From the Editor

New laboratory tests seem to go through a life cycle. At first, some are used mainly by subspecialists, who became aware of them through early clinical trials or studies presented at specialty meetings. The general medical community adopts their use after noting that they are being ordered by consultants or were used in important published studies.

Sometimes, a new test is significantly better than the older ones, and clinical pathologists and subspecialists encourage us to use it. Sometimes, a new test may represent a breakthrough in the understanding of the pathophysiology of a disease, and its use is promoted by clinicians with special interest in that disease. Testing for serum troponin, as discussed by Sebastian et al in this issue of the Journal, is an example primarily of the first situation, while testing for antineutrophil cytoplasmic antibodies (ANCA) and immunoglobulin G4 are two of many examples of the second.

Once a test comes into widespread use, its accuracy and reproducibility can be problematic. The assay itself may have inherent weaknesses, or techniques may not be standardized among different laboratories; think about diagnosis of the antiphospholipid antibody syndrome. Standardization of laboratory techniques can often be achieved. For troponin, this remains a problem, though small, for patients whose serum is tested in different laboratories or for clinicians trying to directly compare different clinical trial results; but it doesn’t affect clinical decision-making when longitudinally following a specific patient through a single hospitalization.

In its mature years, as a useful novel test becomes widely used, it may alter how we view the management and pathophysiology of a disease. For example, in the days when postoperative myocardial infarction (MI) was diagnosed by electrocardiographic changes and then by elevations in creatine kinase (CK) and alterations in the ratio of  aspartate aminotransferase (AST) to alanine aminotransferase (ALT), the peak in MI incidence was thought to occur several days after surgery. With the advent of CK isoenzymes and then cardiac myocyte-derived troponin, it became apparent that perioperative myocardial injury occurs more in a time frame of hours after surgery. Laboratory data dovetailed with pathologic and angiographic data indicating that the mechanism of MI in the perioperative setting for many patients is different than in “native” MI. As newer, highly sensitive troponin assays are introduced, they may further our understanding of mechanisms of cardiac myocyte membrane injury and tissue necrosis, and may further clarify (or blur) the distinction between the two.

Often, a widely used test is ordered in clinical situations that were not specifically evaluated during initial studies of the test and early use by specialists. Case reports of unexpected results then appear in the literature. Intrinsic test performance may occasionally be influenced in unanticipated ways (eg, rheumatoid factor can affect test results of some troponin and cryptococcal antigen assays), but more frequently it is the definition of “normal” and interpretation of the test results in specific clinical conditions that are affected. For example, troponin levels are higher in patients with chronic kidney disease and severe sepsis. These elevations may be explained by decreased renal clearance of detected fragments of troponin but may also reflect subclinical myocardial injury related to circulating cytokines or other factors. Elevation of troponins in patients with these and other conditions has correlated with poorer outcomes. Thus, in some settings, elevated circulating troponin has greater prognostic than diagnostic significance.

Recognizing imperfect test specificity (false-positive results) is critical when using a test in complex clinical situations. This can be especially challenging when using indirect serologic tests: consider the many reasons for “false-positive” antinuclear antibody, ANCA, and rheumatoid factor test results. But it can also be a challenge when trying to use a targeted test like troponin to distinguish between MI, sepsis, and pulmonary embolism as the cause of acute hypotension.

Many routinely ordered tests require more nuanced interpretation than simply checking the value against the defined laboratory “normal.” These nuances may be well known to those who order the test often or to specialists, but not to all. Familiarity with tests can also result in a subliminal assumption that we fully understand their characteristics and can lead to misinterpretation of results. There are forgotten critical concepts about tests that are ordered extremely commonly: eg, AST and ALT do not come only from the liver and do not reflect “liver function.” Liver biopsy is unlikely to provide the explanation for a myositis patient’s sense of weakness, even if the aminotransferase levels are elevated in the several-hundred range.

A CALL FOR MANUSCRIPTS

I invite you to draw on your personal experience and the literature and submit short manuscripts that address the nuanced interpretation, limitations, and cost of specific laboratory tests. As with all submissions, these will undergo peer review for content accuracy, as well as relevancy and utility for our core readership before being considered for publication.

New laboratory tests seem to go through a life cycle. At first, some are used mainly by subspecialists, who became aware of them through early clinical trials or studies presented at specialty meetings. The general medical community adopts their use after noting that they are being ordered by consultants or were used in important published studies.

Sometimes, a new test is significantly better than the older ones, and clinical pathologists and subspecialists encourage us to use it. Sometimes, a new test may represent a breakthrough in the understanding of the pathophysiology of a disease, and its use is promoted by clinicians with special interest in that disease. Testing for serum troponin, as discussed by Sebastian et al in this issue of the Journal, is an example primarily of the first situation, while testing for antineutrophil cytoplasmic antibodies (ANCA) and immunoglobulin G4 are two of many examples of the second.

Once a test comes into widespread use, its accuracy and reproducibility can be problematic. The assay itself may have inherent weaknesses, or techniques may not be standardized among different laboratories; think about diagnosis of the antiphospholipid antibody syndrome. Standardization of laboratory techniques can often be achieved. For troponin, this remains a problem, though small, for patients whose serum is tested in different laboratories or for clinicians trying to directly compare different clinical trial results; but it doesn’t affect clinical decision-making when longitudinally following a specific patient through a single hospitalization.

In its mature years, as a useful novel test becomes widely used, it may alter how we view the management and pathophysiology of a disease. For example, in the days when postoperative myocardial infarction (MI) was diagnosed by electrocardiographic changes and then by elevations in creatine kinase (CK) and alterations in the ratio of  aspartate aminotransferase (AST) to alanine aminotransferase (ALT), the peak in MI incidence was thought to occur several days after surgery. With the advent of CK isoenzymes and then cardiac myocyte-derived troponin, it became apparent that perioperative myocardial injury occurs more in a time frame of hours after surgery. Laboratory data dovetailed with pathologic and angiographic data indicating that the mechanism of MI in the perioperative setting for many patients is different than in “native” MI. As newer, highly sensitive troponin assays are introduced, they may further our understanding of mechanisms of cardiac myocyte membrane injury and tissue necrosis, and may further clarify (or blur) the distinction between the two.

Often, a widely used test is ordered in clinical situations that were not specifically evaluated during initial studies of the test and early use by specialists. Case reports of unexpected results then appear in the literature. Intrinsic test performance may occasionally be influenced in unanticipated ways (eg, rheumatoid factor can affect test results of some troponin and cryptococcal antigen assays), but more frequently it is the definition of “normal” and interpretation of the test results in specific clinical conditions that are affected. For example, troponin levels are higher in patients with chronic kidney disease and severe sepsis. These elevations may be explained by decreased renal clearance of detected fragments of troponin but may also reflect subclinical myocardial injury related to circulating cytokines or other factors. Elevation of troponins in patients with these and other conditions has correlated with poorer outcomes. Thus, in some settings, elevated circulating troponin has greater prognostic than diagnostic significance.

Recognizing imperfect test specificity (false-positive results) is critical when using a test in complex clinical situations. This can be especially challenging when using indirect serologic tests: consider the many reasons for “false-positive” antinuclear antibody, ANCA, and rheumatoid factor test results. But it can also be a challenge when trying to use a targeted test like troponin to distinguish between MI, sepsis, and pulmonary embolism as the cause of acute hypotension.

Many routinely ordered tests require more nuanced interpretation than simply checking the value against the defined laboratory “normal.” These nuances may be well known to those who order the test often or to specialists, but not to all. Familiarity with tests can also result in a subliminal assumption that we fully understand their characteristics and can lead to misinterpretation of results. There are forgotten critical concepts about tests that are ordered extremely commonly: eg, AST and ALT do not come only from the liver and do not reflect “liver function.” Liver biopsy is unlikely to provide the explanation for a myositis patient’s sense of weakness, even if the aminotransferase levels are elevated in the several-hundred range.

A CALL FOR MANUSCRIPTS

I invite you to draw on your personal experience and the literature and submit short manuscripts that address the nuanced interpretation, limitations, and cost of specific laboratory tests. As with all submissions, these will undergo peer review for content accuracy, as well as relevancy and utility for our core readership before being considered for publication.

New laboratory tests seem to go through a life cycle. At first, some are used mainly by subspecialists, who became aware of them through early clinical trials or studies presented at specialty meetings. The general medical community adopts their use after noting that they are being ordered by consultants or were used in important published studies.

Sometimes, a new test is significantly better than the older ones, and clinical pathologists and subspecialists encourage us to use it. Sometimes, a new test may represent a breakthrough in the understanding of the pathophysiology of a disease, and its use is promoted by clinicians with special interest in that disease. Testing for serum troponin, as discussed by Sebastian et al in this issue of the Journal, is an example primarily of the first situation, while testing for antineutrophil cytoplasmic antibodies (ANCA) and immunoglobulin G4 are two of many examples of the second.

Once a test comes into widespread use, its accuracy and reproducibility can be problematic. The assay itself may have inherent weaknesses, or techniques may not be standardized among different laboratories; think about diagnosis of the antiphospholipid antibody syndrome. Standardization of laboratory techniques can often be achieved. For troponin, this remains a problem, though small, for patients whose serum is tested in different laboratories or for clinicians trying to directly compare different clinical trial results; but it doesn’t affect clinical decision-making when longitudinally following a specific patient through a single hospitalization.

In its mature years, as a useful novel test becomes widely used, it may alter how we view the management and pathophysiology of a disease. For example, in the days when postoperative myocardial infarction (MI) was diagnosed by electrocardiographic changes and then by elevations in creatine kinase (CK) and alterations in the ratio of  aspartate aminotransferase (AST) to alanine aminotransferase (ALT), the peak in MI incidence was thought to occur several days after surgery. With the advent of CK isoenzymes and then cardiac myocyte-derived troponin, it became apparent that perioperative myocardial injury occurs more in a time frame of hours after surgery. Laboratory data dovetailed with pathologic and angiographic data indicating that the mechanism of MI in the perioperative setting for many patients is different than in “native” MI. As newer, highly sensitive troponin assays are introduced, they may further our understanding of mechanisms of cardiac myocyte membrane injury and tissue necrosis, and may further clarify (or blur) the distinction between the two.

Often, a widely used test is ordered in clinical situations that were not specifically evaluated during initial studies of the test and early use by specialists. Case reports of unexpected results then appear in the literature. Intrinsic test performance may occasionally be influenced in unanticipated ways (eg, rheumatoid factor can affect test results of some troponin and cryptococcal antigen assays), but more frequently it is the definition of “normal” and interpretation of the test results in specific clinical conditions that are affected. For example, troponin levels are higher in patients with chronic kidney disease and severe sepsis. These elevations may be explained by decreased renal clearance of detected fragments of troponin but may also reflect subclinical myocardial injury related to circulating cytokines or other factors. Elevation of troponins in patients with these and other conditions has correlated with poorer outcomes. Thus, in some settings, elevated circulating troponin has greater prognostic than diagnostic significance.

Recognizing imperfect test specificity (false-positive results) is critical when using a test in complex clinical situations. This can be especially challenging when using indirect serologic tests: consider the many reasons for “false-positive” antinuclear antibody, ANCA, and rheumatoid factor test results. But it can also be a challenge when trying to use a targeted test like troponin to distinguish between MI, sepsis, and pulmonary embolism as the cause of acute hypotension.

Many routinely ordered tests require more nuanced interpretation than simply checking the value against the defined laboratory “normal.” These nuances may be well known to those who order the test often or to specialists, but not to all. Familiarity with tests can also result in a subliminal assumption that we fully understand their characteristics and can lead to misinterpretation of results. There are forgotten critical concepts about tests that are ordered extremely commonly: eg, AST and ALT do not come only from the liver and do not reflect “liver function.” Liver biopsy is unlikely to provide the explanation for a myositis patient’s sense of weakness, even if the aminotransferase levels are elevated in the several-hundred range.

A CALL FOR MANUSCRIPTS

I invite you to draw on your personal experience and the literature and submit short manuscripts that address the nuanced interpretation, limitations, and cost of specific laboratory tests. As with all submissions, these will undergo peer review for content accuracy, as well as relevancy and utility for our core readership before being considered for publication.

It is well established that general medical conditions can be associated with various psychiatric disorders. But the reverse is less recognized: That serious mental illness is associated with many physical maladies, often leading to early mortality. Thus, it is a bidirectional medical reality.

The multisystem adverse effects of psycho­tropic medications, such as metabolic dysregulation, often are blamed for the serious medical problems afflicting psychiatrically ill patients. However, evidence is mounting that while iatrogenic effects play a role, the larger effect appears to be due to a genetic link between psychiatric disorders and cardiovascular risk.¹ Unhealthy lifestyles, including sedentary living, poor dietary habits, smoking, and alcohol/substance use, also play a role in the rapid deterioration of physical health and early mortality of individuals afflicted by mood disorders, psychotic disorders, and anxiety disorders. The mantra of “healthy body, healthy mind” is well known, but “unhealthy mind, unhealthy body” should be equally emphasized as a reason for high morbidity and premature mortality in patients with serious mental disorders.

Consider the following alarming findings:

• A recent study revealed that even before the onset of the first psychotic episode, young patients with schizophrenia already suffer from a wide variety of medical conditions.² In a large sample of 954,351 Danish persons followed from birth to adulthood, of whom 4,371 developed schizophrenia, 95.6% of patients with schizophrenia had a history of hospitalization for somatic problems, including gastrointestinal, endocrine, genitourinary, metabolic, and circulatory system diseases; cancer; and epilepsy. Those findings suggest genetic, physiological, immunological, or developmental overlap between schizophrenia and medical conditions.
• A survey of 67,609 individuals with mood, anxiety, eating, impulse control, or substance use disorders followed for 10 years found that persons with those psychiatric disorders had a significantly higher risk of chronic medical conditions, including heart disease, stroke, hypertension, diabetes, asthma, arthritis, lung disease, peptic ulcer, and cancer.³
• A 7-year follow-up study of 1,138,853 individuals with schizophrenia in the United States found a 350% increase in mortality among this group of patients, who ranged in age from 20 to 64 years, compared with the general population, matched for age, sex, race, ethnicity, and geographic regions.⁴ An editorial accompanying this study urged psychiatrists to urgently address the “deadly consequences” of major psychiatric disorders.⁵
• A study of 18,380 individuals with schizophrenia, schizoaffective disorder, or bipolar disorder in London found that these patients were frequently hospitalized for general medical conditions, most commonly urinary, digestive, respiratory, endocrine/metabolic, hematologic, neurologic, dermatologic, and infectious disorders, neoplasm, and poisoning.⁶ The authors attributed those nonpsychiatric hospitalizations to self-neglect, self-harm, and poor health care access, as well as to “medically unexplained” causes.
• An extremely elevated mortality rate (24-fold higher than the general population) was reported in a 12-month study of young individuals (age 16 to 30 years) diagnosed with psychosis.⁷ The investigators also found that 61% of the cohort did not fill their antipsychotic prescriptions during that year, and 62% had ≥1 hospitalizations and/or emergency room visits during that year. The relationship between high mortality and lack of treatment with antipsychotics in schizophrenia was confirmed by another recent study,⁸ a 7-year follow-up of 29,823 persons with schizophrenia in Sweden that measured all-cause mortality. These researchers found the highest mortality among patients not receiving any antipsychotics, while the lowest mortality was among those receiving a long-acting injectable second-generation antipsychotic.
• A recent systematic review of 16 studies that examined glucose homeostasis in first-episode psychosis⁹ revealed that even at the onset of schizophrenia, glucose homeostasis was already altered, suggesting that predisposition to type 2 diabetes mellitus is a medical condition associated with schizophrenia, and not simply an iatrogenic effect of antipsychotic pharmacotherapy. This adds fodder to the possibility of a genetic overlap between schizophrenia and somatic disorders, including diabetes.¹⁰
• In a meta-analysis of 47 studies of young people at “ultra-high risk” for schizophrenia, cardiovascular risk was found to be high, mostly as a result of lifestyle factors such as low levels of physical activity and high rates of smoking and alcohol use, even before the onset of psychosis.¹¹
• The risk of stroke was found to be higher in 80,569 patients with schizophrenia compared with 241,707 age- and sex-matched control subjects.¹²
• A meta-analysis of the risk of stroke in 6 cohorts with schizophrenia found that there is a higher risk for stroke in schizophrenia, and that this may be related to natural history of the illness itself, not just due to comorbid metabolic risk factors.¹³
• The high rate of cardiovascular disease in depression has been attributed to neuroinflammation¹⁴ or possibly to increased platelet reactivity.¹⁵

Continue to: As psychiatric physicians...

As psychiatric physicians, we always screen our patients for past and current medical conditions that are comorbid with their psychiatric disorders. We are aware of the lifestyle factors that increase these patients’ physical morbidity and mortality, above and beyond their suicide-related mortality. Our patients with schizophrenia and mood disorders have triple the smoking rates of the general population, and they tend to be sedentary with poor eating habits that lead to obesity, obstructive sleep apnea, diabetes, hypertension, and dyslipidemia, which increases their risk for heart attack, stroke, and cancer. Self-neglect during acute episodes of depression or psychosis increases the risk of infection, malnutrition, and tooth decay. We also see skin damage in obsessive-compulsive disorder patients who are compelled to wash their hands numerous times a day, the life-threatening effects of anorexia nervosa, and various types of medical ailments caused by incomplete suicidal attempts. Poverty and substance use among chronically mentally ill patients also increase the odds of physical ailments.

So we need to act diligently to reduce the alarming medical morbidity and mortality of the psychiatric population. Collaborative care with a primary care provider is a must, not an option, for every patient, because studies indicate that without collaborative care, patients receive inadequate primary care.¹⁶ Providing rapid access to standard medical care is the single most critical step for the prevention or amelioration of physical disorders in our psychiatric patients, concurrently with stabilizing their ailing brains and minds. If we focus only on treating psychopathology, then we will win the battle against mental illness, but lose the war of life and death.

It is well established that general medical conditions can be associated with various psychiatric disorders. But the reverse is less recognized: That serious mental illness is associated with many physical maladies, often leading to early mortality. Thus, it is a bidirectional medical reality.

The multisystem adverse effects of psycho­tropic medications, such as metabolic dysregulation, often are blamed for the serious medical problems afflicting psychiatrically ill patients. However, evidence is mounting that while iatrogenic effects play a role, the larger effect appears to be due to a genetic link between psychiatric disorders and cardiovascular risk.¹ Unhealthy lifestyles, including sedentary living, poor dietary habits, smoking, and alcohol/substance use, also play a role in the rapid deterioration of physical health and early mortality of individuals afflicted by mood disorders, psychotic disorders, and anxiety disorders. The mantra of “healthy body, healthy mind” is well known, but “unhealthy mind, unhealthy body” should be equally emphasized as a reason for high morbidity and premature mortality in patients with serious mental disorders.

Consider the following alarming findings:

• A recent study revealed that even before the onset of the first psychotic episode, young patients with schizophrenia already suffer from a wide variety of medical conditions.² In a large sample of 954,351 Danish persons followed from birth to adulthood, of whom 4,371 developed schizophrenia, 95.6% of patients with schizophrenia had a history of hospitalization for somatic problems, including gastrointestinal, endocrine, genitourinary, metabolic, and circulatory system diseases; cancer; and epilepsy. Those findings suggest genetic, physiological, immunological, or developmental overlap between schizophrenia and medical conditions.
• A survey of 67,609 individuals with mood, anxiety, eating, impulse control, or substance use disorders followed for 10 years found that persons with those psychiatric disorders had a significantly higher risk of chronic medical conditions, including heart disease, stroke, hypertension, diabetes, asthma, arthritis, lung disease, peptic ulcer, and cancer.³
• A 7-year follow-up study of 1,138,853 individuals with schizophrenia in the United States found a 350% increase in mortality among this group of patients, who ranged in age from 20 to 64 years, compared with the general population, matched for age, sex, race, ethnicity, and geographic regions.⁴ An editorial accompanying this study urged psychiatrists to urgently address the “deadly consequences” of major psychiatric disorders.⁵
• A study of 18,380 individuals with schizophrenia, schizoaffective disorder, or bipolar disorder in London found that these patients were frequently hospitalized for general medical conditions, most commonly urinary, digestive, respiratory, endocrine/metabolic, hematologic, neurologic, dermatologic, and infectious disorders, neoplasm, and poisoning.⁶ The authors attributed those nonpsychiatric hospitalizations to self-neglect, self-harm, and poor health care access, as well as to “medically unexplained” causes.
• An extremely elevated mortality rate (24-fold higher than the general population) was reported in a 12-month study of young individuals (age 16 to 30 years) diagnosed with psychosis.⁷ The investigators also found that 61% of the cohort did not fill their antipsychotic prescriptions during that year, and 62% had ≥1 hospitalizations and/or emergency room visits during that year. The relationship between high mortality and lack of treatment with antipsychotics in schizophrenia was confirmed by another recent study,⁸ a 7-year follow-up of 29,823 persons with schizophrenia in Sweden that measured all-cause mortality. These researchers found the highest mortality among patients not receiving any antipsychotics, while the lowest mortality was among those receiving a long-acting injectable second-generation antipsychotic.
• A recent systematic review of 16 studies that examined glucose homeostasis in first-episode psychosis⁹ revealed that even at the onset of schizophrenia, glucose homeostasis was already altered, suggesting that predisposition to type 2 diabetes mellitus is a medical condition associated with schizophrenia, and not simply an iatrogenic effect of antipsychotic pharmacotherapy. This adds fodder to the possibility of a genetic overlap between schizophrenia and somatic disorders, including diabetes.¹⁰
• In a meta-analysis of 47 studies of young people at “ultra-high risk” for schizophrenia, cardiovascular risk was found to be high, mostly as a result of lifestyle factors such as low levels of physical activity and high rates of smoking and alcohol use, even before the onset of psychosis.¹¹
• The risk of stroke was found to be higher in 80,569 patients with schizophrenia compared with 241,707 age- and sex-matched control subjects.¹²
• A meta-analysis of the risk of stroke in 6 cohorts with schizophrenia found that there is a higher risk for stroke in schizophrenia, and that this may be related to natural history of the illness itself, not just due to comorbid metabolic risk factors.¹³
• The high rate of cardiovascular disease in depression has been attributed to neuroinflammation¹⁴ or possibly to increased platelet reactivity.¹⁵

Continue to: As psychiatric physicians...

As psychiatric physicians, we always screen our patients for past and current medical conditions that are comorbid with their psychiatric disorders. We are aware of the lifestyle factors that increase these patients’ physical morbidity and mortality, above and beyond their suicide-related mortality. Our patients with schizophrenia and mood disorders have triple the smoking rates of the general population, and they tend to be sedentary with poor eating habits that lead to obesity, obstructive sleep apnea, diabetes, hypertension, and dyslipidemia, which increases their risk for heart attack, stroke, and cancer. Self-neglect during acute episodes of depression or psychosis increases the risk of infection, malnutrition, and tooth decay. We also see skin damage in obsessive-compulsive disorder patients who are compelled to wash their hands numerous times a day, the life-threatening effects of anorexia nervosa, and various types of medical ailments caused by incomplete suicidal attempts. Poverty and substance use among chronically mentally ill patients also increase the odds of physical ailments.

So we need to act diligently to reduce the alarming medical morbidity and mortality of the psychiatric population. Collaborative care with a primary care provider is a must, not an option, for every patient, because studies indicate that without collaborative care, patients receive inadequate primary care.¹⁶ Providing rapid access to standard medical care is the single most critical step for the prevention or amelioration of physical disorders in our psychiatric patients, concurrently with stabilizing their ailing brains and minds. If we focus only on treating psychopathology, then we will win the battle against mental illness, but lose the war of life and death.

It is well established that general medical conditions can be associated with various psychiatric disorders. But the reverse is less recognized: That serious mental illness is associated with many physical maladies, often leading to early mortality. Thus, it is a bidirectional medical reality.

The multisystem adverse effects of psycho­tropic medications, such as metabolic dysregulation, often are blamed for the serious medical problems afflicting psychiatrically ill patients. However, evidence is mounting that while iatrogenic effects play a role, the larger effect appears to be due to a genetic link between psychiatric disorders and cardiovascular risk.¹ Unhealthy lifestyles, including sedentary living, poor dietary habits, smoking, and alcohol/substance use, also play a role in the rapid deterioration of physical health and early mortality of individuals afflicted by mood disorders, psychotic disorders, and anxiety disorders. The mantra of “healthy body, healthy mind” is well known, but “unhealthy mind, unhealthy body” should be equally emphasized as a reason for high morbidity and premature mortality in patients with serious mental disorders.

Consider the following alarming findings:

• A recent study revealed that even before the onset of the first psychotic episode, young patients with schizophrenia already suffer from a wide variety of medical conditions.² In a large sample of 954,351 Danish persons followed from birth to adulthood, of whom 4,371 developed schizophrenia, 95.6% of patients with schizophrenia had a history of hospitalization for somatic problems, including gastrointestinal, endocrine, genitourinary, metabolic, and circulatory system diseases; cancer; and epilepsy. Those findings suggest genetic, physiological, immunological, or developmental overlap between schizophrenia and medical conditions.
• A survey of 67,609 individuals with mood, anxiety, eating, impulse control, or substance use disorders followed for 10 years found that persons with those psychiatric disorders had a significantly higher risk of chronic medical conditions, including heart disease, stroke, hypertension, diabetes, asthma, arthritis, lung disease, peptic ulcer, and cancer.³
• A 7-year follow-up study of 1,138,853 individuals with schizophrenia in the United States found a 350% increase in mortality among this group of patients, who ranged in age from 20 to 64 years, compared with the general population, matched for age, sex, race, ethnicity, and geographic regions.⁴ An editorial accompanying this study urged psychiatrists to urgently address the “deadly consequences” of major psychiatric disorders.⁵
• A study of 18,380 individuals with schizophrenia, schizoaffective disorder, or bipolar disorder in London found that these patients were frequently hospitalized for general medical conditions, most commonly urinary, digestive, respiratory, endocrine/metabolic, hematologic, neurologic, dermatologic, and infectious disorders, neoplasm, and poisoning.⁶ The authors attributed those nonpsychiatric hospitalizations to self-neglect, self-harm, and poor health care access, as well as to “medically unexplained” causes.
• An extremely elevated mortality rate (24-fold higher than the general population) was reported in a 12-month study of young individuals (age 16 to 30 years) diagnosed with psychosis.⁷ The investigators also found that 61% of the cohort did not fill their antipsychotic prescriptions during that year, and 62% had ≥1 hospitalizations and/or emergency room visits during that year. The relationship between high mortality and lack of treatment with antipsychotics in schizophrenia was confirmed by another recent study,⁸ a 7-year follow-up of 29,823 persons with schizophrenia in Sweden that measured all-cause mortality. These researchers found the highest mortality among patients not receiving any antipsychotics, while the lowest mortality was among those receiving a long-acting injectable second-generation antipsychotic.
• A recent systematic review of 16 studies that examined glucose homeostasis in first-episode psychosis⁹ revealed that even at the onset of schizophrenia, glucose homeostasis was already altered, suggesting that predisposition to type 2 diabetes mellitus is a medical condition associated with schizophrenia, and not simply an iatrogenic effect of antipsychotic pharmacotherapy. This adds fodder to the possibility of a genetic overlap between schizophrenia and somatic disorders, including diabetes.¹⁰
• In a meta-analysis of 47 studies of young people at “ultra-high risk” for schizophrenia, cardiovascular risk was found to be high, mostly as a result of lifestyle factors such as low levels of physical activity and high rates of smoking and alcohol use, even before the onset of psychosis.¹¹
• The risk of stroke was found to be higher in 80,569 patients with schizophrenia compared with 241,707 age- and sex-matched control subjects.¹²
• A meta-analysis of the risk of stroke in 6 cohorts with schizophrenia found that there is a higher risk for stroke in schizophrenia, and that this may be related to natural history of the illness itself, not just due to comorbid metabolic risk factors.¹³
• The high rate of cardiovascular disease in depression has been attributed to neuroinflammation¹⁴ or possibly to increased platelet reactivity.¹⁵

Continue to: As psychiatric physicians...

As psychiatric physicians, we always screen our patients for past and current medical conditions that are comorbid with their psychiatric disorders. We are aware of the lifestyle factors that increase these patients’ physical morbidity and mortality, above and beyond their suicide-related mortality. Our patients with schizophrenia and mood disorders have triple the smoking rates of the general population, and they tend to be sedentary with poor eating habits that lead to obesity, obstructive sleep apnea, diabetes, hypertension, and dyslipidemia, which increases their risk for heart attack, stroke, and cancer. Self-neglect during acute episodes of depression or psychosis increases the risk of infection, malnutrition, and tooth decay. We also see skin damage in obsessive-compulsive disorder patients who are compelled to wash their hands numerous times a day, the life-threatening effects of anorexia nervosa, and various types of medical ailments caused by incomplete suicidal attempts. Poverty and substance use among chronically mentally ill patients also increase the odds of physical ailments.

So we need to act diligently to reduce the alarming medical morbidity and mortality of the psychiatric population. Collaborative care with a primary care provider is a must, not an option, for every patient, because studies indicate that without collaborative care, patients receive inadequate primary care.¹⁶ Providing rapid access to standard medical care is the single most critical step for the prevention or amelioration of physical disorders in our psychiatric patients, concurrently with stabilizing their ailing brains and minds. If we focus only on treating psychopathology, then we will win the battle against mental illness, but lose the war of life and death.

Keeping up with refinements in old procedures and adopting new procedures throughout one’s surgical career has always been a challenge.

That challenge has grown as advancements in technology have become ever more disruptive, requiring the learning of radically different skills. Surgeons are highly motivated to learn new procedures, lest they become extinct like professional “dodo birds.” But doing so requires a considerable expenditure of time and money to attend courses and then a period of being proctored in the new procedure once it has been learned.

Coaching by master surgeons should become a professional norm. It is only after surgical education and coaching are incorporated all along the training continuum – from novice to competent to master during residency training – that surgeons already in practice will accept it as a regular part of their work. Refinements in procedures and new procedures would be met by continued professional improvement that would be enhanced by master surgeon coaching. We owe it to ourselves and our patients to achieve excellence, not mere competence. “Okay” is not good enough.

Dr. Deveney is a professor of surgery and the vice chair of education in the department of surgery at Oregon Health & Science University, Portland. She is the coeditor of ACS Surgery News. 

Keeping up with refinements in old procedures and adopting new procedures throughout one’s surgical career has always been a challenge.

That challenge has grown as advancements in technology have become ever more disruptive, requiring the learning of radically different skills. Surgeons are highly motivated to learn new procedures, lest they become extinct like professional “dodo birds.” But doing so requires a considerable expenditure of time and money to attend courses and then a period of being proctored in the new procedure once it has been learned.

Coaching by master surgeons should become a professional norm. It is only after surgical education and coaching are incorporated all along the training continuum – from novice to competent to master during residency training – that surgeons already in practice will accept it as a regular part of their work. Refinements in procedures and new procedures would be met by continued professional improvement that would be enhanced by master surgeon coaching. We owe it to ourselves and our patients to achieve excellence, not mere competence. “Okay” is not good enough.

Dr. Deveney is a professor of surgery and the vice chair of education in the department of surgery at Oregon Health & Science University, Portland. She is the coeditor of ACS Surgery News. 

Keeping up with refinements in old procedures and adopting new procedures throughout one’s surgical career has always been a challenge.

That challenge has grown as advancements in technology have become ever more disruptive, requiring the learning of radically different skills. Surgeons are highly motivated to learn new procedures, lest they become extinct like professional “dodo birds.” But doing so requires a considerable expenditure of time and money to attend courses and then a period of being proctored in the new procedure once it has been learned.

Coaching by master surgeons should become a professional norm. It is only after surgical education and coaching are incorporated all along the training continuum – from novice to competent to master during residency training – that surgeons already in practice will accept it as a regular part of their work. Refinements in procedures and new procedures would be met by continued professional improvement that would be enhanced by master surgeon coaching. We owe it to ourselves and our patients to achieve excellence, not mere competence. “Okay” is not good enough.

Dr. Deveney is a professor of surgery and the vice chair of education in the department of surgery at Oregon Health & Science University, Portland. She is the coeditor of ACS Surgery News. 

Halsted’s surgical principles

Dr. William Steward Halsted, the first chief of surgery at Johns Hopkins Hospital, articulated a set of surgical principles that included strict aseptic technique, gentle tissue handling, meticulous hemostasis, minimum tension on tissue, accurate tissue apposition, preservation of blood supply, and obliteration of dead space where appropriate. These principles of “safe surgery” are believed to improve surgical outcomes and reduce the risk of surgical site infection.¹

Preoperative antibiotics

All obstetricians who perform cesarean delivery know the importance of administering a narrow-spectrum antibiotic, such as cefazolin or ampicillin, prior to the skin incision, but not more than 60 minutes before the incision, to help reduce the risk of wound infection and endometritis. In a meta-analysis of 82 studies involving more than 13,000 women the administration of a preoperative antibiotic compared with placebo reduced the risk of wound infection (relative risk [RR], 0.40; 95% confidence interval [CI], 0.35–0.46) and endometritis (RR, 0.38; 95% CI, 0.34–0.42).²

Cefazolin 3 g versus 2 g for obese patients

There are no data from randomized trials of cesarean delivery that directly compare the efficacy of preoperative cefazolin at doses of 2 g and 3 g to reduce the risk of infection. However, based on the observation that, for any given dose of cefazolin, circulating levels are reduced in obese patients, many authorities recommend that if the patient weighs ≥120 kg that 3 g of cefazolin should be administered.³

Extended-spectrum preoperative antibiotics

Some experts recommend that, for women in labor and for women with more than 4 hours of ruptured membranes, IV azithromycin 500 mg be added to the standard narrow-spectrum cefazolin regimen to reduce the rate of postoperative infection. In one trial, 2,013 women who were in labor or had more than 4 hours of ruptured membranes were randomly assigned to IV cefazolin alone or IV cefazolin plus azithromycin 500 mg prior to cesarean delivery.⁴ The cefazolin dose was reported to be weight-based utilizing the BMI at the time of delivery. The rates of endometritis (3.8% vs 6.1%) and wound infection (2.4% vs 6.6%) were lower in the women receiving extended-spectrum antibiotics versus cefazolin monotherapy.

Concerns have been raised about the impact of extended-spectrum antibiotics on the newborn microbiome and risk of accelerating the emergence of bacteria resistant to available antibiotics. Limiting the use of azithromycin to those cesarean delivery cases in which the patient is immunosuppressed, diabetic, obese, in labor and/or with prolonged ruptured membranes would reduce the number of women and newborns exposed to the drug and achieve the immediate health goal of reducing surgical infection.

Preoperative vaginal preparation

Many authorities recommend the use of a preoperative povidone- iodine vaginal scrub for 30 seconds prior to cesarean delivery for women in labor and women with ruptured membranes. In a meta-analysis of 16 trials involving 4,837 women, the women who received vaginal cleansing before cesarean delivery had a significantly lower incidence of endometritis (4.5% vs 8.8%) and postoperative fever (9.4% vs 14.9%) compared with those who did not have vaginal cleansing.⁵ Most of the benefit in reducing the risk of endometritis was confined to women in labor before the cesarean delivery (8.1% vs 13.8%) and women with ruptured membranes (4.3% vs 20.1%).⁵

Metronidazole gel 5 g also has been reported to be effective in reducing the rate of endometritis associated with cesarean delivery. In one study, 224 women having a cesarean delivery for various indications were randomly assigned to preoperative treatment with vaginally administered metronidazole gel 5 g or placebo gel. All women also received one dose of preoperative intravenous antibiotics. The rates of endometritis were 7% and 17% in the metronidazole and placebo groups, respectively.⁶

Povidone-iodine is approved for vaginal surgical site cleansing. For women with allergies to iodine or povidone-iodine, the options for vaginal cleansing are limited. The American College of Obstetricians and Gynecologists has noted the chlorhexidine gluconate solutions with a high concentration of alcohol should not be used for vaginal cleansing because the alcohol can irritate the mucosal epithelium. However, although not US Food and Drug Administration–approved for vaginal cleansing, solutions of chlorhexidine with a low alcohol content (Hibiclens, chlorhexidine with 4% alcohol concentration) are thought to be safe and may be considered for off-label use in vaginal cleansing.⁷

Preoperative abdominal preparation with chlorhexidine

Some authorities recommend skin preparation with chlorhexidine rather than povidone-iodine prior to cesarean delivery. Two recent randomized trials in women undergoing cesarean delivery^8,9 and one trial in patients undergoing general surgery operations¹⁰ reported a reduction in surgical site infection with chlorhexidine. However, other trials have reported no difference in the rate of surgical site infection with these two skin preparation methods.^11,12

Changing gloves and equipment after delivery of the newborn

Currently there is no high-quality evidence that changing gloves after delivery of the newborn or using new surgical instruments for closure reduces the risk of postcesarean infection. Two small clinical trials reported that changing gloves after delivery of the newborn did not reduce the rate of postcesarean infection.^13,14

Postoperative antibiotics (a heretical challenge to the central dogma of antibiotic prophylaxis in surgery)

The central dogma of antibiotic prevention of postoperative infection is that antibiotics administered just before skin incision are effective, and postoperative antibiotics to prevent surgical infection generally are not useful. For the case of cesarean delivery, where the rate of postcesarean infection is very high, that dogma is being questioned. In a recent clinical trial, 403 women with a prepregnancy BMI ≥30 kg/m² were randomly assigned to postcesarean treatment with oral cephalexin plus metronidazole (500 mg of each medication every 8 hours for 6 doses) or placebo pills.¹⁵ All women received preoperative IV cefazolin 2 g, indicating that the dosing was probably not weight-based. The surgical site infection rates in the cephalexin plus metronidazole and placebo groups were 6.4% and 15.4%, respectively (RR, 0.41; 95% CI, 0.22–0.77; P = .01). In a subgroup analysis based on the presence or absence of ruptured membranes, postoperative oral cephalexin plus metronidazole was most beneficial for the women with ruptured membranes. Among women with ruptured membranes the surgical site infection rates in the cephalexin plus metronidazole and placebo groups were 9.5% and 30.2%, respectively. Among women with intact membranes the surgical site infection rates in the cephalexin plus metronidazole and placebo groups were 5% and 8.7%, respectively.

Given that these findings are not consistent with current dogma, clinicians should be cautious about using postcesarean antibiotics and await confirmation in additional trials. Of relevance, a randomized study of women with chorioamnionitis who were treated precesarean delivery with ampicillin, gentamicin, and clindamycin did not benefit from the administration of additional postoperative antibiotics (one additional dose of gentamicin and clindamycin) compared with no postdelivery antibiotics.¹⁶

Does suture selection matter?

In one randomized trial comparing two suture types, 550 women undergoing nonemergent cesarean delivery were randomly assigned to subcuticular skin closure with polyglactin 910 (Vicryl) or poliglecaprone 25 (Monocryl) suture. The poliglecaprone 25 suture was associated with a lower rate of wound complications (8.8% vs 14.4%; 95% CI, 0.37–99; P = .04).¹⁷ However, a post-hoc analysis of a randomized trial of skin preparation did not observe a difference in wound complications between the use of polyglactinor poliglecaprone suture for skin closure.¹⁸

Prophylactic negative-pressure wound therapy: An evolving best practice?

A meta-analysis of 6 randomized trials and 3 cohort studies reported that in high-risk obese women the use of prophylactic negative-pressure wound therapy compared with standard wound dressing resulted in a decrease in surgical site infection (RR, 0.45; 95% CI, 0.31–0.66).¹⁹ The number needed to treat was 17. In one recent study, the wound outcomes following cesarean delivery among women with a BMI ≥40 kg/m² were compared in 234 women who received and 233 women who did not receive negative-pressure wound therapy.²⁰ Wound infection was observed in 5.6% and 9.9% of the treated and untreated women, respectively.²⁰ However, another meta-analysis of prophylactic negative-pressure wound therapy for obese women undergoing cesarean delivery did not report any benefit.²¹

Let’s work on continuous improvement

Cesarean delivery is a common major operation and is associated with wound infections and endometritis at rates much greater than those observed after vaginal delivery or other major intra-abdominal operations. As obstetricians, we can do more to guide practice toward continuous improvement in surgical outcomes. Systematically using a bundle of evidence-based interventions, including proper antibiotic selection, timing, and dosing; use of hair removal with clippers; use of chlorhexidine abdominal prep; removal of the placenta with gentle traction; and closure of the subcutaneous layer if tissue depth is ≥2 cm, will reduce the rate of postcesarean infection.²² Although aspirational, we may, someday, achieve a post‑cesarean infection rate less than 1%!

CASE Conclusion
The patient was noted to be at high risk for postcesarean infection because she had both an elevated BMI and ruptured membranes. The surgeon astutely decided to administer cefazolin 3 g and azithromycin 500 mg, cleanse the vagina with povidone-iodine, use chlorhexidine for the abdominal prep, use poliglecaprone 25 subcuticular skin closure, and did not use postoperative antibiotics or prophylactic wound vacuum. Following an uneventful cesarean delivery, the patient was discharged without an infection on postoperative day 4.

Share your thoughts! Send your Letter to the Editor to [email protected]. Please include your name and the city and state in which you practice.

Halsted’s surgical principles

Dr. William Steward Halsted, the first chief of surgery at Johns Hopkins Hospital, articulated a set of surgical principles that included strict aseptic technique, gentle tissue handling, meticulous hemostasis, minimum tension on tissue, accurate tissue apposition, preservation of blood supply, and obliteration of dead space where appropriate. These principles of “safe surgery” are believed to improve surgical outcomes and reduce the risk of surgical site infection.¹

Preoperative antibiotics

All obstetricians who perform cesarean delivery know the importance of administering a narrow-spectrum antibiotic, such as cefazolin or ampicillin, prior to the skin incision, but not more than 60 minutes before the incision, to help reduce the risk of wound infection and endometritis. In a meta-analysis of 82 studies involving more than 13,000 women the administration of a preoperative antibiotic compared with placebo reduced the risk of wound infection (relative risk [RR], 0.40; 95% confidence interval [CI], 0.35–0.46) and endometritis (RR, 0.38; 95% CI, 0.34–0.42).²

Cefazolin 3 g versus 2 g for obese patients

There are no data from randomized trials of cesarean delivery that directly compare the efficacy of preoperative cefazolin at doses of 2 g and 3 g to reduce the risk of infection. However, based on the observation that, for any given dose of cefazolin, circulating levels are reduced in obese patients, many authorities recommend that if the patient weighs ≥120 kg that 3 g of cefazolin should be administered.³

Extended-spectrum preoperative antibiotics

Some experts recommend that, for women in labor and for women with more than 4 hours of ruptured membranes, IV azithromycin 500 mg be added to the standard narrow-spectrum cefazolin regimen to reduce the rate of postoperative infection. In one trial, 2,013 women who were in labor or had more than 4 hours of ruptured membranes were randomly assigned to IV cefazolin alone or IV cefazolin plus azithromycin 500 mg prior to cesarean delivery.⁴ The cefazolin dose was reported to be weight-based utilizing the BMI at the time of delivery. The rates of endometritis (3.8% vs 6.1%) and wound infection (2.4% vs 6.6%) were lower in the women receiving extended-spectrum antibiotics versus cefazolin monotherapy.

Concerns have been raised about the impact of extended-spectrum antibiotics on the newborn microbiome and risk of accelerating the emergence of bacteria resistant to available antibiotics. Limiting the use of azithromycin to those cesarean delivery cases in which the patient is immunosuppressed, diabetic, obese, in labor and/or with prolonged ruptured membranes would reduce the number of women and newborns exposed to the drug and achieve the immediate health goal of reducing surgical infection.

Preoperative vaginal preparation

Many authorities recommend the use of a preoperative povidone- iodine vaginal scrub for 30 seconds prior to cesarean delivery for women in labor and women with ruptured membranes. In a meta-analysis of 16 trials involving 4,837 women, the women who received vaginal cleansing before cesarean delivery had a significantly lower incidence of endometritis (4.5% vs 8.8%) and postoperative fever (9.4% vs 14.9%) compared with those who did not have vaginal cleansing.⁵ Most of the benefit in reducing the risk of endometritis was confined to women in labor before the cesarean delivery (8.1% vs 13.8%) and women with ruptured membranes (4.3% vs 20.1%).⁵

Metronidazole gel 5 g also has been reported to be effective in reducing the rate of endometritis associated with cesarean delivery. In one study, 224 women having a cesarean delivery for various indications were randomly assigned to preoperative treatment with vaginally administered metronidazole gel 5 g or placebo gel. All women also received one dose of preoperative intravenous antibiotics. The rates of endometritis were 7% and 17% in the metronidazole and placebo groups, respectively.⁶

Povidone-iodine is approved for vaginal surgical site cleansing. For women with allergies to iodine or povidone-iodine, the options for vaginal cleansing are limited. The American College of Obstetricians and Gynecologists has noted the chlorhexidine gluconate solutions with a high concentration of alcohol should not be used for vaginal cleansing because the alcohol can irritate the mucosal epithelium. However, although not US Food and Drug Administration–approved for vaginal cleansing, solutions of chlorhexidine with a low alcohol content (Hibiclens, chlorhexidine with 4% alcohol concentration) are thought to be safe and may be considered for off-label use in vaginal cleansing.⁷

Preoperative abdominal preparation with chlorhexidine

Some authorities recommend skin preparation with chlorhexidine rather than povidone-iodine prior to cesarean delivery. Two recent randomized trials in women undergoing cesarean delivery^8,9 and one trial in patients undergoing general surgery operations¹⁰ reported a reduction in surgical site infection with chlorhexidine. However, other trials have reported no difference in the rate of surgical site infection with these two skin preparation methods.^11,12

Changing gloves and equipment after delivery of the newborn

Currently there is no high-quality evidence that changing gloves after delivery of the newborn or using new surgical instruments for closure reduces the risk of postcesarean infection. Two small clinical trials reported that changing gloves after delivery of the newborn did not reduce the rate of postcesarean infection.^13,14

Postoperative antibiotics (a heretical challenge to the central dogma of antibiotic prophylaxis in surgery)

The central dogma of antibiotic prevention of postoperative infection is that antibiotics administered just before skin incision are effective, and postoperative antibiotics to prevent surgical infection generally are not useful. For the case of cesarean delivery, where the rate of postcesarean infection is very high, that dogma is being questioned. In a recent clinical trial, 403 women with a prepregnancy BMI ≥30 kg/m² were randomly assigned to postcesarean treatment with oral cephalexin plus metronidazole (500 mg of each medication every 8 hours for 6 doses) or placebo pills.¹⁵ All women received preoperative IV cefazolin 2 g, indicating that the dosing was probably not weight-based. The surgical site infection rates in the cephalexin plus metronidazole and placebo groups were 6.4% and 15.4%, respectively (RR, 0.41; 95% CI, 0.22–0.77; P = .01). In a subgroup analysis based on the presence or absence of ruptured membranes, postoperative oral cephalexin plus metronidazole was most beneficial for the women with ruptured membranes. Among women with ruptured membranes the surgical site infection rates in the cephalexin plus metronidazole and placebo groups were 9.5% and 30.2%, respectively. Among women with intact membranes the surgical site infection rates in the cephalexin plus metronidazole and placebo groups were 5% and 8.7%, respectively.

Given that these findings are not consistent with current dogma, clinicians should be cautious about using postcesarean antibiotics and await confirmation in additional trials. Of relevance, a randomized study of women with chorioamnionitis who were treated precesarean delivery with ampicillin, gentamicin, and clindamycin did not benefit from the administration of additional postoperative antibiotics (one additional dose of gentamicin and clindamycin) compared with no postdelivery antibiotics.¹⁶

Does suture selection matter?

In one randomized trial comparing two suture types, 550 women undergoing nonemergent cesarean delivery were randomly assigned to subcuticular skin closure with polyglactin 910 (Vicryl) or poliglecaprone 25 (Monocryl) suture. The poliglecaprone 25 suture was associated with a lower rate of wound complications (8.8% vs 14.4%; 95% CI, 0.37–99; P = .04).¹⁷ However, a post-hoc analysis of a randomized trial of skin preparation did not observe a difference in wound complications between the use of polyglactinor poliglecaprone suture for skin closure.¹⁸

Prophylactic negative-pressure wound therapy: An evolving best practice?

A meta-analysis of 6 randomized trials and 3 cohort studies reported that in high-risk obese women the use of prophylactic negative-pressure wound therapy compared with standard wound dressing resulted in a decrease in surgical site infection (RR, 0.45; 95% CI, 0.31–0.66).¹⁹ The number needed to treat was 17. In one recent study, the wound outcomes following cesarean delivery among women with a BMI ≥40 kg/m² were compared in 234 women who received and 233 women who did not receive negative-pressure wound therapy.²⁰ Wound infection was observed in 5.6% and 9.9% of the treated and untreated women, respectively.²⁰ However, another meta-analysis of prophylactic negative-pressure wound therapy for obese women undergoing cesarean delivery did not report any benefit.²¹

Let’s work on continuous improvement

Cesarean delivery is a common major operation and is associated with wound infections and endometritis at rates much greater than those observed after vaginal delivery or other major intra-abdominal operations. As obstetricians, we can do more to guide practice toward continuous improvement in surgical outcomes. Systematically using a bundle of evidence-based interventions, including proper antibiotic selection, timing, and dosing; use of hair removal with clippers; use of chlorhexidine abdominal prep; removal of the placenta with gentle traction; and closure of the subcutaneous layer if tissue depth is ≥2 cm, will reduce the rate of postcesarean infection.²² Although aspirational, we may, someday, achieve a post‑cesarean infection rate less than 1%!

CASE Conclusion
The patient was noted to be at high risk for postcesarean infection because she had both an elevated BMI and ruptured membranes. The surgeon astutely decided to administer cefazolin 3 g and azithromycin 500 mg, cleanse the vagina with povidone-iodine, use chlorhexidine for the abdominal prep, use poliglecaprone 25 subcuticular skin closure, and did not use postoperative antibiotics or prophylactic wound vacuum. Following an uneventful cesarean delivery, the patient was discharged without an infection on postoperative day 4.

Share your thoughts! Send your Letter to the Editor to [email protected]. Please include your name and the city and state in which you practice.

Halsted’s surgical principles

Dr. William Steward Halsted, the first chief of surgery at Johns Hopkins Hospital, articulated a set of surgical principles that included strict aseptic technique, gentle tissue handling, meticulous hemostasis, minimum tension on tissue, accurate tissue apposition, preservation of blood supply, and obliteration of dead space where appropriate. These principles of “safe surgery” are believed to improve surgical outcomes and reduce the risk of surgical site infection.¹

Preoperative antibiotics

All obstetricians who perform cesarean delivery know the importance of administering a narrow-spectrum antibiotic, such as cefazolin or ampicillin, prior to the skin incision, but not more than 60 minutes before the incision, to help reduce the risk of wound infection and endometritis. In a meta-analysis of 82 studies involving more than 13,000 women the administration of a preoperative antibiotic compared with placebo reduced the risk of wound infection (relative risk [RR], 0.40; 95% confidence interval [CI], 0.35–0.46) and endometritis (RR, 0.38; 95% CI, 0.34–0.42).²

Cefazolin 3 g versus 2 g for obese patients

There are no data from randomized trials of cesarean delivery that directly compare the efficacy of preoperative cefazolin at doses of 2 g and 3 g to reduce the risk of infection. However, based on the observation that, for any given dose of cefazolin, circulating levels are reduced in obese patients, many authorities recommend that if the patient weighs ≥120 kg that 3 g of cefazolin should be administered.³

Extended-spectrum preoperative antibiotics

Some experts recommend that, for women in labor and for women with more than 4 hours of ruptured membranes, IV azithromycin 500 mg be added to the standard narrow-spectrum cefazolin regimen to reduce the rate of postoperative infection. In one trial, 2,013 women who were in labor or had more than 4 hours of ruptured membranes were randomly assigned to IV cefazolin alone or IV cefazolin plus azithromycin 500 mg prior to cesarean delivery.⁴ The cefazolin dose was reported to be weight-based utilizing the BMI at the time of delivery. The rates of endometritis (3.8% vs 6.1%) and wound infection (2.4% vs 6.6%) were lower in the women receiving extended-spectrum antibiotics versus cefazolin monotherapy.

Concerns have been raised about the impact of extended-spectrum antibiotics on the newborn microbiome and risk of accelerating the emergence of bacteria resistant to available antibiotics. Limiting the use of azithromycin to those cesarean delivery cases in which the patient is immunosuppressed, diabetic, obese, in labor and/or with prolonged ruptured membranes would reduce the number of women and newborns exposed to the drug and achieve the immediate health goal of reducing surgical infection.

Preoperative vaginal preparation

Many authorities recommend the use of a preoperative povidone- iodine vaginal scrub for 30 seconds prior to cesarean delivery for women in labor and women with ruptured membranes. In a meta-analysis of 16 trials involving 4,837 women, the women who received vaginal cleansing before cesarean delivery had a significantly lower incidence of endometritis (4.5% vs 8.8%) and postoperative fever (9.4% vs 14.9%) compared with those who did not have vaginal cleansing.⁵ Most of the benefit in reducing the risk of endometritis was confined to women in labor before the cesarean delivery (8.1% vs 13.8%) and women with ruptured membranes (4.3% vs 20.1%).⁵

Metronidazole gel 5 g also has been reported to be effective in reducing the rate of endometritis associated with cesarean delivery. In one study, 224 women having a cesarean delivery for various indications were randomly assigned to preoperative treatment with vaginally administered metronidazole gel 5 g or placebo gel. All women also received one dose of preoperative intravenous antibiotics. The rates of endometritis were 7% and 17% in the metronidazole and placebo groups, respectively.⁶

Povidone-iodine is approved for vaginal surgical site cleansing. For women with allergies to iodine or povidone-iodine, the options for vaginal cleansing are limited. The American College of Obstetricians and Gynecologists has noted the chlorhexidine gluconate solutions with a high concentration of alcohol should not be used for vaginal cleansing because the alcohol can irritate the mucosal epithelium. However, although not US Food and Drug Administration–approved for vaginal cleansing, solutions of chlorhexidine with a low alcohol content (Hibiclens, chlorhexidine with 4% alcohol concentration) are thought to be safe and may be considered for off-label use in vaginal cleansing.⁷

Preoperative abdominal preparation with chlorhexidine

Some authorities recommend skin preparation with chlorhexidine rather than povidone-iodine prior to cesarean delivery. Two recent randomized trials in women undergoing cesarean delivery^8,9 and one trial in patients undergoing general surgery operations¹⁰ reported a reduction in surgical site infection with chlorhexidine. However, other trials have reported no difference in the rate of surgical site infection with these two skin preparation methods.^11,12

Changing gloves and equipment after delivery of the newborn

Currently there is no high-quality evidence that changing gloves after delivery of the newborn or using new surgical instruments for closure reduces the risk of postcesarean infection. Two small clinical trials reported that changing gloves after delivery of the newborn did not reduce the rate of postcesarean infection.^13,14

Postoperative antibiotics (a heretical challenge to the central dogma of antibiotic prophylaxis in surgery)

The central dogma of antibiotic prevention of postoperative infection is that antibiotics administered just before skin incision are effective, and postoperative antibiotics to prevent surgical infection generally are not useful. For the case of cesarean delivery, where the rate of postcesarean infection is very high, that dogma is being questioned. In a recent clinical trial, 403 women with a prepregnancy BMI ≥30 kg/m² were randomly assigned to postcesarean treatment with oral cephalexin plus metronidazole (500 mg of each medication every 8 hours for 6 doses) or placebo pills.¹⁵ All women received preoperative IV cefazolin 2 g, indicating that the dosing was probably not weight-based. The surgical site infection rates in the cephalexin plus metronidazole and placebo groups were 6.4% and 15.4%, respectively (RR, 0.41; 95% CI, 0.22–0.77; P = .01). In a subgroup analysis based on the presence or absence of ruptured membranes, postoperative oral cephalexin plus metronidazole was most beneficial for the women with ruptured membranes. Among women with ruptured membranes the surgical site infection rates in the cephalexin plus metronidazole and placebo groups were 9.5% and 30.2%, respectively. Among women with intact membranes the surgical site infection rates in the cephalexin plus metronidazole and placebo groups were 5% and 8.7%, respectively.

Given that these findings are not consistent with current dogma, clinicians should be cautious about using postcesarean antibiotics and await confirmation in additional trials. Of relevance, a randomized study of women with chorioamnionitis who were treated precesarean delivery with ampicillin, gentamicin, and clindamycin did not benefit from the administration of additional postoperative antibiotics (one additional dose of gentamicin and clindamycin) compared with no postdelivery antibiotics.¹⁶

Does suture selection matter?

In one randomized trial comparing two suture types, 550 women undergoing nonemergent cesarean delivery were randomly assigned to subcuticular skin closure with polyglactin 910 (Vicryl) or poliglecaprone 25 (Monocryl) suture. The poliglecaprone 25 suture was associated with a lower rate of wound complications (8.8% vs 14.4%; 95% CI, 0.37–99; P = .04).¹⁷ However, a post-hoc analysis of a randomized trial of skin preparation did not observe a difference in wound complications between the use of polyglactinor poliglecaprone suture for skin closure.¹⁸

Prophylactic negative-pressure wound therapy: An evolving best practice?

A meta-analysis of 6 randomized trials and 3 cohort studies reported that in high-risk obese women the use of prophylactic negative-pressure wound therapy compared with standard wound dressing resulted in a decrease in surgical site infection (RR, 0.45; 95% CI, 0.31–0.66).¹⁹ The number needed to treat was 17. In one recent study, the wound outcomes following cesarean delivery among women with a BMI ≥40 kg/m² were compared in 234 women who received and 233 women who did not receive negative-pressure wound therapy.²⁰ Wound infection was observed in 5.6% and 9.9% of the treated and untreated women, respectively.²⁰ However, another meta-analysis of prophylactic negative-pressure wound therapy for obese women undergoing cesarean delivery did not report any benefit.²¹

Let’s work on continuous improvement

Cesarean delivery is a common major operation and is associated with wound infections and endometritis at rates much greater than those observed after vaginal delivery or other major intra-abdominal operations. As obstetricians, we can do more to guide practice toward continuous improvement in surgical outcomes. Systematically using a bundle of evidence-based interventions, including proper antibiotic selection, timing, and dosing; use of hair removal with clippers; use of chlorhexidine abdominal prep; removal of the placenta with gentle traction; and closure of the subcutaneous layer if tissue depth is ≥2 cm, will reduce the rate of postcesarean infection.²² Although aspirational, we may, someday, achieve a post‑cesarean infection rate less than 1%!

CASE Conclusion
The patient was noted to be at high risk for postcesarean infection because she had both an elevated BMI and ruptured membranes. The surgeon astutely decided to administer cefazolin 3 g and azithromycin 500 mg, cleanse the vagina with povidone-iodine, use chlorhexidine for the abdominal prep, use poliglecaprone 25 subcuticular skin closure, and did not use postoperative antibiotics or prophylactic wound vacuum. Following an uneventful cesarean delivery, the patient was discharged without an infection on postoperative day 4.

Share your thoughts! Send your Letter to the Editor to [email protected]. Please include your name and the city and state in which you practice.

Look, I am not a burnout expert. And neither are you (presumably). None of us know much, but that won’t stop the regulations from coming. Program directors are already being asked to provide “wellness plans.” Through the SVS, experts have been enlisted to help, but it is now clear that what works for others won’t necessarily work for vascular surgeons. The next step is up to us. We are the only ones with detailed knowledge of our lives. I believe we are moving closer to answers but still face a few significant hurdles. Don’t worry, there are solutions. Hear me out …

Previously, I shared three studies with you, which found that vascular surgeons had the highest rates of suicidal ideation and career dissatisfaction among surgeons while spending more hours in the hospital than any other specialty. So what has been done to address these horrific numbers? Very little. We need answers now, but most of the data are over 10 years old. Much has changed in our specialty. The endovascular revolution created an entirely new working paradigm. A busy vascular surgeon used to perform 300 cases annually; now this number approaches 1,000. More procedures means more clerical work. Lead aprons and radiation exposure have added new ergonomic and medical concerns. Reimbursement dynamics now favor shorter, more frequent patient interactions over longer, more complex cases. We are benchmarked against old work standards while CPT bundling continuously lowers current RVU designations. EMR was supposed to make our lives better; it has done the opposite. Patient-centered health care has become a mantra, but the measures taken often backfire. Practicing medicine where the desired outcome is a high score on patient satisfaction surveys will likely lead to unnecessary tests, poor cost allocation, and low physician fulfillment. Quality of care is now measured scrupulously while the quality of our lives remains undocumented.

In the absence of organized reform, burnout appears to be increasing. A recent Mayo Clinic–AMA study found the current prevalence to be 54% among physicians. All of this has not happened overnight. I believe practicing vascular surgeons are resilient by default. The majority of us trained prior to the enforcement of duty hour restrictions. Out of high school, I enrolled in a 6-year BA/MD program (skipping 2 years of college seemed like a great idea in high school, less so when I got there). Half of my class never finished. In my intern year, six of the eight categorical residents dropped out. My odds of reaching PGY 2 were 12.5%. Fuzzy math aside, all of your stories are similar. We have proved our resilience over and over again. What is happening here is different.

Burnout is described as emotional exhaustion, low self-esteem, and depersonalization/cynicism. It develops slowly, progressively as stressors increase. A common thread seems to be the feeling that you alone are not enough. Examine your daily life. What are your most common stressors? For me, they relate to time management, clinical documentation, and whatever fresh hell my kids’ teachers have cooked up for “school projects.”

*****Scene*****

Wife: Can you help Luke (kindergarten) finish his diorama? It needs to be a scale depiction of his 3 favorite scenes from Wagner’s Ring cycle.

Me: Sure, I just need to complete the wind tunnel testing on Jack’s (3rd grade) carbon-neutral peanut-free alternative fuel source rocket booster.

Off stage – 7th Grade Son: The genetically modified spiders got loose again!

*****End Scene*****

We want to do a good job, but more hurdles are placed in our way. A recent AMA/Dartmouth Hitchcock study found that 50% of physicians’ time is spent performing data entry and other administrative work. Only 27% of time was spent on patient care. Every hour of face-to-face patient time requires 2 hours of EMR/clerical work. We are trapped in a bureaucratic prison. For years, every quality initiative was solved with a new form. To enter a simple note today, we must first “establish our relationship” with the patient, then ably click through a minefield of “warning boxes” signifying impending DVT prophylaxis catastrophes and antibiotic crimes and misdemeanors, next we scroll through a pre-populated postapocalyptic hellscape of minute- by-minute vital sign entries and lab values dating back to inception. Then, and only then, finally, ON PAGE 11, we can meagerly type: Patient at wound care, will come back on evening rounds.

Dr. Sheahan is the Claude C. Craighead Jr. Professor and Chair, Division of Vascular and Endovascular Surgery, Louisiana State University Health Sciences Center, New Orleans.

Look, I am not a burnout expert. And neither are you (presumably). None of us know much, but that won’t stop the regulations from coming. Program directors are already being asked to provide “wellness plans.” Through the SVS, experts have been enlisted to help, but it is now clear that what works for others won’t necessarily work for vascular surgeons. The next step is up to us. We are the only ones with detailed knowledge of our lives. I believe we are moving closer to answers but still face a few significant hurdles. Don’t worry, there are solutions. Hear me out …

Previously, I shared three studies with you, which found that vascular surgeons had the highest rates of suicidal ideation and career dissatisfaction among surgeons while spending more hours in the hospital than any other specialty. So what has been done to address these horrific numbers? Very little. We need answers now, but most of the data are over 10 years old. Much has changed in our specialty. The endovascular revolution created an entirely new working paradigm. A busy vascular surgeon used to perform 300 cases annually; now this number approaches 1,000. More procedures means more clerical work. Lead aprons and radiation exposure have added new ergonomic and medical concerns. Reimbursement dynamics now favor shorter, more frequent patient interactions over longer, more complex cases. We are benchmarked against old work standards while CPT bundling continuously lowers current RVU designations. EMR was supposed to make our lives better; it has done the opposite. Patient-centered health care has become a mantra, but the measures taken often backfire. Practicing medicine where the desired outcome is a high score on patient satisfaction surveys will likely lead to unnecessary tests, poor cost allocation, and low physician fulfillment. Quality of care is now measured scrupulously while the quality of our lives remains undocumented.

In the absence of organized reform, burnout appears to be increasing. A recent Mayo Clinic–AMA study found the current prevalence to be 54% among physicians. All of this has not happened overnight. I believe practicing vascular surgeons are resilient by default. The majority of us trained prior to the enforcement of duty hour restrictions. Out of high school, I enrolled in a 6-year BA/MD program (skipping 2 years of college seemed like a great idea in high school, less so when I got there). Half of my class never finished. In my intern year, six of the eight categorical residents dropped out. My odds of reaching PGY 2 were 12.5%. Fuzzy math aside, all of your stories are similar. We have proved our resilience over and over again. What is happening here is different.

Burnout is described as emotional exhaustion, low self-esteem, and depersonalization/cynicism. It develops slowly, progressively as stressors increase. A common thread seems to be the feeling that you alone are not enough. Examine your daily life. What are your most common stressors? For me, they relate to time management, clinical documentation, and whatever fresh hell my kids’ teachers have cooked up for “school projects.”

*****Scene*****

Wife: Can you help Luke (kindergarten) finish his diorama? It needs to be a scale depiction of his 3 favorite scenes from Wagner’s Ring cycle.

Me: Sure, I just need to complete the wind tunnel testing on Jack’s (3rd grade) carbon-neutral peanut-free alternative fuel source rocket booster.

Off stage – 7th Grade Son: The genetically modified spiders got loose again!

*****End Scene*****

We want to do a good job, but more hurdles are placed in our way. A recent AMA/Dartmouth Hitchcock study found that 50% of physicians’ time is spent performing data entry and other administrative work. Only 27% of time was spent on patient care. Every hour of face-to-face patient time requires 2 hours of EMR/clerical work. We are trapped in a bureaucratic prison. For years, every quality initiative was solved with a new form. To enter a simple note today, we must first “establish our relationship” with the patient, then ably click through a minefield of “warning boxes” signifying impending DVT prophylaxis catastrophes and antibiotic crimes and misdemeanors, next we scroll through a pre-populated postapocalyptic hellscape of minute- by-minute vital sign entries and lab values dating back to inception. Then, and only then, finally, ON PAGE 11, we can meagerly type: Patient at wound care, will come back on evening rounds.

Dr. Sheahan is the Claude C. Craighead Jr. Professor and Chair, Division of Vascular and Endovascular Surgery, Louisiana State University Health Sciences Center, New Orleans.

Look, I am not a burnout expert. And neither are you (presumably). None of us know much, but that won’t stop the regulations from coming. Program directors are already being asked to provide “wellness plans.” Through the SVS, experts have been enlisted to help, but it is now clear that what works for others won’t necessarily work for vascular surgeons. The next step is up to us. We are the only ones with detailed knowledge of our lives. I believe we are moving closer to answers but still face a few significant hurdles. Don’t worry, there are solutions. Hear me out …

Previously, I shared three studies with you, which found that vascular surgeons had the highest rates of suicidal ideation and career dissatisfaction among surgeons while spending more hours in the hospital than any other specialty. So what has been done to address these horrific numbers? Very little. We need answers now, but most of the data are over 10 years old. Much has changed in our specialty. The endovascular revolution created an entirely new working paradigm. A busy vascular surgeon used to perform 300 cases annually; now this number approaches 1,000. More procedures means more clerical work. Lead aprons and radiation exposure have added new ergonomic and medical concerns. Reimbursement dynamics now favor shorter, more frequent patient interactions over longer, more complex cases. We are benchmarked against old work standards while CPT bundling continuously lowers current RVU designations. EMR was supposed to make our lives better; it has done the opposite. Patient-centered health care has become a mantra, but the measures taken often backfire. Practicing medicine where the desired outcome is a high score on patient satisfaction surveys will likely lead to unnecessary tests, poor cost allocation, and low physician fulfillment. Quality of care is now measured scrupulously while the quality of our lives remains undocumented.

In the absence of organized reform, burnout appears to be increasing. A recent Mayo Clinic–AMA study found the current prevalence to be 54% among physicians. All of this has not happened overnight. I believe practicing vascular surgeons are resilient by default. The majority of us trained prior to the enforcement of duty hour restrictions. Out of high school, I enrolled in a 6-year BA/MD program (skipping 2 years of college seemed like a great idea in high school, less so when I got there). Half of my class never finished. In my intern year, six of the eight categorical residents dropped out. My odds of reaching PGY 2 were 12.5%. Fuzzy math aside, all of your stories are similar. We have proved our resilience over and over again. What is happening here is different.

Burnout is described as emotional exhaustion, low self-esteem, and depersonalization/cynicism. It develops slowly, progressively as stressors increase. A common thread seems to be the feeling that you alone are not enough. Examine your daily life. What are your most common stressors? For me, they relate to time management, clinical documentation, and whatever fresh hell my kids’ teachers have cooked up for “school projects.”

*****Scene*****

Wife: Can you help Luke (kindergarten) finish his diorama? It needs to be a scale depiction of his 3 favorite scenes from Wagner’s Ring cycle.

Me: Sure, I just need to complete the wind tunnel testing on Jack’s (3rd grade) carbon-neutral peanut-free alternative fuel source rocket booster.

Off stage – 7th Grade Son: The genetically modified spiders got loose again!

*****End Scene*****

We want to do a good job, but more hurdles are placed in our way. A recent AMA/Dartmouth Hitchcock study found that 50% of physicians’ time is spent performing data entry and other administrative work. Only 27% of time was spent on patient care. Every hour of face-to-face patient time requires 2 hours of EMR/clerical work. We are trapped in a bureaucratic prison. For years, every quality initiative was solved with a new form. To enter a simple note today, we must first “establish our relationship” with the patient, then ably click through a minefield of “warning boxes” signifying impending DVT prophylaxis catastrophes and antibiotic crimes and misdemeanors, next we scroll through a pre-populated postapocalyptic hellscape of minute- by-minute vital sign entries and lab values dating back to inception. Then, and only then, finally, ON PAGE 11, we can meagerly type: Patient at wound care, will come back on evening rounds.

Dr. Sheahan is the Claude C. Craighead Jr. Professor and Chair, Division of Vascular and Endovascular Surgery, Louisiana State University Health Sciences Center, New Orleans.