WASHINGTON – A rise in the blood level of troponin T immediately after patients underwent noncardiac surgery identified a high risk group with a 30-day mortality rate nearly fivefold higher than that of patients who did not have a postoperative troponin T spike, according to a prospective study of more than 21,000 patients.

For 93% of the patients who have these perioperative spikes in troponin T, a marker of myocardial ischemia, the increased level was the only indicator of a heart problem, P.J. Devereaux, MD, said at the annual meeting of the American College of Cardiology. The painkillers that patients receive following surgery generally mask the chest discomfort they might otherwise feel from their heart damage, he explained. The clinical condition is called myocardial injury after noncardiac surgery.

“We’re seeing more older patients with a high burden of vascular disease undergoing surgery, and surgery is a very significant stress, so a large proportion of these patients will have [myocardial injury after noncardiac surgery] and that affects 30-day survival,” said Dr. Devereaux, professor and director of cardiology at McMaster University in Hamilton, Ont.

Based on the new findings, he recommended performing a baseline assessment of troponin T levels in patients scheduled for noncardiac surgery if they are at least 65 years of age, or if they are age 45-64 years with known vascular disease, followed by repeat testing 1 and 2 days after surgery to check whether a spike in the measure had occurred. The high sensitivity troponin T (hsTnT) test he used in the study is relatively costly (and received Food and Drug Administration approval for U.S. marketing in January 2017), but Dr. Devereaux believed that, used in this way, the cost for testing would be reasonable, given its powerful ability to identify high-risk patients and relative to the cost of other screening tools routinely used in U.S. medical practice.

“It looks very cost-effective,” he said in a video interview.

If the baseline and two follow-up measures of hsTnT showed a postoperative level of at least 20 ng/L that rose above the baseline level by at least 5 ng/L, or if the postoperative level was at least 65 ng/L, Dr. Devereaux recommended starting daily treatment with aspirin and a statin to try to contain any perioperative myocardial damage the patient may have, and follow with comprehensive assessment of the patient by a cardiologist or other internal medicine physician.

“Given the risks associated with a rise in hsTnT in this study, Dr. Devereaux’s recommendations are very reasonable until we collect more data on this,” said Frank W. Sellke, MD, professor of surgery and chief of cardiothoracic surgery at Brown Medical School and the Lifespan Hospitals in Providence, R.I. “What was surprising was how few patients had symptoms” of myocardial ischemia. “You can’t do hsTnT measurements on every patient who goes in for a hernia operation; it’s not practical. But his findings are fairly compelling, and hopefully the cost of this testing will come down,” Dr. Sellke said in an interview.

In the multicenter study of 21,842 patients, 24% had a postoperative hsTnT level of 20 ng/L or greater, including 5% with a level of 65 ng/L or greater. The 30-day mortality rate was 3% among those with a perioperative level of 20-64 ng/L, 9% among patients with perioperative hsTnT levels of 65-999 ng/L, and 30% among the 54 patients (0.2% of the study group) with perioperative levels that reached 1,000 ng/L or greater. Dr. Devereaux reported.

This iteration of the Vascular Events In Noncardiac Surgery Patients Cohort Evaluation Study (VISION) enrolled patients who were at least 45 years of age and underwent noncardiac surgery at 23 centers in 13 countries, including the United States and Canada. All patients underwent hsTnT testing 6-12 hours after surgery and 1, 2, and 3 days after surgery, but only 40% also had a baseline measurement before their surgery began. Full 30-day follow-up occurred for 21,050. The patients’ average age was 63 years. The most common surgery was “low-risk,” in 35%, followed by “major” general surgery in 20%, and “major” orthopedic surgery in 16%. At 30 days, 266 patients (1.2%) had died.

[email protected]

On Twitter @mitchelzoler

WASHINGTON – A rise in the blood level of troponin T immediately after patients underwent noncardiac surgery identified a high risk group with a 30-day mortality rate nearly fivefold higher than that of patients who did not have a postoperative troponin T spike, according to a prospective study of more than 21,000 patients.

For 93% of the patients who have these perioperative spikes in troponin T, a marker of myocardial ischemia, the increased level was the only indicator of a heart problem, P.J. Devereaux, MD, said at the annual meeting of the American College of Cardiology. The painkillers that patients receive following surgery generally mask the chest discomfort they might otherwise feel from their heart damage, he explained. The clinical condition is called myocardial injury after noncardiac surgery.

“We’re seeing more older patients with a high burden of vascular disease undergoing surgery, and surgery is a very significant stress, so a large proportion of these patients will have [myocardial injury after noncardiac surgery] and that affects 30-day survival,” said Dr. Devereaux, professor and director of cardiology at McMaster University in Hamilton, Ont.

Based on the new findings, he recommended performing a baseline assessment of troponin T levels in patients scheduled for noncardiac surgery if they are at least 65 years of age, or if they are age 45-64 years with known vascular disease, followed by repeat testing 1 and 2 days after surgery to check whether a spike in the measure had occurred. The high sensitivity troponin T (hsTnT) test he used in the study is relatively costly (and received Food and Drug Administration approval for U.S. marketing in January 2017), but Dr. Devereaux believed that, used in this way, the cost for testing would be reasonable, given its powerful ability to identify high-risk patients and relative to the cost of other screening tools routinely used in U.S. medical practice.

“It looks very cost-effective,” he said in a video interview.

If the baseline and two follow-up measures of hsTnT showed a postoperative level of at least 20 ng/L that rose above the baseline level by at least 5 ng/L, or if the postoperative level was at least 65 ng/L, Dr. Devereaux recommended starting daily treatment with aspirin and a statin to try to contain any perioperative myocardial damage the patient may have, and follow with comprehensive assessment of the patient by a cardiologist or other internal medicine physician.

“Given the risks associated with a rise in hsTnT in this study, Dr. Devereaux’s recommendations are very reasonable until we collect more data on this,” said Frank W. Sellke, MD, professor of surgery and chief of cardiothoracic surgery at Brown Medical School and the Lifespan Hospitals in Providence, R.I. “What was surprising was how few patients had symptoms” of myocardial ischemia. “You can’t do hsTnT measurements on every patient who goes in for a hernia operation; it’s not practical. But his findings are fairly compelling, and hopefully the cost of this testing will come down,” Dr. Sellke said in an interview.

In the multicenter study of 21,842 patients, 24% had a postoperative hsTnT level of 20 ng/L or greater, including 5% with a level of 65 ng/L or greater. The 30-day mortality rate was 3% among those with a perioperative level of 20-64 ng/L, 9% among patients with perioperative hsTnT levels of 65-999 ng/L, and 30% among the 54 patients (0.2% of the study group) with perioperative levels that reached 1,000 ng/L or greater. Dr. Devereaux reported.

This iteration of the Vascular Events In Noncardiac Surgery Patients Cohort Evaluation Study (VISION) enrolled patients who were at least 45 years of age and underwent noncardiac surgery at 23 centers in 13 countries, including the United States and Canada. All patients underwent hsTnT testing 6-12 hours after surgery and 1, 2, and 3 days after surgery, but only 40% also had a baseline measurement before their surgery began. Full 30-day follow-up occurred for 21,050. The patients’ average age was 63 years. The most common surgery was “low-risk,” in 35%, followed by “major” general surgery in 20%, and “major” orthopedic surgery in 16%. At 30 days, 266 patients (1.2%) had died.

[email protected]

On Twitter @mitchelzoler

WASHINGTON – A rise in the blood level of troponin T immediately after patients underwent noncardiac surgery identified a high risk group with a 30-day mortality rate nearly fivefold higher than that of patients who did not have a postoperative troponin T spike, according to a prospective study of more than 21,000 patients.

For 93% of the patients who have these perioperative spikes in troponin T, a marker of myocardial ischemia, the increased level was the only indicator of a heart problem, P.J. Devereaux, MD, said at the annual meeting of the American College of Cardiology. The painkillers that patients receive following surgery generally mask the chest discomfort they might otherwise feel from their heart damage, he explained. The clinical condition is called myocardial injury after noncardiac surgery.

“We’re seeing more older patients with a high burden of vascular disease undergoing surgery, and surgery is a very significant stress, so a large proportion of these patients will have [myocardial injury after noncardiac surgery] and that affects 30-day survival,” said Dr. Devereaux, professor and director of cardiology at McMaster University in Hamilton, Ont.

Based on the new findings, he recommended performing a baseline assessment of troponin T levels in patients scheduled for noncardiac surgery if they are at least 65 years of age, or if they are age 45-64 years with known vascular disease, followed by repeat testing 1 and 2 days after surgery to check whether a spike in the measure had occurred. The high sensitivity troponin T (hsTnT) test he used in the study is relatively costly (and received Food and Drug Administration approval for U.S. marketing in January 2017), but Dr. Devereaux believed that, used in this way, the cost for testing would be reasonable, given its powerful ability to identify high-risk patients and relative to the cost of other screening tools routinely used in U.S. medical practice.

“It looks very cost-effective,” he said in a video interview.

If the baseline and two follow-up measures of hsTnT showed a postoperative level of at least 20 ng/L that rose above the baseline level by at least 5 ng/L, or if the postoperative level was at least 65 ng/L, Dr. Devereaux recommended starting daily treatment with aspirin and a statin to try to contain any perioperative myocardial damage the patient may have, and follow with comprehensive assessment of the patient by a cardiologist or other internal medicine physician.

“Given the risks associated with a rise in hsTnT in this study, Dr. Devereaux’s recommendations are very reasonable until we collect more data on this,” said Frank W. Sellke, MD, professor of surgery and chief of cardiothoracic surgery at Brown Medical School and the Lifespan Hospitals in Providence, R.I. “What was surprising was how few patients had symptoms” of myocardial ischemia. “You can’t do hsTnT measurements on every patient who goes in for a hernia operation; it’s not practical. But his findings are fairly compelling, and hopefully the cost of this testing will come down,” Dr. Sellke said in an interview.

In the multicenter study of 21,842 patients, 24% had a postoperative hsTnT level of 20 ng/L or greater, including 5% with a level of 65 ng/L or greater. The 30-day mortality rate was 3% among those with a perioperative level of 20-64 ng/L, 9% among patients with perioperative hsTnT levels of 65-999 ng/L, and 30% among the 54 patients (0.2% of the study group) with perioperative levels that reached 1,000 ng/L or greater. Dr. Devereaux reported.

This iteration of the Vascular Events In Noncardiac Surgery Patients Cohort Evaluation Study (VISION) enrolled patients who were at least 45 years of age and underwent noncardiac surgery at 23 centers in 13 countries, including the United States and Canada. All patients underwent hsTnT testing 6-12 hours after surgery and 1, 2, and 3 days after surgery, but only 40% also had a baseline measurement before their surgery began. Full 30-day follow-up occurred for 21,050. The patients’ average age was 63 years. The most common surgery was “low-risk,” in 35%, followed by “major” general surgery in 20%, and “major” orthopedic surgery in 16%. At 30 days, 266 patients (1.2%) had died.

[email protected]

On Twitter @mitchelzoler

ORLANDO – Women with breast cancer who look for well-rounded information about treatment on the websites of prominent U.S. cancer centers are likely to come up short, suggests a study presented at a symposium on quality care sponsored by the American Society of Clinical Oncology.

Research has shown that nearly all women with breast cancer search the Internet for information about its treatment, and two-thirds report that what they find has a strong influence on their decision-making process (J Cancer Educ. 2013;28[4]:662-8).

But the analysis of content on the websites of 63 National Cancer Institute–designated comprehensive cancer centers or clinical cancer centers found that, on average, they addressed only 21% of a set of key concepts that women need to understand to make informed decisions about surgery, radiation therapy, chemotherapy, hormone therapy, and breast reconstruction. This contrasted starkly with 85% for the National Cancer Institute’s own website (cancer.gov) and 88% for the Susan G. Komen Foundation’s website (komen.org).

Susan London/Frontline Medical News

Study details

For the study, the investigators developed a list of 33 decision-specific knowledge questions about breast cancer treatment by drawing on decision quality instruments that assess how informed a woman’s decision-making process is. The primary outcome was whether the website provided sufficient information to answer each question. The researchers assessed seven measures of accessibility as secondary outcomes.

Results showed that websites contained sufficient content to address only 21% of the decision-specific knowledge questions, Dr. Dulaney reported in a poster session. The value was 17% for questions pertaining to breast surgery and radiation therapy, 18% for those pertaining to chemotherapy and hormone therapy, and 21% for those pertaining to breast reconstruction.

In addition, “a lot of websites put the information in silos,” he noted. “You can read about mastectomy, you can read about lumpectomy, you can read about chemo. But you can’t really get the big picture, which is how do these compare to each other, and which treatment is best for me.”

Even the most commonly addressed single question – what type of reconstruction is most likely to require more than one surgery or procedure – was addressed by only 51% of sites. Proportions were similar for questions pertaining to the type of tumors against which hormone therapy works best (48%) and the schedule for radiation therapy after lumpectomy (47%).

At the other extreme, however, very small proportions of sites addressed questions pertaining to how many women with treated early breast cancer will die from the disease (7%), how many undergoing breast reconstruction will experience complications requiring hospitalization or an unplanned procedure (4%), how skipping chemotherapy and hormone therapy influences risk of death (2%), and whether waiting several weeks to decide about those therapies affects survival (2%). These topics are more negative, Dr. Dulaney observed, “but these are things women need to know.”

None of the websites provided sufficient information to answer all 33 knowledge questions. But perhaps more worrisome, 16% did not provide sufficient information to answer any of them, he said.

When it came to accessibility of information, 94% of sites clearly had a breast cancer–specific page, 87% had information about breast cancer–specific trials, and 86% showed members of the center’s breast cancer team. But only 59% were mobile device friendly as assessed with a Google tool, and merely 24% had obvious links to view information in Spanish.

“A lot of minorities and people of lower socioeconomic status exclusively access the Internet via mobile devices, so they may not have a computer or [other] access to the Internet. But they have a cell phone that is probably a smartphone, and they can get online and search for information that way,” Dr. Dulaney said.

Many oncologists may not have had any say regarding the content and accessibility features of their institution’s website, he acknowledged.

“So we should maybe, number one, try to have more involvement in what information goes on to the website, and two, take a look at our own websites to see what’s on there, because patients are going to look for you, and they are going to associate this information with you,” he said. “If you are at a big institution and you really can’t make a change on your website, you can use alternatives such as social media platforms, things like that, to try and get information out to people.”

From a larger perspective, oncologists have often simply counseled patients that they can’t rely on information they have found online, according to Dr. Dulaney.

“But in this day and age, that can’t really be an answer,” he concluded. “Information on the web is ubiquitous, and there is good information out there. We need to do a better job of speaking up in the conversation. We have the answers to a lot of these questions, we just need to make our voices heard and also direct patients to reliable sources of information.”

ORLANDO – Women with breast cancer who look for well-rounded information about treatment on the websites of prominent U.S. cancer centers are likely to come up short, suggests a study presented at a symposium on quality care sponsored by the American Society of Clinical Oncology.

Research has shown that nearly all women with breast cancer search the Internet for information about its treatment, and two-thirds report that what they find has a strong influence on their decision-making process (J Cancer Educ. 2013;28[4]:662-8).

But the analysis of content on the websites of 63 National Cancer Institute–designated comprehensive cancer centers or clinical cancer centers found that, on average, they addressed only 21% of a set of key concepts that women need to understand to make informed decisions about surgery, radiation therapy, chemotherapy, hormone therapy, and breast reconstruction. This contrasted starkly with 85% for the National Cancer Institute’s own website (cancer.gov) and 88% for the Susan G. Komen Foundation’s website (komen.org).

Susan London/Frontline Medical News

Study details

For the study, the investigators developed a list of 33 decision-specific knowledge questions about breast cancer treatment by drawing on decision quality instruments that assess how informed a woman’s decision-making process is. The primary outcome was whether the website provided sufficient information to answer each question. The researchers assessed seven measures of accessibility as secondary outcomes.

Results showed that websites contained sufficient content to address only 21% of the decision-specific knowledge questions, Dr. Dulaney reported in a poster session. The value was 17% for questions pertaining to breast surgery and radiation therapy, 18% for those pertaining to chemotherapy and hormone therapy, and 21% for those pertaining to breast reconstruction.

In addition, “a lot of websites put the information in silos,” he noted. “You can read about mastectomy, you can read about lumpectomy, you can read about chemo. But you can’t really get the big picture, which is how do these compare to each other, and which treatment is best for me.”

Even the most commonly addressed single question – what type of reconstruction is most likely to require more than one surgery or procedure – was addressed by only 51% of sites. Proportions were similar for questions pertaining to the type of tumors against which hormone therapy works best (48%) and the schedule for radiation therapy after lumpectomy (47%).

At the other extreme, however, very small proportions of sites addressed questions pertaining to how many women with treated early breast cancer will die from the disease (7%), how many undergoing breast reconstruction will experience complications requiring hospitalization or an unplanned procedure (4%), how skipping chemotherapy and hormone therapy influences risk of death (2%), and whether waiting several weeks to decide about those therapies affects survival (2%). These topics are more negative, Dr. Dulaney observed, “but these are things women need to know.”

None of the websites provided sufficient information to answer all 33 knowledge questions. But perhaps more worrisome, 16% did not provide sufficient information to answer any of them, he said.

When it came to accessibility of information, 94% of sites clearly had a breast cancer–specific page, 87% had information about breast cancer–specific trials, and 86% showed members of the center’s breast cancer team. But only 59% were mobile device friendly as assessed with a Google tool, and merely 24% had obvious links to view information in Spanish.

“A lot of minorities and people of lower socioeconomic status exclusively access the Internet via mobile devices, so they may not have a computer or [other] access to the Internet. But they have a cell phone that is probably a smartphone, and they can get online and search for information that way,” Dr. Dulaney said.

Many oncologists may not have had any say regarding the content and accessibility features of their institution’s website, he acknowledged.

“So we should maybe, number one, try to have more involvement in what information goes on to the website, and two, take a look at our own websites to see what’s on there, because patients are going to look for you, and they are going to associate this information with you,” he said. “If you are at a big institution and you really can’t make a change on your website, you can use alternatives such as social media platforms, things like that, to try and get information out to people.”

From a larger perspective, oncologists have often simply counseled patients that they can’t rely on information they have found online, according to Dr. Dulaney.

“But in this day and age, that can’t really be an answer,” he concluded. “Information on the web is ubiquitous, and there is good information out there. We need to do a better job of speaking up in the conversation. We have the answers to a lot of these questions, we just need to make our voices heard and also direct patients to reliable sources of information.”

ORLANDO – Women with breast cancer who look for well-rounded information about treatment on the websites of prominent U.S. cancer centers are likely to come up short, suggests a study presented at a symposium on quality care sponsored by the American Society of Clinical Oncology.

Research has shown that nearly all women with breast cancer search the Internet for information about its treatment, and two-thirds report that what they find has a strong influence on their decision-making process (J Cancer Educ. 2013;28[4]:662-8).

But the analysis of content on the websites of 63 National Cancer Institute–designated comprehensive cancer centers or clinical cancer centers found that, on average, they addressed only 21% of a set of key concepts that women need to understand to make informed decisions about surgery, radiation therapy, chemotherapy, hormone therapy, and breast reconstruction. This contrasted starkly with 85% for the National Cancer Institute’s own website (cancer.gov) and 88% for the Susan G. Komen Foundation’s website (komen.org).

Susan London/Frontline Medical News

Study details

For the study, the investigators developed a list of 33 decision-specific knowledge questions about breast cancer treatment by drawing on decision quality instruments that assess how informed a woman’s decision-making process is. The primary outcome was whether the website provided sufficient information to answer each question. The researchers assessed seven measures of accessibility as secondary outcomes.

Results showed that websites contained sufficient content to address only 21% of the decision-specific knowledge questions, Dr. Dulaney reported in a poster session. The value was 17% for questions pertaining to breast surgery and radiation therapy, 18% for those pertaining to chemotherapy and hormone therapy, and 21% for those pertaining to breast reconstruction.

In addition, “a lot of websites put the information in silos,” he noted. “You can read about mastectomy, you can read about lumpectomy, you can read about chemo. But you can’t really get the big picture, which is how do these compare to each other, and which treatment is best for me.”

Even the most commonly addressed single question – what type of reconstruction is most likely to require more than one surgery or procedure – was addressed by only 51% of sites. Proportions were similar for questions pertaining to the type of tumors against which hormone therapy works best (48%) and the schedule for radiation therapy after lumpectomy (47%).

At the other extreme, however, very small proportions of sites addressed questions pertaining to how many women with treated early breast cancer will die from the disease (7%), how many undergoing breast reconstruction will experience complications requiring hospitalization or an unplanned procedure (4%), how skipping chemotherapy and hormone therapy influences risk of death (2%), and whether waiting several weeks to decide about those therapies affects survival (2%). These topics are more negative, Dr. Dulaney observed, “but these are things women need to know.”

None of the websites provided sufficient information to answer all 33 knowledge questions. But perhaps more worrisome, 16% did not provide sufficient information to answer any of them, he said.

When it came to accessibility of information, 94% of sites clearly had a breast cancer–specific page, 87% had information about breast cancer–specific trials, and 86% showed members of the center’s breast cancer team. But only 59% were mobile device friendly as assessed with a Google tool, and merely 24% had obvious links to view information in Spanish.

“A lot of minorities and people of lower socioeconomic status exclusively access the Internet via mobile devices, so they may not have a computer or [other] access to the Internet. But they have a cell phone that is probably a smartphone, and they can get online and search for information that way,” Dr. Dulaney said.

Many oncologists may not have had any say regarding the content and accessibility features of their institution’s website, he acknowledged.

“So we should maybe, number one, try to have more involvement in what information goes on to the website, and two, take a look at our own websites to see what’s on there, because patients are going to look for you, and they are going to associate this information with you,” he said. “If you are at a big institution and you really can’t make a change on your website, you can use alternatives such as social media platforms, things like that, to try and get information out to people.”

From a larger perspective, oncologists have often simply counseled patients that they can’t rely on information they have found online, according to Dr. Dulaney.

“But in this day and age, that can’t really be an answer,” he concluded. “Information on the web is ubiquitous, and there is good information out there. We need to do a better job of speaking up in the conversation. We have the answers to a lot of these questions, we just need to make our voices heard and also direct patients to reliable sources of information.”

The herpes zoster vaccine reduces the risk of shingles in older adults with autoimmune disease, even if they are taking immunosuppressants for their condition, but the protection begins to wane after about 5 years, a recent retrospective study found.

“There has been some concern that patients with autoimmune conditions might have a lower immunogenic response to herpes zoster vaccination, especially when treated with immunosuppressive medications such as glucocorticoids,” wrote Huifeng Yun, PhD, of the University of Alabama at Birmingham, and her colleagues.

copyright clsgraphics/iStockphoto.com

[email protected]

The herpes zoster vaccine reduces the risk of shingles in older adults with autoimmune disease, even if they are taking immunosuppressants for their condition, but the protection begins to wane after about 5 years, a recent retrospective study found.

“There has been some concern that patients with autoimmune conditions might have a lower immunogenic response to herpes zoster vaccination, especially when treated with immunosuppressive medications such as glucocorticoids,” wrote Huifeng Yun, PhD, of the University of Alabama at Birmingham, and her colleagues.

copyright clsgraphics/iStockphoto.com

[email protected]

The herpes zoster vaccine reduces the risk of shingles in older adults with autoimmune disease, even if they are taking immunosuppressants for their condition, but the protection begins to wane after about 5 years, a recent retrospective study found.

“There has been some concern that patients with autoimmune conditions might have a lower immunogenic response to herpes zoster vaccination, especially when treated with immunosuppressive medications such as glucocorticoids,” wrote Huifeng Yun, PhD, of the University of Alabama at Birmingham, and her colleagues.

copyright clsgraphics/iStockphoto.com

[email protected]

The Department of Health & Human Services would see an 18% funding cut under the first budget proposal from the Trump administration.

The proposal, submitted to Congress March 16, would cut $15.1 billion from fiscal 2017 levels, funding the agency at $69 billion for fiscal year 2018. More than a third of the cuts come from the National Institutes of Health.

The NIH’s overall budget would drop to $25.9 billion in FY 2018, down $5.8 billion from this year (fiscal 2017). The proposal includes “a major reorganization of NIH’s institutes and centers to help focus resources on the highest priority research and training activities, including: eliminating the Fogarty International Center, consolidating the Agency for Healthcare Research and Quality within the NIH, and other consolidations and structural changes across NIH organizations and activities,” according to summary documents from the Office of Management and Budget.

The proposed cuts also account for the funds that are to be appropriated for the 21st Century Cures Act, which was supposed to add $4.8 billion in new appropriated funding, including funds dedicated to the Cancer Moonshot and the BRAIN Initiative.

The Centers for Disease Control and Prevention also would be reformed, getting a new $500 million block grant “to increase state flexibility and focus on the leading public health challenges specific to each state.” It also creates a new Federal Emergency Response Fund to respond to public health outbreaks such as the Zika virus.

tupungato/Thinkstock

of GI practice and research remains viable. Contact AGA to learn more about how to get involved in your community at [email protected], and learn more about AGA PAC at www.gastro.org/agapac.

[email protected]

The Department of Health & Human Services would see an 18% funding cut under the first budget proposal from the Trump administration.

The proposal, submitted to Congress March 16, would cut $15.1 billion from fiscal 2017 levels, funding the agency at $69 billion for fiscal year 2018. More than a third of the cuts come from the National Institutes of Health.

The NIH’s overall budget would drop to $25.9 billion in FY 2018, down $5.8 billion from this year (fiscal 2017). The proposal includes “a major reorganization of NIH’s institutes and centers to help focus resources on the highest priority research and training activities, including: eliminating the Fogarty International Center, consolidating the Agency for Healthcare Research and Quality within the NIH, and other consolidations and structural changes across NIH organizations and activities,” according to summary documents from the Office of Management and Budget.

The proposed cuts also account for the funds that are to be appropriated for the 21st Century Cures Act, which was supposed to add $4.8 billion in new appropriated funding, including funds dedicated to the Cancer Moonshot and the BRAIN Initiative.

The Centers for Disease Control and Prevention also would be reformed, getting a new $500 million block grant “to increase state flexibility and focus on the leading public health challenges specific to each state.” It also creates a new Federal Emergency Response Fund to respond to public health outbreaks such as the Zika virus.

tupungato/Thinkstock

of GI practice and research remains viable. Contact AGA to learn more about how to get involved in your community at [email protected], and learn more about AGA PAC at www.gastro.org/agapac.

[email protected]

The Department of Health & Human Services would see an 18% funding cut under the first budget proposal from the Trump administration.

The proposal, submitted to Congress March 16, would cut $15.1 billion from fiscal 2017 levels, funding the agency at $69 billion for fiscal year 2018. More than a third of the cuts come from the National Institutes of Health.

The NIH’s overall budget would drop to $25.9 billion in FY 2018, down $5.8 billion from this year (fiscal 2017). The proposal includes “a major reorganization of NIH’s institutes and centers to help focus resources on the highest priority research and training activities, including: eliminating the Fogarty International Center, consolidating the Agency for Healthcare Research and Quality within the NIH, and other consolidations and structural changes across NIH organizations and activities,” according to summary documents from the Office of Management and Budget.

The proposed cuts also account for the funds that are to be appropriated for the 21st Century Cures Act, which was supposed to add $4.8 billion in new appropriated funding, including funds dedicated to the Cancer Moonshot and the BRAIN Initiative.

The Centers for Disease Control and Prevention also would be reformed, getting a new $500 million block grant “to increase state flexibility and focus on the leading public health challenges specific to each state.” It also creates a new Federal Emergency Response Fund to respond to public health outbreaks such as the Zika virus.

tupungato/Thinkstock

of GI practice and research remains viable. Contact AGA to learn more about how to get involved in your community at [email protected], and learn more about AGA PAC at www.gastro.org/agapac.

[email protected]

In 2021, the first obstetrician-gynecologist trained on a separate rural residency track will graduate from the University of Wisconsin.

Program leaders are gambling that the investment in specialized training – including a quarter of the training time spent in smaller, community hospitals – will eventually pay off in terms of more ob.gyns. living and practicing in Wisconsin’s underserved rural settings.

“The key premise that we’re working on and that’s been borne out in the literature on rural training in family medicine is that people who are ultimately going to practice in a rural setting are people who are interested in it, who have a rural background, and people who have experience in a clinical environment in the rural setting,” said Ellen Hartenbach, MD, ob.gyn. residency program director at the University of Wisconsin, Madison.

Courtesy John Maniaci/UW Health

Maldistribution

This trend is national as well. Nearly half of the 3,107 U.S. counties lack ob.gyns. These counties are located in all states but primarily in the Midwest and Mountain West, according to a 2011 workforce report from ACOG.

As of 2010, the national ratio of ob.gyns. per 10,000 women was 2.1, but that ratio decreases from 2.9 in metropolitan counties to 0.7 in rural counties.

William F. Rayburn, MD, distinguished professor and emeritus chair of obstetrics and gynecology at the University of New Mexico, Albuquerque, is working on an update to the workforce report, expected to be released in May 2017 at ACOG’s annual scientific meeting in San Diego.

GME funding cap

The Association of American Medical Colleges is focused on easing physician shortages by getting lawmakers to lift the cap on federal funding for graduate medical education (GME) positions that was put in place as part of the Balanced Budget Act of 1997.

“The population is getting larger and aging, which increases the need for more physicians and thus we have to work with Congress to lift the cap,” said Janis Orlowski, MD, Chief Health Care Officer at the Association of American Medical Colleges.

[email protected]

On Twitter @maryellenny

In 2021, the first obstetrician-gynecologist trained on a separate rural residency track will graduate from the University of Wisconsin.

Program leaders are gambling that the investment in specialized training – including a quarter of the training time spent in smaller, community hospitals – will eventually pay off in terms of more ob.gyns. living and practicing in Wisconsin’s underserved rural settings.

“The key premise that we’re working on and that’s been borne out in the literature on rural training in family medicine is that people who are ultimately going to practice in a rural setting are people who are interested in it, who have a rural background, and people who have experience in a clinical environment in the rural setting,” said Ellen Hartenbach, MD, ob.gyn. residency program director at the University of Wisconsin, Madison.

Courtesy John Maniaci/UW Health

Maldistribution

This trend is national as well. Nearly half of the 3,107 U.S. counties lack ob.gyns. These counties are located in all states but primarily in the Midwest and Mountain West, according to a 2011 workforce report from ACOG.

As of 2010, the national ratio of ob.gyns. per 10,000 women was 2.1, but that ratio decreases from 2.9 in metropolitan counties to 0.7 in rural counties.

William F. Rayburn, MD, distinguished professor and emeritus chair of obstetrics and gynecology at the University of New Mexico, Albuquerque, is working on an update to the workforce report, expected to be released in May 2017 at ACOG’s annual scientific meeting in San Diego.

GME funding cap

The Association of American Medical Colleges is focused on easing physician shortages by getting lawmakers to lift the cap on federal funding for graduate medical education (GME) positions that was put in place as part of the Balanced Budget Act of 1997.

“The population is getting larger and aging, which increases the need for more physicians and thus we have to work with Congress to lift the cap,” said Janis Orlowski, MD, Chief Health Care Officer at the Association of American Medical Colleges.

[email protected]

On Twitter @maryellenny

In 2021, the first obstetrician-gynecologist trained on a separate rural residency track will graduate from the University of Wisconsin.

Program leaders are gambling that the investment in specialized training – including a quarter of the training time spent in smaller, community hospitals – will eventually pay off in terms of more ob.gyns. living and practicing in Wisconsin’s underserved rural settings.

“The key premise that we’re working on and that’s been borne out in the literature on rural training in family medicine is that people who are ultimately going to practice in a rural setting are people who are interested in it, who have a rural background, and people who have experience in a clinical environment in the rural setting,” said Ellen Hartenbach, MD, ob.gyn. residency program director at the University of Wisconsin, Madison.

Courtesy John Maniaci/UW Health

Maldistribution

This trend is national as well. Nearly half of the 3,107 U.S. counties lack ob.gyns. These counties are located in all states but primarily in the Midwest and Mountain West, according to a 2011 workforce report from ACOG.

As of 2010, the national ratio of ob.gyns. per 10,000 women was 2.1, but that ratio decreases from 2.9 in metropolitan counties to 0.7 in rural counties.

William F. Rayburn, MD, distinguished professor and emeritus chair of obstetrics and gynecology at the University of New Mexico, Albuquerque, is working on an update to the workforce report, expected to be released in May 2017 at ACOG’s annual scientific meeting in San Diego.

GME funding cap

The Association of American Medical Colleges is focused on easing physician shortages by getting lawmakers to lift the cap on federal funding for graduate medical education (GME) positions that was put in place as part of the Balanced Budget Act of 1997.

“The population is getting larger and aging, which increases the need for more physicians and thus we have to work with Congress to lift the cap,” said Janis Orlowski, MD, Chief Health Care Officer at the Association of American Medical Colleges.

[email protected]

On Twitter @maryellenny

Addition of 10 cm H₂O to positive end-expiratory volume (PEEP) during mechanical ventilation was followed by significantly lessened pulmonary complications in hospitalized patients who developed hypoxemia after cardiac surgery, participating in a single-center, randomized trial.

This “intensive” alveolar recruitment strategy yielded a median pulmonary complications score of 1.7 (interquartile range, 1.0-2.0), compared with 2.0 (IQR, 1.5-3.0) among patients who underwent ventilation with a PEEP of 20 cm H₂O, Alcino Costa Leme, RRT, PhD, said at the International Symposium on Intensive Care and Emergency Medicine. The report was published simultaneously online March 21 in JAMA.

Intensive alveolar recruitment nearly doubled the odds of a lower pulmonary complications score (common odds ratio, 1.9; 95% confidence interval, 1.2-2.8; P = .003), Dr. Leme and his associates reported.

The study comprised 320 adults who developed hypoxemia immediately after undergoing elective cardiac surgery at the Heart Institute (Incor) of the University of São Paulo. The median age of the patients was 62 years, and none had a history of lung disease. Pulmonary complications were scored between 0 (no signs or symptoms) and 5 (death), the investigators noted (JAMA. 2017 Mar 21. doi: 10.1001/jama.2017.2297).

The intensive alveolar recruitment strategy consisted of three 60-second cycles of lung inflation with a positive end-expiratory pressure (PEEP) of 30 cm H₂O, pressure-controlled ventilation, driving pressure of 15 cm H₂O, respiratory rate of 15/min, inspiratory time of 1.5 seconds, and FIO₂ of 0.40. Between and after inflations, patients received assist-controlled or pressure-controlled ventilation, with driving pressures set to achieve a tidal volume of 6 mL/kg of predicted body weight, an inspiratory time of 1 second, PEEP of 13 cm H₂O, and minimum respiratory rate to maintain PaCO₂ between 35 and 45 mm Hg.

The “moderate strategy” consisted of three 30-second inflations under continuous positive airway pressure mode at 20 cm H₂O and FIO₂ of 0.60. Between and after inflations, patients received assist or control volume-controlled ventilation (decelerating-flow waveform), tidal volume of 6 mL/kg of predicted body weight, inspiratory time of 1 second, PEEP of 8 cm H₂O, and FIO₂ of 0.60, at a minimum respiratory rate that maintained PaCO₂ at 35-45 mm Hg.

“[The] use of an intensive alveolar recruitment strategy compared with a moderate recruitment strategy resulted in less severe pulmonary complications during the hospital stay,” the investigators wrote. On average, intensively managed patients had shorter stays in the hospital (10.9 vs. 12.4 days; P = .04) and in the intensive care unit (3.8 vs. 4.8 days; P = .01) than did moderately managed patients. Intensive management also was associated with lower rates of hospital mortality and barotrauma, but the differences in these less common outcomes did not reach statistical significance.

“To our knowledge, this is the first study to show a significant effect of lung recruitment maneuvers on clinical outcomes, which objectively resulted in modest reductions in ICU and hospital length of stay,” the researchers wrote. “This is especially noteworthy considering that the control group was also receiving protective lung ventilation with low [tidal volume] and moderate PEEP levels. Thus, the major difference between treatment groups was the intensity of lung recruitment.”

FAPESP (Fundação de Amparo e Pesquisa do Estado de São Paulo) and FINEP (Financiadora de Estudos e Projetos) provided partial funding. Dr. Leme had no disclosures. Senior author Marcelo Britto Passos Amato, MD, PhD, disclosed research funding from Covidien/Medtronics, Dixtal Biomedica Ltd, and Timpel SA.

Addition of 10 cm H₂O to positive end-expiratory volume (PEEP) during mechanical ventilation was followed by significantly lessened pulmonary complications in hospitalized patients who developed hypoxemia after cardiac surgery, participating in a single-center, randomized trial.

This “intensive” alveolar recruitment strategy yielded a median pulmonary complications score of 1.7 (interquartile range, 1.0-2.0), compared with 2.0 (IQR, 1.5-3.0) among patients who underwent ventilation with a PEEP of 20 cm H₂O, Alcino Costa Leme, RRT, PhD, said at the International Symposium on Intensive Care and Emergency Medicine. The report was published simultaneously online March 21 in JAMA.

Intensive alveolar recruitment nearly doubled the odds of a lower pulmonary complications score (common odds ratio, 1.9; 95% confidence interval, 1.2-2.8; P = .003), Dr. Leme and his associates reported.

The study comprised 320 adults who developed hypoxemia immediately after undergoing elective cardiac surgery at the Heart Institute (Incor) of the University of São Paulo. The median age of the patients was 62 years, and none had a history of lung disease. Pulmonary complications were scored between 0 (no signs or symptoms) and 5 (death), the investigators noted (JAMA. 2017 Mar 21. doi: 10.1001/jama.2017.2297).

The intensive alveolar recruitment strategy consisted of three 60-second cycles of lung inflation with a positive end-expiratory pressure (PEEP) of 30 cm H₂O, pressure-controlled ventilation, driving pressure of 15 cm H₂O, respiratory rate of 15/min, inspiratory time of 1.5 seconds, and FIO₂ of 0.40. Between and after inflations, patients received assist-controlled or pressure-controlled ventilation, with driving pressures set to achieve a tidal volume of 6 mL/kg of predicted body weight, an inspiratory time of 1 second, PEEP of 13 cm H₂O, and minimum respiratory rate to maintain PaCO₂ between 35 and 45 mm Hg.

The “moderate strategy” consisted of three 30-second inflations under continuous positive airway pressure mode at 20 cm H₂O and FIO₂ of 0.60. Between and after inflations, patients received assist or control volume-controlled ventilation (decelerating-flow waveform), tidal volume of 6 mL/kg of predicted body weight, inspiratory time of 1 second, PEEP of 8 cm H₂O, and FIO₂ of 0.60, at a minimum respiratory rate that maintained PaCO₂ at 35-45 mm Hg.

“[The] use of an intensive alveolar recruitment strategy compared with a moderate recruitment strategy resulted in less severe pulmonary complications during the hospital stay,” the investigators wrote. On average, intensively managed patients had shorter stays in the hospital (10.9 vs. 12.4 days; P = .04) and in the intensive care unit (3.8 vs. 4.8 days; P = .01) than did moderately managed patients. Intensive management also was associated with lower rates of hospital mortality and barotrauma, but the differences in these less common outcomes did not reach statistical significance.

“To our knowledge, this is the first study to show a significant effect of lung recruitment maneuvers on clinical outcomes, which objectively resulted in modest reductions in ICU and hospital length of stay,” the researchers wrote. “This is especially noteworthy considering that the control group was also receiving protective lung ventilation with low [tidal volume] and moderate PEEP levels. Thus, the major difference between treatment groups was the intensity of lung recruitment.”

FAPESP (Fundação de Amparo e Pesquisa do Estado de São Paulo) and FINEP (Financiadora de Estudos e Projetos) provided partial funding. Dr. Leme had no disclosures. Senior author Marcelo Britto Passos Amato, MD, PhD, disclosed research funding from Covidien/Medtronics, Dixtal Biomedica Ltd, and Timpel SA.

Addition of 10 cm H₂O to positive end-expiratory volume (PEEP) during mechanical ventilation was followed by significantly lessened pulmonary complications in hospitalized patients who developed hypoxemia after cardiac surgery, participating in a single-center, randomized trial.

This “intensive” alveolar recruitment strategy yielded a median pulmonary complications score of 1.7 (interquartile range, 1.0-2.0), compared with 2.0 (IQR, 1.5-3.0) among patients who underwent ventilation with a PEEP of 20 cm H₂O, Alcino Costa Leme, RRT, PhD, said at the International Symposium on Intensive Care and Emergency Medicine. The report was published simultaneously online March 21 in JAMA.

Intensive alveolar recruitment nearly doubled the odds of a lower pulmonary complications score (common odds ratio, 1.9; 95% confidence interval, 1.2-2.8; P = .003), Dr. Leme and his associates reported.

The study comprised 320 adults who developed hypoxemia immediately after undergoing elective cardiac surgery at the Heart Institute (Incor) of the University of São Paulo. The median age of the patients was 62 years, and none had a history of lung disease. Pulmonary complications were scored between 0 (no signs or symptoms) and 5 (death), the investigators noted (JAMA. 2017 Mar 21. doi: 10.1001/jama.2017.2297).

The intensive alveolar recruitment strategy consisted of three 60-second cycles of lung inflation with a positive end-expiratory pressure (PEEP) of 30 cm H₂O, pressure-controlled ventilation, driving pressure of 15 cm H₂O, respiratory rate of 15/min, inspiratory time of 1.5 seconds, and FIO₂ of 0.40. Between and after inflations, patients received assist-controlled or pressure-controlled ventilation, with driving pressures set to achieve a tidal volume of 6 mL/kg of predicted body weight, an inspiratory time of 1 second, PEEP of 13 cm H₂O, and minimum respiratory rate to maintain PaCO₂ between 35 and 45 mm Hg.

The “moderate strategy” consisted of three 30-second inflations under continuous positive airway pressure mode at 20 cm H₂O and FIO₂ of 0.60. Between and after inflations, patients received assist or control volume-controlled ventilation (decelerating-flow waveform), tidal volume of 6 mL/kg of predicted body weight, inspiratory time of 1 second, PEEP of 8 cm H₂O, and FIO₂ of 0.60, at a minimum respiratory rate that maintained PaCO₂ at 35-45 mm Hg.

“[The] use of an intensive alveolar recruitment strategy compared with a moderate recruitment strategy resulted in less severe pulmonary complications during the hospital stay,” the investigators wrote. On average, intensively managed patients had shorter stays in the hospital (10.9 vs. 12.4 days; P = .04) and in the intensive care unit (3.8 vs. 4.8 days; P = .01) than did moderately managed patients. Intensive management also was associated with lower rates of hospital mortality and barotrauma, but the differences in these less common outcomes did not reach statistical significance.

“To our knowledge, this is the first study to show a significant effect of lung recruitment maneuvers on clinical outcomes, which objectively resulted in modest reductions in ICU and hospital length of stay,” the researchers wrote. “This is especially noteworthy considering that the control group was also receiving protective lung ventilation with low [tidal volume] and moderate PEEP levels. Thus, the major difference between treatment groups was the intensity of lung recruitment.”

FAPESP (Fundação de Amparo e Pesquisa do Estado de São Paulo) and FINEP (Financiadora de Estudos e Projetos) provided partial funding. Dr. Leme had no disclosures. Senior author Marcelo Britto Passos Amato, MD, PhD, disclosed research funding from Covidien/Medtronics, Dixtal Biomedica Ltd, and Timpel SA.

Adding a low dose of levosimendan to the standard care for patients on perioperative hemodynamic support does not improve outcomes to any significant extent, according to the findings of a new study presented at the annual congress of the European Society of Intensive Care Medicine and published simultaneously online in the New England Journal of Medicine.

“Levosimendan (Simdax, Orion) is an inotropic agent that has been shown to be associated with a higher rate of survival than other inotropic agents in meta-analyses, especially those involving patients undergoing cardiac surgery,” wrote the authors of the study, led by Giovanni Landoni, MD, of Vita-Salute San Raffaele University in Milan, adding, “Considering the pharmacologic properties of levosimendan and the results of previous studies, we hypothesized that the administration of levosimendan, in addition to standard treatment, might result in lower mortality in this context.”

Dr. Landoni and his colleagues conducted the Levosimendan to Reduce Mortality in High Risk Cardiac Surgery Patients: A Multicenter Randomized Controlled Trial, known more commonly as CHEETAH. Written consent was given by 4,725 patients from 14 centers located in Italy, Russia, and Brazil between November 2009 and April 2016. The investigators recruited a total of 506 patients. All subjects included in the study underwent cardiac surgery and experienced a perioperative cardiovascular dysfunction (N Engl J Med. 2017 Mar 21. doi: 10.1056/NEJMoa1616325).

Subjects were then randomized into a cohort receiving either a placebo or a low dose of levosimendan, which varied between 0.025 to 0.2 mcg/kg of body weight per minute continuously for up to 48 hours. A total of 248 subjects received levosimendan and 258 received placebo. All patients were administered the treatment while in the ICU; patients were taken off their regimen prior to 48 hours if they were discharged from the ICU. Anyone screened for inclusion who already had experienced a negative reaction to levosimendan was excluded from the study.

“We collected preoperative data on baseline characteristics and coexisting conditions, intraoperative and postoperative treatment data, postoperative laboratory values, duration of mechanical ventilation, durations of ICU and hospital stays, and major outcomes,” the authors explained, adding that “telephone follow-up was performed at 30 days and 180 days after randomization by an investigator who was unaware of the trial group assignments.”

The primary outcome of the study was 30-day mortality. The levosimendan cohort experienced 32 deaths (12.9%), while the placebo cohort saw 33 (12.8%), a nonsignificant difference (P = .97) between the two groups. Similarly, the median time spent on mechanical ventilation was 19 hours for those on levosimendan, versus 21 hours for those on placebo (P = .48), and median length of hospital stay was 14 days in both groups (P = .39).

“Previous meta-analyses of randomized, controlled trials showed a higher rate of survival with levosimendan than with other treatment regimens among patients undergoing cardiac surgery,” Dr. Landoni and his coauthors noted. Previous studies also had a number of key differences, such as the number of subjects who underwent coronary artery bypass grafting, the dosing of levosimendan, and inclusion of patients who had reduced preoperative ejection fraction instead of ones with myocardial dysfunction who needed inotropic support, which the current study used.

The study was funded by the Italian Ministry of Health. Dr. Landoni reported receiving nonfinancial support from the Orion Corporation while the study was ongoing; several other coauthors reported similar disclosures.

[email protected]

Adding a low dose of levosimendan to the standard care for patients on perioperative hemodynamic support does not improve outcomes to any significant extent, according to the findings of a new study presented at the annual congress of the European Society of Intensive Care Medicine and published simultaneously online in the New England Journal of Medicine.

“Levosimendan (Simdax, Orion) is an inotropic agent that has been shown to be associated with a higher rate of survival than other inotropic agents in meta-analyses, especially those involving patients undergoing cardiac surgery,” wrote the authors of the study, led by Giovanni Landoni, MD, of Vita-Salute San Raffaele University in Milan, adding, “Considering the pharmacologic properties of levosimendan and the results of previous studies, we hypothesized that the administration of levosimendan, in addition to standard treatment, might result in lower mortality in this context.”

Dr. Landoni and his colleagues conducted the Levosimendan to Reduce Mortality in High Risk Cardiac Surgery Patients: A Multicenter Randomized Controlled Trial, known more commonly as CHEETAH. Written consent was given by 4,725 patients from 14 centers located in Italy, Russia, and Brazil between November 2009 and April 2016. The investigators recruited a total of 506 patients. All subjects included in the study underwent cardiac surgery and experienced a perioperative cardiovascular dysfunction (N Engl J Med. 2017 Mar 21. doi: 10.1056/NEJMoa1616325).

Subjects were then randomized into a cohort receiving either a placebo or a low dose of levosimendan, which varied between 0.025 to 0.2 mcg/kg of body weight per minute continuously for up to 48 hours. A total of 248 subjects received levosimendan and 258 received placebo. All patients were administered the treatment while in the ICU; patients were taken off their regimen prior to 48 hours if they were discharged from the ICU. Anyone screened for inclusion who already had experienced a negative reaction to levosimendan was excluded from the study.

“We collected preoperative data on baseline characteristics and coexisting conditions, intraoperative and postoperative treatment data, postoperative laboratory values, duration of mechanical ventilation, durations of ICU and hospital stays, and major outcomes,” the authors explained, adding that “telephone follow-up was performed at 30 days and 180 days after randomization by an investigator who was unaware of the trial group assignments.”

The primary outcome of the study was 30-day mortality. The levosimendan cohort experienced 32 deaths (12.9%), while the placebo cohort saw 33 (12.8%), a nonsignificant difference (P = .97) between the two groups. Similarly, the median time spent on mechanical ventilation was 19 hours for those on levosimendan, versus 21 hours for those on placebo (P = .48), and median length of hospital stay was 14 days in both groups (P = .39).

“Previous meta-analyses of randomized, controlled trials showed a higher rate of survival with levosimendan than with other treatment regimens among patients undergoing cardiac surgery,” Dr. Landoni and his coauthors noted. Previous studies also had a number of key differences, such as the number of subjects who underwent coronary artery bypass grafting, the dosing of levosimendan, and inclusion of patients who had reduced preoperative ejection fraction instead of ones with myocardial dysfunction who needed inotropic support, which the current study used.

The study was funded by the Italian Ministry of Health. Dr. Landoni reported receiving nonfinancial support from the Orion Corporation while the study was ongoing; several other coauthors reported similar disclosures.

[email protected]

Adding a low dose of levosimendan to the standard care for patients on perioperative hemodynamic support does not improve outcomes to any significant extent, according to the findings of a new study presented at the annual congress of the European Society of Intensive Care Medicine and published simultaneously online in the New England Journal of Medicine.

“Levosimendan (Simdax, Orion) is an inotropic agent that has been shown to be associated with a higher rate of survival than other inotropic agents in meta-analyses, especially those involving patients undergoing cardiac surgery,” wrote the authors of the study, led by Giovanni Landoni, MD, of Vita-Salute San Raffaele University in Milan, adding, “Considering the pharmacologic properties of levosimendan and the results of previous studies, we hypothesized that the administration of levosimendan, in addition to standard treatment, might result in lower mortality in this context.”

Dr. Landoni and his colleagues conducted the Levosimendan to Reduce Mortality in High Risk Cardiac Surgery Patients: A Multicenter Randomized Controlled Trial, known more commonly as CHEETAH. Written consent was given by 4,725 patients from 14 centers located in Italy, Russia, and Brazil between November 2009 and April 2016. The investigators recruited a total of 506 patients. All subjects included in the study underwent cardiac surgery and experienced a perioperative cardiovascular dysfunction (N Engl J Med. 2017 Mar 21. doi: 10.1056/NEJMoa1616325).

Subjects were then randomized into a cohort receiving either a placebo or a low dose of levosimendan, which varied between 0.025 to 0.2 mcg/kg of body weight per minute continuously for up to 48 hours. A total of 248 subjects received levosimendan and 258 received placebo. All patients were administered the treatment while in the ICU; patients were taken off their regimen prior to 48 hours if they were discharged from the ICU. Anyone screened for inclusion who already had experienced a negative reaction to levosimendan was excluded from the study.

“We collected preoperative data on baseline characteristics and coexisting conditions, intraoperative and postoperative treatment data, postoperative laboratory values, duration of mechanical ventilation, durations of ICU and hospital stays, and major outcomes,” the authors explained, adding that “telephone follow-up was performed at 30 days and 180 days after randomization by an investigator who was unaware of the trial group assignments.”

The primary outcome of the study was 30-day mortality. The levosimendan cohort experienced 32 deaths (12.9%), while the placebo cohort saw 33 (12.8%), a nonsignificant difference (P = .97) between the two groups. Similarly, the median time spent on mechanical ventilation was 19 hours for those on levosimendan, versus 21 hours for those on placebo (P = .48), and median length of hospital stay was 14 days in both groups (P = .39).

“Previous meta-analyses of randomized, controlled trials showed a higher rate of survival with levosimendan than with other treatment regimens among patients undergoing cardiac surgery,” Dr. Landoni and his coauthors noted. Previous studies also had a number of key differences, such as the number of subjects who underwent coronary artery bypass grafting, the dosing of levosimendan, and inclusion of patients who had reduced preoperative ejection fraction instead of ones with myocardial dysfunction who needed inotropic support, which the current study used.

The study was funded by the Italian Ministry of Health. Dr. Landoni reported receiving nonfinancial support from the Orion Corporation while the study was ongoing; several other coauthors reported similar disclosures.

[email protected]

Use of dexmedetomidine improved sedation among ventilated patients with sepsis, but did not significantly cut mortality rates or increase ventilator-free days in a multicenter, open-label randomized controlled trial.

Twenty-eight days after the start of mechanical ventilation, cumulative mortality rates were 23% among patients who received dexmedetomidine and 31% among those who did not (hazard ratio, 0.7; 95% confidence interval, 0.4 to 1.2; P = .2), Yu Kawazoe, MD, PhD, and his associates reported at the International Symposium on Intensive Care and Emergency Medicine. The report was simultaneously published in JAMA.

“The study may have identified a clinically important benefit of dexmedetomidine – an 8% reduction in 28-day mortality – that did not demonstrate statistical significance ... ” wrote Dr. Kawazoe of Tohoku University Graduate School of Medicine, Sendai, Japan. “Physicians may consider an 8% difference in 28-day mortality to be clinically significant, but this study was underpowered to detect this difference.”

invisioner/Thinkstock

[email protected]

Use of dexmedetomidine improved sedation among ventilated patients with sepsis, but did not significantly cut mortality rates or increase ventilator-free days in a multicenter, open-label randomized controlled trial.

Twenty-eight days after the start of mechanical ventilation, cumulative mortality rates were 23% among patients who received dexmedetomidine and 31% among those who did not (hazard ratio, 0.7; 95% confidence interval, 0.4 to 1.2; P = .2), Yu Kawazoe, MD, PhD, and his associates reported at the International Symposium on Intensive Care and Emergency Medicine. The report was simultaneously published in JAMA.

“The study may have identified a clinically important benefit of dexmedetomidine – an 8% reduction in 28-day mortality – that did not demonstrate statistical significance ... ” wrote Dr. Kawazoe of Tohoku University Graduate School of Medicine, Sendai, Japan. “Physicians may consider an 8% difference in 28-day mortality to be clinically significant, but this study was underpowered to detect this difference.”

invisioner/Thinkstock

[email protected]

Use of dexmedetomidine improved sedation among ventilated patients with sepsis, but did not significantly cut mortality rates or increase ventilator-free days in a multicenter, open-label randomized controlled trial.

Twenty-eight days after the start of mechanical ventilation, cumulative mortality rates were 23% among patients who received dexmedetomidine and 31% among those who did not (hazard ratio, 0.7; 95% confidence interval, 0.4 to 1.2; P = .2), Yu Kawazoe, MD, PhD, and his associates reported at the International Symposium on Intensive Care and Emergency Medicine. The report was simultaneously published in JAMA.

“The study may have identified a clinically important benefit of dexmedetomidine – an 8% reduction in 28-day mortality – that did not demonstrate statistical significance ... ” wrote Dr. Kawazoe of Tohoku University Graduate School of Medicine, Sendai, Japan. “Physicians may consider an 8% difference in 28-day mortality to be clinically significant, but this study was underpowered to detect this difference.”

invisioner/Thinkstock

[email protected]

The metabolic syndrome’s association with the development of osteoarthritis appears to occur primarily through the influence of factors related to body weight or body mass index, according to an analysis of data from the longitudinal Framingham osteoarthritis study.

Jingbo Niu, DSc, of the Clinical Epidemiology Research and Training Unit at Boston University, and her colleagues found that while the presence of the metabolic syndrome (MetS) and its individual components – central obesity, dyslipidemia, impaired fasting glucose, and hypertension – were associated with a risk of both radiographic osteoarthritis (ROA) and symptomatic OA (SxOA), all associations besides high blood pressure (particularly diastolic blood pressure) disappeared after they adjusted for body mass index (BMI) or body weight (Arthritis Rheumatol. 2017 Mar 3. doi: 10.1002/art.40087).

The metabolic syndrome’s association with the development of osteoarthritis appears to occur primarily through the influence of factors related to body weight or body mass index, according to an analysis of data from the longitudinal Framingham osteoarthritis study.

Jingbo Niu, DSc, of the Clinical Epidemiology Research and Training Unit at Boston University, and her colleagues found that while the presence of the metabolic syndrome (MetS) and its individual components – central obesity, dyslipidemia, impaired fasting glucose, and hypertension – were associated with a risk of both radiographic osteoarthritis (ROA) and symptomatic OA (SxOA), all associations besides high blood pressure (particularly diastolic blood pressure) disappeared after they adjusted for body mass index (BMI) or body weight (Arthritis Rheumatol. 2017 Mar 3. doi: 10.1002/art.40087).

The metabolic syndrome’s association with the development of osteoarthritis appears to occur primarily through the influence of factors related to body weight or body mass index, according to an analysis of data from the longitudinal Framingham osteoarthritis study.

Jingbo Niu, DSc, of the Clinical Epidemiology Research and Training Unit at Boston University, and her colleagues found that while the presence of the metabolic syndrome (MetS) and its individual components – central obesity, dyslipidemia, impaired fasting glucose, and hypertension – were associated with a risk of both radiographic osteoarthritis (ROA) and symptomatic OA (SxOA), all associations besides high blood pressure (particularly diastolic blood pressure) disappeared after they adjusted for body mass index (BMI) or body weight (Arthritis Rheumatol. 2017 Mar 3. doi: 10.1002/art.40087).

The words we choose to use prior to procedures can positively or negatively impact a patient’s experience during a procedure and their decision to have the procedure performed. A practical example would include using the word discomfort instead of pain to describe pain that may be associated with a procedure. The root word of discomfort is comfort, which the mind focuses on and creates less of an anxious state than pain.

Obviously, the need to provide proper and realistic expectations, as well as risks and benefits, is of utmost importance when obtaining informed consent. The words used can put a patient’s mind at ease or cause further anxiety about ideas of needles, scalpels, pain, risk of infection, and bleeding that are part of our everyday procedures.

According to the American Society of Clinical Hypnosis, physicians and dentists used the power of words through hypnosis as anesthesia before the first chemical general anesthetic agent, ether, was used for surgery in the 1840s, followed by chloroform. Prior to this time, British and Scottish physicians John Elliotson, James Esdaile, and James Braid performed over 3,000 procedures and surgeries with clinical hypnosis alone. Some may argue that the ancient Egyptians also used hypnosis for their well-described surgeries, as no other anesthetic has been documented. Moreover, there is evidence of “sleep temples” that the ancient Egyptians used for healing.¹

This article is not to suggest that our words should replace anesthesia. Many advances in anesthesia and pain control have been made since the time of chloroform. However, being mindful of our words can aid and assist in our surgical and aesthetic procedures where less anesthesia is used: Patients feel more comfortable, they heal faster, and overall, they have a more positive outcome and pleasant physician-patient experience.²

For patients, the skill of the doctor and the outcome of the procedure are of the utmost importance, but, especially in aesthetic dermatology, where some of our procedures are repeated or performed periodically, the positive impact of the entire experience will entrust them with your care long term.

Dr. Wesley and Dr. Talakoub are cocontributors to this column. Dr. Wesley practices dermatology in Beverly Hills, Calif. Dr. Talakoub is in private practice in McLean, Va. This month’s column is by Dr. Wesley. Write to them at [email protected]. They had no relevant disclosures.

References

1. Mutter, C.B. (1998). History of Hypnosis. (pp. 10-12) “Hypnotic Induction and Suggestion.” Chicago: American Society of Clinical Hypnosis.

2. Burns. 2010 Aug;36(5):639-46.
 

The words we choose to use prior to procedures can positively or negatively impact a patient’s experience during a procedure and their decision to have the procedure performed. A practical example would include using the word discomfort instead of pain to describe pain that may be associated with a procedure. The root word of discomfort is comfort, which the mind focuses on and creates less of an anxious state than pain.

Obviously, the need to provide proper and realistic expectations, as well as risks and benefits, is of utmost importance when obtaining informed consent. The words used can put a patient’s mind at ease or cause further anxiety about ideas of needles, scalpels, pain, risk of infection, and bleeding that are part of our everyday procedures.

According to the American Society of Clinical Hypnosis, physicians and dentists used the power of words through hypnosis as anesthesia before the first chemical general anesthetic agent, ether, was used for surgery in the 1840s, followed by chloroform. Prior to this time, British and Scottish physicians John Elliotson, James Esdaile, and James Braid performed over 3,000 procedures and surgeries with clinical hypnosis alone. Some may argue that the ancient Egyptians also used hypnosis for their well-described surgeries, as no other anesthetic has been documented. Moreover, there is evidence of “sleep temples” that the ancient Egyptians used for healing.¹

This article is not to suggest that our words should replace anesthesia. Many advances in anesthesia and pain control have been made since the time of chloroform. However, being mindful of our words can aid and assist in our surgical and aesthetic procedures where less anesthesia is used: Patients feel more comfortable, they heal faster, and overall, they have a more positive outcome and pleasant physician-patient experience.²

For patients, the skill of the doctor and the outcome of the procedure are of the utmost importance, but, especially in aesthetic dermatology, where some of our procedures are repeated or performed periodically, the positive impact of the entire experience will entrust them with your care long term.

Dr. Wesley and Dr. Talakoub are cocontributors to this column. Dr. Wesley practices dermatology in Beverly Hills, Calif. Dr. Talakoub is in private practice in McLean, Va. This month’s column is by Dr. Wesley. Write to them at [email protected]. They had no relevant disclosures.

References

1. Mutter, C.B. (1998). History of Hypnosis. (pp. 10-12) “Hypnotic Induction and Suggestion.” Chicago: American Society of Clinical Hypnosis.

2. Burns. 2010 Aug;36(5):639-46.
 

The words we choose to use prior to procedures can positively or negatively impact a patient’s experience during a procedure and their decision to have the procedure performed. A practical example would include using the word discomfort instead of pain to describe pain that may be associated with a procedure. The root word of discomfort is comfort, which the mind focuses on and creates less of an anxious state than pain.

Obviously, the need to provide proper and realistic expectations, as well as risks and benefits, is of utmost importance when obtaining informed consent. The words used can put a patient’s mind at ease or cause further anxiety about ideas of needles, scalpels, pain, risk of infection, and bleeding that are part of our everyday procedures.

According to the American Society of Clinical Hypnosis, physicians and dentists used the power of words through hypnosis as anesthesia before the first chemical general anesthetic agent, ether, was used for surgery in the 1840s, followed by chloroform. Prior to this time, British and Scottish physicians John Elliotson, James Esdaile, and James Braid performed over 3,000 procedures and surgeries with clinical hypnosis alone. Some may argue that the ancient Egyptians also used hypnosis for their well-described surgeries, as no other anesthetic has been documented. Moreover, there is evidence of “sleep temples” that the ancient Egyptians used for healing.¹

This article is not to suggest that our words should replace anesthesia. Many advances in anesthesia and pain control have been made since the time of chloroform. However, being mindful of our words can aid and assist in our surgical and aesthetic procedures where less anesthesia is used: Patients feel more comfortable, they heal faster, and overall, they have a more positive outcome and pleasant physician-patient experience.²

For patients, the skill of the doctor and the outcome of the procedure are of the utmost importance, but, especially in aesthetic dermatology, where some of our procedures are repeated or performed periodically, the positive impact of the entire experience will entrust them with your care long term.

Dr. Wesley and Dr. Talakoub are cocontributors to this column. Dr. Wesley practices dermatology in Beverly Hills, Calif. Dr. Talakoub is in private practice in McLean, Va. This month’s column is by Dr. Wesley. Write to them at [email protected]. They had no relevant disclosures.

References

1. Mutter, C.B. (1998). History of Hypnosis. (pp. 10-12) “Hypnotic Induction and Suggestion.” Chicago: American Society of Clinical Hypnosis.

2. Burns. 2010 Aug;36(5):639-46.