of the data, the risk of autism was higher in exposed than in nonexposed children. However, that association disappeared once the data were adjusted to account for numerous potential confounders.
Further analysis comparing the exposed children with their unexposed siblings also found that after adjusting for confounding factors, prenatal exposure to antidepressants did not affect the risk of developing autism. In addition, this lack of association also was found in the subgroup of children whose mothers took antidepressants shortly before but not during pregnancy.
Taken together, these findings “suggest that confounding by indication for the medication may explain previously observed associations between in utero serotonergic antidepressant exposure and autism spectrum disorder,” Dr. Brown and her associates said (JAMA. 2017 Apr 18. doi: 10.1001.jama.2017.3415). In the other study, Ayesha C. Sujan and her associates analyzed data in several nationwide Swedish registries to examine whether first trimester exposure to any antidepressants raised the risk of a range of neurodevelopmental problems, including autism. This study involved 1,580,629 offspring, including 22,544 (1.4%) whose mothers took antidepressants during the first trimester.
As with Dr. Brown’s study, the initial unadjusted analysis showed an association between antidepressant exposure and autism, but that association disappeared once the data were adjusted to account for confounding factors. In the final data analysis, first trimester exposure was associated with preterm birth (odds ratio, 1.34) but not with small-for-gestational-age size (OR, 1.01), autism spectrum disorder (hazard ratio, 0.83), or attention deficit/hyperactivity disorder (HR, 0.99), said Ms. Sujan of the department of psychological and brain sciences, Indiana University, Bloomington, and her associates.
“These results are consistent with the hypothesis that genetic factors, familial environmental factors, or both, account for the population-wide associations between first-trimester antidepressant exposure and these outcomes,” they noted (JAMA. 2017 Apr 18. doi: 10.1001/jama.2017.3413).
Maternal use of antidepressants during pregnancy is unrelated to autism spectrum disorder in the offspring, according to two separate, population-level cohort studies that used sophisticated statistical techniques to account for numerous confounding factors.
Both studies were reported online April 18 in JAMA.
Some previous studies have reported a possible link between in utero exposure to antidepressants, particularly SSRIs, and autism. But they had limited ability to control for key confounders, notably the mother’s underlying depression.
Overall, 1.1% of these children were diagnosed as having autism spectrum disorder. This prevalence is consistent with current population estimates, indicating that few if any cases of the disorder were missed, said Dr. Brown of Women’s College Research Institute in Toronto and the division of epidemiology, University of Toronto, and her associates.
In initial, unadjusted analyses of the data, the risk of autism was higher in exposed than in nonexposed children. However, that association disappeared once the data were adjusted to account for numerous potential confounders.
Further analysis comparing the exposed children with their unexposed siblings also found that after adjusting for confounding factors, prenatal exposure to antidepressants did not affect the risk of developing autism. In addition, this lack of association also was found in the subgroup of children whose mothers took antidepressants shortly before but not during pregnancy.
Taken together, these findings “suggest that confounding by indication for the medication may explain previously observed associations between in utero serotonergic antidepressant exposure and autism spectrum disorder,” Dr. Brown and her associates said (JAMA. 2017 Apr 18. doi: 10.1001.jama.2017.3415). In the other study, Ayesha C. Sujan and her associates analyzed data in several nationwide Swedish registries to examine whether first trimester exposure to any antidepressants raised the risk of a range of neurodevelopmental problems, including autism. This study involved 1,580,629 offspring, including 22,544 (1.4%) whose mothers took antidepressants during the first trimester.
As with Dr. Brown’s study, the initial unadjusted analysis showed an association between antidepressant exposure and autism, but that association disappeared once the data were adjusted to account for confounding factors. In the final data analysis, first trimester exposure was associated with preterm birth (odds ratio, 1.34) but not with small-for-gestational-age size (OR, 1.01), autism spectrum disorder (hazard ratio, 0.83), or attention deficit/hyperactivity disorder (HR, 0.99), said Ms. Sujan of the department of psychological and brain sciences, Indiana University, Bloomington, and her associates.
“These results are consistent with the hypothesis that genetic factors, familial environmental factors, or both, account for the population-wide associations between first-trimester antidepressant exposure and these outcomes,” they noted (JAMA. 2017 Apr 18. doi: 10.1001/jama.2017.3413).
FROM JAMA
Key clinical point: Maternal use of antidepressants during pregnancy is unrelated to autism spectrum disorder in offspring.
Major finding: Prenatal exposure to antidepressants was not associated with small-for-gestational-age size (OR, 1.01), autism spectrum disorder (HR, 0.83), or attention deficit/hyperactivity disorder (HR, 0.99).
Data source: Two separate retrospective cohort studies involving 35,906 births in Canada and 1,580,629 in Sweden.
Disclosures: Dr. Brown’s study was supported by the Institute for Clinical Evaluative Sciences and the Ontario Ministry of Health and Long-Term Care. Dr. Brown and her associates reported having no relevant financial disclosures. Dr. Sujan’s study was supported by the U.S. National Institute of Mental Health, the National Institute on Drug Abuse, the National Science Foundation, and others. Dr. Sujan reported having no relevant financial disclosures; her associates reported ties to numerous industry sources.
Liposomal bupivacaine cut need for opioids after gyn surgery
SAN ANTONIO – Liposomal bupivacaine reduced pain after midurethral sling surgery, compared with placebo in a randomized trial, but because of its cost it may be best to keep it in reserve for women who can’t, or shouldn’t, take opioids, said lead investigator Donna Mazloomdoost, MD, a gynecologic surgeon at Good Samaritan Hospital, Cincinnati.
Fifty-four women were randomized to receive liposomal bupivacaine (Exparel) injected into the two trocar paths and the vaginal incision at the end of the procedure; 55 others were injected with normal saline as a placebo.
Fewer women in the liposomal bupivacaine group took narcotics on postop day 2 (12 versus 27, P = .006). However, there was no difference in overall satisfaction with pain control at 1 and 2 weeks follow-up.
Even so, “for this common outpatient surgery, liposomal bupivacaine may be a beneficial addition for pain control,” the investigators concluded.
Liposomal bupivacaine is a local anesthetic with slow release over 72 hours, approved for treatment of postsurgical pain in 2011. “The cost is about $300 at our institution; the charge to the patient is about $1,000,” Dr. Mazloomdoost said at the annual scientific meeting of the Society of Gynecologic Surgeons.
Because of the expense, liposomal bupivacaine is restricted in many hospitals, and gynecologic surgeons are trying to figure out what role it has, if any, in low-pain outpatient procedures like midurethral slings.
“I don’t know if you can justify” routine use for low-pain procedures, “but if you are concerned about opioid” use after surgery – intolerance or addiction – “I would use this,” Dr. Mazloomdoost said.
The investigators expanded 20 mL of liposomal bupivacaine with 10 mL of normal saline for a total of 30 mL. It was split evenly between the two trocar sites and the vaginal epithelium; 10 mL was injected in each of the three sites shortly before the intervention women were roused from anesthesia. The needle was inserted as deeply as possible, and liposomal bupivacaine was injected as the needle was drawn back. Because of the viscosity, it takes at least a 25-gauge needle.
Surgeons knew that they were injecting liposomal bupivacaine instead of saline because of the thickness and color, but they weren’t the ones collecting data, and the women were blinded to the treatment.
Patients were a mean age of 52 years. The mean body mass index was 29.2 kg/m2 in the liposomal bupivacaine group, and 31.6 kg/m2 in the placebo group; there were otherwise no significant demographic differences. Fifty-two women in the liposomal bupivacaine group received midazolam during anesthesia induction versus 44 women receiving placebo, but there were no significant differences in operating time or the number of women in each group who had concomitant anterior or urethrocele repairs, and no differences in urinary retention, time to first bowel movement – about 2 days – or adverse events. The most common adverse events in both groups were nausea/vomiting, headache, and itching.
Women in both groups received intravenous acetaminophen before anesthesia induction, and ketorolac before leaving the operating room; 10 mL of lidocaine with epinephrine was injected into the trocar paths and vaginal epithelium prior to the first incision.
The investigators reported having no relevant financial disclosures.
* The meeting sponsor information was updated 6/9/2017.
SAN ANTONIO – Liposomal bupivacaine reduced pain after midurethral sling surgery, compared with placebo in a randomized trial, but because of its cost it may be best to keep it in reserve for women who can’t, or shouldn’t, take opioids, said lead investigator Donna Mazloomdoost, MD, a gynecologic surgeon at Good Samaritan Hospital, Cincinnati.
Fifty-four women were randomized to receive liposomal bupivacaine (Exparel) injected into the two trocar paths and the vaginal incision at the end of the procedure; 55 others were injected with normal saline as a placebo.
Fewer women in the liposomal bupivacaine group took narcotics on postop day 2 (12 versus 27, P = .006). However, there was no difference in overall satisfaction with pain control at 1 and 2 weeks follow-up.
Even so, “for this common outpatient surgery, liposomal bupivacaine may be a beneficial addition for pain control,” the investigators concluded.
Liposomal bupivacaine is a local anesthetic with slow release over 72 hours, approved for treatment of postsurgical pain in 2011. “The cost is about $300 at our institution; the charge to the patient is about $1,000,” Dr. Mazloomdoost said at the annual scientific meeting of the Society of Gynecologic Surgeons.
Because of the expense, liposomal bupivacaine is restricted in many hospitals, and gynecologic surgeons are trying to figure out what role it has, if any, in low-pain outpatient procedures like midurethral slings.
“I don’t know if you can justify” routine use for low-pain procedures, “but if you are concerned about opioid” use after surgery – intolerance or addiction – “I would use this,” Dr. Mazloomdoost said.
The investigators expanded 20 mL of liposomal bupivacaine with 10 mL of normal saline for a total of 30 mL. It was split evenly between the two trocar sites and the vaginal epithelium; 10 mL was injected in each of the three sites shortly before the intervention women were roused from anesthesia. The needle was inserted as deeply as possible, and liposomal bupivacaine was injected as the needle was drawn back. Because of the viscosity, it takes at least a 25-gauge needle.
Surgeons knew that they were injecting liposomal bupivacaine instead of saline because of the thickness and color, but they weren’t the ones collecting data, and the women were blinded to the treatment.
Patients were a mean age of 52 years. The mean body mass index was 29.2 kg/m2 in the liposomal bupivacaine group, and 31.6 kg/m2 in the placebo group; there were otherwise no significant demographic differences. Fifty-two women in the liposomal bupivacaine group received midazolam during anesthesia induction versus 44 women receiving placebo, but there were no significant differences in operating time or the number of women in each group who had concomitant anterior or urethrocele repairs, and no differences in urinary retention, time to first bowel movement – about 2 days – or adverse events. The most common adverse events in both groups were nausea/vomiting, headache, and itching.
Women in both groups received intravenous acetaminophen before anesthesia induction, and ketorolac before leaving the operating room; 10 mL of lidocaine with epinephrine was injected into the trocar paths and vaginal epithelium prior to the first incision.
The investigators reported having no relevant financial disclosures.
* The meeting sponsor information was updated 6/9/2017.
SAN ANTONIO – Liposomal bupivacaine reduced pain after midurethral sling surgery, compared with placebo in a randomized trial, but because of its cost it may be best to keep it in reserve for women who can’t, or shouldn’t, take opioids, said lead investigator Donna Mazloomdoost, MD, a gynecologic surgeon at Good Samaritan Hospital, Cincinnati.
Fifty-four women were randomized to receive liposomal bupivacaine (Exparel) injected into the two trocar paths and the vaginal incision at the end of the procedure; 55 others were injected with normal saline as a placebo.
Fewer women in the liposomal bupivacaine group took narcotics on postop day 2 (12 versus 27, P = .006). However, there was no difference in overall satisfaction with pain control at 1 and 2 weeks follow-up.
Even so, “for this common outpatient surgery, liposomal bupivacaine may be a beneficial addition for pain control,” the investigators concluded.
Liposomal bupivacaine is a local anesthetic with slow release over 72 hours, approved for treatment of postsurgical pain in 2011. “The cost is about $300 at our institution; the charge to the patient is about $1,000,” Dr. Mazloomdoost said at the annual scientific meeting of the Society of Gynecologic Surgeons.
Because of the expense, liposomal bupivacaine is restricted in many hospitals, and gynecologic surgeons are trying to figure out what role it has, if any, in low-pain outpatient procedures like midurethral slings.
“I don’t know if you can justify” routine use for low-pain procedures, “but if you are concerned about opioid” use after surgery – intolerance or addiction – “I would use this,” Dr. Mazloomdoost said.
The investigators expanded 20 mL of liposomal bupivacaine with 10 mL of normal saline for a total of 30 mL. It was split evenly between the two trocar sites and the vaginal epithelium; 10 mL was injected in each of the three sites shortly before the intervention women were roused from anesthesia. The needle was inserted as deeply as possible, and liposomal bupivacaine was injected as the needle was drawn back. Because of the viscosity, it takes at least a 25-gauge needle.
Surgeons knew that they were injecting liposomal bupivacaine instead of saline because of the thickness and color, but they weren’t the ones collecting data, and the women were blinded to the treatment.
Patients were a mean age of 52 years. The mean body mass index was 29.2 kg/m2 in the liposomal bupivacaine group, and 31.6 kg/m2 in the placebo group; there were otherwise no significant demographic differences. Fifty-two women in the liposomal bupivacaine group received midazolam during anesthesia induction versus 44 women receiving placebo, but there were no significant differences in operating time or the number of women in each group who had concomitant anterior or urethrocele repairs, and no differences in urinary retention, time to first bowel movement – about 2 days – or adverse events. The most common adverse events in both groups were nausea/vomiting, headache, and itching.
Women in both groups received intravenous acetaminophen before anesthesia induction, and ketorolac before leaving the operating room; 10 mL of lidocaine with epinephrine was injected into the trocar paths and vaginal epithelium prior to the first incision.
The investigators reported having no relevant financial disclosures.
* The meeting sponsor information was updated 6/9/2017.
AT SGS 2017
Key clinical point:
Major finding: Pain scores, assessed by diary, were lower in the liposomal bupivacaine group 4 hours after discharge on a 100-mm visual analogue scale (3.5 mm versus 13 mm, P = .014).
Data source: Randomized trial with 109 women at Good Samaritan Hospital, Cincinnati.
Disclosures: The investigators reported having no relevant financial disclosures.
Obinutuzumab vs. rituximab weighed as follicular lymphoma therapy
NEW YORK – Does obinutuzumab have a leg up over rituximab for treating follicular lymphoma?
A strict reading of the efficacy records of the two anti-CD20 antibodies when they went head-to-head suggests that obinutuzumab (Gazyva) edged out rituximab (Rituxan), but a broader view leaves the door open for rituximab as a still viable option depending on a patient’s status and priorities, experts said at the conference held by Imedex.
While conceding that quality of life correlates with progression-free survival (PFS), he stressed that it also correlates with treatment toxicities, treatment duration, and disease-related side effects.
Trial results have indicated that patients with newly diagnosed follicular lymphoma are reasonably treated with rituximab alone, or with rituximab plus bendamustine, without need for maintenance therapy, Dr. Leonard said.
In contrast, GALLIUM, a phase III trial that compared rituximab against obinutuzumab, used a maintenance phase of monotherapy with each of these two drugs following an induction phase when each of the drugs was combined with chemotherapy.
“If you use this approach [tested in GALLIUM] you need to use maintenance therapy,” and it was in GALLIUM that the most dramatic efficacy advantage for obinutuzumab over rituximab appeared, in the form of longer PFS although, so far, without demonstrated advantage in overall survival. The GALLIUM results, reported in December 2016 at the American Society of Hematology meeting, showed a 3-year PFS rate of 80% among patients treated with obinutuzumab and 73% among those treated with rituximab, a hazard ratio of 0.66 in favor of obinutuzumab that was statistically significant (P = .001) for the study’s primary endpoint (Blood. 2016 Dec 4;abstract 6).
“If you follow this study, you commit the patient to maintenance. We need to talk with patients about the pros and cons of maintenance, the pros and cons of chemotherapy, and the pros and cons of single agent therapy” with one of these anti-CD20 antibodies, Dr. Leonard said. “Right now, I think it’s unclear which antibody is best,” he concluded
To further buttress the case for obinutuzumab, he also cited the higher response rate among relapsed patients when single-agent obinutuzumab went against single-agent rituximab (J Clin Oncol. 2015 Oct 20:33[30]:3467-74), and the overall survival advantage that obinutuzumab gave patients when combined with bendamustine in patients refractory to rituximab (Blood. 2016 Dec 5; abstract 615).
Agreeing that the design of GALLIUM focused on combining an anti-CD20 antibody with chemotherapy, Dr. Friedberg acknowledged that, as initial therapy, “using rituximab monotherapy is very reasonable for many patients. I divide [follicular lymphoma] patients into those who are very symptomatic” (for example, those with hydronephrosis) “and need chemotherapy, and those who are not that symptomatic for whom single-agent rituximab is very reasonable,” he said in an interview.
Tumor aggressiveness is another way to identify patients who need chemotherapy plus an antibody, he added. “If the patient is not symptomatic, I generally first observe them, and if the growth is slow, you can sometimes intervene with rituximab alone, but, if the growth is fast, you also need chemotherapy,” Dr. Friedberg said.
Cost may soon become another consideration now that the U.S. patent on rituximab has expired leading to the ongoing development of several biosimilar versions of the antibody. If biosimilar formulations of rituximab soon appear on the U.S. market and if they result in a significant drop in drug price, it would introduce yet another significant variable. “Presuming biosimilar rituximab lowers the cost, that would be another important treatment decision,” he said.
Dr. Friedberg has been a consultant to Bayer. Dr. Leonard has been a consultant to 13 drug companies. Neither disclosed a relationship with the companies that market obinutuzumab or rituximab.
[email protected]
On Twitter @mitchelzoler
NEW YORK – Does obinutuzumab have a leg up over rituximab for treating follicular lymphoma?
A strict reading of the efficacy records of the two anti-CD20 antibodies when they went head-to-head suggests that obinutuzumab (Gazyva) edged out rituximab (Rituxan), but a broader view leaves the door open for rituximab as a still viable option depending on a patient’s status and priorities, experts said at the conference held by Imedex.
While conceding that quality of life correlates with progression-free survival (PFS), he stressed that it also correlates with treatment toxicities, treatment duration, and disease-related side effects.
Trial results have indicated that patients with newly diagnosed follicular lymphoma are reasonably treated with rituximab alone, or with rituximab plus bendamustine, without need for maintenance therapy, Dr. Leonard said.
In contrast, GALLIUM, a phase III trial that compared rituximab against obinutuzumab, used a maintenance phase of monotherapy with each of these two drugs following an induction phase when each of the drugs was combined with chemotherapy.
“If you use this approach [tested in GALLIUM] you need to use maintenance therapy,” and it was in GALLIUM that the most dramatic efficacy advantage for obinutuzumab over rituximab appeared, in the form of longer PFS although, so far, without demonstrated advantage in overall survival. The GALLIUM results, reported in December 2016 at the American Society of Hematology meeting, showed a 3-year PFS rate of 80% among patients treated with obinutuzumab and 73% among those treated with rituximab, a hazard ratio of 0.66 in favor of obinutuzumab that was statistically significant (P = .001) for the study’s primary endpoint (Blood. 2016 Dec 4;abstract 6).
“If you follow this study, you commit the patient to maintenance. We need to talk with patients about the pros and cons of maintenance, the pros and cons of chemotherapy, and the pros and cons of single agent therapy” with one of these anti-CD20 antibodies, Dr. Leonard said. “Right now, I think it’s unclear which antibody is best,” he concluded
To further buttress the case for obinutuzumab, he also cited the higher response rate among relapsed patients when single-agent obinutuzumab went against single-agent rituximab (J Clin Oncol. 2015 Oct 20:33[30]:3467-74), and the overall survival advantage that obinutuzumab gave patients when combined with bendamustine in patients refractory to rituximab (Blood. 2016 Dec 5; abstract 615).
Agreeing that the design of GALLIUM focused on combining an anti-CD20 antibody with chemotherapy, Dr. Friedberg acknowledged that, as initial therapy, “using rituximab monotherapy is very reasonable for many patients. I divide [follicular lymphoma] patients into those who are very symptomatic” (for example, those with hydronephrosis) “and need chemotherapy, and those who are not that symptomatic for whom single-agent rituximab is very reasonable,” he said in an interview.
Tumor aggressiveness is another way to identify patients who need chemotherapy plus an antibody, he added. “If the patient is not symptomatic, I generally first observe them, and if the growth is slow, you can sometimes intervene with rituximab alone, but, if the growth is fast, you also need chemotherapy,” Dr. Friedberg said.
Cost may soon become another consideration now that the U.S. patent on rituximab has expired leading to the ongoing development of several biosimilar versions of the antibody. If biosimilar formulations of rituximab soon appear on the U.S. market and if they result in a significant drop in drug price, it would introduce yet another significant variable. “Presuming biosimilar rituximab lowers the cost, that would be another important treatment decision,” he said.
Dr. Friedberg has been a consultant to Bayer. Dr. Leonard has been a consultant to 13 drug companies. Neither disclosed a relationship with the companies that market obinutuzumab or rituximab.
[email protected]
On Twitter @mitchelzoler
NEW YORK – Does obinutuzumab have a leg up over rituximab for treating follicular lymphoma?
A strict reading of the efficacy records of the two anti-CD20 antibodies when they went head-to-head suggests that obinutuzumab (Gazyva) edged out rituximab (Rituxan), but a broader view leaves the door open for rituximab as a still viable option depending on a patient’s status and priorities, experts said at the conference held by Imedex.
While conceding that quality of life correlates with progression-free survival (PFS), he stressed that it also correlates with treatment toxicities, treatment duration, and disease-related side effects.
Trial results have indicated that patients with newly diagnosed follicular lymphoma are reasonably treated with rituximab alone, or with rituximab plus bendamustine, without need for maintenance therapy, Dr. Leonard said.
In contrast, GALLIUM, a phase III trial that compared rituximab against obinutuzumab, used a maintenance phase of monotherapy with each of these two drugs following an induction phase when each of the drugs was combined with chemotherapy.
“If you use this approach [tested in GALLIUM] you need to use maintenance therapy,” and it was in GALLIUM that the most dramatic efficacy advantage for obinutuzumab over rituximab appeared, in the form of longer PFS although, so far, without demonstrated advantage in overall survival. The GALLIUM results, reported in December 2016 at the American Society of Hematology meeting, showed a 3-year PFS rate of 80% among patients treated with obinutuzumab and 73% among those treated with rituximab, a hazard ratio of 0.66 in favor of obinutuzumab that was statistically significant (P = .001) for the study’s primary endpoint (Blood. 2016 Dec 4;abstract 6).
“If you follow this study, you commit the patient to maintenance. We need to talk with patients about the pros and cons of maintenance, the pros and cons of chemotherapy, and the pros and cons of single agent therapy” with one of these anti-CD20 antibodies, Dr. Leonard said. “Right now, I think it’s unclear which antibody is best,” he concluded
To further buttress the case for obinutuzumab, he also cited the higher response rate among relapsed patients when single-agent obinutuzumab went against single-agent rituximab (J Clin Oncol. 2015 Oct 20:33[30]:3467-74), and the overall survival advantage that obinutuzumab gave patients when combined with bendamustine in patients refractory to rituximab (Blood. 2016 Dec 5; abstract 615).
Agreeing that the design of GALLIUM focused on combining an anti-CD20 antibody with chemotherapy, Dr. Friedberg acknowledged that, as initial therapy, “using rituximab monotherapy is very reasonable for many patients. I divide [follicular lymphoma] patients into those who are very symptomatic” (for example, those with hydronephrosis) “and need chemotherapy, and those who are not that symptomatic for whom single-agent rituximab is very reasonable,” he said in an interview.
Tumor aggressiveness is another way to identify patients who need chemotherapy plus an antibody, he added. “If the patient is not symptomatic, I generally first observe them, and if the growth is slow, you can sometimes intervene with rituximab alone, but, if the growth is fast, you also need chemotherapy,” Dr. Friedberg said.
Cost may soon become another consideration now that the U.S. patent on rituximab has expired leading to the ongoing development of several biosimilar versions of the antibody. If biosimilar formulations of rituximab soon appear on the U.S. market and if they result in a significant drop in drug price, it would introduce yet another significant variable. “Presuming biosimilar rituximab lowers the cost, that would be another important treatment decision,” he said.
Dr. Friedberg has been a consultant to Bayer. Dr. Leonard has been a consultant to 13 drug companies. Neither disclosed a relationship with the companies that market obinutuzumab or rituximab.
[email protected]
On Twitter @mitchelzoler
EXPERT ANALYSIS FROM A MEETING ON HEMATOLOGIC MALIGNANCIES
Skin testing and decision support can clarify penicillin allergy
Penicillin allergy skin testing or a computerized guideline app with decision support can increase the use of penicillin or cephalosporin among inpatients reporting penicillin allergy.
“Despite a reported penicillin allergy, more than 95% of patients evaluated for such allergy are found penicillin and cephalosporin tolerant,” wrote Kimberly G. Blumenthal, MD, of Massachusetts General Hospital, Boston, and her coauthors.
In this study, they recruited 625 patients reporting penicillin allergy and explored three approaches over three periods of time. These were standard of care, in which penicillin skin testing and test dose challenge is performed only after allergy/immunology consultation; penicillin skin testing performed in all patients not otherwise ineligible for skin testing; and a computerized guideline available on any computer or mobile device within the hospital.
Researchers saw a significant 80% increase in the odds of penicillin or cephalosporin use overall during the period in which the computerized guidelines were available (P = .02).
“The guideline empowered inpatient providers to group allergic reactions into hypersensitivity type, then recommended if and how specific beta-lactam antibiotics [should] be used (i.e. very low risk: full doses; low risk: test doses; medium to high risk: Allergy/Immunology consultation; serious type II-IV hypersensitivity reactions: avoidance),” the authors wrote.
While patients during the skin testing period did not have a significantly increased odds of receiving the antibiotics overall, the adjusted per-protocol analysis showed a nearly sixfold higher odds of receiving penicillin or cephalosporin (odds ratio, 5.7; P less than .001).
Among the 278 patients present during the skin-testing period, 179 (64%) were eligible for skin testing, in that they did not have penicillin intolerances such as gastrointestinal upset, were not taking medications that interfered with skin testing, didn’t have multiple beta-lactam allergies, had not experienced penicillin anaphylaxis in the last 5 years, or had a type II-IV hypersensitivity reaction to penicillin. Of these, 43 (24%) were tested, none of whom were allergic.
The per-protocol analysis of skin testing also showed a 2.5-fold increase in the odds of discharge use of penicillin or cephalosporin (P = .04).
“Since the impact of overreporting penicillin allergy is felt beyond antibiotic utilization to resultant readmissions, treatment failures, and adverse events, safely increasing the use of penicillin and cephalosporin antibiotics in this patient population is a crucial first step towards improved quality of care and reduced cost,” the authors wrote.
The study was supported by the Brigham Care Redesign Incubator and Start-Up Program. No conflicts of interest were declared.
Penicillin allergy skin testing or a computerized guideline app with decision support can increase the use of penicillin or cephalosporin among inpatients reporting penicillin allergy.
“Despite a reported penicillin allergy, more than 95% of patients evaluated for such allergy are found penicillin and cephalosporin tolerant,” wrote Kimberly G. Blumenthal, MD, of Massachusetts General Hospital, Boston, and her coauthors.
In this study, they recruited 625 patients reporting penicillin allergy and explored three approaches over three periods of time. These were standard of care, in which penicillin skin testing and test dose challenge is performed only after allergy/immunology consultation; penicillin skin testing performed in all patients not otherwise ineligible for skin testing; and a computerized guideline available on any computer or mobile device within the hospital.
Researchers saw a significant 80% increase in the odds of penicillin or cephalosporin use overall during the period in which the computerized guidelines were available (P = .02).
“The guideline empowered inpatient providers to group allergic reactions into hypersensitivity type, then recommended if and how specific beta-lactam antibiotics [should] be used (i.e. very low risk: full doses; low risk: test doses; medium to high risk: Allergy/Immunology consultation; serious type II-IV hypersensitivity reactions: avoidance),” the authors wrote.
While patients during the skin testing period did not have a significantly increased odds of receiving the antibiotics overall, the adjusted per-protocol analysis showed a nearly sixfold higher odds of receiving penicillin or cephalosporin (odds ratio, 5.7; P less than .001).
Among the 278 patients present during the skin-testing period, 179 (64%) were eligible for skin testing, in that they did not have penicillin intolerances such as gastrointestinal upset, were not taking medications that interfered with skin testing, didn’t have multiple beta-lactam allergies, had not experienced penicillin anaphylaxis in the last 5 years, or had a type II-IV hypersensitivity reaction to penicillin. Of these, 43 (24%) were tested, none of whom were allergic.
The per-protocol analysis of skin testing also showed a 2.5-fold increase in the odds of discharge use of penicillin or cephalosporin (P = .04).
“Since the impact of overreporting penicillin allergy is felt beyond antibiotic utilization to resultant readmissions, treatment failures, and adverse events, safely increasing the use of penicillin and cephalosporin antibiotics in this patient population is a crucial first step towards improved quality of care and reduced cost,” the authors wrote.
The study was supported by the Brigham Care Redesign Incubator and Start-Up Program. No conflicts of interest were declared.
Penicillin allergy skin testing or a computerized guideline app with decision support can increase the use of penicillin or cephalosporin among inpatients reporting penicillin allergy.
“Despite a reported penicillin allergy, more than 95% of patients evaluated for such allergy are found penicillin and cephalosporin tolerant,” wrote Kimberly G. Blumenthal, MD, of Massachusetts General Hospital, Boston, and her coauthors.
In this study, they recruited 625 patients reporting penicillin allergy and explored three approaches over three periods of time. These were standard of care, in which penicillin skin testing and test dose challenge is performed only after allergy/immunology consultation; penicillin skin testing performed in all patients not otherwise ineligible for skin testing; and a computerized guideline available on any computer or mobile device within the hospital.
Researchers saw a significant 80% increase in the odds of penicillin or cephalosporin use overall during the period in which the computerized guidelines were available (P = .02).
“The guideline empowered inpatient providers to group allergic reactions into hypersensitivity type, then recommended if and how specific beta-lactam antibiotics [should] be used (i.e. very low risk: full doses; low risk: test doses; medium to high risk: Allergy/Immunology consultation; serious type II-IV hypersensitivity reactions: avoidance),” the authors wrote.
While patients during the skin testing period did not have a significantly increased odds of receiving the antibiotics overall, the adjusted per-protocol analysis showed a nearly sixfold higher odds of receiving penicillin or cephalosporin (odds ratio, 5.7; P less than .001).
Among the 278 patients present during the skin-testing period, 179 (64%) were eligible for skin testing, in that they did not have penicillin intolerances such as gastrointestinal upset, were not taking medications that interfered with skin testing, didn’t have multiple beta-lactam allergies, had not experienced penicillin anaphylaxis in the last 5 years, or had a type II-IV hypersensitivity reaction to penicillin. Of these, 43 (24%) were tested, none of whom were allergic.
The per-protocol analysis of skin testing also showed a 2.5-fold increase in the odds of discharge use of penicillin or cephalosporin (P = .04).
“Since the impact of overreporting penicillin allergy is felt beyond antibiotic utilization to resultant readmissions, treatment failures, and adverse events, safely increasing the use of penicillin and cephalosporin antibiotics in this patient population is a crucial first step towards improved quality of care and reduced cost,” the authors wrote.
The study was supported by the Brigham Care Redesign Incubator and Start-Up Program. No conflicts of interest were declared.
FROM THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY
Key clinical point: Penicillin skin testing or a computerized guideline app with decision support can increase the use of penicillin or cephalosporin among inpatients reporting penicillin allergy.
Major finding: Skin testing and computerized decision support increased the odds of patients’ receiving penicillin or cephalosporin 1.8-5.7 fold.
Data source: A prospective study of 625 inpatients patients reporting penicillin allergy.
Disclosures: The Brigham Care Redesign Incubator and Startup Program supported the study. No conflicts of interest were declared.
Honored Guest Speaker General (Ret.) Stanley A. McChrystal
A transformational leader with a remarkable record of achievement, General Stanley A. McChrystal was called “one of America’s greatest warriors” by Secretary of Defense Robert Gates. A retired four-star general, he is the former commander of U.S. and International Security Assistance Forces (ISAF) Afghanistan and the former commander of the premier military counter-terrorism force, Joint Special Operations Command (JSOC). He is best known for developing and implementing the current counter-insurgency strategy in Afghanistan, and for creating a comprehensive counter-terrorism organization that revolutionized the interagency operating culture. 
The son of Major General McChrystal, General Stanley McChrystal graduated from West Point in 1976 and joined the infantry. He began his military career as a platoon commander in the 82nd Airborne Division at Fort Bragg, North Carolina. Over the course of his career, he held several leadership and staff positions in the Army Special Forces, Army Rangers, 82nd Airborne Division and the XVIII Army Airborne Corp and the Joint Staff. He is a graduate of the US Naval War College and he completed fellowships at Harvard’s John F. Kennedy School of Government in 1997 and at the Council on Foreign Relations in 2000.
After 9/11 until his retirement in 2010, General McChrystal spent more than 7 years deployed to combat in a variety of leadership positions. In 2002, he was the chief of staff for military operations in Afghanistan. A year later he was selected to deliver nationally televised Pentagon briefings about military operations in Iraq. From 2003 to 2008, McChrystal commanded JSOC where he led the US Military’s counter-terrorism efforts all over the world. From the summer of 2008 until June of 2009, General McChrystal was the Director of the Joint Staff. In June of 2009, the President of the United States and the Secretary General of NATO appointed General McChrystal to be the Commander of US Forces Afghanistan and NATO ISAF. His command included more than 150,000 troops from 45 allied countries. On August 1 of 2010 General McChrystal retired from the US Army.
General McChrystal is a senior fellow at Yale University’s Jackson Institute for Global Affairs where he teaches a course on Leadership in Operation. He sits on the board of the Yellow Ribbon Fund, Navistar International Corporation and JetBlue Airways. He is also the chair of Service Year Alliance, a project of Be The Change and the Aspen Institute, which envisions a future in which a service year is a cultural expectation and common opportunity for every young American.
General McChrystal co-founded the McChrystal Group in January of 2011 where he is currently a partner. McChrystal Group’s mission is to deliver innovative leadership solutions to American businesses to help them transform and succeed in challenging and dynamic environments.
General McChrystal resides in Alexandria, Virginia with his wife of 39 years, Annie.
Monday, May 1
Team of Teams – Rules of Engagement for a Complex World
9:45 a.m. - 10:25 a.m.
A transformational leader with a remarkable record of achievement, General Stanley A. McChrystal was called “one of America’s greatest warriors” by Secretary of Defense Robert Gates. A retired four-star general, he is the former commander of U.S. and International Security Assistance Forces (ISAF) Afghanistan and the former commander of the premier military counter-terrorism force, Joint Special Operations Command (JSOC). He is best known for developing and implementing the current counter-insurgency strategy in Afghanistan, and for creating a comprehensive counter-terrorism organization that revolutionized the interagency operating culture.
The son of Major General McChrystal, General Stanley McChrystal graduated from West Point in 1976 and joined the infantry. He began his military career as a platoon commander in the 82nd Airborne Division at Fort Bragg, North Carolina. Over the course of his career, he held several leadership and staff positions in the Army Special Forces, Army Rangers, 82nd Airborne Division and the XVIII Army Airborne Corp and the Joint Staff. He is a graduate of the US Naval War College and he completed fellowships at Harvard’s John F. Kennedy School of Government in 1997 and at the Council on Foreign Relations in 2000.
After 9/11 until his retirement in 2010, General McChrystal spent more than 7 years deployed to combat in a variety of leadership positions. In 2002, he was the chief of staff for military operations in Afghanistan. A year later he was selected to deliver nationally televised Pentagon briefings about military operations in Iraq. From 2003 to 2008, McChrystal commanded JSOC where he led the US Military’s counter-terrorism efforts all over the world. From the summer of 2008 until June of 2009, General McChrystal was the Director of the Joint Staff. In June of 2009, the President of the United States and the Secretary General of NATO appointed General McChrystal to be the Commander of US Forces Afghanistan and NATO ISAF. His command included more than 150,000 troops from 45 allied countries. On August 1 of 2010 General McChrystal retired from the US Army.
General McChrystal is a senior fellow at Yale University’s Jackson Institute for Global Affairs where he teaches a course on Leadership in Operation. He sits on the board of the Yellow Ribbon Fund, Navistar International Corporation and JetBlue Airways. He is also the chair of Service Year Alliance, a project of Be The Change and the Aspen Institute, which envisions a future in which a service year is a cultural expectation and common opportunity for every young American.
General McChrystal co-founded the McChrystal Group in January of 2011 where he is currently a partner. McChrystal Group’s mission is to deliver innovative leadership solutions to American businesses to help them transform and succeed in challenging and dynamic environments.
General McChrystal resides in Alexandria, Virginia with his wife of 39 years, Annie.
Monday, May 1
Team of Teams – Rules of Engagement for a Complex World
9:45 a.m. - 10:25 a.m.
A transformational leader with a remarkable record of achievement, General Stanley A. McChrystal was called “one of America’s greatest warriors” by Secretary of Defense Robert Gates. A retired four-star general, he is the former commander of U.S. and International Security Assistance Forces (ISAF) Afghanistan and the former commander of the premier military counter-terrorism force, Joint Special Operations Command (JSOC). He is best known for developing and implementing the current counter-insurgency strategy in Afghanistan, and for creating a comprehensive counter-terrorism organization that revolutionized the interagency operating culture.
The son of Major General McChrystal, General Stanley McChrystal graduated from West Point in 1976 and joined the infantry. He began his military career as a platoon commander in the 82nd Airborne Division at Fort Bragg, North Carolina. Over the course of his career, he held several leadership and staff positions in the Army Special Forces, Army Rangers, 82nd Airborne Division and the XVIII Army Airborne Corp and the Joint Staff. He is a graduate of the US Naval War College and he completed fellowships at Harvard’s John F. Kennedy School of Government in 1997 and at the Council on Foreign Relations in 2000.
After 9/11 until his retirement in 2010, General McChrystal spent more than 7 years deployed to combat in a variety of leadership positions. In 2002, he was the chief of staff for military operations in Afghanistan. A year later he was selected to deliver nationally televised Pentagon briefings about military operations in Iraq. From 2003 to 2008, McChrystal commanded JSOC where he led the US Military’s counter-terrorism efforts all over the world. From the summer of 2008 until June of 2009, General McChrystal was the Director of the Joint Staff. In June of 2009, the President of the United States and the Secretary General of NATO appointed General McChrystal to be the Commander of US Forces Afghanistan and NATO ISAF. His command included more than 150,000 troops from 45 allied countries. On August 1 of 2010 General McChrystal retired from the US Army.
General McChrystal is a senior fellow at Yale University’s Jackson Institute for Global Affairs where he teaches a course on Leadership in Operation. He sits on the board of the Yellow Ribbon Fund, Navistar International Corporation and JetBlue Airways. He is also the chair of Service Year Alliance, a project of Be The Change and the Aspen Institute, which envisions a future in which a service year is a cultural expectation and common opportunity for every young American.
General McChrystal co-founded the McChrystal Group in January of 2011 where he is currently a partner. McChrystal Group’s mission is to deliver innovative leadership solutions to American businesses to help them transform and succeed in challenging and dynamic environments.
General McChrystal resides in Alexandria, Virginia with his wife of 39 years, Annie.
Monday, May 1
Team of Teams – Rules of Engagement for a Complex World
9:45 a.m. - 10:25 a.m.
Basic Science Lecture
Rhona Flin, PhD, FBPsS, FRSE, FRAeS, FRCSEd, is Professor of Industrial Psychology, Aberdeen Business School, Robert Gordon University and Emeritus Professor of Applied Psychology, University of Aberdeen, Scotland. She carries out research and consultancy on human performance in high risk industries, looking at leadership, culture, team skills and decision making in healthcare, aviation and the energy sectors. 
Dr. Flin will be speaking on Tuesday, at 10:30 a.m.
Rhona Flin, PhD, FBPsS, FRSE, FRAeS, FRCSEd, is Professor of Industrial Psychology, Aberdeen Business School, Robert Gordon University and Emeritus Professor of Applied Psychology, University of Aberdeen, Scotland. She carries out research and consultancy on human performance in high risk industries, looking at leadership, culture, team skills and decision making in healthcare, aviation and the energy sectors.
Dr. Flin will be speaking on Tuesday, at 10:30 a.m.
Rhona Flin, PhD, FBPsS, FRSE, FRAeS, FRCSEd, is Professor of Industrial Psychology, Aberdeen Business School, Robert Gordon University and Emeritus Professor of Applied Psychology, University of Aberdeen, Scotland. She carries out research and consultancy on human performance in high risk industries, looking at leadership, culture, team skills and decision making in healthcare, aviation and the energy sectors.
Dr. Flin will be speaking on Tuesday, at 10:30 a.m.
New diagnostic tool identifies severe ADAMTS13 deficiency
Researchers have developed and validated a new diagnostic tool – the PLASMIC score – that rapidly predicts severe ADAMTS13 deficiency in patients who present with thrombotic microangiopathy, effectively distinguishing those who have thrombotic thrombocytopenic purpura (TTP) from those with other disorders, according to a report published in Lancet Haematology.
Many disorders or clinical events can present as a thrombotic microangiopathy, including hemolytic uremic syndrome, disseminated intravascular coagulation, and malignant hypertension; this abnormality can even be an adverse effect of hematopoietic stem cell transplantation or solid-organ transplantation. Rapidly differentiating TTP from such disorders facilitates urgent treatment with plasma exchange or plasma transfusion. But testing for elevated ADAMTS13 levels to make this distinction currently requires long turnaround times and is unavailable in some locations, said Pavan K. Bendapudi, MD, of the division of hematology, Massachusetts General Hospital, Boston, and his associates.
The PLASMIC score “is designed specifically to aid practitioners who might have little experience managing thrombotic microangiopathy, and it can distinguish TTP from a broad range of thrombotic microangiopathy subtypes, including those that seem most similar to TTP,” they wrote.
The researchers developed a 7-point scoring system to predict the likelihood of elevated ADAMTS13 levels by analyzing 29 clinical and laboratory variables that would aid in diagnosis, using a cohort of 214 consecutive patients enrolled in a multicenter research registry in 2004-2012. They narrowed their initial finding of 11 key variables down to 5 key variables that best predicted severe ADAMTSD13 deficiency: platelet count lower than 29x109 per liter, creatinine less than 1.8 mg/dL, international normalized ratio (INR) less than 1.3, mean corpuscular volume (MCV) less than 86.5/L, and a combined hemolysis variable based on reticulocyte count, the presence of haptoglobin, and bilirubin level.
Two additional variables – cancer diagnosed during the preceding year and the absence of stem cell or organ transplantation – were absent in all patients who had severe ADAMTS13 deficiency in this derivation cohort and were included in the PLASMIC score because of their high negative predictive value. Thus, the diagnostic score was named for its seven components: platelet count, combined hemolysis variable, absence of active cancer; absence of stem cell or solid-organ transplant, MCV, INR, and creatinine. Each component was assigned 1 point on the 7-point scale.
None of the 84 patients in this derivation cohort with a PLASMIC score of 0-4 had severe ADAMTS13 deficiency, while 81% of those with a score of 6 or 7 did have a severe ADAMTS13 deficiency. Patients who were eventually diagnosed as having TTP had a median score of 7. In contrast, patients with thrombotic microangiopathy traced to rheumatologic disorders had a median score of 5, those with drug-associated thrombotic microangiopathy had a median score of 4, and those with disseminated intravascular coagulation had a median score of 4. The PLASMIC score also appeared to discriminate among TTP, typical hemolytic uremia syndrome, and atypical hemolytic uremia syndrome, which have “strikingly similar clinical presentations,” Dr. Bendapudi and his associates said.
Unlike TTP, the disorders with lower PLASMIC scores tended to carry a much poorer prognosis. In this cohort, patients with higher PLASMIC scores had significantly better survival time (median survival not yet reached), compared with those who had a score of 5 (median survival, 1,670 days) and those with a score of 1-4 (median survival, 287 days).
The investigators then validated their findings in two independent cohorts: 154 people with thrombotic microangiopathy from the same patient registry but from more recent years (2012-2015), and 152 patients from an Alabama registry. In the first validation cohort, none of the 89 patients assigned a score of 0-4 had severe ADAMTS13 deficiency, while 62% of those given a score of 6 or 7 had a severe deficiency. In the second validation cohort, only two patients (4%) with scores of 0-4 had a severe ADAMTS13 deficiency, while 82% of those with a score of 6 or 7 had a severe deficiency.
Based on these findings, a PLASMIC score of 0-4 denotes low risk for ADAMTS13 deficiency, a score of 5 denotes intermediate risk, and a score of 6 or 7 denotes high risk and thus probable TTP, Dr. Bendapudi and his associates said (Lancet Haematol. 2017;4:e157-64).
The PLASMIC score was superior to both a two-component prediction tool currently used in France and to a clinical consensus score, “further demonstrating the real-world utility of our prediction tool,” the researchers wrote.
The PLASMIC score offers a clear improvement in the prediction of severe ADAMTS13 deficiency when added to clinical expertise, so it is an important step forward in the early management of TTP.
Use of this score should allow earlier treatment of patients with TTP, who would greatly benefit from plasma exchange or plasma administration. It also can be useful in less serious and less uncertain situations in which emergency plasma therapy is discussed.
Mattieu Jamme, MD, and Eric Rondeau, MD, are in the Service des Urgences Nephrologiques et Transpantation Renale at Hospital Tenon, Paris. They reported having no relevant financial disclosures. Dr. Jamme and Dr. Rondeau made these remarks in an editorial comment accompanying Dr. Bendapudi’s report (Lancet Haematol. 2017. doi: 10.1016/S2352-3026(17)30024-8).
The PLASMIC score offers a clear improvement in the prediction of severe ADAMTS13 deficiency when added to clinical expertise, so it is an important step forward in the early management of TTP.
Use of this score should allow earlier treatment of patients with TTP, who would greatly benefit from plasma exchange or plasma administration. It also can be useful in less serious and less uncertain situations in which emergency plasma therapy is discussed.
Mattieu Jamme, MD, and Eric Rondeau, MD, are in the Service des Urgences Nephrologiques et Transpantation Renale at Hospital Tenon, Paris. They reported having no relevant financial disclosures. Dr. Jamme and Dr. Rondeau made these remarks in an editorial comment accompanying Dr. Bendapudi’s report (Lancet Haematol. 2017. doi: 10.1016/S2352-3026(17)30024-8).
The PLASMIC score offers a clear improvement in the prediction of severe ADAMTS13 deficiency when added to clinical expertise, so it is an important step forward in the early management of TTP.
Use of this score should allow earlier treatment of patients with TTP, who would greatly benefit from plasma exchange or plasma administration. It also can be useful in less serious and less uncertain situations in which emergency plasma therapy is discussed.
Mattieu Jamme, MD, and Eric Rondeau, MD, are in the Service des Urgences Nephrologiques et Transpantation Renale at Hospital Tenon, Paris. They reported having no relevant financial disclosures. Dr. Jamme and Dr. Rondeau made these remarks in an editorial comment accompanying Dr. Bendapudi’s report (Lancet Haematol. 2017. doi: 10.1016/S2352-3026(17)30024-8).
Researchers have developed and validated a new diagnostic tool – the PLASMIC score – that rapidly predicts severe ADAMTS13 deficiency in patients who present with thrombotic microangiopathy, effectively distinguishing those who have thrombotic thrombocytopenic purpura (TTP) from those with other disorders, according to a report published in Lancet Haematology.
Many disorders or clinical events can present as a thrombotic microangiopathy, including hemolytic uremic syndrome, disseminated intravascular coagulation, and malignant hypertension; this abnormality can even be an adverse effect of hematopoietic stem cell transplantation or solid-organ transplantation. Rapidly differentiating TTP from such disorders facilitates urgent treatment with plasma exchange or plasma transfusion. But testing for elevated ADAMTS13 levels to make this distinction currently requires long turnaround times and is unavailable in some locations, said Pavan K. Bendapudi, MD, of the division of hematology, Massachusetts General Hospital, Boston, and his associates.
The PLASMIC score “is designed specifically to aid practitioners who might have little experience managing thrombotic microangiopathy, and it can distinguish TTP from a broad range of thrombotic microangiopathy subtypes, including those that seem most similar to TTP,” they wrote.
The researchers developed a 7-point scoring system to predict the likelihood of elevated ADAMTS13 levels by analyzing 29 clinical and laboratory variables that would aid in diagnosis, using a cohort of 214 consecutive patients enrolled in a multicenter research registry in 2004-2012. They narrowed their initial finding of 11 key variables down to 5 key variables that best predicted severe ADAMTSD13 deficiency: platelet count lower than 29x109 per liter, creatinine less than 1.8 mg/dL, international normalized ratio (INR) less than 1.3, mean corpuscular volume (MCV) less than 86.5/L, and a combined hemolysis variable based on reticulocyte count, the presence of haptoglobin, and bilirubin level.
Two additional variables – cancer diagnosed during the preceding year and the absence of stem cell or organ transplantation – were absent in all patients who had severe ADAMTS13 deficiency in this derivation cohort and were included in the PLASMIC score because of their high negative predictive value. Thus, the diagnostic score was named for its seven components: platelet count, combined hemolysis variable, absence of active cancer; absence of stem cell or solid-organ transplant, MCV, INR, and creatinine. Each component was assigned 1 point on the 7-point scale.
None of the 84 patients in this derivation cohort with a PLASMIC score of 0-4 had severe ADAMTS13 deficiency, while 81% of those with a score of 6 or 7 did have a severe ADAMTS13 deficiency. Patients who were eventually diagnosed as having TTP had a median score of 7. In contrast, patients with thrombotic microangiopathy traced to rheumatologic disorders had a median score of 5, those with drug-associated thrombotic microangiopathy had a median score of 4, and those with disseminated intravascular coagulation had a median score of 4. The PLASMIC score also appeared to discriminate among TTP, typical hemolytic uremia syndrome, and atypical hemolytic uremia syndrome, which have “strikingly similar clinical presentations,” Dr. Bendapudi and his associates said.
Unlike TTP, the disorders with lower PLASMIC scores tended to carry a much poorer prognosis. In this cohort, patients with higher PLASMIC scores had significantly better survival time (median survival not yet reached), compared with those who had a score of 5 (median survival, 1,670 days) and those with a score of 1-4 (median survival, 287 days).
The investigators then validated their findings in two independent cohorts: 154 people with thrombotic microangiopathy from the same patient registry but from more recent years (2012-2015), and 152 patients from an Alabama registry. In the first validation cohort, none of the 89 patients assigned a score of 0-4 had severe ADAMTS13 deficiency, while 62% of those given a score of 6 or 7 had a severe deficiency. In the second validation cohort, only two patients (4%) with scores of 0-4 had a severe ADAMTS13 deficiency, while 82% of those with a score of 6 or 7 had a severe deficiency.
Based on these findings, a PLASMIC score of 0-4 denotes low risk for ADAMTS13 deficiency, a score of 5 denotes intermediate risk, and a score of 6 or 7 denotes high risk and thus probable TTP, Dr. Bendapudi and his associates said (Lancet Haematol. 2017;4:e157-64).
The PLASMIC score was superior to both a two-component prediction tool currently used in France and to a clinical consensus score, “further demonstrating the real-world utility of our prediction tool,” the researchers wrote.
Researchers have developed and validated a new diagnostic tool – the PLASMIC score – that rapidly predicts severe ADAMTS13 deficiency in patients who present with thrombotic microangiopathy, effectively distinguishing those who have thrombotic thrombocytopenic purpura (TTP) from those with other disorders, according to a report published in Lancet Haematology.
Many disorders or clinical events can present as a thrombotic microangiopathy, including hemolytic uremic syndrome, disseminated intravascular coagulation, and malignant hypertension; this abnormality can even be an adverse effect of hematopoietic stem cell transplantation or solid-organ transplantation. Rapidly differentiating TTP from such disorders facilitates urgent treatment with plasma exchange or plasma transfusion. But testing for elevated ADAMTS13 levels to make this distinction currently requires long turnaround times and is unavailable in some locations, said Pavan K. Bendapudi, MD, of the division of hematology, Massachusetts General Hospital, Boston, and his associates.
The PLASMIC score “is designed specifically to aid practitioners who might have little experience managing thrombotic microangiopathy, and it can distinguish TTP from a broad range of thrombotic microangiopathy subtypes, including those that seem most similar to TTP,” they wrote.
The researchers developed a 7-point scoring system to predict the likelihood of elevated ADAMTS13 levels by analyzing 29 clinical and laboratory variables that would aid in diagnosis, using a cohort of 214 consecutive patients enrolled in a multicenter research registry in 2004-2012. They narrowed their initial finding of 11 key variables down to 5 key variables that best predicted severe ADAMTSD13 deficiency: platelet count lower than 29x109 per liter, creatinine less than 1.8 mg/dL, international normalized ratio (INR) less than 1.3, mean corpuscular volume (MCV) less than 86.5/L, and a combined hemolysis variable based on reticulocyte count, the presence of haptoglobin, and bilirubin level.
Two additional variables – cancer diagnosed during the preceding year and the absence of stem cell or organ transplantation – were absent in all patients who had severe ADAMTS13 deficiency in this derivation cohort and were included in the PLASMIC score because of their high negative predictive value. Thus, the diagnostic score was named for its seven components: platelet count, combined hemolysis variable, absence of active cancer; absence of stem cell or solid-organ transplant, MCV, INR, and creatinine. Each component was assigned 1 point on the 7-point scale.
None of the 84 patients in this derivation cohort with a PLASMIC score of 0-4 had severe ADAMTS13 deficiency, while 81% of those with a score of 6 or 7 did have a severe ADAMTS13 deficiency. Patients who were eventually diagnosed as having TTP had a median score of 7. In contrast, patients with thrombotic microangiopathy traced to rheumatologic disorders had a median score of 5, those with drug-associated thrombotic microangiopathy had a median score of 4, and those with disseminated intravascular coagulation had a median score of 4. The PLASMIC score also appeared to discriminate among TTP, typical hemolytic uremia syndrome, and atypical hemolytic uremia syndrome, which have “strikingly similar clinical presentations,” Dr. Bendapudi and his associates said.
Unlike TTP, the disorders with lower PLASMIC scores tended to carry a much poorer prognosis. In this cohort, patients with higher PLASMIC scores had significantly better survival time (median survival not yet reached), compared with those who had a score of 5 (median survival, 1,670 days) and those with a score of 1-4 (median survival, 287 days).
The investigators then validated their findings in two independent cohorts: 154 people with thrombotic microangiopathy from the same patient registry but from more recent years (2012-2015), and 152 patients from an Alabama registry. In the first validation cohort, none of the 89 patients assigned a score of 0-4 had severe ADAMTS13 deficiency, while 62% of those given a score of 6 or 7 had a severe deficiency. In the second validation cohort, only two patients (4%) with scores of 0-4 had a severe ADAMTS13 deficiency, while 82% of those with a score of 6 or 7 had a severe deficiency.
Based on these findings, a PLASMIC score of 0-4 denotes low risk for ADAMTS13 deficiency, a score of 5 denotes intermediate risk, and a score of 6 or 7 denotes high risk and thus probable TTP, Dr. Bendapudi and his associates said (Lancet Haematol. 2017;4:e157-64).
The PLASMIC score was superior to both a two-component prediction tool currently used in France and to a clinical consensus score, “further demonstrating the real-world utility of our prediction tool,” the researchers wrote.
FROM LANCET HAEMATOLOGY
Key clinical point: A new diagnostic tool – the PLASMIC score – predicts severe ADAMTS13 deficiency, effectively distinguishing thrombotic thrombocytopenic purpura from other causes of thrombotic microangiopathy.
Major finding: None of the 84 patients with a PLASMIC score of 0-4 out of a possible 7 proved to have severe ADAMTS13 deficiency, while 81% of those with a score of 6 or 7 did prove to have a severe ADAMTS13 deficiency.
Data source: A series of retrospective cohort studies analyzing data in patient registries to develop (215 patients) and then validate (306 patients) a new diagnostic tool.
Disclosures: This work was supported by the Luick Family Fund of Massachusetts General Hospital, the American Society of Hematology, and the National Heart, Lung, and Blood Institute. Dr. Bendapudi and his associates reported having no relevant financial disclosures.
Work-life balance to be focus of AATS session
The challenge of finding a satisfying balance between work life and personal life is topic that interests many medical professional, thoracic surgeons in particular. A Sunday AATS CT Theater event will be focus on these issues.
“Ideally, the session would be called ‘Work-Life Balance,’” explained, of the Hannover Medical School in Hannover, Germany.
“At this session, we want to hear from young people,” said Dr. Shrestha. “In the past, we’ve heard from more senior members, who often don’t see this as such a big issue [but] at this session we will hear exclusively from younger members.”
Discussions will center on how the field of cardiothoracic surgery can attract the best and brightest young minds coming out of medical schools around the world. One talk will be given by a resident based in the United States; married to a general surgeon and a new mother of twins, the resident will talk about the importance of allowing surgeons enough leeway in their workloads to tend to domestic matters. Such an approach makes for happier surgeons and, ultimately, better care for patients. Another resident from Germany will shed light on the work-life balance approaches of European surgeons, and both the similarities and differences between the U.S. and Europe in this regard.
In addition, “there will be a panel of senior members, [consisting of] the president and general secretary of the AATS, and the president and general secretary of the European Association,” said Dr. Shrestha. “They can not only comment, but they should also give their views as to how they think we can change our system.”
Dr. Shrestha hopes these discussion will offer young surgeons the advice they need to better their own self-care and their lives. Dr. Shrestha also added that the session will address the growing issue of burnout among surgical residents, with conversations about the best way to move forward in addressing that issue. Working hours have dropped from what they were in previous decades, with surgeons often working as much as 100 hours a week and barely spending time at home. That kind of schedule is no longer the expectation, but surgeons still have to struggle to maintain a home life, self-care, and rest in the context of their daily work. Dr. Shrestha hopes that this session will be an important step in making those goals a reality for future generations of cardiothoracic surgeons.
“We need to attract the best possible talent in this field, regardless of where they’re from or if they’re men or women,” said Dr. Shrestha. “Improving work-life balance is one of the best ways to do that.”
The challenge of finding a satisfying balance between work life and personal life is topic that interests many medical professional, thoracic surgeons in particular. A Sunday AATS CT Theater event will be focus on these issues.
“Ideally, the session would be called ‘Work-Life Balance,’” explained, of the Hannover Medical School in Hannover, Germany.
“At this session, we want to hear from young people,” said Dr. Shrestha. “In the past, we’ve heard from more senior members, who often don’t see this as such a big issue [but] at this session we will hear exclusively from younger members.”
Discussions will center on how the field of cardiothoracic surgery can attract the best and brightest young minds coming out of medical schools around the world. One talk will be given by a resident based in the United States; married to a general surgeon and a new mother of twins, the resident will talk about the importance of allowing surgeons enough leeway in their workloads to tend to domestic matters. Such an approach makes for happier surgeons and, ultimately, better care for patients. Another resident from Germany will shed light on the work-life balance approaches of European surgeons, and both the similarities and differences between the U.S. and Europe in this regard.
In addition, “there will be a panel of senior members, [consisting of] the president and general secretary of the AATS, and the president and general secretary of the European Association,” said Dr. Shrestha. “They can not only comment, but they should also give their views as to how they think we can change our system.”
Dr. Shrestha hopes these discussion will offer young surgeons the advice they need to better their own self-care and their lives. Dr. Shrestha also added that the session will address the growing issue of burnout among surgical residents, with conversations about the best way to move forward in addressing that issue. Working hours have dropped from what they were in previous decades, with surgeons often working as much as 100 hours a week and barely spending time at home. That kind of schedule is no longer the expectation, but surgeons still have to struggle to maintain a home life, self-care, and rest in the context of their daily work. Dr. Shrestha hopes that this session will be an important step in making those goals a reality for future generations of cardiothoracic surgeons.
“We need to attract the best possible talent in this field, regardless of where they’re from or if they’re men or women,” said Dr. Shrestha. “Improving work-life balance is one of the best ways to do that.”
The challenge of finding a satisfying balance between work life and personal life is topic that interests many medical professional, thoracic surgeons in particular. A Sunday AATS CT Theater event will be focus on these issues.
“Ideally, the session would be called ‘Work-Life Balance,’” explained, of the Hannover Medical School in Hannover, Germany.
“At this session, we want to hear from young people,” said Dr. Shrestha. “In the past, we’ve heard from more senior members, who often don’t see this as such a big issue [but] at this session we will hear exclusively from younger members.”
Discussions will center on how the field of cardiothoracic surgery can attract the best and brightest young minds coming out of medical schools around the world. One talk will be given by a resident based in the United States; married to a general surgeon and a new mother of twins, the resident will talk about the importance of allowing surgeons enough leeway in their workloads to tend to domestic matters. Such an approach makes for happier surgeons and, ultimately, better care for patients. Another resident from Germany will shed light on the work-life balance approaches of European surgeons, and both the similarities and differences between the U.S. and Europe in this regard.
In addition, “there will be a panel of senior members, [consisting of] the president and general secretary of the AATS, and the president and general secretary of the European Association,” said Dr. Shrestha. “They can not only comment, but they should also give their views as to how they think we can change our system.”
Dr. Shrestha hopes these discussion will offer young surgeons the advice they need to better their own self-care and their lives. Dr. Shrestha also added that the session will address the growing issue of burnout among surgical residents, with conversations about the best way to move forward in addressing that issue. Working hours have dropped from what they were in previous decades, with surgeons often working as much as 100 hours a week and barely spending time at home. That kind of schedule is no longer the expectation, but surgeons still have to struggle to maintain a home life, self-care, and rest in the context of their daily work. Dr. Shrestha hopes that this session will be an important step in making those goals a reality for future generations of cardiothoracic surgeons.
“We need to attract the best possible talent in this field, regardless of where they’re from or if they’re men or women,” said Dr. Shrestha. “Improving work-life balance is one of the best ways to do that.”
The Graham Foundation Honoring Our Mentors
Today, the American Association for Thoracic Surgery continues to promote scholarship, innovation and leadership in thoracic and cardiovascular surgery so that 100 years from now, breakthroughs that seem unimaginable can be routine.
The AATS Centennial celebrates the first 100 years of exchanging ideas, collaboration and building on each other’s work for growth of the specialty. Those in the early parts of their careers may find this aspect of the meeting most valuable as the opportunity to interact with experts and experienced surgeons can be instrumental to the growth of a young surgeon.
These awards are named for surgeons with long resumes of impressive accomplishments who also share the distinction of making an impact on cardiothoracic surgery by teaching and mentoring young surgeons. Each mentor has made significant contributions to their specialties and has held leadership positions in the field, including several who have served as AATS Presidents.
The Fellowships give those who benefitted from working with these surgeons a way to pay tribute to their mentors, ensuring that their legacy of guidance and education is celebrated along with their achievements into the next generation. Established in 2013, there are currently eight Honoring Our Mentors Fellowships:
The inaugural program, the F. Griffith Pearson Fellowship, provides an educational experience for General Thoracic surgeons who have recently completed their residency or fellowship to spend a focused period of four to six weeks studying clinical techniques at a host institution in North America.
That was followed by the Marc R. de Leval Fellowship which is one of the few funding opportunities available that enables North American surgeons to receive specified training in congenital heart surgery at international centers. In 2016, the Lawrence H. Cohn Fellowship began providing young cardiac surgeons from around the world an advanced experience in valvular surgery or care, and the Denton Cooley Fellowship began to give North American cardiothoracic surgeons who are in their final year of their residency or have recently completed their residency the opportunity to spend four weeks enriching his/her education at the Texas Heart Institute (THI) and Baylor St. Luke’s Medical Center.
President of the AATS Graham Foundation Board of Directors, Dr. David J. Sugarbaker says, “The AATS Graham Foundation Honoring Our Mentors Program is a magnificent way for those who have been given the gift of strong mentorship in their career to say thank you to their mentor. By contributing to the HOM award they establish their mentor as among the greatest mentors in the history of cardiothoracic surgery. The fellowships established in the name of the mentor will allow his or her impact to go on for generations to come. Those who donate to the award are enriching our specialty and saying thank you to their most prized teacher of surgery in their career.”
This year, there are four new Honoring Our Mentors Fellowships in the works. The Foundation will be honoring Jack A. Roth, an individual who has made prodigious clinical research contributions to improve multidisciplinary therapy for lung cancer, with the Jack A. Roth Fellowship in Thoracic Surgical Oncology. The Honoring Our Cleveland Clinic Mentors Program will honor the leadership of Drs. Floyd D. Loop, Delos M. Cosgrove and Bruce W. Lytle and will support a 1.5 day leadership course at the Cleveland Clinic for the top residents in North America and offer the chance to observe surgery. Two additional mentors soon to be recognized with programs in their names are Dr. Timothy J. Gardner, a nationally noted heart surgeon and leader in cardiovascular medicine who is not only seen as a great teacher to residents and fellows, but has been very helpful to young staff surgeons in giving advice and guidance, along with Dr. Aldo R. Castaneda whose spirit and drive have been infused throughout the field of congenital heart surgery. These new programs offer us the opportunity to say thank you to the greatest mentors in the specialty. As President of the AATS Graham Foundation, a mentee of Dr. Lawrence H. Cohn and donor to the Honoring Our Mentor Programs, Dr. David Sugarbaker understands the affect that Honoring Our Mentors Fellowships have on both those that give these awards and those that receive them. “We are indebted to those mentees who have contributed to these programs, publicly acknowledging their gratitude to the mentor who shaped their cardiothoracic surgery career.”
These programs would not be possible without the stewardship of leaders in cardiothoracic surgery and the generous support of our donors. To learn more about how you can honor these mentors and support the fellowships, visit the AATS Graham Foundation website at www.aatsgrahamfoundation.org or stop by the AATS Welcome Center in the Exhibit Hall.
Today, the American Association for Thoracic Surgery continues to promote scholarship, innovation and leadership in thoracic and cardiovascular surgery so that 100 years from now, breakthroughs that seem unimaginable can be routine.
The AATS Centennial celebrates the first 100 years of exchanging ideas, collaboration and building on each other’s work for growth of the specialty. Those in the early parts of their careers may find this aspect of the meeting most valuable as the opportunity to interact with experts and experienced surgeons can be instrumental to the growth of a young surgeon.
These awards are named for surgeons with long resumes of impressive accomplishments who also share the distinction of making an impact on cardiothoracic surgery by teaching and mentoring young surgeons. Each mentor has made significant contributions to their specialties and has held leadership positions in the field, including several who have served as AATS Presidents.
The Fellowships give those who benefitted from working with these surgeons a way to pay tribute to their mentors, ensuring that their legacy of guidance and education is celebrated along with their achievements into the next generation. Established in 2013, there are currently eight Honoring Our Mentors Fellowships:
The inaugural program, the F. Griffith Pearson Fellowship, provides an educational experience for General Thoracic surgeons who have recently completed their residency or fellowship to spend a focused period of four to six weeks studying clinical techniques at a host institution in North America.
That was followed by the Marc R. de Leval Fellowship which is one of the few funding opportunities available that enables North American surgeons to receive specified training in congenital heart surgery at international centers. In 2016, the Lawrence H. Cohn Fellowship began providing young cardiac surgeons from around the world an advanced experience in valvular surgery or care, and the Denton Cooley Fellowship began to give North American cardiothoracic surgeons who are in their final year of their residency or have recently completed their residency the opportunity to spend four weeks enriching his/her education at the Texas Heart Institute (THI) and Baylor St. Luke’s Medical Center.
President of the AATS Graham Foundation Board of Directors, Dr. David J. Sugarbaker says, “The AATS Graham Foundation Honoring Our Mentors Program is a magnificent way for those who have been given the gift of strong mentorship in their career to say thank you to their mentor. By contributing to the HOM award they establish their mentor as among the greatest mentors in the history of cardiothoracic surgery. The fellowships established in the name of the mentor will allow his or her impact to go on for generations to come. Those who donate to the award are enriching our specialty and saying thank you to their most prized teacher of surgery in their career.”
This year, there are four new Honoring Our Mentors Fellowships in the works. The Foundation will be honoring Jack A. Roth, an individual who has made prodigious clinical research contributions to improve multidisciplinary therapy for lung cancer, with the Jack A. Roth Fellowship in Thoracic Surgical Oncology. The Honoring Our Cleveland Clinic Mentors Program will honor the leadership of Drs. Floyd D. Loop, Delos M. Cosgrove and Bruce W. Lytle and will support a 1.5 day leadership course at the Cleveland Clinic for the top residents in North America and offer the chance to observe surgery. Two additional mentors soon to be recognized with programs in their names are Dr. Timothy J. Gardner, a nationally noted heart surgeon and leader in cardiovascular medicine who is not only seen as a great teacher to residents and fellows, but has been very helpful to young staff surgeons in giving advice and guidance, along with Dr. Aldo R. Castaneda whose spirit and drive have been infused throughout the field of congenital heart surgery. These new programs offer us the opportunity to say thank you to the greatest mentors in the specialty. As President of the AATS Graham Foundation, a mentee of Dr. Lawrence H. Cohn and donor to the Honoring Our Mentor Programs, Dr. David Sugarbaker understands the affect that Honoring Our Mentors Fellowships have on both those that give these awards and those that receive them. “We are indebted to those mentees who have contributed to these programs, publicly acknowledging their gratitude to the mentor who shaped their cardiothoracic surgery career.”
These programs would not be possible without the stewardship of leaders in cardiothoracic surgery and the generous support of our donors. To learn more about how you can honor these mentors and support the fellowships, visit the AATS Graham Foundation website at www.aatsgrahamfoundation.org or stop by the AATS Welcome Center in the Exhibit Hall.
Today, the American Association for Thoracic Surgery continues to promote scholarship, innovation and leadership in thoracic and cardiovascular surgery so that 100 years from now, breakthroughs that seem unimaginable can be routine.
The AATS Centennial celebrates the first 100 years of exchanging ideas, collaboration and building on each other’s work for growth of the specialty. Those in the early parts of their careers may find this aspect of the meeting most valuable as the opportunity to interact with experts and experienced surgeons can be instrumental to the growth of a young surgeon.
These awards are named for surgeons with long resumes of impressive accomplishments who also share the distinction of making an impact on cardiothoracic surgery by teaching and mentoring young surgeons. Each mentor has made significant contributions to their specialties and has held leadership positions in the field, including several who have served as AATS Presidents.
The Fellowships give those who benefitted from working with these surgeons a way to pay tribute to their mentors, ensuring that their legacy of guidance and education is celebrated along with their achievements into the next generation. Established in 2013, there are currently eight Honoring Our Mentors Fellowships:
The inaugural program, the F. Griffith Pearson Fellowship, provides an educational experience for General Thoracic surgeons who have recently completed their residency or fellowship to spend a focused period of four to six weeks studying clinical techniques at a host institution in North America.
That was followed by the Marc R. de Leval Fellowship which is one of the few funding opportunities available that enables North American surgeons to receive specified training in congenital heart surgery at international centers. In 2016, the Lawrence H. Cohn Fellowship began providing young cardiac surgeons from around the world an advanced experience in valvular surgery or care, and the Denton Cooley Fellowship began to give North American cardiothoracic surgeons who are in their final year of their residency or have recently completed their residency the opportunity to spend four weeks enriching his/her education at the Texas Heart Institute (THI) and Baylor St. Luke’s Medical Center.
President of the AATS Graham Foundation Board of Directors, Dr. David J. Sugarbaker says, “The AATS Graham Foundation Honoring Our Mentors Program is a magnificent way for those who have been given the gift of strong mentorship in their career to say thank you to their mentor. By contributing to the HOM award they establish their mentor as among the greatest mentors in the history of cardiothoracic surgery. The fellowships established in the name of the mentor will allow his or her impact to go on for generations to come. Those who donate to the award are enriching our specialty and saying thank you to their most prized teacher of surgery in their career.”
This year, there are four new Honoring Our Mentors Fellowships in the works. The Foundation will be honoring Jack A. Roth, an individual who has made prodigious clinical research contributions to improve multidisciplinary therapy for lung cancer, with the Jack A. Roth Fellowship in Thoracic Surgical Oncology. The Honoring Our Cleveland Clinic Mentors Program will honor the leadership of Drs. Floyd D. Loop, Delos M. Cosgrove and Bruce W. Lytle and will support a 1.5 day leadership course at the Cleveland Clinic for the top residents in North America and offer the chance to observe surgery. Two additional mentors soon to be recognized with programs in their names are Dr. Timothy J. Gardner, a nationally noted heart surgeon and leader in cardiovascular medicine who is not only seen as a great teacher to residents and fellows, but has been very helpful to young staff surgeons in giving advice and guidance, along with Dr. Aldo R. Castaneda whose spirit and drive have been infused throughout the field of congenital heart surgery. These new programs offer us the opportunity to say thank you to the greatest mentors in the specialty. As President of the AATS Graham Foundation, a mentee of Dr. Lawrence H. Cohn and donor to the Honoring Our Mentor Programs, Dr. David Sugarbaker understands the affect that Honoring Our Mentors Fellowships have on both those that give these awards and those that receive them. “We are indebted to those mentees who have contributed to these programs, publicly acknowledging their gratitude to the mentor who shaped their cardiothoracic surgery career.”
These programs would not be possible without the stewardship of leaders in cardiothoracic surgery and the generous support of our donors. To learn more about how you can honor these mentors and support the fellowships, visit the AATS Graham Foundation website at www.aatsgrahamfoundation.org or stop by the AATS Welcome Center in the Exhibit Hall.