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Peramivir effective against most flu viruses circulating globally
SAN DIEGO – The neuraminidase inhibitor peramivir inhibited about 99% of seasonal influenza A and B viruses circulating globally during the 2013-2014 and 2014-2015 influenza seasons, a large analysis demonstrated.
“The frequency of H1N1pdm09 viruses carrying neuraminidase (NA) H275Y remained low during both seasons; this mutation confers resistance to oseltamivir and peramivir,” said Margaret Okomo-Adhiambo, Ph.D., at the annual Interscience Conference on Antimicrobial Agents and Chemotherapy. In addition, “a small proportion of viruses contained other neuraminidase changes that affect binding of peramivir to viral enzymes and may decrease virus susceptibility. These changes need to be closely monitored.”
Approved by the FDA in December of 2014, peramivir (Rapivab) is the only antiviral agent for influenza treatment to come to market in nearly 20 years. Approved for intravenous administration as a single dose, it is indicated for adults with acute uncomplicated influenza who may have trouble taking orally administered or inhaled neuraminidase (NA) inhibitors. Other NA inhibitors approved by the FDA for influenza infection include oseltamivir, which is orally administered, and zanamivir, which is inhaled.
For the current analysis, Dr. Okomo-Adhiambo of the influenza division at the Centers for Disease Control and Prevention, Atlanta, and her associates tested influenza virus susceptibility to peramivir during the 2013-2014 and 2014-2015 influenza seasons as part of the World Health Organization Global Influenza Surveillance and Response System. A total of 8,426 viruses were tested, 75% of which were circulating in the United States.
Dr. Okomo-Adhiambo reported that during the 2013-2014 and 2014-2015 influenza seasons, about 99% of influenza type A and B viruses were inhibited by peramivir, except for a few viruses belonging to subtype A(H1N1)pdm09 (1.5%), subtype A(H3N2) (0.2%), and type B (0.4%). In addition, NA activity of type A viruses was five to six times more sensitive to inhibition by peramivir, compared with type B NA.
She concluded her presentation by noting that studies “are needed to establish molecular markers of clinically relevant resistance to peramivir.”
The researchers reported having no financial disclosures.
SAN DIEGO – The neuraminidase inhibitor peramivir inhibited about 99% of seasonal influenza A and B viruses circulating globally during the 2013-2014 and 2014-2015 influenza seasons, a large analysis demonstrated.
“The frequency of H1N1pdm09 viruses carrying neuraminidase (NA) H275Y remained low during both seasons; this mutation confers resistance to oseltamivir and peramivir,” said Margaret Okomo-Adhiambo, Ph.D., at the annual Interscience Conference on Antimicrobial Agents and Chemotherapy. In addition, “a small proportion of viruses contained other neuraminidase changes that affect binding of peramivir to viral enzymes and may decrease virus susceptibility. These changes need to be closely monitored.”
Approved by the FDA in December of 2014, peramivir (Rapivab) is the only antiviral agent for influenza treatment to come to market in nearly 20 years. Approved for intravenous administration as a single dose, it is indicated for adults with acute uncomplicated influenza who may have trouble taking orally administered or inhaled neuraminidase (NA) inhibitors. Other NA inhibitors approved by the FDA for influenza infection include oseltamivir, which is orally administered, and zanamivir, which is inhaled.
For the current analysis, Dr. Okomo-Adhiambo of the influenza division at the Centers for Disease Control and Prevention, Atlanta, and her associates tested influenza virus susceptibility to peramivir during the 2013-2014 and 2014-2015 influenza seasons as part of the World Health Organization Global Influenza Surveillance and Response System. A total of 8,426 viruses were tested, 75% of which were circulating in the United States.
Dr. Okomo-Adhiambo reported that during the 2013-2014 and 2014-2015 influenza seasons, about 99% of influenza type A and B viruses were inhibited by peramivir, except for a few viruses belonging to subtype A(H1N1)pdm09 (1.5%), subtype A(H3N2) (0.2%), and type B (0.4%). In addition, NA activity of type A viruses was five to six times more sensitive to inhibition by peramivir, compared with type B NA.
She concluded her presentation by noting that studies “are needed to establish molecular markers of clinically relevant resistance to peramivir.”
The researchers reported having no financial disclosures.
SAN DIEGO – The neuraminidase inhibitor peramivir inhibited about 99% of seasonal influenza A and B viruses circulating globally during the 2013-2014 and 2014-2015 influenza seasons, a large analysis demonstrated.
“The frequency of H1N1pdm09 viruses carrying neuraminidase (NA) H275Y remained low during both seasons; this mutation confers resistance to oseltamivir and peramivir,” said Margaret Okomo-Adhiambo, Ph.D., at the annual Interscience Conference on Antimicrobial Agents and Chemotherapy. In addition, “a small proportion of viruses contained other neuraminidase changes that affect binding of peramivir to viral enzymes and may decrease virus susceptibility. These changes need to be closely monitored.”
Approved by the FDA in December of 2014, peramivir (Rapivab) is the only antiviral agent for influenza treatment to come to market in nearly 20 years. Approved for intravenous administration as a single dose, it is indicated for adults with acute uncomplicated influenza who may have trouble taking orally administered or inhaled neuraminidase (NA) inhibitors. Other NA inhibitors approved by the FDA for influenza infection include oseltamivir, which is orally administered, and zanamivir, which is inhaled.
For the current analysis, Dr. Okomo-Adhiambo of the influenza division at the Centers for Disease Control and Prevention, Atlanta, and her associates tested influenza virus susceptibility to peramivir during the 2013-2014 and 2014-2015 influenza seasons as part of the World Health Organization Global Influenza Surveillance and Response System. A total of 8,426 viruses were tested, 75% of which were circulating in the United States.
Dr. Okomo-Adhiambo reported that during the 2013-2014 and 2014-2015 influenza seasons, about 99% of influenza type A and B viruses were inhibited by peramivir, except for a few viruses belonging to subtype A(H1N1)pdm09 (1.5%), subtype A(H3N2) (0.2%), and type B (0.4%). In addition, NA activity of type A viruses was five to six times more sensitive to inhibition by peramivir, compared with type B NA.
She concluded her presentation by noting that studies “are needed to establish molecular markers of clinically relevant resistance to peramivir.”
The researchers reported having no financial disclosures.
AT ICAAC 2015
Key clinical point: Peramivir is potently effective against seasonal influenza viruses circulating globally.
Major finding: During the 2013-2014 and 2014-2015 influenza seasons, about 99% of influenza type A and B viruses were inhibited by peramivir.
Data source: An analysis of 8,426 influenza viruses that were tested during the 2013-2014 and 2014-2015 influenza seasons as part of the World Health Organization Global Influenza Surveillance and Response System.
Disclosures: The researchers reporting having no financial disclosures.
Reattaching intercostals fails to squelch spinal cord ischemia in TAAA repairs
CHICAGO – Intercostal artery reimplantation fails to significantly reduce spinal cord injury following thoracoabdominal aortic aneurysm surgery, results of a large retrospective study show.
“Although there was a small decrease in spinal cord ischemia with ICAR, reattaching the intercostals did not produce a statistically significant reduction in spinal cord ischemia, even in the highest risk patients,” Dr. Charles W. Acher of the University of Wisconsin–Madison, said at the annual meeting of the Midwestern Vascular Surgical Society.
Intercostal artery reimplantation (ICAR) is one of several strategies that have been used to prevent spinal cord ischemia (SCI), paraplegia, and paraparesis that occurs from the interruption of the blood supply to intercostal arteries (ICAs) during thoracoabdominal aortic aneurysm (TAAA) repair.
Surgeons at UW–Madison adopted the ICAR strategy in 2005and now reimplant open ICAs located at T7-L2 in all Type I, II, and III TAAAs, using a previously published technique (J Surg Res. 2009;154:99-104).
Using a prospectively maintained database, the current analysis sought to compare outcomes between 540 patients who had TAAA surgery during 1989-2004 when open ICAs were ligated and 265 patients who had surgery during 2005-2013 with ICAR.The surgical technique for both groups was cross clamp without assisted circulation. The anesthetic technique was also uniform during the study period and included moderate systemic hypothermia (32° - 33° C); spinal fluid drainage (spinal fluid pressure less than 5 mm Hg); naloxone 1 mcg/kg per hour; use of mannitol, methylprednisolone, and barbiturate burst suppression; goal-directed therapy for a mean arterial pressure of 90-100 mm Hg and cardiac index of 2.5 L per minute/meter2; and proactive component blood therapy to avoid anemia, hypovolemia, and hypertension.
Aneurysm extent, acuity, mortality, renal failure, and pulmonary failure were the same in both groups.
The incidence of SCI was similar in all TAAAs at 5.25% without ICAR and 3.4% with ICAR (P = .23) and in the subset of patients with Type I, II, and III aneurysms (8.8% vs. 5.1%; P = .152), Dr. Acher reported on behalf of lead author and his colleague, Dr. Martha M. Wynn.
Interestingly, ICAR patients had more dissections than did the open ICA ligation patients (18% vs. 15%; P = .0016), more previous aortic surgery (47% vs. 31%; P = .0004), and longer renal ischemia time (61 minutes vs. 53 minutes; P = .0001), but had a shorter length of stay (14 days vs. 22 days; P = .0001) and were younger (mean age, 66 years vs. 70 years; P = .0001).
In a multivariate model of all TAAAs, significant predictors of spinal cord ischemia/injury were type II TAAA (odds ratio, 7.59; P = .0001), dissection (OR, 4.25; P = .0015), age as a continuous variable (P = .0085), and acute TAAA (OR, 2.1; P = .0525), Dr. Acher said. Time period of surgery, and therefore ICAR, was not significant (OR, 0.78; P = .55).
ICAR also failed to achieve significance as an SCI predictor in a subanalysis restricted to the highest-risk patients, defined as those having Type II TAAA, dissection, and acute surgery (OR, 0.67; P = .3387).
“Interrupting blood supply to the spinal cord causes spinal cord ischemia that can be mitigated almost entirely by physiologic interventions that increase spinal cord ischemic tolerance and collateral network perfusion during and after surgery,” Dr. Acher said. “Although the cause of SCI in TAAA surgery is anatomic, prevention of the injury is largely physiologic.”
During a discussion of the study, Dr. Acher surprised the audience by saying the findings have not changed current practice at the university. He cited several reasons, observing that there were more dissections in the ICAR group, and most of the ischemia in the ICAR group was delayed, suggesting that more patients could be rescued. In addition, there was a slight downward trend in spinal cord injury and immediate paraplegia with ICAR, however, these were not statistically significant.
“Because of those things, I still think it’s valuable, particularly in patients that are at highest risk, which are the dissections, with lots of open intercostals, but the emphasis should still be on physiologic parameters,” he said. “If you want to salvage patients, that’s the most important thing.
“Even if ICAR were ever shown to be statistically significant in a larger patient population, any role it has in reducing spinal cord injury would be extremely small,” he added in an interview.
The authors reported having no conflicts of interest.
Spinal cord ischemia is a rare but devastating complication of thoracoabdominal aneurysm repair. Crawford and his colleagues documented in 1993 an incidence of spinal cord ischemia (SCI) as high as 30% for extensive thoracoabdominal repairs. Efforts to diminish the risk of SCI were concentrated in identifying and preserving the direct arterial perfusion to the spinal cord from segmental arteries but continued experimental and clinical experience have suggested that multiple factors contribute to SCI.
 |
Dr. Luis A. Sanchez |
Some generally accepted principles for minimizing SCI include hypothermia, distal aortic perfusion with atriofemoral bypass or partial cardiopulmonary bypass, cerebrospinal fluid drainage, and avoidance of hemodynamic instability. Reimplantation of intercostal branches has been suggested as an adjunct to these techniques by some investigators with limited data to support its generalized application. More recently, a growing body of evidence supports the concept of a collateral network that can support the perfusion to the spinal cord after interruption of multiple intercostal arteries and the importance of the hypogastric and subclavian arteries as critical branches that perfuse the spinal collateral network.
The retrospective review of the extensive experience at the University of Wisconsin in Madison supports the concept that “physiologic interventions that increase spinal cord tolerance and collateral network perfusion during and after surgery” are more important than the reimplantation of intercostal vessels during this complex procedure, even in patients considered at the highest risk for SCI. Intercostal artery reimplantation failed to achieve significance as an SCI predictor when comparing two large cohorts of patients (540 vs. 265) treated with intercostal ligation vs. reimplantation. Increasingly, available data support the concept of a collateral network that maintains perfusion to the spinal cord after intercostal artery occlusion.
Additional new concepts and techniques including a two-stage approach for extensive thoracoabdominal repair, preliminary occlusion of some segmental arteries, and the use of hybrid and endovascular techniques may further decrease the incidence of SCI by taking advantage of the collateral network and allow some preconditioning of the spinal cord. Fortunately for these challenging patients, significant advances continue to be made to better understand and prevent spinal cord ischemia.
Dr. Luis A. Sanchez is Chief, Section of Vascular Surgery and the Gregorio A. Sicard Distinguished Professor of Surgery and Radiology, Department of Surgery, Washington University in St. Louis.
Spinal cord ischemia is a rare but devastating complication of thoracoabdominal aneurysm repair. Crawford and his colleagues documented in 1993 an incidence of spinal cord ischemia (SCI) as high as 30% for extensive thoracoabdominal repairs. Efforts to diminish the risk of SCI were concentrated in identifying and preserving the direct arterial perfusion to the spinal cord from segmental arteries but continued experimental and clinical experience have suggested that multiple factors contribute to SCI.
|
Dr. Luis A. Sanchez |
Some generally accepted principles for minimizing SCI include hypothermia, distal aortic perfusion with atriofemoral bypass or partial cardiopulmonary bypass, cerebrospinal fluid drainage, and avoidance of hemodynamic instability. Reimplantation of intercostal branches has been suggested as an adjunct to these techniques by some investigators with limited data to support its generalized application. More recently, a growing body of evidence supports the concept of a collateral network that can support the perfusion to the spinal cord after interruption of multiple intercostal arteries and the importance of the hypogastric and subclavian arteries as critical branches that perfuse the spinal collateral network.
The retrospective review of the extensive experience at the University of Wisconsin in Madison supports the concept that “physiologic interventions that increase spinal cord tolerance and collateral network perfusion during and after surgery” are more important than the reimplantation of intercostal vessels during this complex procedure, even in patients considered at the highest risk for SCI. Intercostal artery reimplantation failed to achieve significance as an SCI predictor when comparing two large cohorts of patients (540 vs. 265) treated with intercostal ligation vs. reimplantation. Increasingly, available data support the concept of a collateral network that maintains perfusion to the spinal cord after intercostal artery occlusion.
Additional new concepts and techniques including a two-stage approach for extensive thoracoabdominal repair, preliminary occlusion of some segmental arteries, and the use of hybrid and endovascular techniques may further decrease the incidence of SCI by taking advantage of the collateral network and allow some preconditioning of the spinal cord. Fortunately for these challenging patients, significant advances continue to be made to better understand and prevent spinal cord ischemia.
Dr. Luis A. Sanchez is Chief, Section of Vascular Surgery and the Gregorio A. Sicard Distinguished Professor of Surgery and Radiology, Department of Surgery, Washington University in St. Louis.
Spinal cord ischemia is a rare but devastating complication of thoracoabdominal aneurysm repair. Crawford and his colleagues documented in 1993 an incidence of spinal cord ischemia (SCI) as high as 30% for extensive thoracoabdominal repairs. Efforts to diminish the risk of SCI were concentrated in identifying and preserving the direct arterial perfusion to the spinal cord from segmental arteries but continued experimental and clinical experience have suggested that multiple factors contribute to SCI.
|
Dr. Luis A. Sanchez |
Some generally accepted principles for minimizing SCI include hypothermia, distal aortic perfusion with atriofemoral bypass or partial cardiopulmonary bypass, cerebrospinal fluid drainage, and avoidance of hemodynamic instability. Reimplantation of intercostal branches has been suggested as an adjunct to these techniques by some investigators with limited data to support its generalized application. More recently, a growing body of evidence supports the concept of a collateral network that can support the perfusion to the spinal cord after interruption of multiple intercostal arteries and the importance of the hypogastric and subclavian arteries as critical branches that perfuse the spinal collateral network.
The retrospective review of the extensive experience at the University of Wisconsin in Madison supports the concept that “physiologic interventions that increase spinal cord tolerance and collateral network perfusion during and after surgery” are more important than the reimplantation of intercostal vessels during this complex procedure, even in patients considered at the highest risk for SCI. Intercostal artery reimplantation failed to achieve significance as an SCI predictor when comparing two large cohorts of patients (540 vs. 265) treated with intercostal ligation vs. reimplantation. Increasingly, available data support the concept of a collateral network that maintains perfusion to the spinal cord after intercostal artery occlusion.
Additional new concepts and techniques including a two-stage approach for extensive thoracoabdominal repair, preliminary occlusion of some segmental arteries, and the use of hybrid and endovascular techniques may further decrease the incidence of SCI by taking advantage of the collateral network and allow some preconditioning of the spinal cord. Fortunately for these challenging patients, significant advances continue to be made to better understand and prevent spinal cord ischemia.
Dr. Luis A. Sanchez is Chief, Section of Vascular Surgery and the Gregorio A. Sicard Distinguished Professor of Surgery and Radiology, Department of Surgery, Washington University in St. Louis.
CHICAGO – Intercostal artery reimplantation fails to significantly reduce spinal cord injury following thoracoabdominal aortic aneurysm surgery, results of a large retrospective study show.
“Although there was a small decrease in spinal cord ischemia with ICAR, reattaching the intercostals did not produce a statistically significant reduction in spinal cord ischemia, even in the highest risk patients,” Dr. Charles W. Acher of the University of Wisconsin–Madison, said at the annual meeting of the Midwestern Vascular Surgical Society.
Intercostal artery reimplantation (ICAR) is one of several strategies that have been used to prevent spinal cord ischemia (SCI), paraplegia, and paraparesis that occurs from the interruption of the blood supply to intercostal arteries (ICAs) during thoracoabdominal aortic aneurysm (TAAA) repair.
Surgeons at UW–Madison adopted the ICAR strategy in 2005and now reimplant open ICAs located at T7-L2 in all Type I, II, and III TAAAs, using a previously published technique (J Surg Res. 2009;154:99-104).
Using a prospectively maintained database, the current analysis sought to compare outcomes between 540 patients who had TAAA surgery during 1989-2004 when open ICAs were ligated and 265 patients who had surgery during 2005-2013 with ICAR.The surgical technique for both groups was cross clamp without assisted circulation. The anesthetic technique was also uniform during the study period and included moderate systemic hypothermia (32° - 33° C); spinal fluid drainage (spinal fluid pressure less than 5 mm Hg); naloxone 1 mcg/kg per hour; use of mannitol, methylprednisolone, and barbiturate burst suppression; goal-directed therapy for a mean arterial pressure of 90-100 mm Hg and cardiac index of 2.5 L per minute/meter2; and proactive component blood therapy to avoid anemia, hypovolemia, and hypertension.
Aneurysm extent, acuity, mortality, renal failure, and pulmonary failure were the same in both groups.
The incidence of SCI was similar in all TAAAs at 5.25% without ICAR and 3.4% with ICAR (P = .23) and in the subset of patients with Type I, II, and III aneurysms (8.8% vs. 5.1%; P = .152), Dr. Acher reported on behalf of lead author and his colleague, Dr. Martha M. Wynn.
Interestingly, ICAR patients had more dissections than did the open ICA ligation patients (18% vs. 15%; P = .0016), more previous aortic surgery (47% vs. 31%; P = .0004), and longer renal ischemia time (61 minutes vs. 53 minutes; P = .0001), but had a shorter length of stay (14 days vs. 22 days; P = .0001) and were younger (mean age, 66 years vs. 70 years; P = .0001).
In a multivariate model of all TAAAs, significant predictors of spinal cord ischemia/injury were type II TAAA (odds ratio, 7.59; P = .0001), dissection (OR, 4.25; P = .0015), age as a continuous variable (P = .0085), and acute TAAA (OR, 2.1; P = .0525), Dr. Acher said. Time period of surgery, and therefore ICAR, was not significant (OR, 0.78; P = .55).
ICAR also failed to achieve significance as an SCI predictor in a subanalysis restricted to the highest-risk patients, defined as those having Type II TAAA, dissection, and acute surgery (OR, 0.67; P = .3387).
“Interrupting blood supply to the spinal cord causes spinal cord ischemia that can be mitigated almost entirely by physiologic interventions that increase spinal cord ischemic tolerance and collateral network perfusion during and after surgery,” Dr. Acher said. “Although the cause of SCI in TAAA surgery is anatomic, prevention of the injury is largely physiologic.”
During a discussion of the study, Dr. Acher surprised the audience by saying the findings have not changed current practice at the university. He cited several reasons, observing that there were more dissections in the ICAR group, and most of the ischemia in the ICAR group was delayed, suggesting that more patients could be rescued. In addition, there was a slight downward trend in spinal cord injury and immediate paraplegia with ICAR, however, these were not statistically significant.
“Because of those things, I still think it’s valuable, particularly in patients that are at highest risk, which are the dissections, with lots of open intercostals, but the emphasis should still be on physiologic parameters,” he said. “If you want to salvage patients, that’s the most important thing.
“Even if ICAR were ever shown to be statistically significant in a larger patient population, any role it has in reducing spinal cord injury would be extremely small,” he added in an interview.
The authors reported having no conflicts of interest.
CHICAGO – Intercostal artery reimplantation fails to significantly reduce spinal cord injury following thoracoabdominal aortic aneurysm surgery, results of a large retrospective study show.
“Although there was a small decrease in spinal cord ischemia with ICAR, reattaching the intercostals did not produce a statistically significant reduction in spinal cord ischemia, even in the highest risk patients,” Dr. Charles W. Acher of the University of Wisconsin–Madison, said at the annual meeting of the Midwestern Vascular Surgical Society.
Intercostal artery reimplantation (ICAR) is one of several strategies that have been used to prevent spinal cord ischemia (SCI), paraplegia, and paraparesis that occurs from the interruption of the blood supply to intercostal arteries (ICAs) during thoracoabdominal aortic aneurysm (TAAA) repair.
Surgeons at UW–Madison adopted the ICAR strategy in 2005and now reimplant open ICAs located at T7-L2 in all Type I, II, and III TAAAs, using a previously published technique (J Surg Res. 2009;154:99-104).
Using a prospectively maintained database, the current analysis sought to compare outcomes between 540 patients who had TAAA surgery during 1989-2004 when open ICAs were ligated and 265 patients who had surgery during 2005-2013 with ICAR.The surgical technique for both groups was cross clamp without assisted circulation. The anesthetic technique was also uniform during the study period and included moderate systemic hypothermia (32° - 33° C); spinal fluid drainage (spinal fluid pressure less than 5 mm Hg); naloxone 1 mcg/kg per hour; use of mannitol, methylprednisolone, and barbiturate burst suppression; goal-directed therapy for a mean arterial pressure of 90-100 mm Hg and cardiac index of 2.5 L per minute/meter2; and proactive component blood therapy to avoid anemia, hypovolemia, and hypertension.
Aneurysm extent, acuity, mortality, renal failure, and pulmonary failure were the same in both groups.
The incidence of SCI was similar in all TAAAs at 5.25% without ICAR and 3.4% with ICAR (P = .23) and in the subset of patients with Type I, II, and III aneurysms (8.8% vs. 5.1%; P = .152), Dr. Acher reported on behalf of lead author and his colleague, Dr. Martha M. Wynn.
Interestingly, ICAR patients had more dissections than did the open ICA ligation patients (18% vs. 15%; P = .0016), more previous aortic surgery (47% vs. 31%; P = .0004), and longer renal ischemia time (61 minutes vs. 53 minutes; P = .0001), but had a shorter length of stay (14 days vs. 22 days; P = .0001) and were younger (mean age, 66 years vs. 70 years; P = .0001).
In a multivariate model of all TAAAs, significant predictors of spinal cord ischemia/injury were type II TAAA (odds ratio, 7.59; P = .0001), dissection (OR, 4.25; P = .0015), age as a continuous variable (P = .0085), and acute TAAA (OR, 2.1; P = .0525), Dr. Acher said. Time period of surgery, and therefore ICAR, was not significant (OR, 0.78; P = .55).
ICAR also failed to achieve significance as an SCI predictor in a subanalysis restricted to the highest-risk patients, defined as those having Type II TAAA, dissection, and acute surgery (OR, 0.67; P = .3387).
“Interrupting blood supply to the spinal cord causes spinal cord ischemia that can be mitigated almost entirely by physiologic interventions that increase spinal cord ischemic tolerance and collateral network perfusion during and after surgery,” Dr. Acher said. “Although the cause of SCI in TAAA surgery is anatomic, prevention of the injury is largely physiologic.”
During a discussion of the study, Dr. Acher surprised the audience by saying the findings have not changed current practice at the university. He cited several reasons, observing that there were more dissections in the ICAR group, and most of the ischemia in the ICAR group was delayed, suggesting that more patients could be rescued. In addition, there was a slight downward trend in spinal cord injury and immediate paraplegia with ICAR, however, these were not statistically significant.
“Because of those things, I still think it’s valuable, particularly in patients that are at highest risk, which are the dissections, with lots of open intercostals, but the emphasis should still be on physiologic parameters,” he said. “If you want to salvage patients, that’s the most important thing.
“Even if ICAR were ever shown to be statistically significant in a larger patient population, any role it has in reducing spinal cord injury would be extremely small,” he added in an interview.
The authors reported having no conflicts of interest.
AT MIDWESTERN VASCULAR 2015
Key clinical point: Intercostal artery reimplantation (ICAR) did not produce a significant reduction in spinal cord ischemia following thoracoabdominal aortic aneurysm repair, even in the highest risk patients.
Major finding: ICAR was not a significant predictor of spinal cord ischemia (OR, 0.78; P = .55).
Data source: Retrospective analysis of 805 patients undergoing TAAA with or without ICAR.
Disclosures: The authors reported having no conflicts of interest.
Coronary Computed Tomography Angiography, Radionuclide Stress Testing Similar for Evaluation of Chest Pain
Clinical question: Is coronary computed tomography angiography better than stress testing for detecting coronary artery disease?
Bottom line: For the evaluation of chest pain in intermediate-risk patients, coronary computed tomography angiography (CCTA) is comparable with myocardial perfusion imaging (MPI) in its ability to select patients for invasive management. Both modalities are also similar when it comes to downstream resource use and adverse cardiovascular events. CCTA is associated with less radiation exposure (LOE = 1b).
Reference: Levsky JM, Spevack DM, Travin MI, et al. Coronary computed tomography angiography versus radionuclide myocardial perfusion imaging in patients with chest pain admitted to telemetry. Ann Intern Med 2015;163(3):174-183.
Study design: Randomized controlled trial (nonblinded)
Funding source: Foundation
Allocation: Concealed
Setting: Inpatient (any location) with outpatient follow-up
Synopsis
The effectiveness of a noninvasive coronary imaging modality lies in its ability to identify patients who will need invasive management. In this study, intermediate-risk patients admitted to telemetry for the evaluation of chest pain who clinically required noninvasive imaging were randomized, using concealed allocation, to receive either CCTA or radionuclide stress MPI.
At baseline, the mean age in both groups was 57 years, two-thirds of the patients were female, and more than 90% were ethnic minorities. Analysis was by intention to treat. The primary outcome was the rate of cardiac catheterization that did not lead to revascularization within one year of the imaging test. There was no significant difference between the two groups for this outcome. However, in a subgroup analysis of patients with signficantly abnormal results on their imaging test, there was a nonsignificant trend toward fewer catheterizations without revascularization in the CCTA group (25% vs 52%; P=0.083).
For secondary outcomes, there were no differences detected between the two groups in length of stay, major adverse cardiovascular events, or downstream resource use, including rehospitalizations and further imaging. The CCTA group had less radiation exposure and reported a better patient experience.
Dr. Kulkarni is an assistant professor of hospital medicine at Northwestern University in Chicago.
Clinical question: Is coronary computed tomography angiography better than stress testing for detecting coronary artery disease?
Bottom line: For the evaluation of chest pain in intermediate-risk patients, coronary computed tomography angiography (CCTA) is comparable with myocardial perfusion imaging (MPI) in its ability to select patients for invasive management. Both modalities are also similar when it comes to downstream resource use and adverse cardiovascular events. CCTA is associated with less radiation exposure (LOE = 1b).
Reference: Levsky JM, Spevack DM, Travin MI, et al. Coronary computed tomography angiography versus radionuclide myocardial perfusion imaging in patients with chest pain admitted to telemetry. Ann Intern Med 2015;163(3):174-183.
Study design: Randomized controlled trial (nonblinded)
Funding source: Foundation
Allocation: Concealed
Setting: Inpatient (any location) with outpatient follow-up
Synopsis
The effectiveness of a noninvasive coronary imaging modality lies in its ability to identify patients who will need invasive management. In this study, intermediate-risk patients admitted to telemetry for the evaluation of chest pain who clinically required noninvasive imaging were randomized, using concealed allocation, to receive either CCTA or radionuclide stress MPI.
At baseline, the mean age in both groups was 57 years, two-thirds of the patients were female, and more than 90% were ethnic minorities. Analysis was by intention to treat. The primary outcome was the rate of cardiac catheterization that did not lead to revascularization within one year of the imaging test. There was no significant difference between the two groups for this outcome. However, in a subgroup analysis of patients with signficantly abnormal results on their imaging test, there was a nonsignificant trend toward fewer catheterizations without revascularization in the CCTA group (25% vs 52%; P=0.083).
For secondary outcomes, there were no differences detected between the two groups in length of stay, major adverse cardiovascular events, or downstream resource use, including rehospitalizations and further imaging. The CCTA group had less radiation exposure and reported a better patient experience.
Dr. Kulkarni is an assistant professor of hospital medicine at Northwestern University in Chicago.
Clinical question: Is coronary computed tomography angiography better than stress testing for detecting coronary artery disease?
Bottom line: For the evaluation of chest pain in intermediate-risk patients, coronary computed tomography angiography (CCTA) is comparable with myocardial perfusion imaging (MPI) in its ability to select patients for invasive management. Both modalities are also similar when it comes to downstream resource use and adverse cardiovascular events. CCTA is associated with less radiation exposure (LOE = 1b).
Reference: Levsky JM, Spevack DM, Travin MI, et al. Coronary computed tomography angiography versus radionuclide myocardial perfusion imaging in patients with chest pain admitted to telemetry. Ann Intern Med 2015;163(3):174-183.
Study design: Randomized controlled trial (nonblinded)
Funding source: Foundation
Allocation: Concealed
Setting: Inpatient (any location) with outpatient follow-up
Synopsis
The effectiveness of a noninvasive coronary imaging modality lies in its ability to identify patients who will need invasive management. In this study, intermediate-risk patients admitted to telemetry for the evaluation of chest pain who clinically required noninvasive imaging were randomized, using concealed allocation, to receive either CCTA or radionuclide stress MPI.
At baseline, the mean age in both groups was 57 years, two-thirds of the patients were female, and more than 90% were ethnic minorities. Analysis was by intention to treat. The primary outcome was the rate of cardiac catheterization that did not lead to revascularization within one year of the imaging test. There was no significant difference between the two groups for this outcome. However, in a subgroup analysis of patients with signficantly abnormal results on their imaging test, there was a nonsignificant trend toward fewer catheterizations without revascularization in the CCTA group (25% vs 52%; P=0.083).
For secondary outcomes, there were no differences detected between the two groups in length of stay, major adverse cardiovascular events, or downstream resource use, including rehospitalizations and further imaging. The CCTA group had less radiation exposure and reported a better patient experience.
Dr. Kulkarni is an assistant professor of hospital medicine at Northwestern University in Chicago.
Interdisciplinary Team Interventions Have Little Impact on Traditional Quality Measures
Clinical question: Do interdisciplinary team care interventions affect outcomes for hospitalized patients in general medical wards?
Bottom line: Interdisciplinary team care interventions do not significantly affect oft-used quality measures such as length of stay, readmissions, or mortality. However, some experts question whether these measures are appropriate for assessing the effectiveness of such interventions. A small body of evidence suggests that interdisciplinary interventions may affect complications of care or preventable adverse events. In the future, these and other more appropriate measures should be used when assessing interdisciplinary team care interventions. (LOE = 2a)
Reference: Pannick S, Davis R, Ashrafian H, et al. Effects of interdisciplinary team care interventions on general medical wards. JAMA Intern Med 2015;175(8):1288-1298.
Study design: Systematic review
Funding source: Government
Allocation: Uncertain
Setting: Inpatient (any location)
Synopsis
These investigators searched multiple databases including EMBASE and MEDLINE, as well as reference lists of included studies, to find trials that evaluated the effects of interdisciplinary team care on objective patient outcomes in the general medical wards. Study selection, data extraction, and assessment of bias were performed by independent reviewers.
Thirty studies (randomized controlled trials, cluster studies, and before-after studies) were included in the review. The studies had heterogeneous designs and outcome measures and all of them had a medium or high risk of bias. The majority of the studies, however, reported on complications of care, length of stay, readmission, or mortality.
Out of 10 studies that examined complications of care, five showed a reduction in this outcome by formalizing interdisciplinary rounds or adding specialized clinicians or pharmacists to the interdisciplinary team. Overall, 20% of the studies that looked at length of stay showed a reduction in this measure, but these results may have been confounded by secular trends toward length of stay reduction. No study showed a consistent or persistent effect on readmissions or mortality.
Dr. Kulkarni is an assistant professor of hospital medicine at Northwestern University in Chicago.
Clinical question: Do interdisciplinary team care interventions affect outcomes for hospitalized patients in general medical wards?
Bottom line: Interdisciplinary team care interventions do not significantly affect oft-used quality measures such as length of stay, readmissions, or mortality. However, some experts question whether these measures are appropriate for assessing the effectiveness of such interventions. A small body of evidence suggests that interdisciplinary interventions may affect complications of care or preventable adverse events. In the future, these and other more appropriate measures should be used when assessing interdisciplinary team care interventions. (LOE = 2a)
Reference: Pannick S, Davis R, Ashrafian H, et al. Effects of interdisciplinary team care interventions on general medical wards. JAMA Intern Med 2015;175(8):1288-1298.
Study design: Systematic review
Funding source: Government
Allocation: Uncertain
Setting: Inpatient (any location)
Synopsis
These investigators searched multiple databases including EMBASE and MEDLINE, as well as reference lists of included studies, to find trials that evaluated the effects of interdisciplinary team care on objective patient outcomes in the general medical wards. Study selection, data extraction, and assessment of bias were performed by independent reviewers.
Thirty studies (randomized controlled trials, cluster studies, and before-after studies) were included in the review. The studies had heterogeneous designs and outcome measures and all of them had a medium or high risk of bias. The majority of the studies, however, reported on complications of care, length of stay, readmission, or mortality.
Out of 10 studies that examined complications of care, five showed a reduction in this outcome by formalizing interdisciplinary rounds or adding specialized clinicians or pharmacists to the interdisciplinary team. Overall, 20% of the studies that looked at length of stay showed a reduction in this measure, but these results may have been confounded by secular trends toward length of stay reduction. No study showed a consistent or persistent effect on readmissions or mortality.
Dr. Kulkarni is an assistant professor of hospital medicine at Northwestern University in Chicago.
Clinical question: Do interdisciplinary team care interventions affect outcomes for hospitalized patients in general medical wards?
Bottom line: Interdisciplinary team care interventions do not significantly affect oft-used quality measures such as length of stay, readmissions, or mortality. However, some experts question whether these measures are appropriate for assessing the effectiveness of such interventions. A small body of evidence suggests that interdisciplinary interventions may affect complications of care or preventable adverse events. In the future, these and other more appropriate measures should be used when assessing interdisciplinary team care interventions. (LOE = 2a)
Reference: Pannick S, Davis R, Ashrafian H, et al. Effects of interdisciplinary team care interventions on general medical wards. JAMA Intern Med 2015;175(8):1288-1298.
Study design: Systematic review
Funding source: Government
Allocation: Uncertain
Setting: Inpatient (any location)
Synopsis
These investigators searched multiple databases including EMBASE and MEDLINE, as well as reference lists of included studies, to find trials that evaluated the effects of interdisciplinary team care on objective patient outcomes in the general medical wards. Study selection, data extraction, and assessment of bias were performed by independent reviewers.
Thirty studies (randomized controlled trials, cluster studies, and before-after studies) were included in the review. The studies had heterogeneous designs and outcome measures and all of them had a medium or high risk of bias. The majority of the studies, however, reported on complications of care, length of stay, readmission, or mortality.
Out of 10 studies that examined complications of care, five showed a reduction in this outcome by formalizing interdisciplinary rounds or adding specialized clinicians or pharmacists to the interdisciplinary team. Overall, 20% of the studies that looked at length of stay showed a reduction in this measure, but these results may have been confounded by secular trends toward length of stay reduction. No study showed a consistent or persistent effect on readmissions or mortality.
Dr. Kulkarni is an assistant professor of hospital medicine at Northwestern University in Chicago.
Routine imaging for diffuse large B-cell lymphoma offers no survival benefit
A population-based comparison of patients with diffuse large B-cell lymphoma (DLBCL) in first complete remission indicated that routine imaging surveillance did not improve outcomes, researchers reported.
Overall survival was similar for Danish and Swedish populations who received similar follow-up care, except that routine imaging surveillance is the standard of care in Denmark, but not in Sweden. The 3-year overall survival for Danish and Swedish patients was 92% and 91%, respectively.
Outcomes grouped by international prognostic index (IPI) also showed no significant differences between populations (J Clin Oncol. 2015 Oct 5, doi:10.1200/jco.2015.62.0229.).
“An imaging-based follow-up strategy does not improve postremission [overall survival] for DLBCL,” wrote Dr. Tarec Christoffer El-Galaly, of Aalborg University Hospital, Denmark, and colleagues.
They observed that aside from using IPI as risk stratification, the study “also points to baseline [lactate dehyrogenase] as a single discriminator of patients with high versus low risk of progression,” (Hazard ratio, 3.12; 95% CI, 1.78-5.48; P less than .01).
The retrospective study examined records of patients with DLBCL from Sweden (n=696) and Denmark (n=525) who achieved first complete remission after first-line therapy with R-CHOP (rituximab plus cyclophosphamide, doxorubicin, vincristine, and prednisone) and CHOP-like regimens from 2007 to 2012. The proportion of patients with IPI greater than two were similar for both groups, though more Danish patients received radiotherapy compared with their Swedish counterparts (35% v. 9%).
Standard follow-up care after first complete remission is similar in Denmark and Sweden and typically includes symptom assessment, clinical examination, and blood tests at 3- to 4-month intervals for 2 years, and 6-month intervals in the third year. After 3 years, Swedish patients are seen annually for 2 years and then follow-up is ended for most patients. In Denmark, 6-month checks are continued until 5 years and then follow-up is usually ended. However, in Denmark guidelines support routine computerized tomography (CT) scans of the neck, abdomen, and thorax every 6 months for 2 years, which is not encouraged by guidelines in Sweden.
Early relapse detection aims to improve survival, and although low disease burden is associated with durable survival in patients treated for relapsed DLBCL, most studies show similar outcomes for imaging versus non-imaging detection. Additionally, previous retrospective studies that have reported survival differences based on relapse detection method are prone to lead-time bias, according to the researchers.
Given that a majority of patients with recurrent DLBCL experience symptoms before relapse, that elevated lactate dehyrogenase or abnormal physical examination may raise suspicion, and that exposure to ionizing radiation from medical imaging can lead to radiation-induced cancers, “routine imaging for DLBCL in first [complete remission] is not recommended,” the authors wrote.
The research was supported in part by the North Denmark Region. Dr. El-Galaly and coauthors reported having no financial disclosures.
The best way to determine the effectiveness of surveillance imaging would be a randomized trial including patients with diffuse large B-cell lymphoma (DLBCL) after first complete remission, but it is unlikely that such a study will be done. The study by El-Galaly et al may be the next best approach. Taking advantage of the fact that neighboring countries Denmark and Sweden have opposite policies for surveillance imaging but otherwise similar follow-up visit schedules and testing, the authors identified factors that predicted relapse (e.g., age greater than 60 years and elevated LDH), and they found that routine surveillance imaging had no impact on outcome. The study presents the strongest argument yet published against routine surveillance imaging.
The two other outstanding issues of routine surveillance are long-term safety and cost benefit. The study by El-Galaly et al, in combination with several other reports, suggests that routine surveillance imaging, in the absence of new or suspicious symptoms, physical findings, or change in laboratory results, is unlikely to benefit patients, may add to the patient’s stress, may cause long-term health problems, and incurs substantial economic cost.
Dr. James O. Armitage and Dr. Julie M. Vose are both at the University of Nebraska, Omaha. Dr. Armitage disclosed a leadership role with Tesaro and consulting or advisory roles with GlaxoSmithKline, Roche, Spectrum Pharmaceuticals, ZIOPHARM Oncology, Conatus, and Celgene. Dr. Vose reported honoraria from Sanofi-Aventis and Seattle Genetics; consulting or advisory roles with Bioconnections; and institutional research funding from Spectrum Pharmaceuticals, Bristol-Myers Squibb, Celgene, Genentech, GlaxoSmithKline, Incyte, Janssen Biotech, Pharmacyclics, Acerta, and Kite Pharma. These remarks were adapted from their accompanying editorial (J Clin Oncol. 2015 Oct 5, doi:10.1200/jco.2015.63.5946).
The best way to determine the effectiveness of surveillance imaging would be a randomized trial including patients with diffuse large B-cell lymphoma (DLBCL) after first complete remission, but it is unlikely that such a study will be done. The study by El-Galaly et al may be the next best approach. Taking advantage of the fact that neighboring countries Denmark and Sweden have opposite policies for surveillance imaging but otherwise similar follow-up visit schedules and testing, the authors identified factors that predicted relapse (e.g., age greater than 60 years and elevated LDH), and they found that routine surveillance imaging had no impact on outcome. The study presents the strongest argument yet published against routine surveillance imaging.
The two other outstanding issues of routine surveillance are long-term safety and cost benefit. The study by El-Galaly et al, in combination with several other reports, suggests that routine surveillance imaging, in the absence of new or suspicious symptoms, physical findings, or change in laboratory results, is unlikely to benefit patients, may add to the patient’s stress, may cause long-term health problems, and incurs substantial economic cost.
Dr. James O. Armitage and Dr. Julie M. Vose are both at the University of Nebraska, Omaha. Dr. Armitage disclosed a leadership role with Tesaro and consulting or advisory roles with GlaxoSmithKline, Roche, Spectrum Pharmaceuticals, ZIOPHARM Oncology, Conatus, and Celgene. Dr. Vose reported honoraria from Sanofi-Aventis and Seattle Genetics; consulting or advisory roles with Bioconnections; and institutional research funding from Spectrum Pharmaceuticals, Bristol-Myers Squibb, Celgene, Genentech, GlaxoSmithKline, Incyte, Janssen Biotech, Pharmacyclics, Acerta, and Kite Pharma. These remarks were adapted from their accompanying editorial (J Clin Oncol. 2015 Oct 5, doi:10.1200/jco.2015.63.5946).
The best way to determine the effectiveness of surveillance imaging would be a randomized trial including patients with diffuse large B-cell lymphoma (DLBCL) after first complete remission, but it is unlikely that such a study will be done. The study by El-Galaly et al may be the next best approach. Taking advantage of the fact that neighboring countries Denmark and Sweden have opposite policies for surveillance imaging but otherwise similar follow-up visit schedules and testing, the authors identified factors that predicted relapse (e.g., age greater than 60 years and elevated LDH), and they found that routine surveillance imaging had no impact on outcome. The study presents the strongest argument yet published against routine surveillance imaging.
The two other outstanding issues of routine surveillance are long-term safety and cost benefit. The study by El-Galaly et al, in combination with several other reports, suggests that routine surveillance imaging, in the absence of new or suspicious symptoms, physical findings, or change in laboratory results, is unlikely to benefit patients, may add to the patient’s stress, may cause long-term health problems, and incurs substantial economic cost.
Dr. James O. Armitage and Dr. Julie M. Vose are both at the University of Nebraska, Omaha. Dr. Armitage disclosed a leadership role with Tesaro and consulting or advisory roles with GlaxoSmithKline, Roche, Spectrum Pharmaceuticals, ZIOPHARM Oncology, Conatus, and Celgene. Dr. Vose reported honoraria from Sanofi-Aventis and Seattle Genetics; consulting or advisory roles with Bioconnections; and institutional research funding from Spectrum Pharmaceuticals, Bristol-Myers Squibb, Celgene, Genentech, GlaxoSmithKline, Incyte, Janssen Biotech, Pharmacyclics, Acerta, and Kite Pharma. These remarks were adapted from their accompanying editorial (J Clin Oncol. 2015 Oct 5, doi:10.1200/jco.2015.63.5946).
A population-based comparison of patients with diffuse large B-cell lymphoma (DLBCL) in first complete remission indicated that routine imaging surveillance did not improve outcomes, researchers reported.
Overall survival was similar for Danish and Swedish populations who received similar follow-up care, except that routine imaging surveillance is the standard of care in Denmark, but not in Sweden. The 3-year overall survival for Danish and Swedish patients was 92% and 91%, respectively.
Outcomes grouped by international prognostic index (IPI) also showed no significant differences between populations (J Clin Oncol. 2015 Oct 5, doi:10.1200/jco.2015.62.0229.).
“An imaging-based follow-up strategy does not improve postremission [overall survival] for DLBCL,” wrote Dr. Tarec Christoffer El-Galaly, of Aalborg University Hospital, Denmark, and colleagues.
They observed that aside from using IPI as risk stratification, the study “also points to baseline [lactate dehyrogenase] as a single discriminator of patients with high versus low risk of progression,” (Hazard ratio, 3.12; 95% CI, 1.78-5.48; P less than .01).
The retrospective study examined records of patients with DLBCL from Sweden (n=696) and Denmark (n=525) who achieved first complete remission after first-line therapy with R-CHOP (rituximab plus cyclophosphamide, doxorubicin, vincristine, and prednisone) and CHOP-like regimens from 2007 to 2012. The proportion of patients with IPI greater than two were similar for both groups, though more Danish patients received radiotherapy compared with their Swedish counterparts (35% v. 9%).
Standard follow-up care after first complete remission is similar in Denmark and Sweden and typically includes symptom assessment, clinical examination, and blood tests at 3- to 4-month intervals for 2 years, and 6-month intervals in the third year. After 3 years, Swedish patients are seen annually for 2 years and then follow-up is ended for most patients. In Denmark, 6-month checks are continued until 5 years and then follow-up is usually ended. However, in Denmark guidelines support routine computerized tomography (CT) scans of the neck, abdomen, and thorax every 6 months for 2 years, which is not encouraged by guidelines in Sweden.
Early relapse detection aims to improve survival, and although low disease burden is associated with durable survival in patients treated for relapsed DLBCL, most studies show similar outcomes for imaging versus non-imaging detection. Additionally, previous retrospective studies that have reported survival differences based on relapse detection method are prone to lead-time bias, according to the researchers.
Given that a majority of patients with recurrent DLBCL experience symptoms before relapse, that elevated lactate dehyrogenase or abnormal physical examination may raise suspicion, and that exposure to ionizing radiation from medical imaging can lead to radiation-induced cancers, “routine imaging for DLBCL in first [complete remission] is not recommended,” the authors wrote.
The research was supported in part by the North Denmark Region. Dr. El-Galaly and coauthors reported having no financial disclosures.
A population-based comparison of patients with diffuse large B-cell lymphoma (DLBCL) in first complete remission indicated that routine imaging surveillance did not improve outcomes, researchers reported.
Overall survival was similar for Danish and Swedish populations who received similar follow-up care, except that routine imaging surveillance is the standard of care in Denmark, but not in Sweden. The 3-year overall survival for Danish and Swedish patients was 92% and 91%, respectively.
Outcomes grouped by international prognostic index (IPI) also showed no significant differences between populations (J Clin Oncol. 2015 Oct 5, doi:10.1200/jco.2015.62.0229.).
“An imaging-based follow-up strategy does not improve postremission [overall survival] for DLBCL,” wrote Dr. Tarec Christoffer El-Galaly, of Aalborg University Hospital, Denmark, and colleagues.
They observed that aside from using IPI as risk stratification, the study “also points to baseline [lactate dehyrogenase] as a single discriminator of patients with high versus low risk of progression,” (Hazard ratio, 3.12; 95% CI, 1.78-5.48; P less than .01).
The retrospective study examined records of patients with DLBCL from Sweden (n=696) and Denmark (n=525) who achieved first complete remission after first-line therapy with R-CHOP (rituximab plus cyclophosphamide, doxorubicin, vincristine, and prednisone) and CHOP-like regimens from 2007 to 2012. The proportion of patients with IPI greater than two were similar for both groups, though more Danish patients received radiotherapy compared with their Swedish counterparts (35% v. 9%).
Standard follow-up care after first complete remission is similar in Denmark and Sweden and typically includes symptom assessment, clinical examination, and blood tests at 3- to 4-month intervals for 2 years, and 6-month intervals in the third year. After 3 years, Swedish patients are seen annually for 2 years and then follow-up is ended for most patients. In Denmark, 6-month checks are continued until 5 years and then follow-up is usually ended. However, in Denmark guidelines support routine computerized tomography (CT) scans of the neck, abdomen, and thorax every 6 months for 2 years, which is not encouraged by guidelines in Sweden.
Early relapse detection aims to improve survival, and although low disease burden is associated with durable survival in patients treated for relapsed DLBCL, most studies show similar outcomes for imaging versus non-imaging detection. Additionally, previous retrospective studies that have reported survival differences based on relapse detection method are prone to lead-time bias, according to the researchers.
Given that a majority of patients with recurrent DLBCL experience symptoms before relapse, that elevated lactate dehyrogenase or abnormal physical examination may raise suspicion, and that exposure to ionizing radiation from medical imaging can lead to radiation-induced cancers, “routine imaging for DLBCL in first [complete remission] is not recommended,” the authors wrote.
The research was supported in part by the North Denmark Region. Dr. El-Galaly and coauthors reported having no financial disclosures.
FROM THE JOURNAL OF CLINICAL ONCOLOGY
Key clinical point:Danish patients with diffuse large B-cell lymphoma (DLBCL) who received routine imaging during follow up had similar survival to Swedish patients who did not undergo routine imaging surveillance.
Major finding: After first complete remission, the 3-year overall survival for Danish and Swedish patients was 92% and 91%, respectively.
Data source: Population-based study of 525 Danish patients and 696 Swedish patients with DLBCL who achieved first complete remission after R-CHOP/CHOP-like first-line therapies from 2007 to 2012.
Disclosures: The research was supported in part by the North Denmark Region. Dr. El-Galaly and coauthors reported having no financial disclosures.
Pearls on the Use of Tape in Dermatology: Report From the AAD Meeting
At the recent Summer Meeting of the American Academy of Dermatology, Dr. Stone discussed the use of tapes in dermatology. He provides highlights from this session, including the diagnosis of tinea versicolor with plastic tape, suturing in patients with fragile skin to add strength to skin, and the diagnosis of scabies.
At the recent Summer Meeting of the American Academy of Dermatology, Dr. Stone discussed the use of tapes in dermatology. He provides highlights from this session, including the diagnosis of tinea versicolor with plastic tape, suturing in patients with fragile skin to add strength to skin, and the diagnosis of scabies.
At the recent Summer Meeting of the American Academy of Dermatology, Dr. Stone discussed the use of tapes in dermatology. He provides highlights from this session, including the diagnosis of tinea versicolor with plastic tape, suturing in patients with fragile skin to add strength to skin, and the diagnosis of scabies.
Women dogged by unplanned readmissions after aortic surgery
CHICAGO – Women undergoing aortic surgery have a 30% higher chance of unplanned readmission within 30 days than men.
This occurs despite a significantly longer length of stay (6.4 vs. 4.8 days; P < .001), Dr. Benjamin Flink said at the annual meeting of the Midwestern Vascular Surgical Society.
Women undergoing aortic surgery are known to have higher morbidity and mortality with respect to cardiovascular events and infections, but no studies have specifically looked at sex disparities in readmission following aortic surgery, he said.
“We feel gender disparities are an understudied area of surgical care and there is a lot of work to be done in reducing these differences,” principal investigator Dr. Shipra Arya said in an interview.
To better examine this issue, Dr. Arya and Dr. Flink, both of Emory University in Atlanta, and investigators at the University of Michigan identified all patients undergoing open or endovascular abdominal aortic aneurysm (AAA), thoracic aortic aneurysm (TAA), and thoracoabdominal aortic aneurysm (TAAA) repair from 2011 to 2013 who were in the American College of Surgeons National Surgical Quality Improvement Program (ACS/NSQIP) database. Of the 18,977 patients, 23% were women.
Use of endovascular procedures varied significantly by sex, with women having significantly fewer endovascular AAA (68.8% vs. 77.1%; P less than .001) and TAAA (43.2% vs. 65.2%; P < .001) repairs than men. Endovascular TAA repairs were similar in women and men (96.1% vs. 95.6%; P = .8), Dr. Flink said.
Overall, 1,541 patients (8.1%) experienced the primary outcome of an unplanned readmission within 30 days, with a significantly higher risk observed in women than men (10.1% vs. 7.6%; P less than .001).
This risk persisted for most aneurysm types, with women having a higher risk of readmission for AAA (9.4% vs. 7.3%; P less than .001) and TAAA (13.7% vs. 8.3%; P = .03) aneurysms, but not TAAs (13% vs. 12.5%; P = .8), he said.
The overall length of stay was 5.2 days. Women stayed 1.6 days longer than men (data above), readmitted patients stayed 1 day longer during their index hospitalization than patients who avoided readmission (5.1 days vs. 4.1 days; P less than .001), and open-repair patients stayed more than twice as long as endovascular patients (10.3 days vs. 3.7 days; P less than .001).
Patients discharged to home, however, had less than one-third the length of stay as those discharged to a facility other than home (4 days vs. 12.8 days; P less than .001).
Notably, women were discharged to a facility other than home nearly twice as often as men (20.4% vs. 10.6%; P less than .001), Dr. Flink said.
In multivariate analysis, the odds of an unplanned readmission were 30% higher for women than men after controlling for 13 variables (odds ratio, 1.3; 95% confidence interval, 1.14-1.48).
When the analysis was stratified by discharge destination, the higher odds of readmission among women remained for those discharged home (OR, 1.3; 95% CI, 1.12-1.51), but not when discharged to a skilled or rehabilitation facility (OR, 1.1; 95% CI, 0.83-1.45).
“Further study into the discharge planning process, social factors, and the use of rehabilitation is needed,” Dr. Flink said. “For example, why are we keeping women longer? Are we missing opportunities to better utilize rehabilitation in hospital? And what gender-specific social factors might be influencing unplanned readmissions that we’re currently not measuring?”
Dr. John Blebea of the University of Oklahoma, Tulsa, asked whether marital status was examined as an independent variable, “because I would suspect that’s the answer to the question. More women are widowed than men and therefore are less likely to have a spouse at home to take care of them, which would also explain why they’d be in the hospital longer.”
Unfortunately, that information is not available in the ACS/NSQIP database, but “I do agree that home-social factors are likely playing a role,” Dr. Flink responded.
Along the same vein, another attendee questioned whether the study accounted for frailty index scores. They were not, but the analysis included patients’ functional status as well as comorbidities such as congestive heart failure, stroke, peripheral arterial disease, and dialysis dependence that would limit their physical independence, Dr. Flink said.
Dr. Flink reported having no financial disclosures. Principal investigator Dr. Shipra Arya is funded by a research grant from the American Heart Association.
On Twitter @pwendl
CHICAGO – Women undergoing aortic surgery have a 30% higher chance of unplanned readmission within 30 days than men.
This occurs despite a significantly longer length of stay (6.4 vs. 4.8 days; P < .001), Dr. Benjamin Flink said at the annual meeting of the Midwestern Vascular Surgical Society.
Women undergoing aortic surgery are known to have higher morbidity and mortality with respect to cardiovascular events and infections, but no studies have specifically looked at sex disparities in readmission following aortic surgery, he said.
“We feel gender disparities are an understudied area of surgical care and there is a lot of work to be done in reducing these differences,” principal investigator Dr. Shipra Arya said in an interview.
To better examine this issue, Dr. Arya and Dr. Flink, both of Emory University in Atlanta, and investigators at the University of Michigan identified all patients undergoing open or endovascular abdominal aortic aneurysm (AAA), thoracic aortic aneurysm (TAA), and thoracoabdominal aortic aneurysm (TAAA) repair from 2011 to 2013 who were in the American College of Surgeons National Surgical Quality Improvement Program (ACS/NSQIP) database. Of the 18,977 patients, 23% were women.
Use of endovascular procedures varied significantly by sex, with women having significantly fewer endovascular AAA (68.8% vs. 77.1%; P less than .001) and TAAA (43.2% vs. 65.2%; P < .001) repairs than men. Endovascular TAA repairs were similar in women and men (96.1% vs. 95.6%; P = .8), Dr. Flink said.
Overall, 1,541 patients (8.1%) experienced the primary outcome of an unplanned readmission within 30 days, with a significantly higher risk observed in women than men (10.1% vs. 7.6%; P less than .001).
This risk persisted for most aneurysm types, with women having a higher risk of readmission for AAA (9.4% vs. 7.3%; P less than .001) and TAAA (13.7% vs. 8.3%; P = .03) aneurysms, but not TAAs (13% vs. 12.5%; P = .8), he said.
The overall length of stay was 5.2 days. Women stayed 1.6 days longer than men (data above), readmitted patients stayed 1 day longer during their index hospitalization than patients who avoided readmission (5.1 days vs. 4.1 days; P less than .001), and open-repair patients stayed more than twice as long as endovascular patients (10.3 days vs. 3.7 days; P less than .001).
Patients discharged to home, however, had less than one-third the length of stay as those discharged to a facility other than home (4 days vs. 12.8 days; P less than .001).
Notably, women were discharged to a facility other than home nearly twice as often as men (20.4% vs. 10.6%; P less than .001), Dr. Flink said.
In multivariate analysis, the odds of an unplanned readmission were 30% higher for women than men after controlling for 13 variables (odds ratio, 1.3; 95% confidence interval, 1.14-1.48).
When the analysis was stratified by discharge destination, the higher odds of readmission among women remained for those discharged home (OR, 1.3; 95% CI, 1.12-1.51), but not when discharged to a skilled or rehabilitation facility (OR, 1.1; 95% CI, 0.83-1.45).
“Further study into the discharge planning process, social factors, and the use of rehabilitation is needed,” Dr. Flink said. “For example, why are we keeping women longer? Are we missing opportunities to better utilize rehabilitation in hospital? And what gender-specific social factors might be influencing unplanned readmissions that we’re currently not measuring?”
Dr. John Blebea of the University of Oklahoma, Tulsa, asked whether marital status was examined as an independent variable, “because I would suspect that’s the answer to the question. More women are widowed than men and therefore are less likely to have a spouse at home to take care of them, which would also explain why they’d be in the hospital longer.”
Unfortunately, that information is not available in the ACS/NSQIP database, but “I do agree that home-social factors are likely playing a role,” Dr. Flink responded.
Along the same vein, another attendee questioned whether the study accounted for frailty index scores. They were not, but the analysis included patients’ functional status as well as comorbidities such as congestive heart failure, stroke, peripheral arterial disease, and dialysis dependence that would limit their physical independence, Dr. Flink said.
Dr. Flink reported having no financial disclosures. Principal investigator Dr. Shipra Arya is funded by a research grant from the American Heart Association.
On Twitter @pwendl
CHICAGO – Women undergoing aortic surgery have a 30% higher chance of unplanned readmission within 30 days than men.
This occurs despite a significantly longer length of stay (6.4 vs. 4.8 days; P < .001), Dr. Benjamin Flink said at the annual meeting of the Midwestern Vascular Surgical Society.
Women undergoing aortic surgery are known to have higher morbidity and mortality with respect to cardiovascular events and infections, but no studies have specifically looked at sex disparities in readmission following aortic surgery, he said.
“We feel gender disparities are an understudied area of surgical care and there is a lot of work to be done in reducing these differences,” principal investigator Dr. Shipra Arya said in an interview.
To better examine this issue, Dr. Arya and Dr. Flink, both of Emory University in Atlanta, and investigators at the University of Michigan identified all patients undergoing open or endovascular abdominal aortic aneurysm (AAA), thoracic aortic aneurysm (TAA), and thoracoabdominal aortic aneurysm (TAAA) repair from 2011 to 2013 who were in the American College of Surgeons National Surgical Quality Improvement Program (ACS/NSQIP) database. Of the 18,977 patients, 23% were women.
Use of endovascular procedures varied significantly by sex, with women having significantly fewer endovascular AAA (68.8% vs. 77.1%; P less than .001) and TAAA (43.2% vs. 65.2%; P < .001) repairs than men. Endovascular TAA repairs were similar in women and men (96.1% vs. 95.6%; P = .8), Dr. Flink said.
Overall, 1,541 patients (8.1%) experienced the primary outcome of an unplanned readmission within 30 days, with a significantly higher risk observed in women than men (10.1% vs. 7.6%; P less than .001).
This risk persisted for most aneurysm types, with women having a higher risk of readmission for AAA (9.4% vs. 7.3%; P less than .001) and TAAA (13.7% vs. 8.3%; P = .03) aneurysms, but not TAAs (13% vs. 12.5%; P = .8), he said.
The overall length of stay was 5.2 days. Women stayed 1.6 days longer than men (data above), readmitted patients stayed 1 day longer during their index hospitalization than patients who avoided readmission (5.1 days vs. 4.1 days; P less than .001), and open-repair patients stayed more than twice as long as endovascular patients (10.3 days vs. 3.7 days; P less than .001).
Patients discharged to home, however, had less than one-third the length of stay as those discharged to a facility other than home (4 days vs. 12.8 days; P less than .001).
Notably, women were discharged to a facility other than home nearly twice as often as men (20.4% vs. 10.6%; P less than .001), Dr. Flink said.
In multivariate analysis, the odds of an unplanned readmission were 30% higher for women than men after controlling for 13 variables (odds ratio, 1.3; 95% confidence interval, 1.14-1.48).
When the analysis was stratified by discharge destination, the higher odds of readmission among women remained for those discharged home (OR, 1.3; 95% CI, 1.12-1.51), but not when discharged to a skilled or rehabilitation facility (OR, 1.1; 95% CI, 0.83-1.45).
“Further study into the discharge planning process, social factors, and the use of rehabilitation is needed,” Dr. Flink said. “For example, why are we keeping women longer? Are we missing opportunities to better utilize rehabilitation in hospital? And what gender-specific social factors might be influencing unplanned readmissions that we’re currently not measuring?”
Dr. John Blebea of the University of Oklahoma, Tulsa, asked whether marital status was examined as an independent variable, “because I would suspect that’s the answer to the question. More women are widowed than men and therefore are less likely to have a spouse at home to take care of them, which would also explain why they’d be in the hospital longer.”
Unfortunately, that information is not available in the ACS/NSQIP database, but “I do agree that home-social factors are likely playing a role,” Dr. Flink responded.
Along the same vein, another attendee questioned whether the study accounted for frailty index scores. They were not, but the analysis included patients’ functional status as well as comorbidities such as congestive heart failure, stroke, peripheral arterial disease, and dialysis dependence that would limit their physical independence, Dr. Flink said.
Dr. Flink reported having no financial disclosures. Principal investigator Dr. Shipra Arya is funded by a research grant from the American Heart Association.
On Twitter @pwendl
AT MIDWESTERN VASCULAR 2015
Key clinical point: Women undergoing aortic surgery are at higher risk for unplanned readmissions, compared with men, especially when discharged to home.
Major finding: The odds of an unplanned readmission at 30 days were 30% higher for women than men.
Data source: Retrospective study of 18,977 patients undergoing aortic aneurysm repair in the ACS/NSQIP database.
Disclosures: Dr. Flink reported having no financial disclosures. Principal investigator Dr. Shipra Arya is funded by a research grant from the American Heart Association.
Hospital Medicine Administrator Amanda Trask Values Hospitalists, HM Role in Healthcare
Most people think a career in hospital medicine means a medical degree that confers those two ubiquitous letters after your name.
Amanda Trask blazed her own path.
She got to her job—vice president of the national hospitalist service line for Catholic Health Initiatives of Englewood, Colo.—by following a slightly different path. In her case, it was a master’s of business administration (MBA), a master’s in health administration (MHA), and a few fellowships to boot.
“Many years ago I chose to move forward in my education and attain advanced degrees,” says Trask, MBA, MHA, SFHM, FACHE, CMPE. “Through that, you get a really broad perspective of healthcare and the business of healthcare.”
It’s a perspective Dr. Trask is bringing to Team Hospitalist, as one of seven new members of The Hospitalist’s volunteer editorial advisory board. She sees HM as a vital specialty in a changing healthcare landscape.
“Hospital medicine is uniquely positioned to truly impact a very large breadth of patients and improve the continuum of care,” she says.
Question: Tell me about your role at Catholic Health Initiatives.
Answer: CHI operates in 19 states and 105 hospitals. We have a variety of hospitalist models in our hospitals, everything from direct employed with our local medical groups to contracted with hospitalist companies to independent groups that provide hospitalist services to their patients. At CHI, my role is to coordinate hospitalist efforts to improve clinical and efficiency outcomes in our hospitals and in other pre- and post-acute care settings where hospitalists play a role.
Q: People like to say, “If you’ve seen one hospitalist group, you’ve seen one hospitalist group.” How difficult is it to replicate commonalities in different buildings?
A: I definitely agree that “if you’ve seen one hospitalist group, you’ve seen one hospitalist group”; however, a great percentage of the work is common among hospitalists. We have a national hospital medicine leadership team composed of our divisional medical directors and dyad administrative partners to oversee the efforts of hospital medicine at CHI. That leadership team identifies the commonalities of opportunities across our hospital medicine markets. How can we support local innovation while maximizing the opportunity for standardization? What are the things that are fairly consistent no matter where you practice? What are those things that might have a substantial amount of difference? The focus of CHI’s national hospital medicine service line is to align standards that improve the practice of hospital medicine across CHI.
—Dr. Trask
Q: How important is it to find those commonalities?
A: In this day and age of healthcare, as we consider new payment models, we look at population health and what that means in a future state for healthcare. In the future, hospitalists are a critical component of ensuring we deliver higher clinical quality outcomes and better efficiencies to care for our population as a whole. As opposed to having each of our practices continuing to work individually and, in many cases, on many of the same exact issues, we identified the opportunity to bring those efforts together and try to do so in a more efficient fashion.
I’ll give an example: When we look at clinical documentation, much of that is related to electronic health records. How can we work together to identify opportunities to improve the use of our electronic health record when we have the same health record in different divisions?
Q: Where do you see yourself in five years, 10 years?
A: It’s funny you ask that question, as that is the question I always ask people I’m interviewing. My answer to that is not always as concrete as others’ answers.
I look at what doors might open, and I look at what opportunities present themselves. I think, looking at opportunities like we have in hospital medicine and looking at opportunities to really expand beyond current state, many of my experiences have led me to realize that I like to be involved in improvements, change in evolving the healthcare industry, and bringing teams together to improve the status quo.
Q: You work with some 900 hospitalists. What’s your favorite thing about working with them and the role they play?
A: Every single hospitalist I’ve encountered has demonstrated such a strong desire to make improvements in the patients that they’re caring for. What’s great about hospitalists is that they have an innate desire to improve the health and well-being of our communities. Hospitalists are truly passionate about improving the way we care for patients, advancing quality outcomes, and leading the shift from volume to value for the communities we serve. For me, this role is not simply a task or a job that I do, but it really is a passion.
Q: The flip side of that is nobody’s job is perfect. What’s the toughest thing about working with hospitalists?
A: One of the toughest things in this particular industry is the fact that it has been the fastest growing of all of time [in medicine], and there are times when supply and demand are not well balanced. There are a lot of demands placed on hospitalists, and there are a lot of expectations by hospital leaders and health system leaders, that hospitalists can solve many of the problems that may exist. Because of that, sometimes the supply of hospitalists, or the ability to have top talent, is really challenging.
The balance is not yet perfect between the availability of top talent and the ability to meet the needs of the organization and community.
Richard Quinn is a freelance writer in New Jersey.
Most people think a career in hospital medicine means a medical degree that confers those two ubiquitous letters after your name.
Amanda Trask blazed her own path.
She got to her job—vice president of the national hospitalist service line for Catholic Health Initiatives of Englewood, Colo.—by following a slightly different path. In her case, it was a master’s of business administration (MBA), a master’s in health administration (MHA), and a few fellowships to boot.
“Many years ago I chose to move forward in my education and attain advanced degrees,” says Trask, MBA, MHA, SFHM, FACHE, CMPE. “Through that, you get a really broad perspective of healthcare and the business of healthcare.”
It’s a perspective Dr. Trask is bringing to Team Hospitalist, as one of seven new members of The Hospitalist’s volunteer editorial advisory board. She sees HM as a vital specialty in a changing healthcare landscape.
“Hospital medicine is uniquely positioned to truly impact a very large breadth of patients and improve the continuum of care,” she says.
Question: Tell me about your role at Catholic Health Initiatives.
Answer: CHI operates in 19 states and 105 hospitals. We have a variety of hospitalist models in our hospitals, everything from direct employed with our local medical groups to contracted with hospitalist companies to independent groups that provide hospitalist services to their patients. At CHI, my role is to coordinate hospitalist efforts to improve clinical and efficiency outcomes in our hospitals and in other pre- and post-acute care settings where hospitalists play a role.
Q: People like to say, “If you’ve seen one hospitalist group, you’ve seen one hospitalist group.” How difficult is it to replicate commonalities in different buildings?
A: I definitely agree that “if you’ve seen one hospitalist group, you’ve seen one hospitalist group”; however, a great percentage of the work is common among hospitalists. We have a national hospital medicine leadership team composed of our divisional medical directors and dyad administrative partners to oversee the efforts of hospital medicine at CHI. That leadership team identifies the commonalities of opportunities across our hospital medicine markets. How can we support local innovation while maximizing the opportunity for standardization? What are the things that are fairly consistent no matter where you practice? What are those things that might have a substantial amount of difference? The focus of CHI’s national hospital medicine service line is to align standards that improve the practice of hospital medicine across CHI.
—Dr. Trask
Q: How important is it to find those commonalities?
A: In this day and age of healthcare, as we consider new payment models, we look at population health and what that means in a future state for healthcare. In the future, hospitalists are a critical component of ensuring we deliver higher clinical quality outcomes and better efficiencies to care for our population as a whole. As opposed to having each of our practices continuing to work individually and, in many cases, on many of the same exact issues, we identified the opportunity to bring those efforts together and try to do so in a more efficient fashion.
I’ll give an example: When we look at clinical documentation, much of that is related to electronic health records. How can we work together to identify opportunities to improve the use of our electronic health record when we have the same health record in different divisions?
Q: Where do you see yourself in five years, 10 years?
A: It’s funny you ask that question, as that is the question I always ask people I’m interviewing. My answer to that is not always as concrete as others’ answers.
I look at what doors might open, and I look at what opportunities present themselves. I think, looking at opportunities like we have in hospital medicine and looking at opportunities to really expand beyond current state, many of my experiences have led me to realize that I like to be involved in improvements, change in evolving the healthcare industry, and bringing teams together to improve the status quo.
Q: You work with some 900 hospitalists. What’s your favorite thing about working with them and the role they play?
A: Every single hospitalist I’ve encountered has demonstrated such a strong desire to make improvements in the patients that they’re caring for. What’s great about hospitalists is that they have an innate desire to improve the health and well-being of our communities. Hospitalists are truly passionate about improving the way we care for patients, advancing quality outcomes, and leading the shift from volume to value for the communities we serve. For me, this role is not simply a task or a job that I do, but it really is a passion.
Q: The flip side of that is nobody’s job is perfect. What’s the toughest thing about working with hospitalists?
A: One of the toughest things in this particular industry is the fact that it has been the fastest growing of all of time [in medicine], and there are times when supply and demand are not well balanced. There are a lot of demands placed on hospitalists, and there are a lot of expectations by hospital leaders and health system leaders, that hospitalists can solve many of the problems that may exist. Because of that, sometimes the supply of hospitalists, or the ability to have top talent, is really challenging.
The balance is not yet perfect between the availability of top talent and the ability to meet the needs of the organization and community.
Richard Quinn is a freelance writer in New Jersey.
Most people think a career in hospital medicine means a medical degree that confers those two ubiquitous letters after your name.
Amanda Trask blazed her own path.
She got to her job—vice president of the national hospitalist service line for Catholic Health Initiatives of Englewood, Colo.—by following a slightly different path. In her case, it was a master’s of business administration (MBA), a master’s in health administration (MHA), and a few fellowships to boot.
“Many years ago I chose to move forward in my education and attain advanced degrees,” says Trask, MBA, MHA, SFHM, FACHE, CMPE. “Through that, you get a really broad perspective of healthcare and the business of healthcare.”
It’s a perspective Dr. Trask is bringing to Team Hospitalist, as one of seven new members of The Hospitalist’s volunteer editorial advisory board. She sees HM as a vital specialty in a changing healthcare landscape.
“Hospital medicine is uniquely positioned to truly impact a very large breadth of patients and improve the continuum of care,” she says.
Question: Tell me about your role at Catholic Health Initiatives.
Answer: CHI operates in 19 states and 105 hospitals. We have a variety of hospitalist models in our hospitals, everything from direct employed with our local medical groups to contracted with hospitalist companies to independent groups that provide hospitalist services to their patients. At CHI, my role is to coordinate hospitalist efforts to improve clinical and efficiency outcomes in our hospitals and in other pre- and post-acute care settings where hospitalists play a role.
Q: People like to say, “If you’ve seen one hospitalist group, you’ve seen one hospitalist group.” How difficult is it to replicate commonalities in different buildings?
A: I definitely agree that “if you’ve seen one hospitalist group, you’ve seen one hospitalist group”; however, a great percentage of the work is common among hospitalists. We have a national hospital medicine leadership team composed of our divisional medical directors and dyad administrative partners to oversee the efforts of hospital medicine at CHI. That leadership team identifies the commonalities of opportunities across our hospital medicine markets. How can we support local innovation while maximizing the opportunity for standardization? What are the things that are fairly consistent no matter where you practice? What are those things that might have a substantial amount of difference? The focus of CHI’s national hospital medicine service line is to align standards that improve the practice of hospital medicine across CHI.
—Dr. Trask
Q: How important is it to find those commonalities?
A: In this day and age of healthcare, as we consider new payment models, we look at population health and what that means in a future state for healthcare. In the future, hospitalists are a critical component of ensuring we deliver higher clinical quality outcomes and better efficiencies to care for our population as a whole. As opposed to having each of our practices continuing to work individually and, in many cases, on many of the same exact issues, we identified the opportunity to bring those efforts together and try to do so in a more efficient fashion.
I’ll give an example: When we look at clinical documentation, much of that is related to electronic health records. How can we work together to identify opportunities to improve the use of our electronic health record when we have the same health record in different divisions?
Q: Where do you see yourself in five years, 10 years?
A: It’s funny you ask that question, as that is the question I always ask people I’m interviewing. My answer to that is not always as concrete as others’ answers.
I look at what doors might open, and I look at what opportunities present themselves. I think, looking at opportunities like we have in hospital medicine and looking at opportunities to really expand beyond current state, many of my experiences have led me to realize that I like to be involved in improvements, change in evolving the healthcare industry, and bringing teams together to improve the status quo.
Q: You work with some 900 hospitalists. What’s your favorite thing about working with them and the role they play?
A: Every single hospitalist I’ve encountered has demonstrated such a strong desire to make improvements in the patients that they’re caring for. What’s great about hospitalists is that they have an innate desire to improve the health and well-being of our communities. Hospitalists are truly passionate about improving the way we care for patients, advancing quality outcomes, and leading the shift from volume to value for the communities we serve. For me, this role is not simply a task or a job that I do, but it really is a passion.
Q: The flip side of that is nobody’s job is perfect. What’s the toughest thing about working with hospitalists?
A: One of the toughest things in this particular industry is the fact that it has been the fastest growing of all of time [in medicine], and there are times when supply and demand are not well balanced. There are a lot of demands placed on hospitalists, and there are a lot of expectations by hospital leaders and health system leaders, that hospitalists can solve many of the problems that may exist. Because of that, sometimes the supply of hospitalists, or the ability to have top talent, is really challenging.
The balance is not yet perfect between the availability of top talent and the ability to meet the needs of the organization and community.
Richard Quinn is a freelance writer in New Jersey.
Hospitals Save Estimated $67 Million by Tracking Energy Consumption
Estimated savings in energy costs posted by hospitals participating in the American Hospital Association’s affiliated American Society for Healthcare Engineering (ASHE) Energy to Care Program. Twenty participating hospitals received Energy to Care awards from ASHE in July for reducing their energy consumption by 10% or more. ASHE’s free program includes a benchmarking dashboard hospitals can use to track their own energy consumption, thereby saving energy and reducing costs.
Larry Beresford is a freelance writer in Alameda, Calif.
Estimated savings in energy costs posted by hospitals participating in the American Hospital Association’s affiliated American Society for Healthcare Engineering (ASHE) Energy to Care Program. Twenty participating hospitals received Energy to Care awards from ASHE in July for reducing their energy consumption by 10% or more. ASHE’s free program includes a benchmarking dashboard hospitals can use to track their own energy consumption, thereby saving energy and reducing costs.
Larry Beresford is a freelance writer in Alameda, Calif.
Estimated savings in energy costs posted by hospitals participating in the American Hospital Association’s affiliated American Society for Healthcare Engineering (ASHE) Energy to Care Program. Twenty participating hospitals received Energy to Care awards from ASHE in July for reducing their energy consumption by 10% or more. ASHE’s free program includes a benchmarking dashboard hospitals can use to track their own energy consumption, thereby saving energy and reducing costs.
Larry Beresford is a freelance writer in Alameda, Calif.
How to Develop a Comprehensive Pediatric Palliative Care Program
For Ami Doshi, MD, FAAP, a hospitalist at Rady Children’s Hospital San Diego, the path to establishing a comprehensive pediatric palliative care program began with her realization during medical training that doctors didn’t always adequately address the suffering of young patients with advanced disease and their families. Then, in a hospice rotation, she saw that the palliative approach could offer a better way.
During a pediatric hospital medicine fellowship at the University of California at San Diego, Dr. Doshi conducted an educational needs assessment and then created a palliative care curriculum for residents. Rady administrators supported her attending the Palliative Care Leadership Center training at UC San Francisco, with a team from Rady and Harvard Medical School’s program in Palliative Care Education and Practice.
After five years of development, the program Dr. Doshi helped to launch at Rady has grown into a division of palliative medicine, with a medical director, an inpatient consultation service, a palliative home care program coordinated by a health navigator, and a variety of models in the outpatient clinics.
“The goal is to be seamless and to treat patients across the continuum of care,” says Dr. Doshi, who is now board certified in hospice and palliative. Although she is based in the division of hospital medicine, she leads sit-down rounds with the full palliative care team and bioethics consultants every other week.
“Finding time for this work is always a challenge,” she says, adding that administrative support for physicians’ protected time is growing and that the program is ramping up its data collection to document outcomes resulting from palliative care.
For more information on the program, email her at [email protected].
Larry Beresford is a freelance writer in Alameda, Calif.
For Ami Doshi, MD, FAAP, a hospitalist at Rady Children’s Hospital San Diego, the path to establishing a comprehensive pediatric palliative care program began with her realization during medical training that doctors didn’t always adequately address the suffering of young patients with advanced disease and their families. Then, in a hospice rotation, she saw that the palliative approach could offer a better way.
During a pediatric hospital medicine fellowship at the University of California at San Diego, Dr. Doshi conducted an educational needs assessment and then created a palliative care curriculum for residents. Rady administrators supported her attending the Palliative Care Leadership Center training at UC San Francisco, with a team from Rady and Harvard Medical School’s program in Palliative Care Education and Practice.
After five years of development, the program Dr. Doshi helped to launch at Rady has grown into a division of palliative medicine, with a medical director, an inpatient consultation service, a palliative home care program coordinated by a health navigator, and a variety of models in the outpatient clinics.
“The goal is to be seamless and to treat patients across the continuum of care,” says Dr. Doshi, who is now board certified in hospice and palliative. Although she is based in the division of hospital medicine, she leads sit-down rounds with the full palliative care team and bioethics consultants every other week.
“Finding time for this work is always a challenge,” she says, adding that administrative support for physicians’ protected time is growing and that the program is ramping up its data collection to document outcomes resulting from palliative care.
For more information on the program, email her at [email protected].
Larry Beresford is a freelance writer in Alameda, Calif.
For Ami Doshi, MD, FAAP, a hospitalist at Rady Children’s Hospital San Diego, the path to establishing a comprehensive pediatric palliative care program began with her realization during medical training that doctors didn’t always adequately address the suffering of young patients with advanced disease and their families. Then, in a hospice rotation, she saw that the palliative approach could offer a better way.
During a pediatric hospital medicine fellowship at the University of California at San Diego, Dr. Doshi conducted an educational needs assessment and then created a palliative care curriculum for residents. Rady administrators supported her attending the Palliative Care Leadership Center training at UC San Francisco, with a team from Rady and Harvard Medical School’s program in Palliative Care Education and Practice.
After five years of development, the program Dr. Doshi helped to launch at Rady has grown into a division of palliative medicine, with a medical director, an inpatient consultation service, a palliative home care program coordinated by a health navigator, and a variety of models in the outpatient clinics.
“The goal is to be seamless and to treat patients across the continuum of care,” says Dr. Doshi, who is now board certified in hospice and palliative. Although she is based in the division of hospital medicine, she leads sit-down rounds with the full palliative care team and bioethics consultants every other week.
“Finding time for this work is always a challenge,” she says, adding that administrative support for physicians’ protected time is growing and that the program is ramping up its data collection to document outcomes resulting from palliative care.
For more information on the program, email her at [email protected].
Larry Beresford is a freelance writer in Alameda, Calif.