Many antimicrobial stewards, such as infection prevention specialists, hospital epidemiologists, pharmacists, nurses, and hospitalists, are at the center of quality improvement and seek to achieve optimal clinical outcomes related to antimicrobial use.4 These antimicrobial stewards often strive to minimize harms and other adverse events, reduce the costs of healthcare for infections, and decrease the threat of antimicrobial resistance.3

Hospitalists play a critical role in quality improvement and directly influence inpatient outcomes daily. It’s essential that hospitalists continue to make patient safety and quality care a priority while employing a multidisciplinary approach in implementing antimicrobial stewardship best practices. Although antimicrobial stewardship programs have typically been led by infectious disease physicians and pharmacists, SHM recognizes the significant value of hospitalist leadership and/or participation.5 Although most hospitalists are familiar with the adverse effects of overprescribing antibiotics, their insight and collaboration with other hospital clinicians is necessary in order to Fight the Resistance.

Fight the Resistance, a new behavior change campaign from SHM and our Center for Hospital Innovation and Improvement, is intended to encourage appropriate prescribing and use of antibiotics in the hospital. The campaign’s primary objective is to change prescribing behaviors among hospitalists and other hospital clinicians and facilitate behavior change related to antibiotic prescribing.

The campaign officially launched on Nov. 10, 2015, with a kickoff webinar presented by Scott Flanders, MD, FACP, MHM, and Melhim Bou Alwan, MD. Dr. Flanders discussed the importance of hospitalist involvement in antimicrobial stewardship and the significance of working in multidisciplinary teams in order to reduce overprescribing and the threat of antibiotic resistance.

Dr. Bou Alwan explained SHM’s efforts to fight antimicrobial resistance and informed the audience of SHM’s commitment to antibiotic stewardship. The webinar launch was a huge success, and SHM is excited to continue fighting the resistance with physicians across the country.

In order to Fight the Resistance, SHM is asking hospitalists to commit to the following actions:

• Work with your team. Physicians, nurse practitioners, physician assistants, pharmacists, and infectious disease experts need to work together to ensure that antibiotics are used appropriately. Consider the patients part of your team, too, by discussing with them why antibiotics may not be the best choice of treatment.
• Pay attention to appropriate antibiotic choice and resistance patterns, and identify mechanisms that can be used to educate providers about overprescribing in your hospital.
• Rethink your antibiotic treatment time course. Be sure to adhere to your hospital’s antibiotic treatment guidelines, track use of antibiotics, and set a stop date from when you first prescribe them.

SHM believes changing antibiotic prescription behaviors is a team effort and encourages hospitalists to get involved by visiting www.fighttheresistance.org. There you can find Fight the Resistance themed posters, resources, and educational materials to encourage enhanced stewardship and teamwork in your hospital. TH

Mobola Owolabi is senior project manager for The Center for Hospital Innovation and Improvement

References

1. The White House. Office of the Press Secretary. FACT SHEET: Obama Administration releases national action plan to combat antibiotic-resistant bacteria. March 27, 2015. Available at: https://www.whitehouse.gov/the-press-office/2015/03/27/fact-sheet-obama-administration-releases-national-action-plan-combat-ant. Accessed December 3, 2015.
2. CDC. Federal engagement in antimicrobial resistance. June 2015. Available at: http://www.cdc.gov/drugresistance/federal-engagement-in-ar/index.html. Accessed December 3, 2015.
3. Infectious Diseases Society of America. Promoting antimicrobial stewardship in human medicine. 2015. Available at: http://www.idsociety.org/Stewardship_Policy/. Accessed December 3, 2015.
4. CDC. Core elements of hospital antibiotic stewardship programs. 2015. Available at: http://www.cdc.gov/getsmart/healthcare/implementation/core-elements.html. Accessed December 3, 2015.
5. Rohde JM, Jacobsen D, Rosenberg DJ. Role of the hospitalist in antimicrobial stewardship: a review of work completed and description of a multisite collaborative. Clin Ther. 2013; 35(6):751-757.

Many antimicrobial stewards, such as infection prevention specialists, hospital epidemiologists, pharmacists, nurses, and hospitalists, are at the center of quality improvement and seek to achieve optimal clinical outcomes related to antimicrobial use.4 These antimicrobial stewards often strive to minimize harms and other adverse events, reduce the costs of healthcare for infections, and decrease the threat of antimicrobial resistance.3

Hospitalists play a critical role in quality improvement and directly influence inpatient outcomes daily. It’s essential that hospitalists continue to make patient safety and quality care a priority while employing a multidisciplinary approach in implementing antimicrobial stewardship best practices. Although antimicrobial stewardship programs have typically been led by infectious disease physicians and pharmacists, SHM recognizes the significant value of hospitalist leadership and/or participation.5 Although most hospitalists are familiar with the adverse effects of overprescribing antibiotics, their insight and collaboration with other hospital clinicians is necessary in order to Fight the Resistance.

Fight the Resistance, a new behavior change campaign from SHM and our Center for Hospital Innovation and Improvement, is intended to encourage appropriate prescribing and use of antibiotics in the hospital. The campaign’s primary objective is to change prescribing behaviors among hospitalists and other hospital clinicians and facilitate behavior change related to antibiotic prescribing.

The campaign officially launched on Nov. 10, 2015, with a kickoff webinar presented by Scott Flanders, MD, FACP, MHM, and Melhim Bou Alwan, MD. Dr. Flanders discussed the importance of hospitalist involvement in antimicrobial stewardship and the significance of working in multidisciplinary teams in order to reduce overprescribing and the threat of antibiotic resistance.

Dr. Bou Alwan explained SHM’s efforts to fight antimicrobial resistance and informed the audience of SHM’s commitment to antibiotic stewardship. The webinar launch was a huge success, and SHM is excited to continue fighting the resistance with physicians across the country.

In order to Fight the Resistance, SHM is asking hospitalists to commit to the following actions:

• Work with your team. Physicians, nurse practitioners, physician assistants, pharmacists, and infectious disease experts need to work together to ensure that antibiotics are used appropriately. Consider the patients part of your team, too, by discussing with them why antibiotics may not be the best choice of treatment.
• Pay attention to appropriate antibiotic choice and resistance patterns, and identify mechanisms that can be used to educate providers about overprescribing in your hospital.
• Rethink your antibiotic treatment time course. Be sure to adhere to your hospital’s antibiotic treatment guidelines, track use of antibiotics, and set a stop date from when you first prescribe them.

SHM believes changing antibiotic prescription behaviors is a team effort and encourages hospitalists to get involved by visiting www.fighttheresistance.org. There you can find Fight the Resistance themed posters, resources, and educational materials to encourage enhanced stewardship and teamwork in your hospital. TH

Mobola Owolabi is senior project manager for The Center for Hospital Innovation and Improvement

References

1. The White House. Office of the Press Secretary. FACT SHEET: Obama Administration releases national action plan to combat antibiotic-resistant bacteria. March 27, 2015. Available at: https://www.whitehouse.gov/the-press-office/2015/03/27/fact-sheet-obama-administration-releases-national-action-plan-combat-ant. Accessed December 3, 2015.
2. CDC. Federal engagement in antimicrobial resistance. June 2015. Available at: http://www.cdc.gov/drugresistance/federal-engagement-in-ar/index.html. Accessed December 3, 2015.
3. Infectious Diseases Society of America. Promoting antimicrobial stewardship in human medicine. 2015. Available at: http://www.idsociety.org/Stewardship_Policy/. Accessed December 3, 2015.
4. CDC. Core elements of hospital antibiotic stewardship programs. 2015. Available at: http://www.cdc.gov/getsmart/healthcare/implementation/core-elements.html. Accessed December 3, 2015.
5. Rohde JM, Jacobsen D, Rosenberg DJ. Role of the hospitalist in antimicrobial stewardship: a review of work completed and description of a multisite collaborative. Clin Ther. 2013; 35(6):751-757.

Many antimicrobial stewards, such as infection prevention specialists, hospital epidemiologists, pharmacists, nurses, and hospitalists, are at the center of quality improvement and seek to achieve optimal clinical outcomes related to antimicrobial use.4 These antimicrobial stewards often strive to minimize harms and other adverse events, reduce the costs of healthcare for infections, and decrease the threat of antimicrobial resistance.3

Hospitalists play a critical role in quality improvement and directly influence inpatient outcomes daily. It’s essential that hospitalists continue to make patient safety and quality care a priority while employing a multidisciplinary approach in implementing antimicrobial stewardship best practices. Although antimicrobial stewardship programs have typically been led by infectious disease physicians and pharmacists, SHM recognizes the significant value of hospitalist leadership and/or participation.5 Although most hospitalists are familiar with the adverse effects of overprescribing antibiotics, their insight and collaboration with other hospital clinicians is necessary in order to Fight the Resistance.

Fight the Resistance, a new behavior change campaign from SHM and our Center for Hospital Innovation and Improvement, is intended to encourage appropriate prescribing and use of antibiotics in the hospital. The campaign’s primary objective is to change prescribing behaviors among hospitalists and other hospital clinicians and facilitate behavior change related to antibiotic prescribing.

The campaign officially launched on Nov. 10, 2015, with a kickoff webinar presented by Scott Flanders, MD, FACP, MHM, and Melhim Bou Alwan, MD. Dr. Flanders discussed the importance of hospitalist involvement in antimicrobial stewardship and the significance of working in multidisciplinary teams in order to reduce overprescribing and the threat of antibiotic resistance.

Dr. Bou Alwan explained SHM’s efforts to fight antimicrobial resistance and informed the audience of SHM’s commitment to antibiotic stewardship. The webinar launch was a huge success, and SHM is excited to continue fighting the resistance with physicians across the country.

In order to Fight the Resistance, SHM is asking hospitalists to commit to the following actions:

• Work with your team. Physicians, nurse practitioners, physician assistants, pharmacists, and infectious disease experts need to work together to ensure that antibiotics are used appropriately. Consider the patients part of your team, too, by discussing with them why antibiotics may not be the best choice of treatment.
• Pay attention to appropriate antibiotic choice and resistance patterns, and identify mechanisms that can be used to educate providers about overprescribing in your hospital.
• Rethink your antibiotic treatment time course. Be sure to adhere to your hospital’s antibiotic treatment guidelines, track use of antibiotics, and set a stop date from when you first prescribe them.

SHM believes changing antibiotic prescription behaviors is a team effort and encourages hospitalists to get involved by visiting www.fighttheresistance.org. There you can find Fight the Resistance themed posters, resources, and educational materials to encourage enhanced stewardship and teamwork in your hospital. TH

Mobola Owolabi is senior project manager for The Center for Hospital Innovation and Improvement

References

1. The White House. Office of the Press Secretary. FACT SHEET: Obama Administration releases national action plan to combat antibiotic-resistant bacteria. March 27, 2015. Available at: https://www.whitehouse.gov/the-press-office/2015/03/27/fact-sheet-obama-administration-releases-national-action-plan-combat-ant. Accessed December 3, 2015.
2. CDC. Federal engagement in antimicrobial resistance. June 2015. Available at: http://www.cdc.gov/drugresistance/federal-engagement-in-ar/index.html. Accessed December 3, 2015.
3. Infectious Diseases Society of America. Promoting antimicrobial stewardship in human medicine. 2015. Available at: http://www.idsociety.org/Stewardship_Policy/. Accessed December 3, 2015.
4. CDC. Core elements of hospital antibiotic stewardship programs. 2015. Available at: http://www.cdc.gov/getsmart/healthcare/implementation/core-elements.html. Accessed December 3, 2015.
5. Rohde JM, Jacobsen D, Rosenberg DJ. Role of the hospitalist in antimicrobial stewardship: a review of work completed and description of a multisite collaborative. Clin Ther. 2013; 35(6):751-757.

Doctor and cancer patient

Photo courtesy of the

National Cancer Institute

and Mathews Media Group

End-of-life (EOL) discussions often occur “too late” for patients with hematologic malignancies, according to a survey of US hematologists.

The researchers who conducted the survey speculate that physicians may delay EOL discussions with these patients because, unlike most solid tumors,

which are incurable when they reach an advanced stage, many advanced hematologic malignancies remain curable.

So it may not be clear that a patient has entered the EOL phase.

Oreofe O. Odejide, MD, of the Dana-Farber Cancer Institute in Boston, Massachusetts, and colleagues conducted the survey and reported the results in a letter to JAMA Internal Medicine.

The researchers mailed their survey on EOL discussions to US hematologists found in the clinical directory of the American Society of Hematology. The individuals surveyed provide direct care for adults with hematologic malignancies.

Three hundred and forty-nine hematologists completed the survey. Most were men (75.4%), and they had a median age of 52. More than half (55.4%) practiced in community centers, and 42.9% practiced primarily in tertiary centers.

Three hundred and forty-five individuals answered the question about typical timing of EOL discussions, and 55.9% said these discussions occur too late.

Hematologists practicing in tertiary centers were more likely to report late EOL discussions than those practicing in community centers—64.9% and 48.7%, respectively (P=0.003). This difference was still significant in multivariable analysis, with an odds ratio of 1.92 (P=0.004).

When it comes to specific aspects of EOL care, 42.5% of the hematologists reported conducting their first conversation about resuscitation status at less than optimal times; 23.2% reported waiting until death was clearly imminent before having an initial conversation about hospice care; and 39.9% reported waiting until death was clearly imminent before having an initial conversation about the preferred site of death.

The researchers said the lack of a clear distinction between the curative and EOL phases of hematologic malignancies may explain these findings. Additionally, physicians may hesitate to have EOL discussions because they don’t want to affect a patient’s mentality or because they themselves find it difficult to “give up” on patients who might still be cured.

Doctor and cancer patient

Photo courtesy of the

National Cancer Institute

and Mathews Media Group

End-of-life (EOL) discussions often occur “too late” for patients with hematologic malignancies, according to a survey of US hematologists.

The researchers who conducted the survey speculate that physicians may delay EOL discussions with these patients because, unlike most solid tumors,

which are incurable when they reach an advanced stage, many advanced hematologic malignancies remain curable.

So it may not be clear that a patient has entered the EOL phase.

Oreofe O. Odejide, MD, of the Dana-Farber Cancer Institute in Boston, Massachusetts, and colleagues conducted the survey and reported the results in a letter to JAMA Internal Medicine.

The researchers mailed their survey on EOL discussions to US hematologists found in the clinical directory of the American Society of Hematology. The individuals surveyed provide direct care for adults with hematologic malignancies.

Three hundred and forty-nine hematologists completed the survey. Most were men (75.4%), and they had a median age of 52. More than half (55.4%) practiced in community centers, and 42.9% practiced primarily in tertiary centers.

Three hundred and forty-five individuals answered the question about typical timing of EOL discussions, and 55.9% said these discussions occur too late.

Hematologists practicing in tertiary centers were more likely to report late EOL discussions than those practicing in community centers—64.9% and 48.7%, respectively (P=0.003). This difference was still significant in multivariable analysis, with an odds ratio of 1.92 (P=0.004).

When it comes to specific aspects of EOL care, 42.5% of the hematologists reported conducting their first conversation about resuscitation status at less than optimal times; 23.2% reported waiting until death was clearly imminent before having an initial conversation about hospice care; and 39.9% reported waiting until death was clearly imminent before having an initial conversation about the preferred site of death.

The researchers said the lack of a clear distinction between the curative and EOL phases of hematologic malignancies may explain these findings. Additionally, physicians may hesitate to have EOL discussions because they don’t want to affect a patient’s mentality or because they themselves find it difficult to “give up” on patients who might still be cured.

Doctor and cancer patient

Photo courtesy of the

National Cancer Institute

and Mathews Media Group

End-of-life (EOL) discussions often occur “too late” for patients with hematologic malignancies, according to a survey of US hematologists.

The researchers who conducted the survey speculate that physicians may delay EOL discussions with these patients because, unlike most solid tumors,

which are incurable when they reach an advanced stage, many advanced hematologic malignancies remain curable.

So it may not be clear that a patient has entered the EOL phase.

Oreofe O. Odejide, MD, of the Dana-Farber Cancer Institute in Boston, Massachusetts, and colleagues conducted the survey and reported the results in a letter to JAMA Internal Medicine.

The researchers mailed their survey on EOL discussions to US hematologists found in the clinical directory of the American Society of Hematology. The individuals surveyed provide direct care for adults with hematologic malignancies.

Three hundred and forty-nine hematologists completed the survey. Most were men (75.4%), and they had a median age of 52. More than half (55.4%) practiced in community centers, and 42.9% practiced primarily in tertiary centers.

Three hundred and forty-five individuals answered the question about typical timing of EOL discussions, and 55.9% said these discussions occur too late.

Hematologists practicing in tertiary centers were more likely to report late EOL discussions than those practicing in community centers—64.9% and 48.7%, respectively (P=0.003). This difference was still significant in multivariable analysis, with an odds ratio of 1.92 (P=0.004).

When it comes to specific aspects of EOL care, 42.5% of the hematologists reported conducting their first conversation about resuscitation status at less than optimal times; 23.2% reported waiting until death was clearly imminent before having an initial conversation about hospice care; and 39.9% reported waiting until death was clearly imminent before having an initial conversation about the preferred site of death.

The researchers said the lack of a clear distinction between the curative and EOL phases of hematologic malignancies may explain these findings. Additionally, physicians may hesitate to have EOL discussions because they don’t want to affect a patient’s mentality or because they themselves find it difficult to “give up” on patients who might still be cured.

Blood donation

Photo by Михаило Јовановић

The US Food and Drug Administration (FDA) has issued a final guidance outlining updated blood donor deferral recommendations.

As part of the guidance, the FDA is changing its recommendation that men who have sex with men (MSM) be indefinitely deferred from donating blood—a policy that has been in place for approximately 30 years.

Now, the agency is recommending that MSMs be deferred for 12 months since their last sexual contact with another man.

The FDA’s guidance also reflects a change in the rationale for deferring potential blood donors with hemophilia or related clotting disorders who have received clotting factor concentrates.

The FDA recommends that blood establishments make corresponding revisions to donor educational materials, donor history questionnaires, and accompanying materials, as well as donor requalification and product management procedures.

MSM deferral

The FDA said its recommendation regarding MSM blood donors reflects the most current scientific evidence and will help ensure continued safety of the blood supply by reducing the risk of human immunodeficiency virus (HIV) transmission by blood and blood products.

The agency also said this recommendation better aligns the deferral period for MSMs with the deferral period for other men and women at increased risk for HIV infection, such as those who had a recent blood transfusion or those who have been accidentally exposed to the blood of another individual.

Before issuing this guidance, the FDA reviewed its policies regarding HIV transmission through blood products to determine appropriate changes based on the most recent scientific evidence. The agency examined a variety of studies, epidemiologic data, and shared experiences from other countries that have made recent MSM deferral policy changes.

“In reviewing our policies to help reduce the risk of HIV transmission through blood products, we rigorously examined several alternative options, including individual risk assessment,” said Peter Marks, MD, PhD, deputy director of the FDA’s Center for Biologics Evaluation and Research.

“Ultimately, the 12-month deferral window is supported by the best available scientific evidence, at this point in time, relevant to the US population. We will continue to actively conduct research in this area and further revise our policies as new data emerge.”

Several countries, including the UK and Australia, currently have 12-month deferral policies for MSM blood donors.

During the change in Australia from an indefinite blood donor deferral policy for MSMs to a 12-month deferral, studies evaluating over 8 million units of donated blood were performed using a national blood surveillance system. These studies (CR Seed et al, Transfusion 2010; TTA Lucky et al, Transfusion 2014) show no change in risk to the blood supply with use of the 12-month deferral.

A study conducted in the UK produced similar results, although it also suggested that 3 in 10 MSMs don’t comply with the 12-month deferral policy.

And a study conducted in Canada, which recently shortened its MSM deferral period to 5 years, showed no change in risk to the blood supply with the 5-year deferral as compared to indefinite deferral. Based on these results, Canadian regulators are considering changing to a 12-month deferral period as well.

Patients with clotting disorders

The FDA’s new guidance also reflects a change in the rationale for deferring patients with hemophilia or related clotting disorders who have received clotting factor concentrates. Previously, potential donors with hemophilia or related clotting disorders were deferred due to the increased risk of HIV transmission to potential recipients.

Based on new scientific evidence, these potential donors are still deferred, but not due to the risk of HIV transmission—instead, for their own protection due to potential harm from large needles used during the donation process.

FDA policies and actions

Throughout the process of updating blood donor deferral policies over the past several years, the FDA has worked with other government agencies, considered input from external advisory committees, reviewed comments from stakeholders to its May 2015 draft guidance, and examined the most recent available scientific evidence to support the current policy revision.

The FDA has also implemented a nationally representative safety monitoring system for the blood supply with assistance from the National Heart, Lung and Blood Institute at the National Institutes of Health. This system will provide information to help inform future actions the FDA may take on blood donor policies.

The FDA said it will continue to reevaluate and update its blood donor deferral policies as new scientific information becomes available.

Blood donation

Photo by Михаило Јовановић

The US Food and Drug Administration (FDA) has issued a final guidance outlining updated blood donor deferral recommendations.

As part of the guidance, the FDA is changing its recommendation that men who have sex with men (MSM) be indefinitely deferred from donating blood—a policy that has been in place for approximately 30 years.

Now, the agency is recommending that MSMs be deferred for 12 months since their last sexual contact with another man.

The FDA’s guidance also reflects a change in the rationale for deferring potential blood donors with hemophilia or related clotting disorders who have received clotting factor concentrates.

The FDA recommends that blood establishments make corresponding revisions to donor educational materials, donor history questionnaires, and accompanying materials, as well as donor requalification and product management procedures.

MSM deferral

The FDA said its recommendation regarding MSM blood donors reflects the most current scientific evidence and will help ensure continued safety of the blood supply by reducing the risk of human immunodeficiency virus (HIV) transmission by blood and blood products.

The agency also said this recommendation better aligns the deferral period for MSMs with the deferral period for other men and women at increased risk for HIV infection, such as those who had a recent blood transfusion or those who have been accidentally exposed to the blood of another individual.

Before issuing this guidance, the FDA reviewed its policies regarding HIV transmission through blood products to determine appropriate changes based on the most recent scientific evidence. The agency examined a variety of studies, epidemiologic data, and shared experiences from other countries that have made recent MSM deferral policy changes.

“In reviewing our policies to help reduce the risk of HIV transmission through blood products, we rigorously examined several alternative options, including individual risk assessment,” said Peter Marks, MD, PhD, deputy director of the FDA’s Center for Biologics Evaluation and Research.

“Ultimately, the 12-month deferral window is supported by the best available scientific evidence, at this point in time, relevant to the US population. We will continue to actively conduct research in this area and further revise our policies as new data emerge.”

Several countries, including the UK and Australia, currently have 12-month deferral policies for MSM blood donors.

During the change in Australia from an indefinite blood donor deferral policy for MSMs to a 12-month deferral, studies evaluating over 8 million units of donated blood were performed using a national blood surveillance system. These studies (CR Seed et al, Transfusion 2010; TTA Lucky et al, Transfusion 2014) show no change in risk to the blood supply with use of the 12-month deferral.

A study conducted in the UK produced similar results, although it also suggested that 3 in 10 MSMs don’t comply with the 12-month deferral policy.

And a study conducted in Canada, which recently shortened its MSM deferral period to 5 years, showed no change in risk to the blood supply with the 5-year deferral as compared to indefinite deferral. Based on these results, Canadian regulators are considering changing to a 12-month deferral period as well.

Patients with clotting disorders

The FDA’s new guidance also reflects a change in the rationale for deferring patients with hemophilia or related clotting disorders who have received clotting factor concentrates. Previously, potential donors with hemophilia or related clotting disorders were deferred due to the increased risk of HIV transmission to potential recipients.

Based on new scientific evidence, these potential donors are still deferred, but not due to the risk of HIV transmission—instead, for their own protection due to potential harm from large needles used during the donation process.

FDA policies and actions

Throughout the process of updating blood donor deferral policies over the past several years, the FDA has worked with other government agencies, considered input from external advisory committees, reviewed comments from stakeholders to its May 2015 draft guidance, and examined the most recent available scientific evidence to support the current policy revision.

The FDA has also implemented a nationally representative safety monitoring system for the blood supply with assistance from the National Heart, Lung and Blood Institute at the National Institutes of Health. This system will provide information to help inform future actions the FDA may take on blood donor policies.

The FDA said it will continue to reevaluate and update its blood donor deferral policies as new scientific information becomes available.

Blood donation

Photo by Михаило Јовановић

The US Food and Drug Administration (FDA) has issued a final guidance outlining updated blood donor deferral recommendations.

As part of the guidance, the FDA is changing its recommendation that men who have sex with men (MSM) be indefinitely deferred from donating blood—a policy that has been in place for approximately 30 years.

Now, the agency is recommending that MSMs be deferred for 12 months since their last sexual contact with another man.

The FDA’s guidance also reflects a change in the rationale for deferring potential blood donors with hemophilia or related clotting disorders who have received clotting factor concentrates.

The FDA recommends that blood establishments make corresponding revisions to donor educational materials, donor history questionnaires, and accompanying materials, as well as donor requalification and product management procedures.

MSM deferral

The FDA said its recommendation regarding MSM blood donors reflects the most current scientific evidence and will help ensure continued safety of the blood supply by reducing the risk of human immunodeficiency virus (HIV) transmission by blood and blood products.

The agency also said this recommendation better aligns the deferral period for MSMs with the deferral period for other men and women at increased risk for HIV infection, such as those who had a recent blood transfusion or those who have been accidentally exposed to the blood of another individual.

Before issuing this guidance, the FDA reviewed its policies regarding HIV transmission through blood products to determine appropriate changes based on the most recent scientific evidence. The agency examined a variety of studies, epidemiologic data, and shared experiences from other countries that have made recent MSM deferral policy changes.

“In reviewing our policies to help reduce the risk of HIV transmission through blood products, we rigorously examined several alternative options, including individual risk assessment,” said Peter Marks, MD, PhD, deputy director of the FDA’s Center for Biologics Evaluation and Research.

“Ultimately, the 12-month deferral window is supported by the best available scientific evidence, at this point in time, relevant to the US population. We will continue to actively conduct research in this area and further revise our policies as new data emerge.”

Several countries, including the UK and Australia, currently have 12-month deferral policies for MSM blood donors.

During the change in Australia from an indefinite blood donor deferral policy for MSMs to a 12-month deferral, studies evaluating over 8 million units of donated blood were performed using a national blood surveillance system. These studies (CR Seed et al, Transfusion 2010; TTA Lucky et al, Transfusion 2014) show no change in risk to the blood supply with use of the 12-month deferral.

A study conducted in the UK produced similar results, although it also suggested that 3 in 10 MSMs don’t comply with the 12-month deferral policy.

And a study conducted in Canada, which recently shortened its MSM deferral period to 5 years, showed no change in risk to the blood supply with the 5-year deferral as compared to indefinite deferral. Based on these results, Canadian regulators are considering changing to a 12-month deferral period as well.

Patients with clotting disorders

The FDA’s new guidance also reflects a change in the rationale for deferring patients with hemophilia or related clotting disorders who have received clotting factor concentrates. Previously, potential donors with hemophilia or related clotting disorders were deferred due to the increased risk of HIV transmission to potential recipients.

Based on new scientific evidence, these potential donors are still deferred, but not due to the risk of HIV transmission—instead, for their own protection due to potential harm from large needles used during the donation process.

FDA policies and actions

Throughout the process of updating blood donor deferral policies over the past several years, the FDA has worked with other government agencies, considered input from external advisory committees, reviewed comments from stakeholders to its May 2015 draft guidance, and examined the most recent available scientific evidence to support the current policy revision.

The FDA has also implemented a nationally representative safety monitoring system for the blood supply with assistance from the National Heart, Lung and Blood Institute at the National Institutes of Health. This system will provide information to help inform future actions the FDA may take on blood donor policies.

The FDA said it will continue to reevaluate and update its blood donor deferral policies as new scientific information becomes available.

Micrograph showing CLL

Preclinical research suggests a humanized monoclonal antibody called cirmtuzumab (UC-961) might be an effective treatment for chronic lymphocytic leukemia (CLL).

Experiments revealed that the Wnt5a protein acts on the tumor-surface proteins ROR1 and ROR2 to accelerate the proliferation and spread of CLL cells.

But cirmtuzumab, which is specific for ROR1, can block the effects of Wnt5a and inhibit the growth and spread of CLL cells both in vitro and in vivo.

Investigators reported these results in The Journal of Clinical Investigation.

They noted that ROR1 and ROR2 are considered orphan receptors, which are expressed primarily during embryonic development. The expression of these proteins, particularly ROR1, becomes suppressed during fetal development and is negligible on normal adult tissues. However, CLL and many solid tissue cancers re-express these orphan receptors.

“Our findings show that ROR1 and ROR2 team up to stimulate tumor cell growth and metastasis in response to Wnt5a, which appears overexpressed in patients with CLL and can act as a survival/growth factor for leukemia cells,” said study author Thomas J. Kipps, MD, PhD, of Moores Cancer Center at the University of California, San Diego.

“By blocking the capacity of Wnt5a to stimulate tumor cells, cirmtuzumab can inhibit the growth and spread of cancer cells. We now have better insight into how cirmtuzumab works against leukemia cells. This should help find better ways to treat patients who have other cancers with cirmtuzumab, which currently is being evaluated in a phase 1 clinical trial for patients with CLL.”

The JCI paper follows a series of related findings by Dr Kipps and his colleagues in recent years.

In 2008, they reported that patients vaccinated with their own CLL cells could make antibodies against ROR1, some of which had the ability to reduce CLL cell survival. They found ROR1 on CLL cells but not on all normal adult tissues examined.

In 2012, the investigators reported finding ROR1 on many different types of cancer, particularly cancers that appear less differentiated and more likely to spread to other parts in the body. Because this protein was not found on normal adult tissues, these findings made ROR1 a new target for anticancer drug research.

In June 2013, the team linked ROR1 to a process used in early development, suggesting cancer cells hijack an embryological process called epithelial-mesenchymal transition to spread or metastasize more quickly.

In January 2014, the investigators reported expression of ROR1 resulted in a faster-developing, more aggressive form of CLL in mice.

In September 2014, the team launched a phase 1 trial of cirmtuzumab in patients with CLL. The trial is ongoing.

In November 2014, the investigators described cellular experiments indicating that cirmtuzumab might be effective against cancer stem cells, which appear responsible for the relapse and spread of cancer after conventional therapy.

The latest research more precisely defines the roles of ROR1 and ROR2 in CLL development.

Both are evolutionarily conserved proteins that are found in many species and are most active in the early stages of embryogenesis when cells are migrating to form organs and parts of the body. The lack of either during this process results in severe developmental abnormalities.

Low levels of ROR2 remain in some adult tissues, but ROR1 is found only in cancer cells. The investigators found that, in response to signaling by Wnt5a, ROR1 and ROR2 come together to signal the growth and migration of CLL cells.

But treating mice with cirmtuzumab disrupted the process, inhibiting the engraftment of CLL cells and slowing or stopping the disease from spreading.

Micrograph showing CLL

Preclinical research suggests a humanized monoclonal antibody called cirmtuzumab (UC-961) might be an effective treatment for chronic lymphocytic leukemia (CLL).

Experiments revealed that the Wnt5a protein acts on the tumor-surface proteins ROR1 and ROR2 to accelerate the proliferation and spread of CLL cells.

But cirmtuzumab, which is specific for ROR1, can block the effects of Wnt5a and inhibit the growth and spread of CLL cells both in vitro and in vivo.

Investigators reported these results in The Journal of Clinical Investigation.

They noted that ROR1 and ROR2 are considered orphan receptors, which are expressed primarily during embryonic development. The expression of these proteins, particularly ROR1, becomes suppressed during fetal development and is negligible on normal adult tissues. However, CLL and many solid tissue cancers re-express these orphan receptors.

“Our findings show that ROR1 and ROR2 team up to stimulate tumor cell growth and metastasis in response to Wnt5a, which appears overexpressed in patients with CLL and can act as a survival/growth factor for leukemia cells,” said study author Thomas J. Kipps, MD, PhD, of Moores Cancer Center at the University of California, San Diego.

“By blocking the capacity of Wnt5a to stimulate tumor cells, cirmtuzumab can inhibit the growth and spread of cancer cells. We now have better insight into how cirmtuzumab works against leukemia cells. This should help find better ways to treat patients who have other cancers with cirmtuzumab, which currently is being evaluated in a phase 1 clinical trial for patients with CLL.”

The JCI paper follows a series of related findings by Dr Kipps and his colleagues in recent years.

In 2008, they reported that patients vaccinated with their own CLL cells could make antibodies against ROR1, some of which had the ability to reduce CLL cell survival. They found ROR1 on CLL cells but not on all normal adult tissues examined.

In 2012, the investigators reported finding ROR1 on many different types of cancer, particularly cancers that appear less differentiated and more likely to spread to other parts in the body. Because this protein was not found on normal adult tissues, these findings made ROR1 a new target for anticancer drug research.

In June 2013, the team linked ROR1 to a process used in early development, suggesting cancer cells hijack an embryological process called epithelial-mesenchymal transition to spread or metastasize more quickly.

In January 2014, the investigators reported expression of ROR1 resulted in a faster-developing, more aggressive form of CLL in mice.

In September 2014, the team launched a phase 1 trial of cirmtuzumab in patients with CLL. The trial is ongoing.

In November 2014, the investigators described cellular experiments indicating that cirmtuzumab might be effective against cancer stem cells, which appear responsible for the relapse and spread of cancer after conventional therapy.

The latest research more precisely defines the roles of ROR1 and ROR2 in CLL development.

Both are evolutionarily conserved proteins that are found in many species and are most active in the early stages of embryogenesis when cells are migrating to form organs and parts of the body. The lack of either during this process results in severe developmental abnormalities.

Low levels of ROR2 remain in some adult tissues, but ROR1 is found only in cancer cells. The investigators found that, in response to signaling by Wnt5a, ROR1 and ROR2 come together to signal the growth and migration of CLL cells.

But treating mice with cirmtuzumab disrupted the process, inhibiting the engraftment of CLL cells and slowing or stopping the disease from spreading.

Micrograph showing CLL

Preclinical research suggests a humanized monoclonal antibody called cirmtuzumab (UC-961) might be an effective treatment for chronic lymphocytic leukemia (CLL).

Experiments revealed that the Wnt5a protein acts on the tumor-surface proteins ROR1 and ROR2 to accelerate the proliferation and spread of CLL cells.

But cirmtuzumab, which is specific for ROR1, can block the effects of Wnt5a and inhibit the growth and spread of CLL cells both in vitro and in vivo.

Investigators reported these results in The Journal of Clinical Investigation.

They noted that ROR1 and ROR2 are considered orphan receptors, which are expressed primarily during embryonic development. The expression of these proteins, particularly ROR1, becomes suppressed during fetal development and is negligible on normal adult tissues. However, CLL and many solid tissue cancers re-express these orphan receptors.

“Our findings show that ROR1 and ROR2 team up to stimulate tumor cell growth and metastasis in response to Wnt5a, which appears overexpressed in patients with CLL and can act as a survival/growth factor for leukemia cells,” said study author Thomas J. Kipps, MD, PhD, of Moores Cancer Center at the University of California, San Diego.

“By blocking the capacity of Wnt5a to stimulate tumor cells, cirmtuzumab can inhibit the growth and spread of cancer cells. We now have better insight into how cirmtuzumab works against leukemia cells. This should help find better ways to treat patients who have other cancers with cirmtuzumab, which currently is being evaluated in a phase 1 clinical trial for patients with CLL.”

The JCI paper follows a series of related findings by Dr Kipps and his colleagues in recent years.

In 2008, they reported that patients vaccinated with their own CLL cells could make antibodies against ROR1, some of which had the ability to reduce CLL cell survival. They found ROR1 on CLL cells but not on all normal adult tissues examined.

In 2012, the investigators reported finding ROR1 on many different types of cancer, particularly cancers that appear less differentiated and more likely to spread to other parts in the body. Because this protein was not found on normal adult tissues, these findings made ROR1 a new target for anticancer drug research.

In June 2013, the team linked ROR1 to a process used in early development, suggesting cancer cells hijack an embryological process called epithelial-mesenchymal transition to spread or metastasize more quickly.

In January 2014, the investigators reported expression of ROR1 resulted in a faster-developing, more aggressive form of CLL in mice.

In September 2014, the team launched a phase 1 trial of cirmtuzumab in patients with CLL. The trial is ongoing.

In November 2014, the investigators described cellular experiments indicating that cirmtuzumab might be effective against cancer stem cells, which appear responsible for the relapse and spread of cancer after conventional therapy.

The latest research more precisely defines the roles of ROR1 and ROR2 in CLL development.

Both are evolutionarily conserved proteins that are found in many species and are most active in the early stages of embryogenesis when cells are migrating to form organs and parts of the body. The lack of either during this process results in severe developmental abnormalities.

Low levels of ROR2 remain in some adult tissues, but ROR1 is found only in cancer cells. The investigators found that, in response to signaling by Wnt5a, ROR1 and ROR2 come together to signal the growth and migration of CLL cells.

But treating mice with cirmtuzumab disrupted the process, inhibiting the engraftment of CLL cells and slowing or stopping the disease from spreading.

Red blood cells

A population-based study conducted in Germany has suggested a link between anemia and mild cognitive impairment (MCI).

Researchers found that subjects with anemia, defined as hemoglobin <13 g/dL in men and <12 g/dL in women, performed worse on cognitive tests than their nonanemic peers.

And MCI occurred almost twice as often in subjects with anemia than in subjects with normal hemoglobin levels.

This study was published in the Journal of Alzheimer’s Disease.

About MCI

MCI represents an intermediate and possibly modifiable stage between normal cognitive aging and dementia. Although individuals with MCI have an increased risk of developing dementia or Alzheimer’s disease, they can also remain stable for many years or even revert to a cognitively normal state over time. This modifiable characteristic makes the concept of MCI a promising target in the prevention of dementia.

The following 4 criteria are used to diagnose MCI. First, subjects must report a decline in cognitive performance over the past 2 years. Second, they must show a cognitive impairment in objective cognitive tasks that is greater than one would expect taking their age and education into consideration.

Third, the impairment must not be as pronounced as in demented individuals since people with MCI can perform normal daily living activities or are only slightly impaired in carrying out complex instrumental functions. Fourth, the cognitive impairment has to be insufficient to fulfil criteria for dementia.

The concept of MCI distinguishes between amnestic MCI (aMCI) and non-amnestic MCI (naMCI). In the former, impairment in the memory domain is evident, most likely reflecting Alzheimer’s disease pathology. In the latter, impairment in non-memory domains is present, mainly reflecting vascular pathology but also frontotemporal dementia or dementia with Lewy bodies.

Study details

The Heinz Nixdorf Recall study is an observational, population-based, prospective study in which researchers examined 4814 subjects between 2000 and 2003. Subjects were 50 to 80 years of age and lived in the metropolitan Ruhr Area. Both genders were equally represented.

After 5 years, the researchers conducted a second examination with 92% of the subjects taking part. The publication includes cross-sectional results of the second examination.

First, 163 subjects with anemia and 3870 without anemia were included to compare their performance in all cognitive subtests.

The subjects took verbal memory tests, which were used to gauge immediate recall and delayed recall. They were also tested on executive functioning, which included problem-solving/speed of processing, verbal fluency, visual spatial organization, and the clock drawing test.

In the initial analysis, anemic subjects showed more pronounced cardiovascular risk profiles and lower cognitive performance in all administered cognitive subtests. After adjusting for age, anemic subjects showed a significantly lower performance in the immediate recall task (P=0.009) and the verbal fluency task (P=0.004).

Next, the researchers compared 579 subjects diagnosed with MCI—299 with aMCI and 280 with naMCI—to 1438 cognitively normal subjects to determine the association between anemia at follow-up and MCI.

The team found that MCI occurred more often in anemic than non-anemic subjects. The unadjusted odds ratio (OR) was 2.59 (P<0.001). The OR after adjustment for age, gender, and years of education was 2.15 (P=0.002).

In a third analysis, the researchers adjusted for the aforementioned variables as well as body mass index, high-sensitivity C-reactive protein, glomerular filtration rate, cholesterol, serum iron, hypertension, diabetes mellitus, history of coronary heart disease, history of stroke, history of cancer, APOE4, smoking, severe depressive symptoms, and use of antidepressants. The OR after adjustment for these factors was 1.92 (P=0.04).

Similar results were found for aMCI and naMCI. The researchers said this suggests that having a low hemoglobin level may contribute to cognitive impairment via different pathways.

The team believes that, overall, their study results indicate that anemia is associated with an increased risk of MCI independent of traditional cardiovascular risk factors. They said the association between anemia and MCI has important clinical relevance because—depending on etiology—anemia can be treated effectively, and this might provide means to prevent or delay cognitive decline.

Red blood cells

A population-based study conducted in Germany has suggested a link between anemia and mild cognitive impairment (MCI).

Researchers found that subjects with anemia, defined as hemoglobin <13 g/dL in men and <12 g/dL in women, performed worse on cognitive tests than their nonanemic peers.

And MCI occurred almost twice as often in subjects with anemia than in subjects with normal hemoglobin levels.

This study was published in the Journal of Alzheimer’s Disease.

About MCI

MCI represents an intermediate and possibly modifiable stage between normal cognitive aging and dementia. Although individuals with MCI have an increased risk of developing dementia or Alzheimer’s disease, they can also remain stable for many years or even revert to a cognitively normal state over time. This modifiable characteristic makes the concept of MCI a promising target in the prevention of dementia.

The following 4 criteria are used to diagnose MCI. First, subjects must report a decline in cognitive performance over the past 2 years. Second, they must show a cognitive impairment in objective cognitive tasks that is greater than one would expect taking their age and education into consideration.

Third, the impairment must not be as pronounced as in demented individuals since people with MCI can perform normal daily living activities or are only slightly impaired in carrying out complex instrumental functions. Fourth, the cognitive impairment has to be insufficient to fulfil criteria for dementia.

The concept of MCI distinguishes between amnestic MCI (aMCI) and non-amnestic MCI (naMCI). In the former, impairment in the memory domain is evident, most likely reflecting Alzheimer’s disease pathology. In the latter, impairment in non-memory domains is present, mainly reflecting vascular pathology but also frontotemporal dementia or dementia with Lewy bodies.

Study details

The Heinz Nixdorf Recall study is an observational, population-based, prospective study in which researchers examined 4814 subjects between 2000 and 2003. Subjects were 50 to 80 years of age and lived in the metropolitan Ruhr Area. Both genders were equally represented.

After 5 years, the researchers conducted a second examination with 92% of the subjects taking part. The publication includes cross-sectional results of the second examination.

First, 163 subjects with anemia and 3870 without anemia were included to compare their performance in all cognitive subtests.

The subjects took verbal memory tests, which were used to gauge immediate recall and delayed recall. They were also tested on executive functioning, which included problem-solving/speed of processing, verbal fluency, visual spatial organization, and the clock drawing test.

In the initial analysis, anemic subjects showed more pronounced cardiovascular risk profiles and lower cognitive performance in all administered cognitive subtests. After adjusting for age, anemic subjects showed a significantly lower performance in the immediate recall task (P=0.009) and the verbal fluency task (P=0.004).

Next, the researchers compared 579 subjects diagnosed with MCI—299 with aMCI and 280 with naMCI—to 1438 cognitively normal subjects to determine the association between anemia at follow-up and MCI.

The team found that MCI occurred more often in anemic than non-anemic subjects. The unadjusted odds ratio (OR) was 2.59 (P<0.001). The OR after adjustment for age, gender, and years of education was 2.15 (P=0.002).

In a third analysis, the researchers adjusted for the aforementioned variables as well as body mass index, high-sensitivity C-reactive protein, glomerular filtration rate, cholesterol, serum iron, hypertension, diabetes mellitus, history of coronary heart disease, history of stroke, history of cancer, APOE4, smoking, severe depressive symptoms, and use of antidepressants. The OR after adjustment for these factors was 1.92 (P=0.04).

Similar results were found for aMCI and naMCI. The researchers said this suggests that having a low hemoglobin level may contribute to cognitive impairment via different pathways.

The team believes that, overall, their study results indicate that anemia is associated with an increased risk of MCI independent of traditional cardiovascular risk factors. They said the association between anemia and MCI has important clinical relevance because—depending on etiology—anemia can be treated effectively, and this might provide means to prevent or delay cognitive decline.

Red blood cells

A population-based study conducted in Germany has suggested a link between anemia and mild cognitive impairment (MCI).

Researchers found that subjects with anemia, defined as hemoglobin <13 g/dL in men and <12 g/dL in women, performed worse on cognitive tests than their nonanemic peers.

And MCI occurred almost twice as often in subjects with anemia than in subjects with normal hemoglobin levels.

This study was published in the Journal of Alzheimer’s Disease.

About MCI

MCI represents an intermediate and possibly modifiable stage between normal cognitive aging and dementia. Although individuals with MCI have an increased risk of developing dementia or Alzheimer’s disease, they can also remain stable for many years or even revert to a cognitively normal state over time. This modifiable characteristic makes the concept of MCI a promising target in the prevention of dementia.

The following 4 criteria are used to diagnose MCI. First, subjects must report a decline in cognitive performance over the past 2 years. Second, they must show a cognitive impairment in objective cognitive tasks that is greater than one would expect taking their age and education into consideration.

Third, the impairment must not be as pronounced as in demented individuals since people with MCI can perform normal daily living activities or are only slightly impaired in carrying out complex instrumental functions. Fourth, the cognitive impairment has to be insufficient to fulfil criteria for dementia.

The concept of MCI distinguishes between amnestic MCI (aMCI) and non-amnestic MCI (naMCI). In the former, impairment in the memory domain is evident, most likely reflecting Alzheimer’s disease pathology. In the latter, impairment in non-memory domains is present, mainly reflecting vascular pathology but also frontotemporal dementia or dementia with Lewy bodies.

Study details

The Heinz Nixdorf Recall study is an observational, population-based, prospective study in which researchers examined 4814 subjects between 2000 and 2003. Subjects were 50 to 80 years of age and lived in the metropolitan Ruhr Area. Both genders were equally represented.

After 5 years, the researchers conducted a second examination with 92% of the subjects taking part. The publication includes cross-sectional results of the second examination.

First, 163 subjects with anemia and 3870 without anemia were included to compare their performance in all cognitive subtests.

The subjects took verbal memory tests, which were used to gauge immediate recall and delayed recall. They were also tested on executive functioning, which included problem-solving/speed of processing, verbal fluency, visual spatial organization, and the clock drawing test.

In the initial analysis, anemic subjects showed more pronounced cardiovascular risk profiles and lower cognitive performance in all administered cognitive subtests. After adjusting for age, anemic subjects showed a significantly lower performance in the immediate recall task (P=0.009) and the verbal fluency task (P=0.004).

Next, the researchers compared 579 subjects diagnosed with MCI—299 with aMCI and 280 with naMCI—to 1438 cognitively normal subjects to determine the association between anemia at follow-up and MCI.

The team found that MCI occurred more often in anemic than non-anemic subjects. The unadjusted odds ratio (OR) was 2.59 (P<0.001). The OR after adjustment for age, gender, and years of education was 2.15 (P=0.002).

In a third analysis, the researchers adjusted for the aforementioned variables as well as body mass index, high-sensitivity C-reactive protein, glomerular filtration rate, cholesterol, serum iron, hypertension, diabetes mellitus, history of coronary heart disease, history of stroke, history of cancer, APOE4, smoking, severe depressive symptoms, and use of antidepressants. The OR after adjustment for these factors was 1.92 (P=0.04).

Similar results were found for aMCI and naMCI. The researchers said this suggests that having a low hemoglobin level may contribute to cognitive impairment via different pathways.

The team believes that, overall, their study results indicate that anemia is associated with an increased risk of MCI independent of traditional cardiovascular risk factors. They said the association between anemia and MCI has important clinical relevance because—depending on etiology—anemia can be treated effectively, and this might provide means to prevent or delay cognitive decline.

Delirium, or the state of mental confusion that may occur with physical or mental illness, is common, morbid, and costly; however, of the diagnosed cases, delirium is mentioned in hospital discharge summaries only 16% to 55% of the time.^1-3

Social workers often coordinate care transitions for hospitalized older veterans. They serve as interdisciplinary team members who communicate with VA medical staff as well as with the patient and family. This position, in addition to their training in communication and advocacy, primes social workers for a role in delirium care and provides the needed support for veterans who experience delirium and their families.

Background

Delirium is a sudden disturbance of attention with reduced awareness of the environment. Because attention is impaired, other changes in cognition are common, including perceptual and thought disturbances. Additionally, delirium includes fluctuations in consciousness over the course of a day. The acute development of these cognitive disturbances is distinct from a preexisting chronic cognitive impairment, such as dementia. Delirium is a direct consequence of underlying medical conditions, such as infections, polypharmacy, dehydration, and surgery.⁴

Delirium subtypes all have inattention as a core symptom. In half of the cases, patients are hypoactive and will not awaken easily or participate in daily care plans readily.⁴ Hyperactive delirium occurs in a quarter of cases. In the remaining mixed delirium cases patients fluctuate between the 2 states.⁴

Delirium is often falsely mistaken for dementia. Although delirium and dementia can present similarly, delirium has a sudden onset, which can alert health care professionals (HCPs) to the likelihood of delirium. Another important distinction is that delirium is typically reversible. Symptom manifestations of delirium may also be confused with depression. 

Related: Delirium in the Cardiac ICU

Preventing delirium is important due to its many negative health outcomes. Older adults who develop delirium are more likely to die sooner. In a Canadian study of hospitalized patients aged ≥ 65 years, 41.6% of the delirium cohort and 14.4% of the control group died within 12 months of hospital admission.⁵ The death rate predicted by delirium in the Canadian study was comparable to the death rate of those who experience other serious medical conditions, such as sepsis or a heart attack.⁶

Those who survive delirium experience other serious outcomes, such as a negative impact on function and cognition and an increase in long-term care placement.⁷ Even when the condition resolves quickly, lasting functional impairment may be evident without return to baseline functioning.⁸ Hospitalized veterans are generally older, making them susceptible to developing delirium.⁹

Prevalence

Delirium can result from multiple medical conditions and develops in up to 50% of patients after general surgery and up to 80% of patients in the intensive care unit.^10,11 From 20% to 40% of hospitalized older adults and from 50% to 89% of patients with preexisting Alzheimer disease may develop delirium.^12-15 The increasing number of aging adults who will be hospitalized may also result in an increased prevalence of delirium.^1,16

Delirium is a result of various predisposing and precipitating factors.¹ Predisposing vulnerabilities are intrinsic to the individual, whereas precipitating external stressors are found in the environment. External stressors may trigger delirium in an individual who is vulnerable due to predisposing risk. The primary risk factors for delirium include dementia, advanced age, sensory impairment, fracture, infection, and dehydration (Table 1).¹²

Predisposing factors for delirium, such as age and sex, lifestyle choices (alcohol, tobacco), and chronic conditions (atherosclerosis, depression, prior stroke/transient ischemic attack) are more prevalent in the veteran population.^9,17-20 In 2011, the median age for male veterans was 64 and the median age for male nonveterans was 41. Of male veterans, 49.9% are aged ≥ 65 years in comparison with 10.5% of the nonveteran male population.²¹ Veterans also have higher rates of comorbidities; a significant risk factor for delirium.²⁰ A study by Agha and colleagues found that veterans were 14 times more likely to have 5 or more medical conditions than that of the general population.⁹ In a study comparing veterans aged ≥ 65 years with their age matched nonveteran peers, the health status of the veterans was poorer overall.²² Veterans are more likely to have posttraumatic stress disorder, which can increase the risk of postsurgery delirium and dementia, a primary risk factor for delirium.^23-26

Delirium Intervention

Up to 40% of delirium cases can be prevented.²⁷ But delirium may remain undetected in older veterans because its symptoms are sometimes thought to be the unavoidable consequences of aging, dementia, preexisting mental health conditions, substance abuse, a disease process, or the hospital environment.²⁸ Therefore, to avoid the negative consequences of delirium, prevention is critical.²⁸

The goals of delirium treatment are to identify and reverse its underlying cause(s).²⁹ Because delirium is typically multifactorial, an HCP must carefully consider the various sources that could have initiated a change in mental status. Delirium may be prevented if HCPs can reduce patient risk factors. The 2010 National Institute for Health and Clinical Excellence (NICE) Delirium Guideline recommended a set of prevention strategies to address delirium risk factors (Table 2).¹²

As a member of the health care team, social workers can help prevent delirium through attention to pain management, infection control, medication review, sensory improvement, adequate nutrition and hydration, hypoxia prevention, and mobilization.¹²No pharmacologic approach has been approved for the treatment of delirium.³⁰ Drugs may manage symptoms associated with delirium, but they do not treat the disease and could be associated with toxicity in high-risk patients. However, there are a variety of nonpharmacologic preventative measures that have proven effective. Environmental interventions to prevent delirium include orientation, cognitive stimulation, and sensory aids. A 2013 meta-analysis of 19 delirium prevention programs found that most were effective in preventing delirium in patients at risk during hospitalization.³¹ This review found that the most successful programs included multidisciplinary teams providing staff education and therapeutic cognitive activities.³¹ Social workers can encourage and directly provide such services. The Delirium Toolbox is a delirium risk modification program that was piloted with frontline staff, including social workers, at the VA Boston Healthcare System in West Roxbury, Massachusetts, and has been associated with restraint reduction, shortened length of stay (LOS), and lower variable direct costs.³²

Social Worker Role

Several studies, both national and international, have indicated that little has been done over the past 2 decades to increase the diagnosis of delirium, because only 12% to 35% of delirium cases are clinically detected within the emergency department and in acute care settings.^33-37 Patients may hesitate to report their experience due to a sense of embarrassment or because of an inability to describe it.³⁸

Social workers are skilled at helping individuals feel more at ease when disclosing distressing experiences. Delirium is relevant to HCPs and hospital social workers with care transition responsibilities, because delirium detection should impact discharge planning.^1,39 Delirium education needs to be included in efforts to improve transitions from intensive care settings to lower levels of care and from lower levels of care to discharge.⁴⁰ Hospital social workers are in a position to offer additional support because they see patients at a critical juncture in their care and can take steps to improve postdischarge outcomes.⁴¹

Prior to Onset

Social workers can play an important role prior to delirium onset.⁴² Patient education on delirium needs to be provided during the routine hospital intake assessment. Informing patients in advance that delirium is common, based on their risk factors, as well as what to expect if delirium is experienced has been found to provide comfort.³⁸ Families who anticipated possible delirium-related confusion reported that they experienced less distress.³⁸

Related: Baseball Reminiscence Therapy for Cognitively Impaired Veterans

During hospitalization, social workers can ascertain from families whether an alteration in mental status is a rapid change, possibly indicating delirium, or a gradual dementia onset. The social work skills of advocacy and education can be used to support delirium-risk identification to avoid adverse outcomes.43 When no family caregiver is present to provide a history of the individual’s cognitive function prior to hospitalization, the social worker may be the first to notice an acute change in cognitive status and can report this to the medical team.

During Delirium

Lack of patient responsiveness and difficulty following a conversation are possible signs of delirium. This situation should be reported to the medical team for further delirium assessment and diagnosis.⁴ The social worker can also attempt to determine whether a patient’s presentation is unusual by contacting the family. Social work training recognizes the important role of the family.⁴⁴ Social workers often interact with families at the critical period between acute onset of delirium in the hospital and discharge.⁴² Studies have shown that delirium causes stress for the patient’s loved ones. Moreover, caregivers of patients who experience the syndrome are at a 12 times increased risk of meeting the criteria for generalized anxiety disorder.³⁰ In one study, delirium was rated as more distressing for the caregivers who witnessed it than for the patients who experienced it.³⁸ Education has been shown to reduce delirium-related distress.³⁰

In cases where delirium is irreversible, such as during the active dying process, social workers can serve in a palliative role to ease family confusion and provide comfort.³⁰ The presence of family and other familiar people are considered part of the nonpharmacologic management of delirium.²⁸

Posthospitalization

Delirium complicates physical aspects of care for families, as their loved one may need direct care in areas where they were previously independent due to a loss of function. Logistic considerations such as increased supervision may be necessary due to delirium, and the patient’s condition may be upsetting and confusing for family members, triggering the need for emotional support. During the discharge process, social workers can provide support and education to family members or placement facilities.³⁸

Social workers in the hospital setting are often responsible for discharge planning, including the reduction of extended LOS and unnecessary readmissions to the hospital.⁴⁵ Increased LOS and hospital readmissions are 2 of the primary negative outcomes associated with delirium. Delirium can persist for months beyond hospitalization, making it a relevant issue at the time of discharge and beyond.⁴⁶ Distress related to delirium has been documented up to 2 years after onset, due to manifestations of anxiety and depression.³⁸

Distress impacts patients as well as caregivers who witness the delirium and provide care to the patient afterward.³⁸ Long-term changes in mood in addition to loss of function as a result of delirium can lead to an increase in stress for both patients and their caregivers.³⁰ The social work emphasis on counseling and family dynamics as well as the common role of coordinating post-discharge arrangements makes the profession uniquely suited for delirium care.

Barriers

Social workers can play a key role in delirium risk identification and coordination of care but face substantial barriers. Delirium assessments are complex and require training and education in the features of delirium and cognitive assessment.⁴⁷ To date, social workers receive limited education about delirium and typically do not make deliberate efforts in prevention, support, and follow-up care.

Conclusion

Social workers will encounter delirium, and their training makes them particularly suited to address this health concern. An understanding of the larger ecologic system is a foundational aspect of social work and an essential component of delirium prevention and care.⁴¹ The multipathway nature of delirium as well as the importance of prevention suggests that multiple disciplines, including social work, should be involved.¹ The American Delirium Society and the European Delirium Association both recognize the need for all HCPs to be engaged in delirium care.^1,48

Related: Sharing Alzheimer Research, FasterSharing Alzheimer Research, Faster

 Social workers in the hospital setting provide communication, advocacy, and education to other HCPs, as well as to patients and families (Figure). Because delirium directly impacts the emotional and logistic needs of patients and their families, it would be advantageous for social workers to take a more active role in delirium risk identification, prevention, and care. Fortunately, the nonpharmacologic approaches that social workers are skilled in providing (eg, education and emotional support) have been shown to benefit patients with delirium and their families. 

Author disclosures

The authors report no actual or potential conflicts of interest with regard to this article.

Disclaimer
The opinions expressed herein are those of the authors and do not necessarily reflect those of Federal Practitioner, Frontline Medical Communications Inc., the U.S. Government, or any of its agencies. This article may discuss unlabeled or investigational use of certain drugs. Please review the complete prescribing information for specific drugs or drug combinations—including indications, contraindications, warnings, and adverse effects—before administering pharmacologic therapy to patients.

Delirium, or the state of mental confusion that may occur with physical or mental illness, is common, morbid, and costly; however, of the diagnosed cases, delirium is mentioned in hospital discharge summaries only 16% to 55% of the time.^1-3

Social workers often coordinate care transitions for hospitalized older veterans. They serve as interdisciplinary team members who communicate with VA medical staff as well as with the patient and family. This position, in addition to their training in communication and advocacy, primes social workers for a role in delirium care and provides the needed support for veterans who experience delirium and their families.

Background

Delirium is a sudden disturbance of attention with reduced awareness of the environment. Because attention is impaired, other changes in cognition are common, including perceptual and thought disturbances. Additionally, delirium includes fluctuations in consciousness over the course of a day. The acute development of these cognitive disturbances is distinct from a preexisting chronic cognitive impairment, such as dementia. Delirium is a direct consequence of underlying medical conditions, such as infections, polypharmacy, dehydration, and surgery.⁴

Delirium subtypes all have inattention as a core symptom. In half of the cases, patients are hypoactive and will not awaken easily or participate in daily care plans readily.⁴ Hyperactive delirium occurs in a quarter of cases. In the remaining mixed delirium cases patients fluctuate between the 2 states.⁴

Delirium is often falsely mistaken for dementia. Although delirium and dementia can present similarly, delirium has a sudden onset, which can alert health care professionals (HCPs) to the likelihood of delirium. Another important distinction is that delirium is typically reversible. Symptom manifestations of delirium may also be confused with depression. 

Related: Delirium in the Cardiac ICU

Preventing delirium is important due to its many negative health outcomes. Older adults who develop delirium are more likely to die sooner. In a Canadian study of hospitalized patients aged ≥ 65 years, 41.6% of the delirium cohort and 14.4% of the control group died within 12 months of hospital admission.⁵ The death rate predicted by delirium in the Canadian study was comparable to the death rate of those who experience other serious medical conditions, such as sepsis or a heart attack.⁶

Those who survive delirium experience other serious outcomes, such as a negative impact on function and cognition and an increase in long-term care placement.⁷ Even when the condition resolves quickly, lasting functional impairment may be evident without return to baseline functioning.⁸ Hospitalized veterans are generally older, making them susceptible to developing delirium.⁹

Prevalence

Delirium can result from multiple medical conditions and develops in up to 50% of patients after general surgery and up to 80% of patients in the intensive care unit.^10,11 From 20% to 40% of hospitalized older adults and from 50% to 89% of patients with preexisting Alzheimer disease may develop delirium.^12-15 The increasing number of aging adults who will be hospitalized may also result in an increased prevalence of delirium.^1,16

Delirium is a result of various predisposing and precipitating factors.¹ Predisposing vulnerabilities are intrinsic to the individual, whereas precipitating external stressors are found in the environment. External stressors may trigger delirium in an individual who is vulnerable due to predisposing risk. The primary risk factors for delirium include dementia, advanced age, sensory impairment, fracture, infection, and dehydration (Table 1).¹²

Predisposing factors for delirium, such as age and sex, lifestyle choices (alcohol, tobacco), and chronic conditions (atherosclerosis, depression, prior stroke/transient ischemic attack) are more prevalent in the veteran population.^9,17-20 In 2011, the median age for male veterans was 64 and the median age for male nonveterans was 41. Of male veterans, 49.9% are aged ≥ 65 years in comparison with 10.5% of the nonveteran male population.²¹ Veterans also have higher rates of comorbidities; a significant risk factor for delirium.²⁰ A study by Agha and colleagues found that veterans were 14 times more likely to have 5 or more medical conditions than that of the general population.⁹ In a study comparing veterans aged ≥ 65 years with their age matched nonveteran peers, the health status of the veterans was poorer overall.²² Veterans are more likely to have posttraumatic stress disorder, which can increase the risk of postsurgery delirium and dementia, a primary risk factor for delirium.^23-26

Delirium Intervention

Up to 40% of delirium cases can be prevented.²⁷ But delirium may remain undetected in older veterans because its symptoms are sometimes thought to be the unavoidable consequences of aging, dementia, preexisting mental health conditions, substance abuse, a disease process, or the hospital environment.²⁸ Therefore, to avoid the negative consequences of delirium, prevention is critical.²⁸

The goals of delirium treatment are to identify and reverse its underlying cause(s).²⁹ Because delirium is typically multifactorial, an HCP must carefully consider the various sources that could have initiated a change in mental status. Delirium may be prevented if HCPs can reduce patient risk factors. The 2010 National Institute for Health and Clinical Excellence (NICE) Delirium Guideline recommended a set of prevention strategies to address delirium risk factors (Table 2).¹²

As a member of the health care team, social workers can help prevent delirium through attention to pain management, infection control, medication review, sensory improvement, adequate nutrition and hydration, hypoxia prevention, and mobilization.¹²No pharmacologic approach has been approved for the treatment of delirium.³⁰ Drugs may manage symptoms associated with delirium, but they do not treat the disease and could be associated with toxicity in high-risk patients. However, there are a variety of nonpharmacologic preventative measures that have proven effective. Environmental interventions to prevent delirium include orientation, cognitive stimulation, and sensory aids. A 2013 meta-analysis of 19 delirium prevention programs found that most were effective in preventing delirium in patients at risk during hospitalization.³¹ This review found that the most successful programs included multidisciplinary teams providing staff education and therapeutic cognitive activities.³¹ Social workers can encourage and directly provide such services. The Delirium Toolbox is a delirium risk modification program that was piloted with frontline staff, including social workers, at the VA Boston Healthcare System in West Roxbury, Massachusetts, and has been associated with restraint reduction, shortened length of stay (LOS), and lower variable direct costs.³²

Social Worker Role

Several studies, both national and international, have indicated that little has been done over the past 2 decades to increase the diagnosis of delirium, because only 12% to 35% of delirium cases are clinically detected within the emergency department and in acute care settings.^33-37 Patients may hesitate to report their experience due to a sense of embarrassment or because of an inability to describe it.³⁸

Social workers are skilled at helping individuals feel more at ease when disclosing distressing experiences. Delirium is relevant to HCPs and hospital social workers with care transition responsibilities, because delirium detection should impact discharge planning.^1,39 Delirium education needs to be included in efforts to improve transitions from intensive care settings to lower levels of care and from lower levels of care to discharge.⁴⁰ Hospital social workers are in a position to offer additional support because they see patients at a critical juncture in their care and can take steps to improve postdischarge outcomes.⁴¹

Prior to Onset

Social workers can play an important role prior to delirium onset.⁴² Patient education on delirium needs to be provided during the routine hospital intake assessment. Informing patients in advance that delirium is common, based on their risk factors, as well as what to expect if delirium is experienced has been found to provide comfort.³⁸ Families who anticipated possible delirium-related confusion reported that they experienced less distress.³⁸

Related: Baseball Reminiscence Therapy for Cognitively Impaired Veterans

During hospitalization, social workers can ascertain from families whether an alteration in mental status is a rapid change, possibly indicating delirium, or a gradual dementia onset. The social work skills of advocacy and education can be used to support delirium-risk identification to avoid adverse outcomes.43 When no family caregiver is present to provide a history of the individual’s cognitive function prior to hospitalization, the social worker may be the first to notice an acute change in cognitive status and can report this to the medical team.

During Delirium

Lack of patient responsiveness and difficulty following a conversation are possible signs of delirium. This situation should be reported to the medical team for further delirium assessment and diagnosis.⁴ The social worker can also attempt to determine whether a patient’s presentation is unusual by contacting the family. Social work training recognizes the important role of the family.⁴⁴ Social workers often interact with families at the critical period between acute onset of delirium in the hospital and discharge.⁴² Studies have shown that delirium causes stress for the patient’s loved ones. Moreover, caregivers of patients who experience the syndrome are at a 12 times increased risk of meeting the criteria for generalized anxiety disorder.³⁰ In one study, delirium was rated as more distressing for the caregivers who witnessed it than for the patients who experienced it.³⁸ Education has been shown to reduce delirium-related distress.³⁰

In cases where delirium is irreversible, such as during the active dying process, social workers can serve in a palliative role to ease family confusion and provide comfort.³⁰ The presence of family and other familiar people are considered part of the nonpharmacologic management of delirium.²⁸

Posthospitalization

Delirium complicates physical aspects of care for families, as their loved one may need direct care in areas where they were previously independent due to a loss of function. Logistic considerations such as increased supervision may be necessary due to delirium, and the patient’s condition may be upsetting and confusing for family members, triggering the need for emotional support. During the discharge process, social workers can provide support and education to family members or placement facilities.³⁸

Social workers in the hospital setting are often responsible for discharge planning, including the reduction of extended LOS and unnecessary readmissions to the hospital.⁴⁵ Increased LOS and hospital readmissions are 2 of the primary negative outcomes associated with delirium. Delirium can persist for months beyond hospitalization, making it a relevant issue at the time of discharge and beyond.⁴⁶ Distress related to delirium has been documented up to 2 years after onset, due to manifestations of anxiety and depression.³⁸

Distress impacts patients as well as caregivers who witness the delirium and provide care to the patient afterward.³⁸ Long-term changes in mood in addition to loss of function as a result of delirium can lead to an increase in stress for both patients and their caregivers.³⁰ The social work emphasis on counseling and family dynamics as well as the common role of coordinating post-discharge arrangements makes the profession uniquely suited for delirium care.

Barriers

Social workers can play a key role in delirium risk identification and coordination of care but face substantial barriers. Delirium assessments are complex and require training and education in the features of delirium and cognitive assessment.⁴⁷ To date, social workers receive limited education about delirium and typically do not make deliberate efforts in prevention, support, and follow-up care.

Conclusion

Social workers will encounter delirium, and their training makes them particularly suited to address this health concern. An understanding of the larger ecologic system is a foundational aspect of social work and an essential component of delirium prevention and care.⁴¹ The multipathway nature of delirium as well as the importance of prevention suggests that multiple disciplines, including social work, should be involved.¹ The American Delirium Society and the European Delirium Association both recognize the need for all HCPs to be engaged in delirium care.^1,48

Related: Sharing Alzheimer Research, FasterSharing Alzheimer Research, Faster

 Social workers in the hospital setting provide communication, advocacy, and education to other HCPs, as well as to patients and families (Figure). Because delirium directly impacts the emotional and logistic needs of patients and their families, it would be advantageous for social workers to take a more active role in delirium risk identification, prevention, and care. Fortunately, the nonpharmacologic approaches that social workers are skilled in providing (eg, education and emotional support) have been shown to benefit patients with delirium and their families. 

Author disclosures

The authors report no actual or potential conflicts of interest with regard to this article.

Disclaimer
The opinions expressed herein are those of the authors and do not necessarily reflect those of Federal Practitioner, Frontline Medical Communications Inc., the U.S. Government, or any of its agencies. This article may discuss unlabeled or investigational use of certain drugs. Please review the complete prescribing information for specific drugs or drug combinations—including indications, contraindications, warnings, and adverse effects—before administering pharmacologic therapy to patients.

Delirium, or the state of mental confusion that may occur with physical or mental illness, is common, morbid, and costly; however, of the diagnosed cases, delirium is mentioned in hospital discharge summaries only 16% to 55% of the time.^1-3

Social workers often coordinate care transitions for hospitalized older veterans. They serve as interdisciplinary team members who communicate with VA medical staff as well as with the patient and family. This position, in addition to their training in communication and advocacy, primes social workers for a role in delirium care and provides the needed support for veterans who experience delirium and their families.

Background

Delirium is a sudden disturbance of attention with reduced awareness of the environment. Because attention is impaired, other changes in cognition are common, including perceptual and thought disturbances. Additionally, delirium includes fluctuations in consciousness over the course of a day. The acute development of these cognitive disturbances is distinct from a preexisting chronic cognitive impairment, such as dementia. Delirium is a direct consequence of underlying medical conditions, such as infections, polypharmacy, dehydration, and surgery.⁴

Delirium subtypes all have inattention as a core symptom. In half of the cases, patients are hypoactive and will not awaken easily or participate in daily care plans readily.⁴ Hyperactive delirium occurs in a quarter of cases. In the remaining mixed delirium cases patients fluctuate between the 2 states.⁴

Delirium is often falsely mistaken for dementia. Although delirium and dementia can present similarly, delirium has a sudden onset, which can alert health care professionals (HCPs) to the likelihood of delirium. Another important distinction is that delirium is typically reversible. Symptom manifestations of delirium may also be confused with depression. 

Related: Delirium in the Cardiac ICU

Preventing delirium is important due to its many negative health outcomes. Older adults who develop delirium are more likely to die sooner. In a Canadian study of hospitalized patients aged ≥ 65 years, 41.6% of the delirium cohort and 14.4% of the control group died within 12 months of hospital admission.⁵ The death rate predicted by delirium in the Canadian study was comparable to the death rate of those who experience other serious medical conditions, such as sepsis or a heart attack.⁶

Those who survive delirium experience other serious outcomes, such as a negative impact on function and cognition and an increase in long-term care placement.⁷ Even when the condition resolves quickly, lasting functional impairment may be evident without return to baseline functioning.⁸ Hospitalized veterans are generally older, making them susceptible to developing delirium.⁹

Prevalence

Delirium can result from multiple medical conditions and develops in up to 50% of patients after general surgery and up to 80% of patients in the intensive care unit.^10,11 From 20% to 40% of hospitalized older adults and from 50% to 89% of patients with preexisting Alzheimer disease may develop delirium.^12-15 The increasing number of aging adults who will be hospitalized may also result in an increased prevalence of delirium.^1,16

Delirium is a result of various predisposing and precipitating factors.¹ Predisposing vulnerabilities are intrinsic to the individual, whereas precipitating external stressors are found in the environment. External stressors may trigger delirium in an individual who is vulnerable due to predisposing risk. The primary risk factors for delirium include dementia, advanced age, sensory impairment, fracture, infection, and dehydration (Table 1).¹²

Predisposing factors for delirium, such as age and sex, lifestyle choices (alcohol, tobacco), and chronic conditions (atherosclerosis, depression, prior stroke/transient ischemic attack) are more prevalent in the veteran population.^9,17-20 In 2011, the median age for male veterans was 64 and the median age for male nonveterans was 41. Of male veterans, 49.9% are aged ≥ 65 years in comparison with 10.5% of the nonveteran male population.²¹ Veterans also have higher rates of comorbidities; a significant risk factor for delirium.²⁰ A study by Agha and colleagues found that veterans were 14 times more likely to have 5 or more medical conditions than that of the general population.⁹ In a study comparing veterans aged ≥ 65 years with their age matched nonveteran peers, the health status of the veterans was poorer overall.²² Veterans are more likely to have posttraumatic stress disorder, which can increase the risk of postsurgery delirium and dementia, a primary risk factor for delirium.^23-26

Delirium Intervention

Up to 40% of delirium cases can be prevented.²⁷ But delirium may remain undetected in older veterans because its symptoms are sometimes thought to be the unavoidable consequences of aging, dementia, preexisting mental health conditions, substance abuse, a disease process, or the hospital environment.²⁸ Therefore, to avoid the negative consequences of delirium, prevention is critical.²⁸

The goals of delirium treatment are to identify and reverse its underlying cause(s).²⁹ Because delirium is typically multifactorial, an HCP must carefully consider the various sources that could have initiated a change in mental status. Delirium may be prevented if HCPs can reduce patient risk factors. The 2010 National Institute for Health and Clinical Excellence (NICE) Delirium Guideline recommended a set of prevention strategies to address delirium risk factors (Table 2).¹²

As a member of the health care team, social workers can help prevent delirium through attention to pain management, infection control, medication review, sensory improvement, adequate nutrition and hydration, hypoxia prevention, and mobilization.¹²No pharmacologic approach has been approved for the treatment of delirium.³⁰ Drugs may manage symptoms associated with delirium, but they do not treat the disease and could be associated with toxicity in high-risk patients. However, there are a variety of nonpharmacologic preventative measures that have proven effective. Environmental interventions to prevent delirium include orientation, cognitive stimulation, and sensory aids. A 2013 meta-analysis of 19 delirium prevention programs found that most were effective in preventing delirium in patients at risk during hospitalization.³¹ This review found that the most successful programs included multidisciplinary teams providing staff education and therapeutic cognitive activities.³¹ Social workers can encourage and directly provide such services. The Delirium Toolbox is a delirium risk modification program that was piloted with frontline staff, including social workers, at the VA Boston Healthcare System in West Roxbury, Massachusetts, and has been associated with restraint reduction, shortened length of stay (LOS), and lower variable direct costs.³²

Social Worker Role

Several studies, both national and international, have indicated that little has been done over the past 2 decades to increase the diagnosis of delirium, because only 12% to 35% of delirium cases are clinically detected within the emergency department and in acute care settings.^33-37 Patients may hesitate to report their experience due to a sense of embarrassment or because of an inability to describe it.³⁸

Social workers are skilled at helping individuals feel more at ease when disclosing distressing experiences. Delirium is relevant to HCPs and hospital social workers with care transition responsibilities, because delirium detection should impact discharge planning.^1,39 Delirium education needs to be included in efforts to improve transitions from intensive care settings to lower levels of care and from lower levels of care to discharge.⁴⁰ Hospital social workers are in a position to offer additional support because they see patients at a critical juncture in their care and can take steps to improve postdischarge outcomes.⁴¹

Prior to Onset

Social workers can play an important role prior to delirium onset.⁴² Patient education on delirium needs to be provided during the routine hospital intake assessment. Informing patients in advance that delirium is common, based on their risk factors, as well as what to expect if delirium is experienced has been found to provide comfort.³⁸ Families who anticipated possible delirium-related confusion reported that they experienced less distress.³⁸

Related: Baseball Reminiscence Therapy for Cognitively Impaired Veterans

During hospitalization, social workers can ascertain from families whether an alteration in mental status is a rapid change, possibly indicating delirium, or a gradual dementia onset. The social work skills of advocacy and education can be used to support delirium-risk identification to avoid adverse outcomes.43 When no family caregiver is present to provide a history of the individual’s cognitive function prior to hospitalization, the social worker may be the first to notice an acute change in cognitive status and can report this to the medical team.

During Delirium

Lack of patient responsiveness and difficulty following a conversation are possible signs of delirium. This situation should be reported to the medical team for further delirium assessment and diagnosis.⁴ The social worker can also attempt to determine whether a patient’s presentation is unusual by contacting the family. Social work training recognizes the important role of the family.⁴⁴ Social workers often interact with families at the critical period between acute onset of delirium in the hospital and discharge.⁴² Studies have shown that delirium causes stress for the patient’s loved ones. Moreover, caregivers of patients who experience the syndrome are at a 12 times increased risk of meeting the criteria for generalized anxiety disorder.³⁰ In one study, delirium was rated as more distressing for the caregivers who witnessed it than for the patients who experienced it.³⁸ Education has been shown to reduce delirium-related distress.³⁰

In cases where delirium is irreversible, such as during the active dying process, social workers can serve in a palliative role to ease family confusion and provide comfort.³⁰ The presence of family and other familiar people are considered part of the nonpharmacologic management of delirium.²⁸

Posthospitalization

Delirium complicates physical aspects of care for families, as their loved one may need direct care in areas where they were previously independent due to a loss of function. Logistic considerations such as increased supervision may be necessary due to delirium, and the patient’s condition may be upsetting and confusing for family members, triggering the need for emotional support. During the discharge process, social workers can provide support and education to family members or placement facilities.³⁸

Social workers in the hospital setting are often responsible for discharge planning, including the reduction of extended LOS and unnecessary readmissions to the hospital.⁴⁵ Increased LOS and hospital readmissions are 2 of the primary negative outcomes associated with delirium. Delirium can persist for months beyond hospitalization, making it a relevant issue at the time of discharge and beyond.⁴⁶ Distress related to delirium has been documented up to 2 years after onset, due to manifestations of anxiety and depression.³⁸

Distress impacts patients as well as caregivers who witness the delirium and provide care to the patient afterward.³⁸ Long-term changes in mood in addition to loss of function as a result of delirium can lead to an increase in stress for both patients and their caregivers.³⁰ The social work emphasis on counseling and family dynamics as well as the common role of coordinating post-discharge arrangements makes the profession uniquely suited for delirium care.

Barriers

Social workers can play a key role in delirium risk identification and coordination of care but face substantial barriers. Delirium assessments are complex and require training and education in the features of delirium and cognitive assessment.⁴⁷ To date, social workers receive limited education about delirium and typically do not make deliberate efforts in prevention, support, and follow-up care.

Conclusion

Social workers will encounter delirium, and their training makes them particularly suited to address this health concern. An understanding of the larger ecologic system is a foundational aspect of social work and an essential component of delirium prevention and care.⁴¹ The multipathway nature of delirium as well as the importance of prevention suggests that multiple disciplines, including social work, should be involved.¹ The American Delirium Society and the European Delirium Association both recognize the need for all HCPs to be engaged in delirium care.^1,48

Related: Sharing Alzheimer Research, FasterSharing Alzheimer Research, Faster

 Social workers in the hospital setting provide communication, advocacy, and education to other HCPs, as well as to patients and families (Figure). Because delirium directly impacts the emotional and logistic needs of patients and their families, it would be advantageous for social workers to take a more active role in delirium risk identification, prevention, and care. Fortunately, the nonpharmacologic approaches that social workers are skilled in providing (eg, education and emotional support) have been shown to benefit patients with delirium and their families. 

Author disclosures

The authors report no actual or potential conflicts of interest with regard to this article.

Disclaimer
The opinions expressed herein are those of the authors and do not necessarily reflect those of Federal Practitioner, Frontline Medical Communications Inc., the U.S. Government, or any of its agencies. This article may discuss unlabeled or investigational use of certain drugs. Please review the complete prescribing information for specific drugs or drug combinations—including indications, contraindications, warnings, and adverse effects—before administering pharmacologic therapy to patients.

Credit: These cases were adapted from Usatine R, Smith M, Mayeaux EJ, et al, eds. Color Atlas of Family Medicine. 2nd ed. New York, NY: McGraw-Hill; 2013.  You can now get the second edition of the Color Atlas of Family Medicine as an app for mobile devices by clicking this link: usatinemedia.com.

1. A painless white, thick lesion with fissuring had been on the side of this 57-year-old man’s tongue for the past 7 months. The patient drinks two to three beers in the evening and smokes one pack of cigarettes a day.

Diagnosis: This patient was given a diagnosis of leukoplakia and the biopsy indicated that the lesion was premalignant. The World Health Organization defines leukoplakia as “white plaques of questionable risk” in cases where other known diseases that don’t carry an increased risk for cancer have been excluded.  For all types of leukoplakia, the risk of malignant transformation is approximately 1%, with a much higher risk associated with leukoplakias that contain red spots and/or rough spots.

For more information, read “White patch on tongue.” J Fam Pract. 2014.

For the next photograph, proceed to the next page >>

2. This nonhealing painful lesion on the side of her tongue had increased in size recently, and the patient, a 56-year-old homeless woman, was worried because her dad had died from oral cancer. She had smoked since she was 11 and acknowledged being a heavy drinker.

Diagnosis: A punch biopsy revealed that the patient had a squamous cell carcinoma. Fully two-thirds of oropharyngeal cancers (OPCs) will present with advanced disease at the time of diagnosis. Ninety percent of OPCs are of the squamous cell type. Reports in the literature suggest that clinicians may be missing early disease by not conducting thorough soft-tissue examinations on a routine basis. However, the fact that more than 35% of patients do not see a dentist on a routine basis likely contributes to the diagnostic delay. The 5-year survival rate for OPC is 62% for whites and 42% for blacks.

Tobacco use is the major risk factor for OPC and is implicated in approximately 75% of cases. Alcohol use is also a major risk factor. The combined use of tobacco and alcohol increases the risk of OPC far more than either alone. Human papillomavirus (especially HPV 16) is a newly recognized major risk factor for carcinomas affecting the lingual and palatine tonsils.

For more information, read “Lesion on side of tongue.” J Fam Pract. 2014.

For the next photograph, proceed to the next page >>

3. A 58-year-old man sought care for painful sores that had been in his mouth, on and off, for a year. The ulcers erupted on his tongue, gums, buccal mucosa, and inner lips, making it painful to eat. The patient was not taking any medications.

Diagnosis: The clinician recognized his condition as recurrent aphthous ulcers with giant ulcers. Aphthous ulcers are painful ulcerations in the mouth, which can be single, multiple, occasional, or recurrent. These ulcers can be small or large but are uniformly painful and may interfere with eating, speaking, and swallowing.

For more information, read “Lesions on tongue.” J Fam Pract. 2014.

For the next photograph, proceed to the next page >>

4. A 60-year-old man, smelling of alcohol and tobacco, complained of a black discoloration of his tongue and occasional gagging sensation. He smoked one to 2 packs of cigarettes and drank 6 to 8 beers daily. On physical exam, his teeth were stained and his tongue shows elongated papillae with brown discoloration.

Diagnosis: This patient had a black hairy tongue (BHT), poor oral hygiene, and tobacco and alcohol addiction. BHT is a benign disorder of the tongue characterized by abnormally hypertrophied and elongated filiform papillae on the surface of the tongue. In addition, there is defective desquamation of the papillae on the dorsal tongue, resulting in a hair-like appearance. These papillae, which are normally about 1 mm in length, may become as long as 12 mm. The elongated filiform papillae can then collect debris, bacteria, fungus, or other foreign materials.

For more information, read “Discoloration of the tongue.” J Fam Pract. 2014.

For the next photograph, proceed to the next page >>

5. A 5-year-old girl had a temperature of 102.4°F, a sore throat, and a red tongue with prominent papillae. The posterior pharynx was also erythematous with slight exudate visible. The anterior cervical lymph nodes were mildly tender and somewhat enlarged, and no rashes were noted.

Diagnosis: The child had a strawberry tongue and scarlet fever caused by strep pharyngitis. The tongue had prominent papillae along with erythema, making it resemble a strawberry. Strawberry tongue is most commonly seen in children with scarlet fever or Kawasaki disease. Strawberry tongue usually develops within the first 2 to 3 days of illness. A white or yellowish coating usually precedes the classic red tongue with white papillae.

For more information, read “Papillae on tongue.” J Fam Pract. 2014.

Credit: These cases were adapted from Usatine R, Smith M, Mayeaux EJ, et al, eds. Color Atlas of Family Medicine. 2nd ed. New York, NY: McGraw-Hill; 2013.  You can now get the second edition of the Color Atlas of Family Medicine as an app for mobile devices by clicking this link: usatinemedia.com.

1. A painless white, thick lesion with fissuring had been on the side of this 57-year-old man’s tongue for the past 7 months. The patient drinks two to three beers in the evening and smokes one pack of cigarettes a day.

Diagnosis: This patient was given a diagnosis of leukoplakia and the biopsy indicated that the lesion was premalignant. The World Health Organization defines leukoplakia as “white plaques of questionable risk” in cases where other known diseases that don’t carry an increased risk for cancer have been excluded.  For all types of leukoplakia, the risk of malignant transformation is approximately 1%, with a much higher risk associated with leukoplakias that contain red spots and/or rough spots.

For more information, read “White patch on tongue.” J Fam Pract. 2014.

For the next photograph, proceed to the next page >>

2. This nonhealing painful lesion on the side of her tongue had increased in size recently, and the patient, a 56-year-old homeless woman, was worried because her dad had died from oral cancer. She had smoked since she was 11 and acknowledged being a heavy drinker.

Diagnosis: A punch biopsy revealed that the patient had a squamous cell carcinoma. Fully two-thirds of oropharyngeal cancers (OPCs) will present with advanced disease at the time of diagnosis. Ninety percent of OPCs are of the squamous cell type. Reports in the literature suggest that clinicians may be missing early disease by not conducting thorough soft-tissue examinations on a routine basis. However, the fact that more than 35% of patients do not see a dentist on a routine basis likely contributes to the diagnostic delay. The 5-year survival rate for OPC is 62% for whites and 42% for blacks.

Tobacco use is the major risk factor for OPC and is implicated in approximately 75% of cases. Alcohol use is also a major risk factor. The combined use of tobacco and alcohol increases the risk of OPC far more than either alone. Human papillomavirus (especially HPV 16) is a newly recognized major risk factor for carcinomas affecting the lingual and palatine tonsils.

For more information, read “Lesion on side of tongue.” J Fam Pract. 2014.

For the next photograph, proceed to the next page >>

3. A 58-year-old man sought care for painful sores that had been in his mouth, on and off, for a year. The ulcers erupted on his tongue, gums, buccal mucosa, and inner lips, making it painful to eat. The patient was not taking any medications.

Diagnosis: The clinician recognized his condition as recurrent aphthous ulcers with giant ulcers. Aphthous ulcers are painful ulcerations in the mouth, which can be single, multiple, occasional, or recurrent. These ulcers can be small or large but are uniformly painful and may interfere with eating, speaking, and swallowing.

For more information, read “Lesions on tongue.” J Fam Pract. 2014.

For the next photograph, proceed to the next page >>

4. A 60-year-old man, smelling of alcohol and tobacco, complained of a black discoloration of his tongue and occasional gagging sensation. He smoked one to 2 packs of cigarettes and drank 6 to 8 beers daily. On physical exam, his teeth were stained and his tongue shows elongated papillae with brown discoloration.

Diagnosis: This patient had a black hairy tongue (BHT), poor oral hygiene, and tobacco and alcohol addiction. BHT is a benign disorder of the tongue characterized by abnormally hypertrophied and elongated filiform papillae on the surface of the tongue. In addition, there is defective desquamation of the papillae on the dorsal tongue, resulting in a hair-like appearance. These papillae, which are normally about 1 mm in length, may become as long as 12 mm. The elongated filiform papillae can then collect debris, bacteria, fungus, or other foreign materials.

For more information, read “Discoloration of the tongue.” J Fam Pract. 2014.

For the next photograph, proceed to the next page >>

5. A 5-year-old girl had a temperature of 102.4°F, a sore throat, and a red tongue with prominent papillae. The posterior pharynx was also erythematous with slight exudate visible. The anterior cervical lymph nodes were mildly tender and somewhat enlarged, and no rashes were noted.

Diagnosis: The child had a strawberry tongue and scarlet fever caused by strep pharyngitis. The tongue had prominent papillae along with erythema, making it resemble a strawberry. Strawberry tongue is most commonly seen in children with scarlet fever or Kawasaki disease. Strawberry tongue usually develops within the first 2 to 3 days of illness. A white or yellowish coating usually precedes the classic red tongue with white papillae.

For more information, read “Papillae on tongue.” J Fam Pract. 2014.

Credit: These cases were adapted from Usatine R, Smith M, Mayeaux EJ, et al, eds. Color Atlas of Family Medicine. 2nd ed. New York, NY: McGraw-Hill; 2013.  You can now get the second edition of the Color Atlas of Family Medicine as an app for mobile devices by clicking this link: usatinemedia.com.

1. A painless white, thick lesion with fissuring had been on the side of this 57-year-old man’s tongue for the past 7 months. The patient drinks two to three beers in the evening and smokes one pack of cigarettes a day.

Diagnosis: This patient was given a diagnosis of leukoplakia and the biopsy indicated that the lesion was premalignant. The World Health Organization defines leukoplakia as “white plaques of questionable risk” in cases where other known diseases that don’t carry an increased risk for cancer have been excluded.  For all types of leukoplakia, the risk of malignant transformation is approximately 1%, with a much higher risk associated with leukoplakias that contain red spots and/or rough spots.

For more information, read “White patch on tongue.” J Fam Pract. 2014.

For the next photograph, proceed to the next page >>

2. This nonhealing painful lesion on the side of her tongue had increased in size recently, and the patient, a 56-year-old homeless woman, was worried because her dad had died from oral cancer. She had smoked since she was 11 and acknowledged being a heavy drinker.

Diagnosis: A punch biopsy revealed that the patient had a squamous cell carcinoma. Fully two-thirds of oropharyngeal cancers (OPCs) will present with advanced disease at the time of diagnosis. Ninety percent of OPCs are of the squamous cell type. Reports in the literature suggest that clinicians may be missing early disease by not conducting thorough soft-tissue examinations on a routine basis. However, the fact that more than 35% of patients do not see a dentist on a routine basis likely contributes to the diagnostic delay. The 5-year survival rate for OPC is 62% for whites and 42% for blacks.

Tobacco use is the major risk factor for OPC and is implicated in approximately 75% of cases. Alcohol use is also a major risk factor. The combined use of tobacco and alcohol increases the risk of OPC far more than either alone. Human papillomavirus (especially HPV 16) is a newly recognized major risk factor for carcinomas affecting the lingual and palatine tonsils.

For more information, read “Lesion on side of tongue.” J Fam Pract. 2014.

For the next photograph, proceed to the next page >>

3. A 58-year-old man sought care for painful sores that had been in his mouth, on and off, for a year. The ulcers erupted on his tongue, gums, buccal mucosa, and inner lips, making it painful to eat. The patient was not taking any medications.

Diagnosis: The clinician recognized his condition as recurrent aphthous ulcers with giant ulcers. Aphthous ulcers are painful ulcerations in the mouth, which can be single, multiple, occasional, or recurrent. These ulcers can be small or large but are uniformly painful and may interfere with eating, speaking, and swallowing.

For more information, read “Lesions on tongue.” J Fam Pract. 2014.

For the next photograph, proceed to the next page >>

4. A 60-year-old man, smelling of alcohol and tobacco, complained of a black discoloration of his tongue and occasional gagging sensation. He smoked one to 2 packs of cigarettes and drank 6 to 8 beers daily. On physical exam, his teeth were stained and his tongue shows elongated papillae with brown discoloration.

Diagnosis: This patient had a black hairy tongue (BHT), poor oral hygiene, and tobacco and alcohol addiction. BHT is a benign disorder of the tongue characterized by abnormally hypertrophied and elongated filiform papillae on the surface of the tongue. In addition, there is defective desquamation of the papillae on the dorsal tongue, resulting in a hair-like appearance. These papillae, which are normally about 1 mm in length, may become as long as 12 mm. The elongated filiform papillae can then collect debris, bacteria, fungus, or other foreign materials.

For more information, read “Discoloration of the tongue.” J Fam Pract. 2014.

For the next photograph, proceed to the next page >>

5. A 5-year-old girl had a temperature of 102.4°F, a sore throat, and a red tongue with prominent papillae. The posterior pharynx was also erythematous with slight exudate visible. The anterior cervical lymph nodes were mildly tender and somewhat enlarged, and no rashes were noted.

Diagnosis: The child had a strawberry tongue and scarlet fever caused by strep pharyngitis. The tongue had prominent papillae along with erythema, making it resemble a strawberry. Strawberry tongue is most commonly seen in children with scarlet fever or Kawasaki disease. Strawberry tongue usually develops within the first 2 to 3 days of illness. A white or yellowish coating usually precedes the classic red tongue with white papillae.

For more information, read “Papillae on tongue.” J Fam Pract. 2014.

Blount disease (tibia vara) is an angular tibia deformity that includes varus, increased posterior slope, and internal rotation. This deformity was first described in 1922 by Erlacher1 in Germany. In 1937, Walter Blount2 reported on it in the United States. It is the most common cause of pathologic genu varum in adolescence and childhood.

An oblique incomplete closing wedge osteotomy of the proximal tibial metaphysis was described by Wagner³ for the treatment of unicompartmental osteoarthrosis of the knee in adults. Laurencin and colleagues⁴ applied this technique to the treatment of pediatric tibia vara with favorable results. They spared the medial cortex of the tibia in their incomplete closing wedge osteotomy technique. In each of the 9 cases we treated and describe here, we accidentally completed the tibial osteotomy when attempting the Laurencin technique. Given that the osteotomy was completed, we modified the Laurencin technique by using a 6-hole, 4.5-mm compression plate rather than a 5-hole semitubular plate, and added a large oblique screw from the medial side to compress the osteotomy site and to protect the plate from fracture. In addition, in 2 patients who weighed more than 250 pounds, we used an external fixator for additional stability. In this article, we report the outcomes of correcting adolescent tibia vara with a complete closing wedge tibial osteotomy and an oblique fibular osteotomy.

Materials and Methods

This study was approved by the Institutional Review Board at Pennsylvania State University. Between 2009 and 2012, we performed 9 complete oblique proximal tibial lateral closing wedge osteotomies on 8 patients (2 girls, 6 boys). In each case, the primary diagnosis was Blount disease. One patient also had renal dysplasia and was receiving dialysis. Mean age at time of operation was 15 years (range, 13-17 years). Mean preoperative weight was 215 pounds (range, 119-317 lb). Mean weight gain at follow-up was 4.39 pounds (range, –10 to 19 lb). Mean body mass index (BMI) was 38 (range, 25-48) (Table). All patients had varus angulation of the proximal tibia before surgery. Mean preoperative varus on standing films was 22° (range, 10°-36°). Because of the patients’ size, we used standing long-leg radiographs, on individual cassettes, for each leg.

Surgical Technique

Before surgery, we use paper cutouts to template the osteotomy wedge. We also use perioperative antibiotics and a standard time-out. For visualization of the entire leg for accurate correction, we prepare and drape the entire leg. A sterile tourniquet is used. At the midshaft of the fibula, a 4-cm incision is made, and dissection is carefully carried down to the fibula. Subperiosteal dissection is performed about the fibula, allowing adequate clearance for an oblique osteotomy. The osteotomy removes about 1 cm of fibula, which is to be used as bone graft for the tibial osteotomy. In addition, a lateral compartment fasciotomy is performed to prevent swelling-related complications. The wound is irrigated and injected with bupivacaine and closed in routine fashion.

We then make an inverted hockey-stick incision over the proximal tibia, centered down to the tibial tubercle. After dissecting down to the anterior compartment, we perform a fasciotomy of about 8 cm to accommodate swelling. Subperiosteal dissection is then performed around the proximal tibia. The medial soft tissues are left attached to increase blood supply and healing. During subperiosteal dissection, soft elevators are used to gently retract the lateral soft tissues along with the inferior and posterior structures. We use fluoroscopic imaging to guide the osteotomy as well as screw and plate placement. We use a 6-hole, 4.5-mm compression plate and screws for fixation. The 2 proximal screws of the plate are predrilled in place to allow for application of the plate after completion of the osteotomy. The plate is then rotated out of position on 1 screw, and the osteotomy is identified under fluoroscopy with the appropriate position distal to the second hole of the 6-hole plate.

An oscillating saw and osteotomes are used to perform the oblique osteotomy. The pre-estimated bone wedge is removed. Wedge size is adjusted, if needed. The bone wedge is morselized for bone graft. The osteotomy is then closed, correcting both varus and internal tibial torsion. Our goal is 5° valgus. After correction is obtained, the plate is placed, and the proximal screw is snugly seated. Three cortical screws are placed distally to hold the plate in place under compression mode, and a cancellous screw is placed superiorly at the proximal portion of the plate for additional fixation. The screw placed proximal to the osteotomy site is a fully threaded cortical screw with excellent compression. Correction and proper placement of hardware are verified with fluoroscopy.

The wound is irrigated and injected with bupivacaine. Bone graft is then placed at the osteotomy site. Additional bone graft is placed posteriorly between the osteotomy site and the muscle mass to stimulate additional healing. Another screw is placed obliquely from the medial side across the osteotomy site to provide additional fixation (Figure 1).

Copyright belongs to the authors

A deep drain is placed and connected to bulb suction for 24 hours after surgery. The wound is then closed in routine fashion. In 2 patients who weighed more than 250 pounds, we used an external fixator for additional stability (Figure 2).

Copyright belongs to the authors

Postoperative Care

The incisions are dressed with antibiotic ointment and 4×4-in bandages and then wrapped with sterile cotton under-cast padding. The leg is placed into a well-padded cylinder cast with the knee flexed 10°. The leg is aligned to about 5° valgus. The cast is then split on the side and spread to allow for swelling and to prevent compartment syndrome.⁵ We also use a drain hooked to bulb suction, which is removed 24 hours after surgery. Toe-touch weight-bearing with crutches is allowed immediately after surgery. The cast is removed at 6 weeks, and a hinged range-of-motion knee brace is worn for another 6 weeks. All patients are allowed to resume normal activity after 4 months. In our 2 external-fixator cases, a cast was not used, and toe-touch weight-bearing and knee motion were allowed immediately. The external fixators were removed at about 10 weeks.

Results

Mean postoperative mechanical femoral-tibial angle was 3°, and mean correction was 26° (range, 16°-43°) (Table). Lateral distal femoral angle did not show significant femoral deformity in our sample. Mean medial proximal tibial angle was 74° (range, 63°-79°). In each case, the varus deformity was primarily in the tibia. Mean tourniquet time was 88 minutes (range, 50-119 min). Our complication rate was 11% (1 knee). In our first case, in which we did not use an extra medial screw, the 4.5-mm plate fractured at the osteotomy site 2.5 months after surgery. The 250-pound patient subsequently lost 17° of correction, and valgus alignment was not achieved. Preoperative varus was 25°, and postoperative alignment was 8° varus. This plate fracture led us to use an extra medial screw for additional stability in all subsequent cases and to consider using an external fixator for patients weighing more than 250 pounds. After the first case, there were no other plate fractures. A potential problem with closing wedge osteotomy is shortening, but varus correction restores some length. Mean postoperative leg-length difference was 10 mm (range, 0-16 mm). No patient complained of leg-length difference during the postoperative follow-up.

Eight and a half months after surgery, 1 patient had hardware removed, at the family’s request. No patient experienced perioperative infection or neurovascular damage. Our overall patient population was obese—mean BMI was 38 (range, 25-48), and mean postoperative weight was 219 pounds. Three of our 8 patients were overweight (BMI, 25-30), and 5 were obese (BMI, >30). For prevention of plate failure, we recommend using an extra oblique screw in all patients and considering an external fixator for patients who weigh more than 250 pounds.

Discussion

Correction of adolescent tibia vara can be challenging because of patient obesity. The technique described here—a modification of the technique of Laurencin and colleagues⁴—is practical and reproducible in this population. The goals in performing osteotomy are to correct the deformity, restore joint alignment, preserve leg length, and prevent recurrent deformity and other complications, such as neurovascular injury, nonunion, and infection.^3,6-8 Our technique minimizes the risk for these complications. For example, the fasciotomy provides excellent decompression of the anterior and lateral compartments, minimizing neurovascular ischemia and the risk for compartment syndrome. During cast placement, splitting and spreading reduce the risk for compartment syndrome as well.⁵

Wagner3,9 demonstrated the utility of a closing wedge proximal tibial osteotomy in adults. Laurencin and colleagues4 showed this technique is effective in correcting tibia vara in a pediatric population. However, they did not specify patient weight and used a small semitubular plate for fixation, and some of their patients had infantile Blount disease. We modified the technique in 3 ways. First, we performed a complete osteotomy. Second, because our patients were adolescents and very large, we used a 6-hole, 4.5-mm compression plate and screws. Third, we used an external fixator for increased stability in patients who weighed more than 250 pounds.

The reported technique, using an oblique metaphyseal closing wedge osteotomy with internal fixation in obese patients, is practical, safe, and reliable. This technique is a useful alternative to an external fixator. We used it on 9 knees with tibia vara, and it was completely successful in 8 cases and partially successful in 1 (hardware breakage occurred). An external fixator was used to prevent hardware breakage in 2 patients who weighed more than 250 pounds. This technique is a valuable treatment option for surgical correction, especially in obese patients.

Blount disease (tibia vara) is an angular tibia deformity that includes varus, increased posterior slope, and internal rotation. This deformity was first described in 1922 by Erlacher1 in Germany. In 1937, Walter Blount2 reported on it in the United States. It is the most common cause of pathologic genu varum in adolescence and childhood.

An oblique incomplete closing wedge osteotomy of the proximal tibial metaphysis was described by Wagner³ for the treatment of unicompartmental osteoarthrosis of the knee in adults. Laurencin and colleagues⁴ applied this technique to the treatment of pediatric tibia vara with favorable results. They spared the medial cortex of the tibia in their incomplete closing wedge osteotomy technique. In each of the 9 cases we treated and describe here, we accidentally completed the tibial osteotomy when attempting the Laurencin technique. Given that the osteotomy was completed, we modified the Laurencin technique by using a 6-hole, 4.5-mm compression plate rather than a 5-hole semitubular plate, and added a large oblique screw from the medial side to compress the osteotomy site and to protect the plate from fracture. In addition, in 2 patients who weighed more than 250 pounds, we used an external fixator for additional stability. In this article, we report the outcomes of correcting adolescent tibia vara with a complete closing wedge tibial osteotomy and an oblique fibular osteotomy.

Materials and Methods

This study was approved by the Institutional Review Board at Pennsylvania State University. Between 2009 and 2012, we performed 9 complete oblique proximal tibial lateral closing wedge osteotomies on 8 patients (2 girls, 6 boys). In each case, the primary diagnosis was Blount disease. One patient also had renal dysplasia and was receiving dialysis. Mean age at time of operation was 15 years (range, 13-17 years). Mean preoperative weight was 215 pounds (range, 119-317 lb). Mean weight gain at follow-up was 4.39 pounds (range, –10 to 19 lb). Mean body mass index (BMI) was 38 (range, 25-48) (Table). All patients had varus angulation of the proximal tibia before surgery. Mean preoperative varus on standing films was 22° (range, 10°-36°). Because of the patients’ size, we used standing long-leg radiographs, on individual cassettes, for each leg.

Surgical Technique

Before surgery, we use paper cutouts to template the osteotomy wedge. We also use perioperative antibiotics and a standard time-out. For visualization of the entire leg for accurate correction, we prepare and drape the entire leg. A sterile tourniquet is used. At the midshaft of the fibula, a 4-cm incision is made, and dissection is carefully carried down to the fibula. Subperiosteal dissection is performed about the fibula, allowing adequate clearance for an oblique osteotomy. The osteotomy removes about 1 cm of fibula, which is to be used as bone graft for the tibial osteotomy. In addition, a lateral compartment fasciotomy is performed to prevent swelling-related complications. The wound is irrigated and injected with bupivacaine and closed in routine fashion.

We then make an inverted hockey-stick incision over the proximal tibia, centered down to the tibial tubercle. After dissecting down to the anterior compartment, we perform a fasciotomy of about 8 cm to accommodate swelling. Subperiosteal dissection is then performed around the proximal tibia. The medial soft tissues are left attached to increase blood supply and healing. During subperiosteal dissection, soft elevators are used to gently retract the lateral soft tissues along with the inferior and posterior structures. We use fluoroscopic imaging to guide the osteotomy as well as screw and plate placement. We use a 6-hole, 4.5-mm compression plate and screws for fixation. The 2 proximal screws of the plate are predrilled in place to allow for application of the plate after completion of the osteotomy. The plate is then rotated out of position on 1 screw, and the osteotomy is identified under fluoroscopy with the appropriate position distal to the second hole of the 6-hole plate.

An oscillating saw and osteotomes are used to perform the oblique osteotomy. The pre-estimated bone wedge is removed. Wedge size is adjusted, if needed. The bone wedge is morselized for bone graft. The osteotomy is then closed, correcting both varus and internal tibial torsion. Our goal is 5° valgus. After correction is obtained, the plate is placed, and the proximal screw is snugly seated. Three cortical screws are placed distally to hold the plate in place under compression mode, and a cancellous screw is placed superiorly at the proximal portion of the plate for additional fixation. The screw placed proximal to the osteotomy site is a fully threaded cortical screw with excellent compression. Correction and proper placement of hardware are verified with fluoroscopy.

The wound is irrigated and injected with bupivacaine. Bone graft is then placed at the osteotomy site. Additional bone graft is placed posteriorly between the osteotomy site and the muscle mass to stimulate additional healing. Another screw is placed obliquely from the medial side across the osteotomy site to provide additional fixation (Figure 1).

Copyright belongs to the authors

A deep drain is placed and connected to bulb suction for 24 hours after surgery. The wound is then closed in routine fashion. In 2 patients who weighed more than 250 pounds, we used an external fixator for additional stability (Figure 2).

Copyright belongs to the authors

Postoperative Care

The incisions are dressed with antibiotic ointment and 4×4-in bandages and then wrapped with sterile cotton under-cast padding. The leg is placed into a well-padded cylinder cast with the knee flexed 10°. The leg is aligned to about 5° valgus. The cast is then split on the side and spread to allow for swelling and to prevent compartment syndrome.⁵ We also use a drain hooked to bulb suction, which is removed 24 hours after surgery. Toe-touch weight-bearing with crutches is allowed immediately after surgery. The cast is removed at 6 weeks, and a hinged range-of-motion knee brace is worn for another 6 weeks. All patients are allowed to resume normal activity after 4 months. In our 2 external-fixator cases, a cast was not used, and toe-touch weight-bearing and knee motion were allowed immediately. The external fixators were removed at about 10 weeks.

Results

Mean postoperative mechanical femoral-tibial angle was 3°, and mean correction was 26° (range, 16°-43°) (Table). Lateral distal femoral angle did not show significant femoral deformity in our sample. Mean medial proximal tibial angle was 74° (range, 63°-79°). In each case, the varus deformity was primarily in the tibia. Mean tourniquet time was 88 minutes (range, 50-119 min). Our complication rate was 11% (1 knee). In our first case, in which we did not use an extra medial screw, the 4.5-mm plate fractured at the osteotomy site 2.5 months after surgery. The 250-pound patient subsequently lost 17° of correction, and valgus alignment was not achieved. Preoperative varus was 25°, and postoperative alignment was 8° varus. This plate fracture led us to use an extra medial screw for additional stability in all subsequent cases and to consider using an external fixator for patients weighing more than 250 pounds. After the first case, there were no other plate fractures. A potential problem with closing wedge osteotomy is shortening, but varus correction restores some length. Mean postoperative leg-length difference was 10 mm (range, 0-16 mm). No patient complained of leg-length difference during the postoperative follow-up.

Eight and a half months after surgery, 1 patient had hardware removed, at the family’s request. No patient experienced perioperative infection or neurovascular damage. Our overall patient population was obese—mean BMI was 38 (range, 25-48), and mean postoperative weight was 219 pounds. Three of our 8 patients were overweight (BMI, 25-30), and 5 were obese (BMI, >30). For prevention of plate failure, we recommend using an extra oblique screw in all patients and considering an external fixator for patients who weigh more than 250 pounds.

Discussion

Correction of adolescent tibia vara can be challenging because of patient obesity. The technique described here—a modification of the technique of Laurencin and colleagues⁴—is practical and reproducible in this population. The goals in performing osteotomy are to correct the deformity, restore joint alignment, preserve leg length, and prevent recurrent deformity and other complications, such as neurovascular injury, nonunion, and infection.^3,6-8 Our technique minimizes the risk for these complications. For example, the fasciotomy provides excellent decompression of the anterior and lateral compartments, minimizing neurovascular ischemia and the risk for compartment syndrome. During cast placement, splitting and spreading reduce the risk for compartment syndrome as well.⁵

Wagner3,9 demonstrated the utility of a closing wedge proximal tibial osteotomy in adults. Laurencin and colleagues4 showed this technique is effective in correcting tibia vara in a pediatric population. However, they did not specify patient weight and used a small semitubular plate for fixation, and some of their patients had infantile Blount disease. We modified the technique in 3 ways. First, we performed a complete osteotomy. Second, because our patients were adolescents and very large, we used a 6-hole, 4.5-mm compression plate and screws. Third, we used an external fixator for increased stability in patients who weighed more than 250 pounds.

The reported technique, using an oblique metaphyseal closing wedge osteotomy with internal fixation in obese patients, is practical, safe, and reliable. This technique is a useful alternative to an external fixator. We used it on 9 knees with tibia vara, and it was completely successful in 8 cases and partially successful in 1 (hardware breakage occurred). An external fixator was used to prevent hardware breakage in 2 patients who weighed more than 250 pounds. This technique is a valuable treatment option for surgical correction, especially in obese patients.

Blount disease (tibia vara) is an angular tibia deformity that includes varus, increased posterior slope, and internal rotation. This deformity was first described in 1922 by Erlacher1 in Germany. In 1937, Walter Blount2 reported on it in the United States. It is the most common cause of pathologic genu varum in adolescence and childhood.

An oblique incomplete closing wedge osteotomy of the proximal tibial metaphysis was described by Wagner³ for the treatment of unicompartmental osteoarthrosis of the knee in adults. Laurencin and colleagues⁴ applied this technique to the treatment of pediatric tibia vara with favorable results. They spared the medial cortex of the tibia in their incomplete closing wedge osteotomy technique. In each of the 9 cases we treated and describe here, we accidentally completed the tibial osteotomy when attempting the Laurencin technique. Given that the osteotomy was completed, we modified the Laurencin technique by using a 6-hole, 4.5-mm compression plate rather than a 5-hole semitubular plate, and added a large oblique screw from the medial side to compress the osteotomy site and to protect the plate from fracture. In addition, in 2 patients who weighed more than 250 pounds, we used an external fixator for additional stability. In this article, we report the outcomes of correcting adolescent tibia vara with a complete closing wedge tibial osteotomy and an oblique fibular osteotomy.

Materials and Methods

This study was approved by the Institutional Review Board at Pennsylvania State University. Between 2009 and 2012, we performed 9 complete oblique proximal tibial lateral closing wedge osteotomies on 8 patients (2 girls, 6 boys). In each case, the primary diagnosis was Blount disease. One patient also had renal dysplasia and was receiving dialysis. Mean age at time of operation was 15 years (range, 13-17 years). Mean preoperative weight was 215 pounds (range, 119-317 lb). Mean weight gain at follow-up was 4.39 pounds (range, –10 to 19 lb). Mean body mass index (BMI) was 38 (range, 25-48) (Table). All patients had varus angulation of the proximal tibia before surgery. Mean preoperative varus on standing films was 22° (range, 10°-36°). Because of the patients’ size, we used standing long-leg radiographs, on individual cassettes, for each leg.

Surgical Technique

Before surgery, we use paper cutouts to template the osteotomy wedge. We also use perioperative antibiotics and a standard time-out. For visualization of the entire leg for accurate correction, we prepare and drape the entire leg. A sterile tourniquet is used. At the midshaft of the fibula, a 4-cm incision is made, and dissection is carefully carried down to the fibula. Subperiosteal dissection is performed about the fibula, allowing adequate clearance for an oblique osteotomy. The osteotomy removes about 1 cm of fibula, which is to be used as bone graft for the tibial osteotomy. In addition, a lateral compartment fasciotomy is performed to prevent swelling-related complications. The wound is irrigated and injected with bupivacaine and closed in routine fashion.

We then make an inverted hockey-stick incision over the proximal tibia, centered down to the tibial tubercle. After dissecting down to the anterior compartment, we perform a fasciotomy of about 8 cm to accommodate swelling. Subperiosteal dissection is then performed around the proximal tibia. The medial soft tissues are left attached to increase blood supply and healing. During subperiosteal dissection, soft elevators are used to gently retract the lateral soft tissues along with the inferior and posterior structures. We use fluoroscopic imaging to guide the osteotomy as well as screw and plate placement. We use a 6-hole, 4.5-mm compression plate and screws for fixation. The 2 proximal screws of the plate are predrilled in place to allow for application of the plate after completion of the osteotomy. The plate is then rotated out of position on 1 screw, and the osteotomy is identified under fluoroscopy with the appropriate position distal to the second hole of the 6-hole plate.

An oscillating saw and osteotomes are used to perform the oblique osteotomy. The pre-estimated bone wedge is removed. Wedge size is adjusted, if needed. The bone wedge is morselized for bone graft. The osteotomy is then closed, correcting both varus and internal tibial torsion. Our goal is 5° valgus. After correction is obtained, the plate is placed, and the proximal screw is snugly seated. Three cortical screws are placed distally to hold the plate in place under compression mode, and a cancellous screw is placed superiorly at the proximal portion of the plate for additional fixation. The screw placed proximal to the osteotomy site is a fully threaded cortical screw with excellent compression. Correction and proper placement of hardware are verified with fluoroscopy.

The wound is irrigated and injected with bupivacaine. Bone graft is then placed at the osteotomy site. Additional bone graft is placed posteriorly between the osteotomy site and the muscle mass to stimulate additional healing. Another screw is placed obliquely from the medial side across the osteotomy site to provide additional fixation (Figure 1).

Copyright belongs to the authors

A deep drain is placed and connected to bulb suction for 24 hours after surgery. The wound is then closed in routine fashion. In 2 patients who weighed more than 250 pounds, we used an external fixator for additional stability (Figure 2).

Copyright belongs to the authors

Postoperative Care

The incisions are dressed with antibiotic ointment and 4×4-in bandages and then wrapped with sterile cotton under-cast padding. The leg is placed into a well-padded cylinder cast with the knee flexed 10°. The leg is aligned to about 5° valgus. The cast is then split on the side and spread to allow for swelling and to prevent compartment syndrome.⁵ We also use a drain hooked to bulb suction, which is removed 24 hours after surgery. Toe-touch weight-bearing with crutches is allowed immediately after surgery. The cast is removed at 6 weeks, and a hinged range-of-motion knee brace is worn for another 6 weeks. All patients are allowed to resume normal activity after 4 months. In our 2 external-fixator cases, a cast was not used, and toe-touch weight-bearing and knee motion were allowed immediately. The external fixators were removed at about 10 weeks.

Results

Mean postoperative mechanical femoral-tibial angle was 3°, and mean correction was 26° (range, 16°-43°) (Table). Lateral distal femoral angle did not show significant femoral deformity in our sample. Mean medial proximal tibial angle was 74° (range, 63°-79°). In each case, the varus deformity was primarily in the tibia. Mean tourniquet time was 88 minutes (range, 50-119 min). Our complication rate was 11% (1 knee). In our first case, in which we did not use an extra medial screw, the 4.5-mm plate fractured at the osteotomy site 2.5 months after surgery. The 250-pound patient subsequently lost 17° of correction, and valgus alignment was not achieved. Preoperative varus was 25°, and postoperative alignment was 8° varus. This plate fracture led us to use an extra medial screw for additional stability in all subsequent cases and to consider using an external fixator for patients weighing more than 250 pounds. After the first case, there were no other plate fractures. A potential problem with closing wedge osteotomy is shortening, but varus correction restores some length. Mean postoperative leg-length difference was 10 mm (range, 0-16 mm). No patient complained of leg-length difference during the postoperative follow-up.

Eight and a half months after surgery, 1 patient had hardware removed, at the family’s request. No patient experienced perioperative infection or neurovascular damage. Our overall patient population was obese—mean BMI was 38 (range, 25-48), and mean postoperative weight was 219 pounds. Three of our 8 patients were overweight (BMI, 25-30), and 5 were obese (BMI, >30). For prevention of plate failure, we recommend using an extra oblique screw in all patients and considering an external fixator for patients who weigh more than 250 pounds.

Discussion

Correction of adolescent tibia vara can be challenging because of patient obesity. The technique described here—a modification of the technique of Laurencin and colleagues⁴—is practical and reproducible in this population. The goals in performing osteotomy are to correct the deformity, restore joint alignment, preserve leg length, and prevent recurrent deformity and other complications, such as neurovascular injury, nonunion, and infection.^3,6-8 Our technique minimizes the risk for these complications. For example, the fasciotomy provides excellent decompression of the anterior and lateral compartments, minimizing neurovascular ischemia and the risk for compartment syndrome. During cast placement, splitting and spreading reduce the risk for compartment syndrome as well.⁵

Wagner3,9 demonstrated the utility of a closing wedge proximal tibial osteotomy in adults. Laurencin and colleagues4 showed this technique is effective in correcting tibia vara in a pediatric population. However, they did not specify patient weight and used a small semitubular plate for fixation, and some of their patients had infantile Blount disease. We modified the technique in 3 ways. First, we performed a complete osteotomy. Second, because our patients were adolescents and very large, we used a 6-hole, 4.5-mm compression plate and screws. Third, we used an external fixator for increased stability in patients who weighed more than 250 pounds.

The reported technique, using an oblique metaphyseal closing wedge osteotomy with internal fixation in obese patients, is practical, safe, and reliable. This technique is a useful alternative to an external fixator. We used it on 9 knees with tibia vara, and it was completely successful in 8 cases and partially successful in 1 (hardware breakage occurred). An external fixator was used to prevent hardware breakage in 2 patients who weighed more than 250 pounds. This technique is a valuable treatment option for surgical correction, especially in obese patients.

LAKE BUENA VISTA, FLA. – When making diagnostic and treatment decisions about thyroid nodules, many endocrinologists are not following current clinical practice guidelines, according to a recent survey. Further, according to a recent international survey of endocrinologists, there is wide regional variation in the use of molecular testing and calcitonin levels.

Dr. Nicole Vietor of the department of endocrinology at Walter Reed National Military Medical Center, Bethesda, Md., and her collaborators contacted members of the American Thyroid Association (ATA), the Endocrine Society (TES), and the American Association of Clinical Endocrinologists (AACE). Members of these societies were contacted directly by investigators and asked to complete a web-based survey regarding their practices for diagnosing and managing thyroid nodules.

©Nevit Dilmen/Wikimedia Commons/CC SA 3.0

The survey consisted of 36 questions, with an index case with variations presented to respondents, who then answered questions about diagnostic and management decisionmaking practices. The hypothetical index patient was a 52 year old woman with an incidental finding of a 1.5 cm right thyroid nodule. The patient was healthy and without risk factors; the patient’s nodule was not palpable on physical exam and she had no cervical lymphadenopathy.

Almost all respondents (99.4%) would order a thyroid-stimulating hormone for initial lab testing. Other commonly ordered exams included free T4 levels and thyroid peroxidase antibody requested by 41.5% and 24.3% of respondents, respectively. Fewer than 15% of respondents would have ordered any further lab exams.

All but 1.5% of respondents would order an anatomic or functional test for this index patient, with 57.2% ordering a thyroid ultrasound to be performed in radiology and 52.1% ordering an ultrasound in clinic (multiple responses were permitted). Cervical lymph nodes were included in the initial ultrasound assessment by 68.5% of respondents. Overall, more than half (56.6%) of thyroid ultrasounds were performed by endocrinologists, and about a third (31.9%) done by radiologists.

Practice variation from guidelines became apparent when respondents were asked how various nodule characteristics affected the decision to perform a fine needle aspiration (FNA). For a 1.5-cm solid hypoechoic nodule, 93.8% of respondents would perform FNA, while two thirds (67.0%) would perform an FNA for a 0.7-cm hypoechoic nodule with microcalcifications.

When performing FNAs, 83.3% of respondents use ultrasound to guide the biopsy, with most operators performing two (19.2%), three (28.5%), or four (23.0%) passes per nodule.

Of the 897 respondents, 80.5% were TES members, 56.5% were AACE members, and 44.5% were ATA members; most respondents belonged to more than one society. Almost two thirds of respondents (63.0%) were from North America, while 12.2% were from Europe, 10.8% were from Latin America, 6.5% were from Asia, 5.6% were from the Middle East or Africa, and just 1.9% were from Oceania. More men (60.2%) than women responded.

The AACE issued clinical practice guidelines for the management of thyroid nodules in 2010, as did the ATA in 2009 and 2015.

“In summary, management of a thyroid nodule is highly variable and differs from societal guidelines in multiple areas,” wrote Dr. Vietor and her colleagues in the presentation abstract.

[email protected]

On Twitter @karioakes

LAKE BUENA VISTA, FLA. – When making diagnostic and treatment decisions about thyroid nodules, many endocrinologists are not following current clinical practice guidelines, according to a recent survey. Further, according to a recent international survey of endocrinologists, there is wide regional variation in the use of molecular testing and calcitonin levels.

Dr. Nicole Vietor of the department of endocrinology at Walter Reed National Military Medical Center, Bethesda, Md., and her collaborators contacted members of the American Thyroid Association (ATA), the Endocrine Society (TES), and the American Association of Clinical Endocrinologists (AACE). Members of these societies were contacted directly by investigators and asked to complete a web-based survey regarding their practices for diagnosing and managing thyroid nodules.

©Nevit Dilmen/Wikimedia Commons/CC SA 3.0

The survey consisted of 36 questions, with an index case with variations presented to respondents, who then answered questions about diagnostic and management decisionmaking practices. The hypothetical index patient was a 52 year old woman with an incidental finding of a 1.5 cm right thyroid nodule. The patient was healthy and without risk factors; the patient’s nodule was not palpable on physical exam and she had no cervical lymphadenopathy.

Almost all respondents (99.4%) would order a thyroid-stimulating hormone for initial lab testing. Other commonly ordered exams included free T4 levels and thyroid peroxidase antibody requested by 41.5% and 24.3% of respondents, respectively. Fewer than 15% of respondents would have ordered any further lab exams.

All but 1.5% of respondents would order an anatomic or functional test for this index patient, with 57.2% ordering a thyroid ultrasound to be performed in radiology and 52.1% ordering an ultrasound in clinic (multiple responses were permitted). Cervical lymph nodes were included in the initial ultrasound assessment by 68.5% of respondents. Overall, more than half (56.6%) of thyroid ultrasounds were performed by endocrinologists, and about a third (31.9%) done by radiologists.

Practice variation from guidelines became apparent when respondents were asked how various nodule characteristics affected the decision to perform a fine needle aspiration (FNA). For a 1.5-cm solid hypoechoic nodule, 93.8% of respondents would perform FNA, while two thirds (67.0%) would perform an FNA for a 0.7-cm hypoechoic nodule with microcalcifications.

When performing FNAs, 83.3% of respondents use ultrasound to guide the biopsy, with most operators performing two (19.2%), three (28.5%), or four (23.0%) passes per nodule.

Of the 897 respondents, 80.5% were TES members, 56.5% were AACE members, and 44.5% were ATA members; most respondents belonged to more than one society. Almost two thirds of respondents (63.0%) were from North America, while 12.2% were from Europe, 10.8% were from Latin America, 6.5% were from Asia, 5.6% were from the Middle East or Africa, and just 1.9% were from Oceania. More men (60.2%) than women responded.

The AACE issued clinical practice guidelines for the management of thyroid nodules in 2010, as did the ATA in 2009 and 2015.

“In summary, management of a thyroid nodule is highly variable and differs from societal guidelines in multiple areas,” wrote Dr. Vietor and her colleagues in the presentation abstract.

[email protected]

On Twitter @karioakes

LAKE BUENA VISTA, FLA. – When making diagnostic and treatment decisions about thyroid nodules, many endocrinologists are not following current clinical practice guidelines, according to a recent survey. Further, according to a recent international survey of endocrinologists, there is wide regional variation in the use of molecular testing and calcitonin levels.

Dr. Nicole Vietor of the department of endocrinology at Walter Reed National Military Medical Center, Bethesda, Md., and her collaborators contacted members of the American Thyroid Association (ATA), the Endocrine Society (TES), and the American Association of Clinical Endocrinologists (AACE). Members of these societies were contacted directly by investigators and asked to complete a web-based survey regarding their practices for diagnosing and managing thyroid nodules.

©Nevit Dilmen/Wikimedia Commons/CC SA 3.0

The survey consisted of 36 questions, with an index case with variations presented to respondents, who then answered questions about diagnostic and management decisionmaking practices. The hypothetical index patient was a 52 year old woman with an incidental finding of a 1.5 cm right thyroid nodule. The patient was healthy and without risk factors; the patient’s nodule was not palpable on physical exam and she had no cervical lymphadenopathy.

Almost all respondents (99.4%) would order a thyroid-stimulating hormone for initial lab testing. Other commonly ordered exams included free T4 levels and thyroid peroxidase antibody requested by 41.5% and 24.3% of respondents, respectively. Fewer than 15% of respondents would have ordered any further lab exams.

All but 1.5% of respondents would order an anatomic or functional test for this index patient, with 57.2% ordering a thyroid ultrasound to be performed in radiology and 52.1% ordering an ultrasound in clinic (multiple responses were permitted). Cervical lymph nodes were included in the initial ultrasound assessment by 68.5% of respondents. Overall, more than half (56.6%) of thyroid ultrasounds were performed by endocrinologists, and about a third (31.9%) done by radiologists.

Practice variation from guidelines became apparent when respondents were asked how various nodule characteristics affected the decision to perform a fine needle aspiration (FNA). For a 1.5-cm solid hypoechoic nodule, 93.8% of respondents would perform FNA, while two thirds (67.0%) would perform an FNA for a 0.7-cm hypoechoic nodule with microcalcifications.

When performing FNAs, 83.3% of respondents use ultrasound to guide the biopsy, with most operators performing two (19.2%), three (28.5%), or four (23.0%) passes per nodule.

Of the 897 respondents, 80.5% were TES members, 56.5% were AACE members, and 44.5% were ATA members; most respondents belonged to more than one society. Almost two thirds of respondents (63.0%) were from North America, while 12.2% were from Europe, 10.8% were from Latin America, 6.5% were from Asia, 5.6% were from the Middle East or Africa, and just 1.9% were from Oceania. More men (60.2%) than women responded.

The AACE issued clinical practice guidelines for the management of thyroid nodules in 2010, as did the ATA in 2009 and 2015.

“In summary, management of a thyroid nodule is highly variable and differs from societal guidelines in multiple areas,” wrote Dr. Vietor and her colleagues in the presentation abstract.

[email protected]

On Twitter @karioakes