Guidelines

(Reuters Health) - Older people who break a bone are often receiving medications that can increase the risk of a fracture - and even after a fracture, less than 10 percent of them stop taking those drugs, according to a new study.

"One would expect that a significant health event like a fracture would result in some change in the use of prescription drugs that might have contributed to that event," said lead author Dr. Jeffrey C. Munson of the Geisel School of Medicine at Dartmouth in Lebanon, New Hampshire. "In contrast to this expectation, we observed that for the overwhelming majority of patients we studied, a fragility fracture did not lead to any change in medications that have been linked to fracture risk."

The authors used data on 168,000 Medicare beneficiaries, more than 80 percent of whom were women, on average age 80, who had experienced a hip, shoulder or wrist fracture. They compared these records with retail pharmacy claims to identify which patients had been taking medicines that increase the risk of a fall, decrease bone density or are otherwise tied to an increased risk of fracture.

About 75 percent of fracture patients had been taking one of these medications. While seven percent of people stopped taking the medication after their fracture, a similar number started to take a new medication also tied to fracture risk, the authors reported in JAMA Internal Medicine, online August 22.

"Some drugs affect balance and memory, like the sleeping pills, which can lead to a fall," said Dr. Sarah D. Berry of the Institute for Aging Research at Hebrew SeniorLife in Boston, Massachusetts, who coauthored a linked editorial.

Blood pressure medications cause changes in blood pressure that could lead to a fall. Other drugs, like prednisone or medications for heartburn, increase bone loss which can lead to a fracture, Berry told Reuters Health by email.

"Fractures are the leading cause of death from injury and one of the main reasons for nursing home placement in persons over the age of 65," she said.

"When a patient has a hip, shoulder or wrist fracture, it is important for healthcare providers to examine all the prescription medications he or she is taking, and carefully assess whether there is an opportunity to eliminate those that might cause a future fracture," Munson told Reuters Health by email.

However, he said, "In many cases, the benefits of a drug may outweigh its risks, even when those risks are significant."

Which drugs can be stopped will vary from case to case, Munson noted.

"For many of the drugs we studied, there are alternative drugs that treat the same conditions but with a lower risk of fracture," he said. "In other cases, it may be possible to eliminate a drug altogether."

SOURCE: http://bit.ly/2bc6PIN

JAMA Intern Med 2016.

(c) Copyright Thomson Reuters 2016.

(Reuters Health) - Older people who break a bone are often receiving medications that can increase the risk of a fracture - and even after a fracture, less than 10 percent of them stop taking those drugs, according to a new study.

"One would expect that a significant health event like a fracture would result in some change in the use of prescription drugs that might have contributed to that event," said lead author Dr. Jeffrey C. Munson of the Geisel School of Medicine at Dartmouth in Lebanon, New Hampshire. "In contrast to this expectation, we observed that for the overwhelming majority of patients we studied, a fragility fracture did not lead to any change in medications that have been linked to fracture risk."

The authors used data on 168,000 Medicare beneficiaries, more than 80 percent of whom were women, on average age 80, who had experienced a hip, shoulder or wrist fracture. They compared these records with retail pharmacy claims to identify which patients had been taking medicines that increase the risk of a fall, decrease bone density or are otherwise tied to an increased risk of fracture.

About 75 percent of fracture patients had been taking one of these medications. While seven percent of people stopped taking the medication after their fracture, a similar number started to take a new medication also tied to fracture risk, the authors reported in JAMA Internal Medicine, online August 22.

"Some drugs affect balance and memory, like the sleeping pills, which can lead to a fall," said Dr. Sarah D. Berry of the Institute for Aging Research at Hebrew SeniorLife in Boston, Massachusetts, who coauthored a linked editorial.

Blood pressure medications cause changes in blood pressure that could lead to a fall. Other drugs, like prednisone or medications for heartburn, increase bone loss which can lead to a fracture, Berry told Reuters Health by email.

"Fractures are the leading cause of death from injury and one of the main reasons for nursing home placement in persons over the age of 65," she said.

"When a patient has a hip, shoulder or wrist fracture, it is important for healthcare providers to examine all the prescription medications he or she is taking, and carefully assess whether there is an opportunity to eliminate those that might cause a future fracture," Munson told Reuters Health by email.

However, he said, "In many cases, the benefits of a drug may outweigh its risks, even when those risks are significant."

Which drugs can be stopped will vary from case to case, Munson noted.

"For many of the drugs we studied, there are alternative drugs that treat the same conditions but with a lower risk of fracture," he said. "In other cases, it may be possible to eliminate a drug altogether."

SOURCE: http://bit.ly/2bc6PIN

JAMA Intern Med 2016.

(c) Copyright Thomson Reuters 2016.

(Reuters Health) - Older people who break a bone are often receiving medications that can increase the risk of a fracture - and even after a fracture, less than 10 percent of them stop taking those drugs, according to a new study.

"One would expect that a significant health event like a fracture would result in some change in the use of prescription drugs that might have contributed to that event," said lead author Dr. Jeffrey C. Munson of the Geisel School of Medicine at Dartmouth in Lebanon, New Hampshire. "In contrast to this expectation, we observed that for the overwhelming majority of patients we studied, a fragility fracture did not lead to any change in medications that have been linked to fracture risk."

The authors used data on 168,000 Medicare beneficiaries, more than 80 percent of whom were women, on average age 80, who had experienced a hip, shoulder or wrist fracture. They compared these records with retail pharmacy claims to identify which patients had been taking medicines that increase the risk of a fall, decrease bone density or are otherwise tied to an increased risk of fracture.

About 75 percent of fracture patients had been taking one of these medications. While seven percent of people stopped taking the medication after their fracture, a similar number started to take a new medication also tied to fracture risk, the authors reported in JAMA Internal Medicine, online August 22.

"Some drugs affect balance and memory, like the sleeping pills, which can lead to a fall," said Dr. Sarah D. Berry of the Institute for Aging Research at Hebrew SeniorLife in Boston, Massachusetts, who coauthored a linked editorial.

Blood pressure medications cause changes in blood pressure that could lead to a fall. Other drugs, like prednisone or medications for heartburn, increase bone loss which can lead to a fracture, Berry told Reuters Health by email.

"Fractures are the leading cause of death from injury and one of the main reasons for nursing home placement in persons over the age of 65," she said.

"When a patient has a hip, shoulder or wrist fracture, it is important for healthcare providers to examine all the prescription medications he or she is taking, and carefully assess whether there is an opportunity to eliminate those that might cause a future fracture," Munson told Reuters Health by email.

However, he said, "In many cases, the benefits of a drug may outweigh its risks, even when those risks are significant."

Which drugs can be stopped will vary from case to case, Munson noted.

"For many of the drugs we studied, there are alternative drugs that treat the same conditions but with a lower risk of fracture," he said. "In other cases, it may be possible to eliminate a drug altogether."

SOURCE: http://bit.ly/2bc6PIN

JAMA Intern Med 2016.

(c) Copyright Thomson Reuters 2016.

Presenter: Kenneth Roberts, MD

One of PHM16’s most highly attended sessions was about anticipated updated from the American Academy of Pediatrics (AAP) to its guidelines for febrile infants ages 7¬–90 days. The proposed update stresses the need to separate individual components of serious bacterial infections (UTI, bacteremia, and meningitis) as the incidence and clinical course can vary greatly in this population.

The proposed inclusion criteria for infants for this algorithm require an infant to be full-term (37–43 weeks’ gestation), aged 7–90 days, well-appearing, and presenting with a temperature of 38°C. Proposed exclusion criteria include perinatal/prenatal/neonatal maternal fever, infection, or antimicrobial treatment; the presence of any evident infection; being technology-dependent; and the presence of congenital anomalies.

The proposed guideline update will aim to stratify management by ages 7–28 days, 29–60 days, and 61–90 days to provide the most appropriate and directed treatment. It will also include a role for inflammatory markers and allow for a “kinder, gentler” approach, including withholding certain treatments and procedures if infants are at low risk of infection. An active need for observation may be appropriate for certain infants as well.

Key Takeaway

It is likely that the AAP will update its algorithm for the management of well-appearing febrile infants ages 7–28 days, 29–60 days and 60–90 days. It will help standardize care in this population but should not be used as a substitute for clinical judgment. The new guidelines are expected to be published in early 2017.

Chandani DeZure, MD, FAAP, is a pediatric hospitalist at Children’s National Health System and instructor of pediatrics at George Washington University School of Medicine & Health Sciences in Washington, D.C.

Presenter: Kenneth Roberts, MD

One of PHM16’s most highly attended sessions was about anticipated updated from the American Academy of Pediatrics (AAP) to its guidelines for febrile infants ages 7¬–90 days. The proposed update stresses the need to separate individual components of serious bacterial infections (UTI, bacteremia, and meningitis) as the incidence and clinical course can vary greatly in this population.

The proposed inclusion criteria for infants for this algorithm require an infant to be full-term (37–43 weeks’ gestation), aged 7–90 days, well-appearing, and presenting with a temperature of 38°C. Proposed exclusion criteria include perinatal/prenatal/neonatal maternal fever, infection, or antimicrobial treatment; the presence of any evident infection; being technology-dependent; and the presence of congenital anomalies.

The proposed guideline update will aim to stratify management by ages 7–28 days, 29–60 days, and 61–90 days to provide the most appropriate and directed treatment. It will also include a role for inflammatory markers and allow for a “kinder, gentler” approach, including withholding certain treatments and procedures if infants are at low risk of infection. An active need for observation may be appropriate for certain infants as well.

Key Takeaway

It is likely that the AAP will update its algorithm for the management of well-appearing febrile infants ages 7–28 days, 29–60 days and 60–90 days. It will help standardize care in this population but should not be used as a substitute for clinical judgment. The new guidelines are expected to be published in early 2017.

Chandani DeZure, MD, FAAP, is a pediatric hospitalist at Children’s National Health System and instructor of pediatrics at George Washington University School of Medicine & Health Sciences in Washington, D.C.

Presenter: Kenneth Roberts, MD

One of PHM16’s most highly attended sessions was about anticipated updated from the American Academy of Pediatrics (AAP) to its guidelines for febrile infants ages 7¬–90 days. The proposed update stresses the need to separate individual components of serious bacterial infections (UTI, bacteremia, and meningitis) as the incidence and clinical course can vary greatly in this population.

The proposed inclusion criteria for infants for this algorithm require an infant to be full-term (37–43 weeks’ gestation), aged 7–90 days, well-appearing, and presenting with a temperature of 38°C. Proposed exclusion criteria include perinatal/prenatal/neonatal maternal fever, infection, or antimicrobial treatment; the presence of any evident infection; being technology-dependent; and the presence of congenital anomalies.

The proposed guideline update will aim to stratify management by ages 7–28 days, 29–60 days, and 61–90 days to provide the most appropriate and directed treatment. It will also include a role for inflammatory markers and allow for a “kinder, gentler” approach, including withholding certain treatments and procedures if infants are at low risk of infection. An active need for observation may be appropriate for certain infants as well.

Key Takeaway

It is likely that the AAP will update its algorithm for the management of well-appearing febrile infants ages 7–28 days, 29–60 days and 60–90 days. It will help standardize care in this population but should not be used as a substitute for clinical judgment. The new guidelines are expected to be published in early 2017.

Chandani DeZure, MD, FAAP, is a pediatric hospitalist at Children’s National Health System and instructor of pediatrics at George Washington University School of Medicine & Health Sciences in Washington, D.C.

Presenters: Mary L Ehlenbach, MD, FAAP; Megan Z Cardoso, MD, FAAP; and Christina Kleier, ARNP, PNP

This session at PHM16 was focused on logistical tips on how to build a pediatric complex care program.  Presenters opened with a discussion of how to define children with medical complexity going through a variety of different methods including some research based aggregation of ICD-10 codes, referral from both families and other providers, and identifying patients by consumption of hospital resources. The presentation continued by highlighting that although medically complex children make up only a small percentage of the overall population of children, they account for about 1/3 of healthcare spending and due to advances in technology and medicine this group of children is growing in numbers. This group makes up about 10% of all pediatric admissions.

The session then went on to break down into four small groups which focused on details about how to create a complex care program and how to evaluate effectiveness of the program. Group 1 discussed methods of identifying patients that the program will serve. This included setting guidelines if a certain group or diagnosis should be excluded from the program. Different models of what services were also discussed which ranged from providing a comprehensive medical home to inpatient consults or care coordination services. The second group focused on what team members it may be beneficial to have involved. Team composition varied widely usually including MDs, NPs, social workers, RNs and at times a documentation expert who could aid with proper billing to boost revenue. The third group focused on how to measure quality services including family surveys of quantitative impact and satisfaction, PCP satisfaction. The final session consisted of the business and financial considerations of beginning a complex care program.

Key Takeaways:

1. Children with medical complexity are a growing population on which a large proportion of healthcare resources are utilized. A program dedicated to serving the needs of this population may be helpful in reducing costs and improving the patient and family experience during hospitalizations.
2. When working to initiate a complex care program:

   • Set clear guidelines about which children the program is intended to serve and in what capacity it will function.
   • Ensure the team composition is sustainable and meets the needs of the patients.
   • Aggregate data about if the program is helping. This may be difficult to quantify since these are mostly qualitative measures.
   • Include team members who are non-clinical to aid in improving hospital revenue and highlighting program benefits to the institution.

Presenters: Mary L Ehlenbach, MD, FAAP; Megan Z Cardoso, MD, FAAP; and Christina Kleier, ARNP, PNP

This session at PHM16 was focused on logistical tips on how to build a pediatric complex care program.  Presenters opened with a discussion of how to define children with medical complexity going through a variety of different methods including some research based aggregation of ICD-10 codes, referral from both families and other providers, and identifying patients by consumption of hospital resources. The presentation continued by highlighting that although medically complex children make up only a small percentage of the overall population of children, they account for about 1/3 of healthcare spending and due to advances in technology and medicine this group of children is growing in numbers. This group makes up about 10% of all pediatric admissions.

The session then went on to break down into four small groups which focused on details about how to create a complex care program and how to evaluate effectiveness of the program. Group 1 discussed methods of identifying patients that the program will serve. This included setting guidelines if a certain group or diagnosis should be excluded from the program. Different models of what services were also discussed which ranged from providing a comprehensive medical home to inpatient consults or care coordination services. The second group focused on what team members it may be beneficial to have involved. Team composition varied widely usually including MDs, NPs, social workers, RNs and at times a documentation expert who could aid with proper billing to boost revenue. The third group focused on how to measure quality services including family surveys of quantitative impact and satisfaction, PCP satisfaction. The final session consisted of the business and financial considerations of beginning a complex care program.

Key Takeaways:

1. Children with medical complexity are a growing population on which a large proportion of healthcare resources are utilized. A program dedicated to serving the needs of this population may be helpful in reducing costs and improving the patient and family experience during hospitalizations.
2. When working to initiate a complex care program:

   • Set clear guidelines about which children the program is intended to serve and in what capacity it will function.
   • Ensure the team composition is sustainable and meets the needs of the patients.
   • Aggregate data about if the program is helping. This may be difficult to quantify since these are mostly qualitative measures.
   • Include team members who are non-clinical to aid in improving hospital revenue and highlighting program benefits to the institution.

Presenters: Mary L Ehlenbach, MD, FAAP; Megan Z Cardoso, MD, FAAP; and Christina Kleier, ARNP, PNP

This session at PHM16 was focused on logistical tips on how to build a pediatric complex care program.  Presenters opened with a discussion of how to define children with medical complexity going through a variety of different methods including some research based aggregation of ICD-10 codes, referral from both families and other providers, and identifying patients by consumption of hospital resources. The presentation continued by highlighting that although medically complex children make up only a small percentage of the overall population of children, they account for about 1/3 of healthcare spending and due to advances in technology and medicine this group of children is growing in numbers. This group makes up about 10% of all pediatric admissions.

The session then went on to break down into four small groups which focused on details about how to create a complex care program and how to evaluate effectiveness of the program. Group 1 discussed methods of identifying patients that the program will serve. This included setting guidelines if a certain group or diagnosis should be excluded from the program. Different models of what services were also discussed which ranged from providing a comprehensive medical home to inpatient consults or care coordination services. The second group focused on what team members it may be beneficial to have involved. Team composition varied widely usually including MDs, NPs, social workers, RNs and at times a documentation expert who could aid with proper billing to boost revenue. The third group focused on how to measure quality services including family surveys of quantitative impact and satisfaction, PCP satisfaction. The final session consisted of the business and financial considerations of beginning a complex care program.

Key Takeaways:

1. Children with medical complexity are a growing population on which a large proportion of healthcare resources are utilized. A program dedicated to serving the needs of this population may be helpful in reducing costs and improving the patient and family experience during hospitalizations.
2. When working to initiate a complex care program:

   • Set clear guidelines about which children the program is intended to serve and in what capacity it will function.
   • Ensure the team composition is sustainable and meets the needs of the patients.
   • Aggregate data about if the program is helping. This may be difficult to quantify since these are mostly qualitative measures.
   • Include team members who are non-clinical to aid in improving hospital revenue and highlighting program benefits to the institution.

One of PHM16’s most highly-attended sessions was an update on the anticipated AAP guidelines for febrile infants between ages 7-90 days given by Dr. Kenneth Roberts. The goal is to give evidence-based guidelines, not rules, from the most recent literature available. It also stresses the need to separate individual components of serious bacterial infections (UTI, bacteremia, and meningitis) as the incidence and clinical course can vary greatly in this population.

The inclusion criteria for infants for this upcoming algorithm require an infant to be full-term (37-43 weeks gestation), aged 7-90 days, well-appearing, and presenting with a temperature of 38 degrees Celsius.

Exclusion criteria include perinatal/prenatal/neonatal: maternal fever, infection, or antimicrobial treatment, the presence of any evident infection, being technology-dependent, and the presence of congenital anomalies.

The updated guideline will aim to stratify management by age 7-28 days, 29-60 days, and 61 to 90 days to provide the most appropriate and directed treatment.

It will also include a role for inflammatory markers, and allow for a “kinder, gentler” approach to the management of febrile infants aged 7-90 days including withholding certain treatments and procedures if infants are at low risk of infection. An active, not passive, need for observation may be appropriate for certain infants as well. These guidelines should be tailored for individual patients to provide the best care possible while minimizing risk in this population.

Key Takeaway:

An updated AAP Practice guideline algorithm for the management of well-appearing febrile infants 7-28 days, 29-60 days, and 60-90 days will be coming in the near future that will help standardize care in this population, but should not be used as a substitute for clinical judgment.

One of PHM16’s most highly-attended sessions was an update on the anticipated AAP guidelines for febrile infants between ages 7-90 days given by Dr. Kenneth Roberts. The goal is to give evidence-based guidelines, not rules, from the most recent literature available. It also stresses the need to separate individual components of serious bacterial infections (UTI, bacteremia, and meningitis) as the incidence and clinical course can vary greatly in this population.

The inclusion criteria for infants for this upcoming algorithm require an infant to be full-term (37-43 weeks gestation), aged 7-90 days, well-appearing, and presenting with a temperature of 38 degrees Celsius.

Exclusion criteria include perinatal/prenatal/neonatal: maternal fever, infection, or antimicrobial treatment, the presence of any evident infection, being technology-dependent, and the presence of congenital anomalies.

The updated guideline will aim to stratify management by age 7-28 days, 29-60 days, and 61 to 90 days to provide the most appropriate and directed treatment.

It will also include a role for inflammatory markers, and allow for a “kinder, gentler” approach to the management of febrile infants aged 7-90 days including withholding certain treatments and procedures if infants are at low risk of infection. An active, not passive, need for observation may be appropriate for certain infants as well. These guidelines should be tailored for individual patients to provide the best care possible while minimizing risk in this population.

Key Takeaway:

An updated AAP Practice guideline algorithm for the management of well-appearing febrile infants 7-28 days, 29-60 days, and 60-90 days will be coming in the near future that will help standardize care in this population, but should not be used as a substitute for clinical judgment.

One of PHM16’s most highly-attended sessions was an update on the anticipated AAP guidelines for febrile infants between ages 7-90 days given by Dr. Kenneth Roberts. The goal is to give evidence-based guidelines, not rules, from the most recent literature available. It also stresses the need to separate individual components of serious bacterial infections (UTI, bacteremia, and meningitis) as the incidence and clinical course can vary greatly in this population.

The inclusion criteria for infants for this upcoming algorithm require an infant to be full-term (37-43 weeks gestation), aged 7-90 days, well-appearing, and presenting with a temperature of 38 degrees Celsius.

Exclusion criteria include perinatal/prenatal/neonatal: maternal fever, infection, or antimicrobial treatment, the presence of any evident infection, being technology-dependent, and the presence of congenital anomalies.

The updated guideline will aim to stratify management by age 7-28 days, 29-60 days, and 61 to 90 days to provide the most appropriate and directed treatment.

It will also include a role for inflammatory markers, and allow for a “kinder, gentler” approach to the management of febrile infants aged 7-90 days including withholding certain treatments and procedures if infants are at low risk of infection. An active, not passive, need for observation may be appropriate for certain infants as well. These guidelines should be tailored for individual patients to provide the best care possible while minimizing risk in this population.

Key Takeaway:

An updated AAP Practice guideline algorithm for the management of well-appearing febrile infants 7-28 days, 29-60 days, and 60-90 days will be coming in the near future that will help standardize care in this population, but should not be used as a substitute for clinical judgment.

All adult cancer survivors should be screened for chronic pain at every visit, according to the American Society of Clinical Oncology’s first clinical practice guideline for managing this patient population, published July 25 in the Journal of Clinical Oncology.

An estimated 14 million adults with a history of cancer are living in the United States alone, and the prevalence of chronic pain related to their malignancy is reported to be as high as 40%. Yet most health care providers “haven’t been trained to recognize or treat long-term pain associated with cancer,” Judith A. Paice, PhD, RN, said in a press statement accompanying the release of the new guideline.

Existing guidelines focus on the acute pain of cancer and its treatment, or on acute pain related to advanced cancer, said Dr. Paice, cochair of the expert panel that developed the guideline and research professor of hematology/oncology at Northwestern University, Chicago.

©Thinkstock.com

The chronic pain addressed in the new guideline document can be related to the malignancy itself or to its treatment. Surgery, chemotherapy, hormone therapy, radiation treatment, and stem-cell transplantation can induce dozens of pain-producing complications, including osteonecrosis, bone fractures, peripheral or central nerve damage, fistulas, lymphedema, arthralgias, and myelopathy. The pain can develop months or years after diagnosis, significantly impacting patients’ quality of life well after treatment is completed.

“This guideline will help clinicians identify pain early and develop comprehensive treatment plans using a broad range of approaches,” Dr. Paice said in the statement.

The panel that developed the guideline comprised experts in medical oncology, hematology, pain medicine, palliative care, hospice, radiation oncology, social work, rehabilitation, psychology, and anesthesiology. They performed a systematic review of the literature and based their recommendations on 35 meta-analyses, 9 randomized controlled trials, 19 comparative studies, and expert consensus.

Some key recommendations include the following:

• Screen all survivors of adult cancers for chronic pain using both a physical exam and an in-depth interview that covers physical, functional, psychological, social, and spiritual aspects of pain, as well as the patient’s treatment history and comorbid conditions. The guideline includes a list of 36 common pain syndromes resulting from cancer treatments.

• Monitor patients at every visit for late-onset treatment effects that can produce pain, just as they are monitored for recurrent disease and secondary malignancy. Some cancer survivors may not recognize that their current pain is related to past disease or its treatments, or may consider it an untreatable complication that they have to endure.

• Consider the entire range of pain medicines – not just opioid analgesics – including NSAIDs, acetaminophen, and selected antidepressants and anticonvulsants with analgesic efficacy. The panel noted that some cancer survivors with chronic pain may benefit from other drugs, including muscle relaxants, benzodiazepines, N-methyl-D-aspartate receptor blockers, alpha-2 agonists, and neutraceuticals and botanicals. But they urged caution since the efficacy of these agents has not been fully established.

Consider nonmedical treatments such as physical, occupational, and recreation therapy; exercise; orthotics; ultrasound; massage; acupuncture; cognitive behavioral therapy; relaxation therapy; and TENS or other types of nerve stimulation.

Consider medical cannabis or cannabinoids as an adjuvant but not a first-line pain treatment, being sure to follow specific state regulations.

Consider a trial of opioids only for carefully selected patients who don’t respond to more conservative management. Weigh potential risks against benefits and employ universal precautions to minimize abuse and addiction, and be cautious in coprescribing other centrally-acting agents (J Clin Oncol. 2016 July 25. doi: 10.1200/JCO.2016.68.5206).

The full clinical practice guideline and other clinical tools and resources are available at www.asco.org/chronic-pai-guideline.

The guideline development process was supported by ASCO. Dr. Paice reported having no relevant financial disclosures; some of her associates reported financial ties to industry sources.

All adult cancer survivors should be screened for chronic pain at every visit, according to the American Society of Clinical Oncology’s first clinical practice guideline for managing this patient population, published July 25 in the Journal of Clinical Oncology.

An estimated 14 million adults with a history of cancer are living in the United States alone, and the prevalence of chronic pain related to their malignancy is reported to be as high as 40%. Yet most health care providers “haven’t been trained to recognize or treat long-term pain associated with cancer,” Judith A. Paice, PhD, RN, said in a press statement accompanying the release of the new guideline.

Existing guidelines focus on the acute pain of cancer and its treatment, or on acute pain related to advanced cancer, said Dr. Paice, cochair of the expert panel that developed the guideline and research professor of hematology/oncology at Northwestern University, Chicago.

©Thinkstock.com

The chronic pain addressed in the new guideline document can be related to the malignancy itself or to its treatment. Surgery, chemotherapy, hormone therapy, radiation treatment, and stem-cell transplantation can induce dozens of pain-producing complications, including osteonecrosis, bone fractures, peripheral or central nerve damage, fistulas, lymphedema, arthralgias, and myelopathy. The pain can develop months or years after diagnosis, significantly impacting patients’ quality of life well after treatment is completed.

“This guideline will help clinicians identify pain early and develop comprehensive treatment plans using a broad range of approaches,” Dr. Paice said in the statement.

The panel that developed the guideline comprised experts in medical oncology, hematology, pain medicine, palliative care, hospice, radiation oncology, social work, rehabilitation, psychology, and anesthesiology. They performed a systematic review of the literature and based their recommendations on 35 meta-analyses, 9 randomized controlled trials, 19 comparative studies, and expert consensus.

Some key recommendations include the following:

• Screen all survivors of adult cancers for chronic pain using both a physical exam and an in-depth interview that covers physical, functional, psychological, social, and spiritual aspects of pain, as well as the patient’s treatment history and comorbid conditions. The guideline includes a list of 36 common pain syndromes resulting from cancer treatments.

• Monitor patients at every visit for late-onset treatment effects that can produce pain, just as they are monitored for recurrent disease and secondary malignancy. Some cancer survivors may not recognize that their current pain is related to past disease or its treatments, or may consider it an untreatable complication that they have to endure.

• Consider the entire range of pain medicines – not just opioid analgesics – including NSAIDs, acetaminophen, and selected antidepressants and anticonvulsants with analgesic efficacy. The panel noted that some cancer survivors with chronic pain may benefit from other drugs, including muscle relaxants, benzodiazepines, N-methyl-D-aspartate receptor blockers, alpha-2 agonists, and neutraceuticals and botanicals. But they urged caution since the efficacy of these agents has not been fully established.

Consider nonmedical treatments such as physical, occupational, and recreation therapy; exercise; orthotics; ultrasound; massage; acupuncture; cognitive behavioral therapy; relaxation therapy; and TENS or other types of nerve stimulation.

Consider medical cannabis or cannabinoids as an adjuvant but not a first-line pain treatment, being sure to follow specific state regulations.

Consider a trial of opioids only for carefully selected patients who don’t respond to more conservative management. Weigh potential risks against benefits and employ universal precautions to minimize abuse and addiction, and be cautious in coprescribing other centrally-acting agents (J Clin Oncol. 2016 July 25. doi: 10.1200/JCO.2016.68.5206).

The full clinical practice guideline and other clinical tools and resources are available at www.asco.org/chronic-pai-guideline.

The guideline development process was supported by ASCO. Dr. Paice reported having no relevant financial disclosures; some of her associates reported financial ties to industry sources.

All adult cancer survivors should be screened for chronic pain at every visit, according to the American Society of Clinical Oncology’s first clinical practice guideline for managing this patient population, published July 25 in the Journal of Clinical Oncology.

An estimated 14 million adults with a history of cancer are living in the United States alone, and the prevalence of chronic pain related to their malignancy is reported to be as high as 40%. Yet most health care providers “haven’t been trained to recognize or treat long-term pain associated with cancer,” Judith A. Paice, PhD, RN, said in a press statement accompanying the release of the new guideline.

Existing guidelines focus on the acute pain of cancer and its treatment, or on acute pain related to advanced cancer, said Dr. Paice, cochair of the expert panel that developed the guideline and research professor of hematology/oncology at Northwestern University, Chicago.

©Thinkstock.com

The chronic pain addressed in the new guideline document can be related to the malignancy itself or to its treatment. Surgery, chemotherapy, hormone therapy, radiation treatment, and stem-cell transplantation can induce dozens of pain-producing complications, including osteonecrosis, bone fractures, peripheral or central nerve damage, fistulas, lymphedema, arthralgias, and myelopathy. The pain can develop months or years after diagnosis, significantly impacting patients’ quality of life well after treatment is completed.

“This guideline will help clinicians identify pain early and develop comprehensive treatment plans using a broad range of approaches,” Dr. Paice said in the statement.

The panel that developed the guideline comprised experts in medical oncology, hematology, pain medicine, palliative care, hospice, radiation oncology, social work, rehabilitation, psychology, and anesthesiology. They performed a systematic review of the literature and based their recommendations on 35 meta-analyses, 9 randomized controlled trials, 19 comparative studies, and expert consensus.

Some key recommendations include the following:

• Screen all survivors of adult cancers for chronic pain using both a physical exam and an in-depth interview that covers physical, functional, psychological, social, and spiritual aspects of pain, as well as the patient’s treatment history and comorbid conditions. The guideline includes a list of 36 common pain syndromes resulting from cancer treatments.

• Monitor patients at every visit for late-onset treatment effects that can produce pain, just as they are monitored for recurrent disease and secondary malignancy. Some cancer survivors may not recognize that their current pain is related to past disease or its treatments, or may consider it an untreatable complication that they have to endure.

• Consider the entire range of pain medicines – not just opioid analgesics – including NSAIDs, acetaminophen, and selected antidepressants and anticonvulsants with analgesic efficacy. The panel noted that some cancer survivors with chronic pain may benefit from other drugs, including muscle relaxants, benzodiazepines, N-methyl-D-aspartate receptor blockers, alpha-2 agonists, and neutraceuticals and botanicals. But they urged caution since the efficacy of these agents has not been fully established.

Consider nonmedical treatments such as physical, occupational, and recreation therapy; exercise; orthotics; ultrasound; massage; acupuncture; cognitive behavioral therapy; relaxation therapy; and TENS or other types of nerve stimulation.

Consider medical cannabis or cannabinoids as an adjuvant but not a first-line pain treatment, being sure to follow specific state regulations.

Consider a trial of opioids only for carefully selected patients who don’t respond to more conservative management. Weigh potential risks against benefits and employ universal precautions to minimize abuse and addiction, and be cautious in coprescribing other centrally-acting agents (J Clin Oncol. 2016 July 25. doi: 10.1200/JCO.2016.68.5206).

The full clinical practice guideline and other clinical tools and resources are available at www.asco.org/chronic-pai-guideline.

The guideline development process was supported by ASCO. Dr. Paice reported having no relevant financial disclosures; some of her associates reported financial ties to industry sources.

SHM’s implementation tool kits provide hospitalists the information and tools they need to lead quality improvement projects on specific clinical topics, including two recent releases focused on anemia and congestive heart failure.

One third of the world’s population suffers from anemia, and SHM’s Center for Hospital Innovation and Improvement recently released a tool kit to improve outcomes by providing a framework for hospital-based anemia management quality improvement projects. It reviews each step of the process from forming a multidisciplinary team, obtaining institutional support, assessing baseline performance, and defining key metrics to implementing changes and monitoring their effects, with a focus on blood transfusion best practices.

Such projects can be expected to improve patient outcomes, improve the utilization of scarce resources such as allogeneic blood, and decrease transfusion-related adverse events, enabling hospitals to provide a better quality of care at a lower cost. In today’s competitive healthcare environment, these are quality gains and cost savings that hospitals cannot afford to miss.

Another recent release from the center, the congestive heart failure implementation guide, reviews methods to optimize heart failure care during and after hospital admission episodes. Congestive heart failure is responsible for 11 million physician visits annually and more hospitalizations than all forms of cancer combined.

Other recently added tool kits cover COPD, glycemic control, opioid monitoring, delirium, and pain management.

For more information on these tool kits and how the Center for Hospital Innovation and Improvement can share its proven best practices with your hospital, visit www.hospitalmedicine.org/CenterTJ16.

SHM’s implementation tool kits provide hospitalists the information and tools they need to lead quality improvement projects on specific clinical topics, including two recent releases focused on anemia and congestive heart failure.

One third of the world’s population suffers from anemia, and SHM’s Center for Hospital Innovation and Improvement recently released a tool kit to improve outcomes by providing a framework for hospital-based anemia management quality improvement projects. It reviews each step of the process from forming a multidisciplinary team, obtaining institutional support, assessing baseline performance, and defining key metrics to implementing changes and monitoring their effects, with a focus on blood transfusion best practices.

Such projects can be expected to improve patient outcomes, improve the utilization of scarce resources such as allogeneic blood, and decrease transfusion-related adverse events, enabling hospitals to provide a better quality of care at a lower cost. In today’s competitive healthcare environment, these are quality gains and cost savings that hospitals cannot afford to miss.

Another recent release from the center, the congestive heart failure implementation guide, reviews methods to optimize heart failure care during and after hospital admission episodes. Congestive heart failure is responsible for 11 million physician visits annually and more hospitalizations than all forms of cancer combined.

Other recently added tool kits cover COPD, glycemic control, opioid monitoring, delirium, and pain management.

For more information on these tool kits and how the Center for Hospital Innovation and Improvement can share its proven best practices with your hospital, visit www.hospitalmedicine.org/CenterTJ16.

SHM’s implementation tool kits provide hospitalists the information and tools they need to lead quality improvement projects on specific clinical topics, including two recent releases focused on anemia and congestive heart failure.

One third of the world’s population suffers from anemia, and SHM’s Center for Hospital Innovation and Improvement recently released a tool kit to improve outcomes by providing a framework for hospital-based anemia management quality improvement projects. It reviews each step of the process from forming a multidisciplinary team, obtaining institutional support, assessing baseline performance, and defining key metrics to implementing changes and monitoring their effects, with a focus on blood transfusion best practices.

Such projects can be expected to improve patient outcomes, improve the utilization of scarce resources such as allogeneic blood, and decrease transfusion-related adverse events, enabling hospitals to provide a better quality of care at a lower cost. In today’s competitive healthcare environment, these are quality gains and cost savings that hospitals cannot afford to miss.

Another recent release from the center, the congestive heart failure implementation guide, reviews methods to optimize heart failure care during and after hospital admission episodes. Congestive heart failure is responsible for 11 million physician visits annually and more hospitalizations than all forms of cancer combined.

Other recently added tool kits cover COPD, glycemic control, opioid monitoring, delirium, and pain management.

For more information on these tool kits and how the Center for Hospital Innovation and Improvement can share its proven best practices with your hospital, visit www.hospitalmedicine.org/CenterTJ16.

[WpProQuiz 5]

[WpProQuiz_toplist 5]

[WpProQuiz 5]

[WpProQuiz_toplist 5]

[WpProQuiz 5]

[WpProQuiz_toplist 5]

The U.S. Department of Health and Human Services and the U.S. Department of Agriculture have released the eighth iteration of the Dietary Guidelines for Americans, a set of recommendations for healthy eating habits Americans should adopt to prevent development of hypertension, heart disease, and type 2 diabetes, among other conditions.

The new guidelines, effective through 2020, highlight the importance of eating a wide variety of fruits, vegetables, grains, and dairy products, while staying away from processed foods heavy in saturated fats, sugar, and cholesterol as much as possible. The difference between this and earlier editions of the guidelines, the health agencies say, is to promote the importance of a wider variety of foods Americans should be consuming, rather than focusing on just a few isolated foods that should be integrated into an otherwise inadequate diet.

Courtesy of National Cancer Institute

“Protecting the health of the American public includes empowering them with the tools they need to make healthy choices in their daily lives,” Secretary of Health and Human Services Sylvia M. Burwell said in a statement. “By focusing on small shifts in what we eat and drink, eating healthy becomes more manageable. The Dietary Guidelines provide science-based recommendations on food and nutrition so people can make decisions that may help keep their weight under control, and prevent chronic conditions, like Type 2 diabetes, hypertension, and heart disease.”

The American Medical Association voiced their support of the new guidelines, saying that they are “extremely pleased that the new recommendations call for significantly reducing the amount of added sugars and sugar sweetened beverages from the American diet.” Similarly, the American College of Cardiology issued a statement saying that the existence of “a source of clear science-based information about diet” is more important than ever for Americans in the face of increasingly omnipresent and often confusing information available; the college also lauded the recommendations to limit the intake of added sugars, saturated and trans fats, and sodium. The American Heart Association released a new Authoritative Review of data on the topic of nutritional balance as it related to chronic diseases.

While the recommendations may seem common sense and geared more towards patients and laymen, they are of equal importance to health care providers. Dr. Carolyn Lopez – a Chicago-area family physician and adjunct professor of medicine at Northwestern University – called the guidelines an important resource for physicians, with several elements that will be of particular benefit to physicians and clinicians looking to improve the quality of care given to their patients.

“People [should] understand that while individual food choices are important, the pattern of eating is paramount,” Dr. Lopez explained in an interview. “It’s not impossible to bring vegetables into breakfast – veggie omelettes are great – but it’s hard to imagine bringing a vegetable into the whole grain cereals with skim milk breakfast.”

As a family practitioner, however, Dr. Lopez stressed the difficulty of any doctor having a significant enough amount of time with each patient to really go in-depth into what needs to be done to enact meaningful nutritional and lifestyle changes. “These guidelines can only be effective if the whole team is talking to patients,” she explained. “On its own, it would be extraordinarily difficult [or] impossible to accomplish.

Dr. Nazrat Mirza, a pediatrician who is medical director of the IDEAL Pediatric Weight Management Clinic at Children’s National Health System, Washington, said in an interview that the guidelines are “significant in that they are leading us even closer to healthier dietary living – and from my pediatric perspective, healthier children who will grow into healthier adults. We must keep in mind that these guidelines are not prescriptive – but generalized to relatively healthy people. In particular, the recommendation to reduce sugar intake with specification of an upper limit of 10% of calories from added sugar factored into the suggested daily nutritional intake is an excellent update. Added sugar consumption is linked to diabetes, so any reduction in recommended intake will steer people away from potentially developing diabetes.”

She continued, “In my clinic and day-to-day counseling of patients, being able to point to helpful resources such as these guidelines is crucial. These guidelines will continue to serve as yet another way to reach parents and affect the daily dietary habits they practice at home. I was happy to see resources such as MyPlate.gov referenced in the guidelines; that is a tool I use regularly. When educating families on what a healthy plate looks like, I’m able to point directly to the MyPlate.gov posters hanging in the clinic. Comprehensive resources such as these guidelines, [which] give parents actual examples of foods, and deliver the information in a clear, concise, implementable way, are the best methods to reach parents and kids.” 

“As a medical provider, such guidelines provide us with tools and reinforcement to say ‘this is policy,’ when approaching schools about the food and drink options they offer children on a daily basis – because the schools are going to have to follow these guidelines. If these guidelines can enforce public policy for the kids to eat healthy, ... and we can implement changes according to the guidelines, that would help greatly in the prevention of chronic disorders such as obesity, hypertension and diabetes – which is a step in the right direction,” said Dr. Mirza, also of George Washington University, Washington.

“Most physicians are so rushed nowadays by the health care system that they typically do not have adequate time to discuss these very important issues,” Dr. Rodbard said in an interview. “It takes time and perseverance to educate the patient and provide individualized care, assessing their current diet, assessing their willingness or potential for changing their diet or increasing their physical activity.”

On that last point. Dr. Rodbard criticized the new guidelines for not emphasizing the importance of exercise enough. “More clarity and emphasis on physical activity should have been provided,” she said, adding that “people need continual, gentle reminders with repetition and long-term follow-up.” Dr. Rodbard summed up the guidelines as “marginally adequate” but “a step in the right direction.”

An endocrinologist who practices in Winter Park, Fla., Dr. Victor L. Roberts – a Fellow of the ACP and ACE – agreed that time with the patients is critical in order for these guidelines to have any effect, calling the guidelines “just the GPS, not the destination.”

Preaching an ABC strategy – accountability, behavior, and calories, the latter of which he stressed is the most important part of any dietary strategy – Dr. Roberts explained that clinicians and physicians should leave the more specific dietary advice to nutritional experts and focus on telling their patients to watch calories, watch the amount of food they’re eating of any given type, and to exercise more.

“These guidelines crystallize and summarize what we’ve already known, and what we should have been practicing and advocating, for decades,” Dr. Roberts said in an interview, adding that “the difficulty is putting these recommendations into practice and having patients and doctors accept responsibility.”

Ultimately, the three doctors who treat adult patients concurred that the new guidelines are imperfect, and likely won’t result in any automatic widespread change. Dr. Rodbard admitted that she does not anticipate the guidelines affecting the way she treats her patients very much, if at all, while Dr. Lopez said that she’s “not sure it’s going to have a major effect.” Furthermore, the sheer volume of data and information available often leads to patients simply not knowing what to believe, which Dr. Roberts described as a “glazed over” effect of being told so many different things from so many different sources, patients just tune everything out.

Ultimately, while it’s important for health care providers to give advice and recommendations as necessary, these should be done on an individual basis. And, if a patient requires extensive dietary and nutritional intervention, that should be left in the hands of specialist who can accurately determine what the patient is capable of, what their goals should be, and how to tailor a plan specifically for them.

“I don’t know many clinicians, even in my own specialty, who know much about what specifically to eat,” said Dr. Roberts. “That should come from nutritional medicine people, not us.”

Dr. Lopez, Dr. Rodbard, and Dr. Roberts did not report any relevant financial disclosures.

[email protected]

*This article was updated 1/12/2016.

The U.S. Department of Health and Human Services and the U.S. Department of Agriculture have released the eighth iteration of the Dietary Guidelines for Americans, a set of recommendations for healthy eating habits Americans should adopt to prevent development of hypertension, heart disease, and type 2 diabetes, among other conditions.

The new guidelines, effective through 2020, highlight the importance of eating a wide variety of fruits, vegetables, grains, and dairy products, while staying away from processed foods heavy in saturated fats, sugar, and cholesterol as much as possible. The difference between this and earlier editions of the guidelines, the health agencies say, is to promote the importance of a wider variety of foods Americans should be consuming, rather than focusing on just a few isolated foods that should be integrated into an otherwise inadequate diet.

Courtesy of National Cancer Institute

“Protecting the health of the American public includes empowering them with the tools they need to make healthy choices in their daily lives,” Secretary of Health and Human Services Sylvia M. Burwell said in a statement. “By focusing on small shifts in what we eat and drink, eating healthy becomes more manageable. The Dietary Guidelines provide science-based recommendations on food and nutrition so people can make decisions that may help keep their weight under control, and prevent chronic conditions, like Type 2 diabetes, hypertension, and heart disease.”

The American Medical Association voiced their support of the new guidelines, saying that they are “extremely pleased that the new recommendations call for significantly reducing the amount of added sugars and sugar sweetened beverages from the American diet.” Similarly, the American College of Cardiology issued a statement saying that the existence of “a source of clear science-based information about diet” is more important than ever for Americans in the face of increasingly omnipresent and often confusing information available; the college also lauded the recommendations to limit the intake of added sugars, saturated and trans fats, and sodium. The American Heart Association released a new Authoritative Review of data on the topic of nutritional balance as it related to chronic diseases.

While the recommendations may seem common sense and geared more towards patients and laymen, they are of equal importance to health care providers. Dr. Carolyn Lopez – a Chicago-area family physician and adjunct professor of medicine at Northwestern University – called the guidelines an important resource for physicians, with several elements that will be of particular benefit to physicians and clinicians looking to improve the quality of care given to their patients.

“People [should] understand that while individual food choices are important, the pattern of eating is paramount,” Dr. Lopez explained in an interview. “It’s not impossible to bring vegetables into breakfast – veggie omelettes are great – but it’s hard to imagine bringing a vegetable into the whole grain cereals with skim milk breakfast.”

As a family practitioner, however, Dr. Lopez stressed the difficulty of any doctor having a significant enough amount of time with each patient to really go in-depth into what needs to be done to enact meaningful nutritional and lifestyle changes. “These guidelines can only be effective if the whole team is talking to patients,” she explained. “On its own, it would be extraordinarily difficult [or] impossible to accomplish.

Dr. Nazrat Mirza, a pediatrician who is medical director of the IDEAL Pediatric Weight Management Clinic at Children’s National Health System, Washington, said in an interview that the guidelines are “significant in that they are leading us even closer to healthier dietary living – and from my pediatric perspective, healthier children who will grow into healthier adults. We must keep in mind that these guidelines are not prescriptive – but generalized to relatively healthy people. In particular, the recommendation to reduce sugar intake with specification of an upper limit of 10% of calories from added sugar factored into the suggested daily nutritional intake is an excellent update. Added sugar consumption is linked to diabetes, so any reduction in recommended intake will steer people away from potentially developing diabetes.”

She continued, “In my clinic and day-to-day counseling of patients, being able to point to helpful resources such as these guidelines is crucial. These guidelines will continue to serve as yet another way to reach parents and affect the daily dietary habits they practice at home. I was happy to see resources such as MyPlate.gov referenced in the guidelines; that is a tool I use regularly. When educating families on what a healthy plate looks like, I’m able to point directly to the MyPlate.gov posters hanging in the clinic. Comprehensive resources such as these guidelines, [which] give parents actual examples of foods, and deliver the information in a clear, concise, implementable way, are the best methods to reach parents and kids.” 

“As a medical provider, such guidelines provide us with tools and reinforcement to say ‘this is policy,’ when approaching schools about the food and drink options they offer children on a daily basis – because the schools are going to have to follow these guidelines. If these guidelines can enforce public policy for the kids to eat healthy, ... and we can implement changes according to the guidelines, that would help greatly in the prevention of chronic disorders such as obesity, hypertension and diabetes – which is a step in the right direction,” said Dr. Mirza, also of George Washington University, Washington.

“Most physicians are so rushed nowadays by the health care system that they typically do not have adequate time to discuss these very important issues,” Dr. Rodbard said in an interview. “It takes time and perseverance to educate the patient and provide individualized care, assessing their current diet, assessing their willingness or potential for changing their diet or increasing their physical activity.”

On that last point. Dr. Rodbard criticized the new guidelines for not emphasizing the importance of exercise enough. “More clarity and emphasis on physical activity should have been provided,” she said, adding that “people need continual, gentle reminders with repetition and long-term follow-up.” Dr. Rodbard summed up the guidelines as “marginally adequate” but “a step in the right direction.”

An endocrinologist who practices in Winter Park, Fla., Dr. Victor L. Roberts – a Fellow of the ACP and ACE – agreed that time with the patients is critical in order for these guidelines to have any effect, calling the guidelines “just the GPS, not the destination.”

Preaching an ABC strategy – accountability, behavior, and calories, the latter of which he stressed is the most important part of any dietary strategy – Dr. Roberts explained that clinicians and physicians should leave the more specific dietary advice to nutritional experts and focus on telling their patients to watch calories, watch the amount of food they’re eating of any given type, and to exercise more.

“These guidelines crystallize and summarize what we’ve already known, and what we should have been practicing and advocating, for decades,” Dr. Roberts said in an interview, adding that “the difficulty is putting these recommendations into practice and having patients and doctors accept responsibility.”

Ultimately, the three doctors who treat adult patients concurred that the new guidelines are imperfect, and likely won’t result in any automatic widespread change. Dr. Rodbard admitted that she does not anticipate the guidelines affecting the way she treats her patients very much, if at all, while Dr. Lopez said that she’s “not sure it’s going to have a major effect.” Furthermore, the sheer volume of data and information available often leads to patients simply not knowing what to believe, which Dr. Roberts described as a “glazed over” effect of being told so many different things from so many different sources, patients just tune everything out.

Ultimately, while it’s important for health care providers to give advice and recommendations as necessary, these should be done on an individual basis. And, if a patient requires extensive dietary and nutritional intervention, that should be left in the hands of specialist who can accurately determine what the patient is capable of, what their goals should be, and how to tailor a plan specifically for them.

“I don’t know many clinicians, even in my own specialty, who know much about what specifically to eat,” said Dr. Roberts. “That should come from nutritional medicine people, not us.”

Dr. Lopez, Dr. Rodbard, and Dr. Roberts did not report any relevant financial disclosures.

[email protected]

*This article was updated 1/12/2016.

The U.S. Department of Health and Human Services and the U.S. Department of Agriculture have released the eighth iteration of the Dietary Guidelines for Americans, a set of recommendations for healthy eating habits Americans should adopt to prevent development of hypertension, heart disease, and type 2 diabetes, among other conditions.

The new guidelines, effective through 2020, highlight the importance of eating a wide variety of fruits, vegetables, grains, and dairy products, while staying away from processed foods heavy in saturated fats, sugar, and cholesterol as much as possible. The difference between this and earlier editions of the guidelines, the health agencies say, is to promote the importance of a wider variety of foods Americans should be consuming, rather than focusing on just a few isolated foods that should be integrated into an otherwise inadequate diet.

Courtesy of National Cancer Institute

“Protecting the health of the American public includes empowering them with the tools they need to make healthy choices in their daily lives,” Secretary of Health and Human Services Sylvia M. Burwell said in a statement. “By focusing on small shifts in what we eat and drink, eating healthy becomes more manageable. The Dietary Guidelines provide science-based recommendations on food and nutrition so people can make decisions that may help keep their weight under control, and prevent chronic conditions, like Type 2 diabetes, hypertension, and heart disease.”

The American Medical Association voiced their support of the new guidelines, saying that they are “extremely pleased that the new recommendations call for significantly reducing the amount of added sugars and sugar sweetened beverages from the American diet.” Similarly, the American College of Cardiology issued a statement saying that the existence of “a source of clear science-based information about diet” is more important than ever for Americans in the face of increasingly omnipresent and often confusing information available; the college also lauded the recommendations to limit the intake of added sugars, saturated and trans fats, and sodium. The American Heart Association released a new Authoritative Review of data on the topic of nutritional balance as it related to chronic diseases.

While the recommendations may seem common sense and geared more towards patients and laymen, they are of equal importance to health care providers. Dr. Carolyn Lopez – a Chicago-area family physician and adjunct professor of medicine at Northwestern University – called the guidelines an important resource for physicians, with several elements that will be of particular benefit to physicians and clinicians looking to improve the quality of care given to their patients.

“People [should] understand that while individual food choices are important, the pattern of eating is paramount,” Dr. Lopez explained in an interview. “It’s not impossible to bring vegetables into breakfast – veggie omelettes are great – but it’s hard to imagine bringing a vegetable into the whole grain cereals with skim milk breakfast.”

As a family practitioner, however, Dr. Lopez stressed the difficulty of any doctor having a significant enough amount of time with each patient to really go in-depth into what needs to be done to enact meaningful nutritional and lifestyle changes. “These guidelines can only be effective if the whole team is talking to patients,” she explained. “On its own, it would be extraordinarily difficult [or] impossible to accomplish.

Dr. Nazrat Mirza, a pediatrician who is medical director of the IDEAL Pediatric Weight Management Clinic at Children’s National Health System, Washington, said in an interview that the guidelines are “significant in that they are leading us even closer to healthier dietary living – and from my pediatric perspective, healthier children who will grow into healthier adults. We must keep in mind that these guidelines are not prescriptive – but generalized to relatively healthy people. In particular, the recommendation to reduce sugar intake with specification of an upper limit of 10% of calories from added sugar factored into the suggested daily nutritional intake is an excellent update. Added sugar consumption is linked to diabetes, so any reduction in recommended intake will steer people away from potentially developing diabetes.”

She continued, “In my clinic and day-to-day counseling of patients, being able to point to helpful resources such as these guidelines is crucial. These guidelines will continue to serve as yet another way to reach parents and affect the daily dietary habits they practice at home. I was happy to see resources such as MyPlate.gov referenced in the guidelines; that is a tool I use regularly. When educating families on what a healthy plate looks like, I’m able to point directly to the MyPlate.gov posters hanging in the clinic. Comprehensive resources such as these guidelines, [which] give parents actual examples of foods, and deliver the information in a clear, concise, implementable way, are the best methods to reach parents and kids.” 

“As a medical provider, such guidelines provide us with tools and reinforcement to say ‘this is policy,’ when approaching schools about the food and drink options they offer children on a daily basis – because the schools are going to have to follow these guidelines. If these guidelines can enforce public policy for the kids to eat healthy, ... and we can implement changes according to the guidelines, that would help greatly in the prevention of chronic disorders such as obesity, hypertension and diabetes – which is a step in the right direction,” said Dr. Mirza, also of George Washington University, Washington.

“Most physicians are so rushed nowadays by the health care system that they typically do not have adequate time to discuss these very important issues,” Dr. Rodbard said in an interview. “It takes time and perseverance to educate the patient and provide individualized care, assessing their current diet, assessing their willingness or potential for changing their diet or increasing their physical activity.”

On that last point. Dr. Rodbard criticized the new guidelines for not emphasizing the importance of exercise enough. “More clarity and emphasis on physical activity should have been provided,” she said, adding that “people need continual, gentle reminders with repetition and long-term follow-up.” Dr. Rodbard summed up the guidelines as “marginally adequate” but “a step in the right direction.”

An endocrinologist who practices in Winter Park, Fla., Dr. Victor L. Roberts – a Fellow of the ACP and ACE – agreed that time with the patients is critical in order for these guidelines to have any effect, calling the guidelines “just the GPS, not the destination.”

Preaching an ABC strategy – accountability, behavior, and calories, the latter of which he stressed is the most important part of any dietary strategy – Dr. Roberts explained that clinicians and physicians should leave the more specific dietary advice to nutritional experts and focus on telling their patients to watch calories, watch the amount of food they’re eating of any given type, and to exercise more.

“These guidelines crystallize and summarize what we’ve already known, and what we should have been practicing and advocating, for decades,” Dr. Roberts said in an interview, adding that “the difficulty is putting these recommendations into practice and having patients and doctors accept responsibility.”

Ultimately, the three doctors who treat adult patients concurred that the new guidelines are imperfect, and likely won’t result in any automatic widespread change. Dr. Rodbard admitted that she does not anticipate the guidelines affecting the way she treats her patients very much, if at all, while Dr. Lopez said that she’s “not sure it’s going to have a major effect.” Furthermore, the sheer volume of data and information available often leads to patients simply not knowing what to believe, which Dr. Roberts described as a “glazed over” effect of being told so many different things from so many different sources, patients just tune everything out.

Ultimately, while it’s important for health care providers to give advice and recommendations as necessary, these should be done on an individual basis. And, if a patient requires extensive dietary and nutritional intervention, that should be left in the hands of specialist who can accurately determine what the patient is capable of, what their goals should be, and how to tailor a plan specifically for them.

“I don’t know many clinicians, even in my own specialty, who know much about what specifically to eat,” said Dr. Roberts. “That should come from nutritional medicine people, not us.”

Dr. Lopez, Dr. Rodbard, and Dr. Roberts did not report any relevant financial disclosures.

[email protected]

*This article was updated 1/12/2016.

Updated guidelines regarding the treatment of patients with venous thromboembolism advise abandoning the routine use of compression stockings for prevention of postthrombotic syndrome in patients who have had an acute deep vein thrombosis, according to Dr. Clive Kearon, lead author of the American College of Chest Physicians’ 10th edition of “Antithrombotic Therapy for VTE Disease” (Chest. 2015. doi: 10.1016/j.chest.2015.11.026).

The VTE guidelines include 12 recommendations. Two other key changes from the previous guidelines include new treatment recommendations about which patients with isolated subsegmental pulmonary embolism (PE) should, and should not, receive anticoagulant therapy, and as a recommendation for the use of non–vitamin K antagonist oral anticoagulants (NOACs) instead of warfarin for initial and long-term treatment of VTE in patients without cancer.

It is another of the group’s “living guidelines,” intended to be flexible, easy-to-update recommendations … based on the best available evidence, and to identify gaps in our knowledge and areas for future research,” Dr. Kearon of McMaster University, Hamilton, Ont., said in an interview.

“Clinicians and guideline developers would like clinician decisions to be supported by very strong, or almost irrefutable, evidence,” he said. ”It’s difficult to do studies that provide irrefutable evidence, however,” and most of the updated recommendations are not based on the highest level of study evidence – large, randomized controlled trials.

Nevertheless, “the quality of evidence that supports guidelines and clinical decision making is much better now than it was 20 or 30 years ago,” Dr. Kearon said, mainly because more recent studies are considerably larger and involve multiple clinical centers. Plus, “we’re continually improving our skills at doing high-quality studies and studies that have a low potential for bias.”

The old recommendation to use graduated compression stockings for 2 years after DVT to reduce the risk of postthrombotic syndrome was mainly based on findings of two small single-center randomized trials, published in the Lancet and Annals of Internal Medicine, in which patients and study personnel were not blinded to stocking use. Since then, a much larger multicenter, placebo-controlled trial found that routine use of graduated compression stockings did not reduce postthrombotic syndrome or have other important benefits in 410 patients with a first proximal DVT randomized to receive either active or placebo compression stockings. The incidence of postthrombotic syndrome was 14% in the active group and 13% in the placebo group – a nonsignificant difference. The same study also found that routine use of graduated compression stockings did not reduce leg pain during the 3 months after a DVT – although the stockings were still able to reduce acute symptoms of DVT, and chronic symptoms in patients with postthrombotic syndrome.

The recommendation to replace warfarin with NOACs is based on new data suggesting that the agents are associated with a lower risk of bleeding, and on observations that NOACs are much easier for patients and clinicians to use. Several of the studies upon which earlier guidelines were based have been reanalyzed, Dr. Kearon and his coauthors wrote. There are also now extensive data on the comparative safety of NOACs and warfarin.

“Based on less bleeding with NOACs and greater convenience for patients and health care providers, we now suggest that a NOAC is used in preference to VKA [vitamin K antagonist] for the initial and long-term treatment of VTE in patients without cancer,” they wrote.

The recommendation to employ watchful waiting over anticoagulation in some patients with subsegmental pulmonary embolism is based on a compendium of clinical evidence rather than on large studies. A true subsegmental PE is unlikely to need anticoagulation, because it will have arisen from a small clot and thus carry a small risk of progression or recurrence.

“There is, however, high-quality evidence for the efficacy and safety of anticoagulant therapy in patients with larger PE, and this is expected to apply similarly to patients with subsegmental PE,” the authors wrote. “Whether the risk of progressive or recurrent VTE is high enough to justify anticoagulation in patients with subsegmental PE is uncertain.”

If clinical assessment suggests that anticoagulation isn’t appropriate, these patients should have a confirmatory bilateral ultrasound to rule out proximal DVTs, especially in high-risk locations. If a DVT is detected, clinicians may choose to conduct subsequent ultrasounds to identify and treat any evolving proximal clots.

The guideline has been endorsed by the American Association for Clinical Chemistry, the American College of Clinical Pharmacy, the International Society for Thrombosis and Haemostasis, and the American Society of Health-System Pharmacists.

Dr. Kearon has been compensated for speaking engagements sponsored by Boehringer Ingelheim and Bayer Healthcare related to VTE therapy. Some of the other guideline authors also disclosed relationships with pharmaceutical companies.

[email protected]

Updated guidelines regarding the treatment of patients with venous thromboembolism advise abandoning the routine use of compression stockings for prevention of postthrombotic syndrome in patients who have had an acute deep vein thrombosis, according to Dr. Clive Kearon, lead author of the American College of Chest Physicians’ 10th edition of “Antithrombotic Therapy for VTE Disease” (Chest. 2015. doi: 10.1016/j.chest.2015.11.026).

The VTE guidelines include 12 recommendations. Two other key changes from the previous guidelines include new treatment recommendations about which patients with isolated subsegmental pulmonary embolism (PE) should, and should not, receive anticoagulant therapy, and as a recommendation for the use of non–vitamin K antagonist oral anticoagulants (NOACs) instead of warfarin for initial and long-term treatment of VTE in patients without cancer.

It is another of the group’s “living guidelines,” intended to be flexible, easy-to-update recommendations … based on the best available evidence, and to identify gaps in our knowledge and areas for future research,” Dr. Kearon of McMaster University, Hamilton, Ont., said in an interview.

“Clinicians and guideline developers would like clinician decisions to be supported by very strong, or almost irrefutable, evidence,” he said. ”It’s difficult to do studies that provide irrefutable evidence, however,” and most of the updated recommendations are not based on the highest level of study evidence – large, randomized controlled trials.

Nevertheless, “the quality of evidence that supports guidelines and clinical decision making is much better now than it was 20 or 30 years ago,” Dr. Kearon said, mainly because more recent studies are considerably larger and involve multiple clinical centers. Plus, “we’re continually improving our skills at doing high-quality studies and studies that have a low potential for bias.”

The old recommendation to use graduated compression stockings for 2 years after DVT to reduce the risk of postthrombotic syndrome was mainly based on findings of two small single-center randomized trials, published in the Lancet and Annals of Internal Medicine, in which patients and study personnel were not blinded to stocking use. Since then, a much larger multicenter, placebo-controlled trial found that routine use of graduated compression stockings did not reduce postthrombotic syndrome or have other important benefits in 410 patients with a first proximal DVT randomized to receive either active or placebo compression stockings. The incidence of postthrombotic syndrome was 14% in the active group and 13% in the placebo group – a nonsignificant difference. The same study also found that routine use of graduated compression stockings did not reduce leg pain during the 3 months after a DVT – although the stockings were still able to reduce acute symptoms of DVT, and chronic symptoms in patients with postthrombotic syndrome.

The recommendation to replace warfarin with NOACs is based on new data suggesting that the agents are associated with a lower risk of bleeding, and on observations that NOACs are much easier for patients and clinicians to use. Several of the studies upon which earlier guidelines were based have been reanalyzed, Dr. Kearon and his coauthors wrote. There are also now extensive data on the comparative safety of NOACs and warfarin.

“Based on less bleeding with NOACs and greater convenience for patients and health care providers, we now suggest that a NOAC is used in preference to VKA [vitamin K antagonist] for the initial and long-term treatment of VTE in patients without cancer,” they wrote.

The recommendation to employ watchful waiting over anticoagulation in some patients with subsegmental pulmonary embolism is based on a compendium of clinical evidence rather than on large studies. A true subsegmental PE is unlikely to need anticoagulation, because it will have arisen from a small clot and thus carry a small risk of progression or recurrence.

“There is, however, high-quality evidence for the efficacy and safety of anticoagulant therapy in patients with larger PE, and this is expected to apply similarly to patients with subsegmental PE,” the authors wrote. “Whether the risk of progressive or recurrent VTE is high enough to justify anticoagulation in patients with subsegmental PE is uncertain.”

If clinical assessment suggests that anticoagulation isn’t appropriate, these patients should have a confirmatory bilateral ultrasound to rule out proximal DVTs, especially in high-risk locations. If a DVT is detected, clinicians may choose to conduct subsequent ultrasounds to identify and treat any evolving proximal clots.

The guideline has been endorsed by the American Association for Clinical Chemistry, the American College of Clinical Pharmacy, the International Society for Thrombosis and Haemostasis, and the American Society of Health-System Pharmacists.

Dr. Kearon has been compensated for speaking engagements sponsored by Boehringer Ingelheim and Bayer Healthcare related to VTE therapy. Some of the other guideline authors also disclosed relationships with pharmaceutical companies.

[email protected]

Updated guidelines regarding the treatment of patients with venous thromboembolism advise abandoning the routine use of compression stockings for prevention of postthrombotic syndrome in patients who have had an acute deep vein thrombosis, according to Dr. Clive Kearon, lead author of the American College of Chest Physicians’ 10th edition of “Antithrombotic Therapy for VTE Disease” (Chest. 2015. doi: 10.1016/j.chest.2015.11.026).

The VTE guidelines include 12 recommendations. Two other key changes from the previous guidelines include new treatment recommendations about which patients with isolated subsegmental pulmonary embolism (PE) should, and should not, receive anticoagulant therapy, and as a recommendation for the use of non–vitamin K antagonist oral anticoagulants (NOACs) instead of warfarin for initial and long-term treatment of VTE in patients without cancer.

It is another of the group’s “living guidelines,” intended to be flexible, easy-to-update recommendations … based on the best available evidence, and to identify gaps in our knowledge and areas for future research,” Dr. Kearon of McMaster University, Hamilton, Ont., said in an interview.

“Clinicians and guideline developers would like clinician decisions to be supported by very strong, or almost irrefutable, evidence,” he said. ”It’s difficult to do studies that provide irrefutable evidence, however,” and most of the updated recommendations are not based on the highest level of study evidence – large, randomized controlled trials.

Nevertheless, “the quality of evidence that supports guidelines and clinical decision making is much better now than it was 20 or 30 years ago,” Dr. Kearon said, mainly because more recent studies are considerably larger and involve multiple clinical centers. Plus, “we’re continually improving our skills at doing high-quality studies and studies that have a low potential for bias.”

The old recommendation to use graduated compression stockings for 2 years after DVT to reduce the risk of postthrombotic syndrome was mainly based on findings of two small single-center randomized trials, published in the Lancet and Annals of Internal Medicine, in which patients and study personnel were not blinded to stocking use. Since then, a much larger multicenter, placebo-controlled trial found that routine use of graduated compression stockings did not reduce postthrombotic syndrome or have other important benefits in 410 patients with a first proximal DVT randomized to receive either active or placebo compression stockings. The incidence of postthrombotic syndrome was 14% in the active group and 13% in the placebo group – a nonsignificant difference. The same study also found that routine use of graduated compression stockings did not reduce leg pain during the 3 months after a DVT – although the stockings were still able to reduce acute symptoms of DVT, and chronic symptoms in patients with postthrombotic syndrome.

The recommendation to replace warfarin with NOACs is based on new data suggesting that the agents are associated with a lower risk of bleeding, and on observations that NOACs are much easier for patients and clinicians to use. Several of the studies upon which earlier guidelines were based have been reanalyzed, Dr. Kearon and his coauthors wrote. There are also now extensive data on the comparative safety of NOACs and warfarin.

“Based on less bleeding with NOACs and greater convenience for patients and health care providers, we now suggest that a NOAC is used in preference to VKA [vitamin K antagonist] for the initial and long-term treatment of VTE in patients without cancer,” they wrote.

The recommendation to employ watchful waiting over anticoagulation in some patients with subsegmental pulmonary embolism is based on a compendium of clinical evidence rather than on large studies. A true subsegmental PE is unlikely to need anticoagulation, because it will have arisen from a small clot and thus carry a small risk of progression or recurrence.

“There is, however, high-quality evidence for the efficacy and safety of anticoagulant therapy in patients with larger PE, and this is expected to apply similarly to patients with subsegmental PE,” the authors wrote. “Whether the risk of progressive or recurrent VTE is high enough to justify anticoagulation in patients with subsegmental PE is uncertain.”

If clinical assessment suggests that anticoagulation isn’t appropriate, these patients should have a confirmatory bilateral ultrasound to rule out proximal DVTs, especially in high-risk locations. If a DVT is detected, clinicians may choose to conduct subsequent ultrasounds to identify and treat any evolving proximal clots.

The guideline has been endorsed by the American Association for Clinical Chemistry, the American College of Clinical Pharmacy, the International Society for Thrombosis and Haemostasis, and the American Society of Health-System Pharmacists.

Dr. Kearon has been compensated for speaking engagements sponsored by Boehringer Ingelheim and Bayer Healthcare related to VTE therapy. Some of the other guideline authors also disclosed relationships with pharmaceutical companies.

[email protected]

Case

A 45-year-old woman was admitted with choledocholithiasis. Two days prior, following endoscopic retrograde cholangiopancreatography (ERCP), she had gone to the OR for cholecystectomy. The procedure was completed laparoscopically, though the surgeon reported a difficult dissection. The surgeon left a Blake drain in the gallbladder fossa, which initially contained punch-colored fluid. Today, there is bilious fluid in the drain.

Overview

Surgical drains are used to monitor for postoperative leaks or abscesses, to collect normal physiologic fluid, or to minimize dead space. A hospitalist caring for surgical patients may be the first provider to note when something changes in the color or volume of surgical drains. Table 1 lists various types of drains with their indications for use.

Surgical Tubes and Drains

Chest tubes. Chest tubes are placed in the pleural space to evacuate air or fluid. They can be as thin as 20 French or as thick as 40 French (for adults). Chest tubes are typically placed between the fourth and fifth intercostal spaces in the anterior axillary or mid-axillary line; however, the location may vary according to the indication for placement. The tubes can be straight or angled.

The tubes are connected to a collecting system with a three-way chamber. The water chamber holds a column of water, which prevents air from being sucked into the pleural space with inhalation. The suction chamber can be attached to continuous wall suction to remove air or fluid, or it can be placed on “water seal” with no active suction mechanism. The third chamber is the collection chamber for fluid drainage.

Indications for a chest tube include pneumothorax, hemothorax, or a persistent or large pleural effusion. Pneumothorax and hemothorax usually require immediate chest tube placement. Chest tubes are also commonly placed at the end of thoracic surgeries to allow for appropriate re-expansion of the lung tissue.

A chest X-ray should be obtained after any chest tube insertion to ensure appropriate placement. Chest tubes are equipped with a radiopaque line along the longitudinal axis, which should be visible on X-ray. Respiratory variation in the fluid in the collecting tube, called “tidling,” should also be seen in a correctly placed chest tube, and should be monitored at the bedside to reassure continued appropriate location. The interventional radiologist or surgeon who placed the tube should determine the subsequent frequency of serial chest X-rays required to monitor the location of the chest tube.

If the patient has a pneumothorax, air bubbles will be visible in the water chamber; called an air leak, these are often more apparent when the patient coughs. The chest tube should initially be set to continuous suction at -20 mmHg to evacuate the air. Once the air leak has stopped, the chest tube should be placed on water seal to confirm resolution of the pneumothorax (water seal mimics normal physiology). If, after the transition from suction to water seal, resumption of the air leak is noted, it may indicate recurrence of the patient’s pneumothorax. A stat chest X-ray should be obtained, and the chest tube should be placed back on continuous suction. In general, a chest X-ray should be obtained any time the chest tube is changed from suction to water seal or vice versa.

If the patient experiences ongoing or worsening pain, fever, or inadequate drainage, a chest computed tomographic (CT) scan may be warranted to identify inappropriate positioning or other complications, such as occlusion or effusion of the tube. Blood or other debris might clog chest tubes; the surgical team may be able to evacuate the tube with suction tubing at the bedside. If unsuccessful, the tube may need to be removed and reinserted.

The team that placed the tube should help the hospitalist determine the timing of the chest tube removal. If the patient has a pleural effusion, the chest tube can usually be removed when the output is less than 100-200 mL per day and the lung is expanded. The tube should usually be taken off suction and placed on water seal to rule out pneumothorax prior to tube removal.

Penrose drains. Penrose drains are often used to drain fluid or to keep a space open for drainage. Surgeons may use sutures to anchor Penrose drains to skin. Common indications include:

• Ventral hernia repair;
• Debridement of infected pancreatitis; and
• Drainage of superficial abscess cavities.

Penrose drains are simple, flexible tubes that are open at both ends; in contrast to closed drains, they permit ingress as well as egress, facilitating colonization.

Closed suction drains. Closed suction drains with a plastic bulb attachment (i.e., Jackson-Pratt, Blake, Hemovac) are used to collect fluid from a postoperative cavity. Common indications include:

• Post-mastectomy to drain subcutaneous fluid;
• Abdominal surgery;
• Plastic surgery to prevent seroma formation and promote tissue apposition;
• Cholecystectomy if there is concern for damage to ducts of Luschka or other source of bile leak;
• Inadvertent postoperative leakage following a difficult rectal anastomosis; and
• Post-pancreatic surgery.

The quality and quantity of fluid drained should always be carefully noted and recorded. Changes in the fluid can imply development of bleed, leak, or other complications. The surgical team should be contacted immediately if changes are noted.

Typically, closed suction drains will be left in place until the drainage is less than 20 mL per day. These drains can be left in for weeks if necessary and will often be removed during the patient’s scheduled surgical follow-up. Rare complications include erosion into surrounding tissues and inadvertent suturing of the drain in place, such that reexploration is required to remove it. If a closed suction drain becomes occluded, contact the team that placed the drain for further recommendations on adjustment, replacement, or removal.

Nasogastric and duodenal tubes. Nasogastric tubes (NGTs) are often used in the nonoperative management of small bowel obstruction or ileus. They should be placed in the most dependent portion of the gastric lumen and confirmed by chest or abdominal X-ray. NGTs are sump pumps and have a double lumen, which includes an air port to assure flow. The air port should be patent for optimal functioning. The tube may be connected to continuous wall suction or intermittent suction, set to low (less than 60 mmHg) to avoid mucosal avulsion.

NGT output should decrease during the resolution of obstruction or ileus, and symptoms of nausea, vomiting, and abdominal distention should concomitantly improve. Persistently high output in a patient with other indicators of bowel function (flatus, for example) may suggest postpyloric placement (and placement should be checked by X-ray). The timing of NGT removal depends on resumption of bowel function.

Gastrostomy and jejunostomy tubes. Gastrostomy tubes are most commonly used for feeding but may also be used for decompression of functional or anatomic gastric outlet obstruction. They are indicated when patients need prolonged enteral access, such as those with prolonged mechanical ventilation or head and neck pathology that prohibits oral feeding. They are also rarely used for gastropexy to tack an atonic or patulous stomach to the abdominal wall or to prevent recurrence of paraesophageal hernias. These tubes can be placed percutaneously by interventional radiologists, endoscopically by surgeons and gastroenterologists, or laparoscopically or laparotomally by surgeons. This last option is often reserved for patients with difficult anatomy or those who are having laparotomy for another reason.

Because of the stomach’s generous lumen, gastrostomy tubes rarely clog. In the event that they do get clogged, carbonated liquids, meat tenderizer, or enzymes can help dissolve the obstruction. If a gastrostomy tube is left to drain, the patient may experience significant fluid and electrolyte losses, so these need to be carefully monitored.

Jejunostomy tubes are used exclusively for feeding and are usually placed 10-20 cm distal to the ligament of Treitz. These tubes are indicated in patients who require distal feedings due to gastric dysfunction or in those who have undergone a surgery in which a proximal anastomosis requires time to heal. These tubes are more apt to clog and can be more difficult to manage because the lumen of the small bowel is smaller than the stomach. Some prefer not to put pills down the tube to mitigate this risk. Routine flushes with water or saline (30 mL every four to six hours) are also helpful in mitigating the risk of clogging. In the event that they do get clogged, they may be treated like gastrostomy tubes, using carbonated liquids, meat tenderizer, or enzymes to help dissolve the obstruction.

Percutaneous tube sites should be examined frequently for signs of infection. Though gastrostomy and jejunostomy tubes are typically well secured intraabdominally, they can become dislodged. If a gastrostomy or jejunostomy tube has been in place for more than two weeks, it can easily be replaced at the bedside with a tube of comparable caliber by a member of the surgical team or by an experienced hospitalist. If the tube has been in place less than two weeks, it requires replacement with radiographic guidance, as the risk of creating a false lumen is high. Over time, tubes can become loose and fall out. If they need replacement, the preceding guidelines apply.

Back to the Case

A potential major complication of cholecystectomy is severance of the common bile duct, which necessitates significant further surgery. Less severe complications include injuries to the cholecystohepatic ducts (otherwise known as the ducts of Luschka), which can result in leakage of bile into the peritoneal cavity. A bile leak can lead to abscess and systemic infection if left undrained.

Surgeons who are concerned for such a complication intraoperatively may opt to leave a closed suction drain in the gallbladder fossa, such as a Blake drain, for monitoring and subsequent drainage. The drain will remain in place at least until the patient’s diet has been advanced fully, because digestion promotes the secretion of bile and may elucidate a leak. Bilious fluid in the Blake drain is suspicious for a leak.

The surgeon should be notified, and imaging should be obtained to find the nature of the injury to the biliary tree (CT scan with IV contrast, hepatobiliary iminodiacetic acid scan, or endoscopic retrograde cholangiopancreatography). If injury to major biliary structures (the cystic duct stump, the hepatic ducts, or the common bile duct) is diagnosed, a stent may be placed in order to restore ductile continuity.

Minor leaks, with damage to the cystic duct stump, hepatic ducts, and common bile duct ruled out, more often resolve on their own over time, and thus the patient’s closed suction drain will be left in place until biliary drainage ceases, without further initial intervention.

Bottom Line

Surgical tubes and drains have several placement indications. Alterations in quality and quantity of output can indicate changes in clinical status, and hospitalists should be able to handle initial troubleshooting. TH

Dr. Columbus is a general surgery resident at Brigham and Women’s Hospital in Boston. Dr. Havens is an instructor for the department of surgery at Brigham and Women’s Hospital. Dr. Peetz is an instructor for the department of surgery at University Hospital Case Medical Center in Cleveland.

Case

A 45-year-old woman was admitted with choledocholithiasis. Two days prior, following endoscopic retrograde cholangiopancreatography (ERCP), she had gone to the OR for cholecystectomy. The procedure was completed laparoscopically, though the surgeon reported a difficult dissection. The surgeon left a Blake drain in the gallbladder fossa, which initially contained punch-colored fluid. Today, there is bilious fluid in the drain.

Overview

Surgical drains are used to monitor for postoperative leaks or abscesses, to collect normal physiologic fluid, or to minimize dead space. A hospitalist caring for surgical patients may be the first provider to note when something changes in the color or volume of surgical drains. Table 1 lists various types of drains with their indications for use.

Surgical Tubes and Drains

Chest tubes. Chest tubes are placed in the pleural space to evacuate air or fluid. They can be as thin as 20 French or as thick as 40 French (for adults). Chest tubes are typically placed between the fourth and fifth intercostal spaces in the anterior axillary or mid-axillary line; however, the location may vary according to the indication for placement. The tubes can be straight or angled.

The tubes are connected to a collecting system with a three-way chamber. The water chamber holds a column of water, which prevents air from being sucked into the pleural space with inhalation. The suction chamber can be attached to continuous wall suction to remove air or fluid, or it can be placed on “water seal” with no active suction mechanism. The third chamber is the collection chamber for fluid drainage.

Indications for a chest tube include pneumothorax, hemothorax, or a persistent or large pleural effusion. Pneumothorax and hemothorax usually require immediate chest tube placement. Chest tubes are also commonly placed at the end of thoracic surgeries to allow for appropriate re-expansion of the lung tissue.

A chest X-ray should be obtained after any chest tube insertion to ensure appropriate placement. Chest tubes are equipped with a radiopaque line along the longitudinal axis, which should be visible on X-ray. Respiratory variation in the fluid in the collecting tube, called “tidling,” should also be seen in a correctly placed chest tube, and should be monitored at the bedside to reassure continued appropriate location. The interventional radiologist or surgeon who placed the tube should determine the subsequent frequency of serial chest X-rays required to monitor the location of the chest tube.

If the patient has a pneumothorax, air bubbles will be visible in the water chamber; called an air leak, these are often more apparent when the patient coughs. The chest tube should initially be set to continuous suction at -20 mmHg to evacuate the air. Once the air leak has stopped, the chest tube should be placed on water seal to confirm resolution of the pneumothorax (water seal mimics normal physiology). If, after the transition from suction to water seal, resumption of the air leak is noted, it may indicate recurrence of the patient’s pneumothorax. A stat chest X-ray should be obtained, and the chest tube should be placed back on continuous suction. In general, a chest X-ray should be obtained any time the chest tube is changed from suction to water seal or vice versa.

If the patient experiences ongoing or worsening pain, fever, or inadequate drainage, a chest computed tomographic (CT) scan may be warranted to identify inappropriate positioning or other complications, such as occlusion or effusion of the tube. Blood or other debris might clog chest tubes; the surgical team may be able to evacuate the tube with suction tubing at the bedside. If unsuccessful, the tube may need to be removed and reinserted.

The team that placed the tube should help the hospitalist determine the timing of the chest tube removal. If the patient has a pleural effusion, the chest tube can usually be removed when the output is less than 100-200 mL per day and the lung is expanded. The tube should usually be taken off suction and placed on water seal to rule out pneumothorax prior to tube removal.

Penrose drains. Penrose drains are often used to drain fluid or to keep a space open for drainage. Surgeons may use sutures to anchor Penrose drains to skin. Common indications include:

• Ventral hernia repair;
• Debridement of infected pancreatitis; and
• Drainage of superficial abscess cavities.

Penrose drains are simple, flexible tubes that are open at both ends; in contrast to closed drains, they permit ingress as well as egress, facilitating colonization.

Closed suction drains. Closed suction drains with a plastic bulb attachment (i.e., Jackson-Pratt, Blake, Hemovac) are used to collect fluid from a postoperative cavity. Common indications include:

• Post-mastectomy to drain subcutaneous fluid;
• Abdominal surgery;
• Plastic surgery to prevent seroma formation and promote tissue apposition;
• Cholecystectomy if there is concern for damage to ducts of Luschka or other source of bile leak;
• Inadvertent postoperative leakage following a difficult rectal anastomosis; and
• Post-pancreatic surgery.

The quality and quantity of fluid drained should always be carefully noted and recorded. Changes in the fluid can imply development of bleed, leak, or other complications. The surgical team should be contacted immediately if changes are noted.

Typically, closed suction drains will be left in place until the drainage is less than 20 mL per day. These drains can be left in for weeks if necessary and will often be removed during the patient’s scheduled surgical follow-up. Rare complications include erosion into surrounding tissues and inadvertent suturing of the drain in place, such that reexploration is required to remove it. If a closed suction drain becomes occluded, contact the team that placed the drain for further recommendations on adjustment, replacement, or removal.

Nasogastric and duodenal tubes. Nasogastric tubes (NGTs) are often used in the nonoperative management of small bowel obstruction or ileus. They should be placed in the most dependent portion of the gastric lumen and confirmed by chest or abdominal X-ray. NGTs are sump pumps and have a double lumen, which includes an air port to assure flow. The air port should be patent for optimal functioning. The tube may be connected to continuous wall suction or intermittent suction, set to low (less than 60 mmHg) to avoid mucosal avulsion.

NGT output should decrease during the resolution of obstruction or ileus, and symptoms of nausea, vomiting, and abdominal distention should concomitantly improve. Persistently high output in a patient with other indicators of bowel function (flatus, for example) may suggest postpyloric placement (and placement should be checked by X-ray). The timing of NGT removal depends on resumption of bowel function.

Gastrostomy and jejunostomy tubes. Gastrostomy tubes are most commonly used for feeding but may also be used for decompression of functional or anatomic gastric outlet obstruction. They are indicated when patients need prolonged enteral access, such as those with prolonged mechanical ventilation or head and neck pathology that prohibits oral feeding. They are also rarely used for gastropexy to tack an atonic or patulous stomach to the abdominal wall or to prevent recurrence of paraesophageal hernias. These tubes can be placed percutaneously by interventional radiologists, endoscopically by surgeons and gastroenterologists, or laparoscopically or laparotomally by surgeons. This last option is often reserved for patients with difficult anatomy or those who are having laparotomy for another reason.

Because of the stomach’s generous lumen, gastrostomy tubes rarely clog. In the event that they do get clogged, carbonated liquids, meat tenderizer, or enzymes can help dissolve the obstruction. If a gastrostomy tube is left to drain, the patient may experience significant fluid and electrolyte losses, so these need to be carefully monitored.

Jejunostomy tubes are used exclusively for feeding and are usually placed 10-20 cm distal to the ligament of Treitz. These tubes are indicated in patients who require distal feedings due to gastric dysfunction or in those who have undergone a surgery in which a proximal anastomosis requires time to heal. These tubes are more apt to clog and can be more difficult to manage because the lumen of the small bowel is smaller than the stomach. Some prefer not to put pills down the tube to mitigate this risk. Routine flushes with water or saline (30 mL every four to six hours) are also helpful in mitigating the risk of clogging. In the event that they do get clogged, they may be treated like gastrostomy tubes, using carbonated liquids, meat tenderizer, or enzymes to help dissolve the obstruction.

Percutaneous tube sites should be examined frequently for signs of infection. Though gastrostomy and jejunostomy tubes are typically well secured intraabdominally, they can become dislodged. If a gastrostomy or jejunostomy tube has been in place for more than two weeks, it can easily be replaced at the bedside with a tube of comparable caliber by a member of the surgical team or by an experienced hospitalist. If the tube has been in place less than two weeks, it requires replacement with radiographic guidance, as the risk of creating a false lumen is high. Over time, tubes can become loose and fall out. If they need replacement, the preceding guidelines apply.

Back to the Case

A potential major complication of cholecystectomy is severance of the common bile duct, which necessitates significant further surgery. Less severe complications include injuries to the cholecystohepatic ducts (otherwise known as the ducts of Luschka), which can result in leakage of bile into the peritoneal cavity. A bile leak can lead to abscess and systemic infection if left undrained.

Surgeons who are concerned for such a complication intraoperatively may opt to leave a closed suction drain in the gallbladder fossa, such as a Blake drain, for monitoring and subsequent drainage. The drain will remain in place at least until the patient’s diet has been advanced fully, because digestion promotes the secretion of bile and may elucidate a leak. Bilious fluid in the Blake drain is suspicious for a leak.

The surgeon should be notified, and imaging should be obtained to find the nature of the injury to the biliary tree (CT scan with IV contrast, hepatobiliary iminodiacetic acid scan, or endoscopic retrograde cholangiopancreatography). If injury to major biliary structures (the cystic duct stump, the hepatic ducts, or the common bile duct) is diagnosed, a stent may be placed in order to restore ductile continuity.

Minor leaks, with damage to the cystic duct stump, hepatic ducts, and common bile duct ruled out, more often resolve on their own over time, and thus the patient’s closed suction drain will be left in place until biliary drainage ceases, without further initial intervention.

Bottom Line

Surgical tubes and drains have several placement indications. Alterations in quality and quantity of output can indicate changes in clinical status, and hospitalists should be able to handle initial troubleshooting. TH

Dr. Columbus is a general surgery resident at Brigham and Women’s Hospital in Boston. Dr. Havens is an instructor for the department of surgery at Brigham and Women’s Hospital. Dr. Peetz is an instructor for the department of surgery at University Hospital Case Medical Center in Cleveland.

Case

A 45-year-old woman was admitted with choledocholithiasis. Two days prior, following endoscopic retrograde cholangiopancreatography (ERCP), she had gone to the OR for cholecystectomy. The procedure was completed laparoscopically, though the surgeon reported a difficult dissection. The surgeon left a Blake drain in the gallbladder fossa, which initially contained punch-colored fluid. Today, there is bilious fluid in the drain.

Overview

Surgical drains are used to monitor for postoperative leaks or abscesses, to collect normal physiologic fluid, or to minimize dead space. A hospitalist caring for surgical patients may be the first provider to note when something changes in the color or volume of surgical drains. Table 1 lists various types of drains with their indications for use.

Surgical Tubes and Drains

Chest tubes. Chest tubes are placed in the pleural space to evacuate air or fluid. They can be as thin as 20 French or as thick as 40 French (for adults). Chest tubes are typically placed between the fourth and fifth intercostal spaces in the anterior axillary or mid-axillary line; however, the location may vary according to the indication for placement. The tubes can be straight or angled.

The tubes are connected to a collecting system with a three-way chamber. The water chamber holds a column of water, which prevents air from being sucked into the pleural space with inhalation. The suction chamber can be attached to continuous wall suction to remove air or fluid, or it can be placed on “water seal” with no active suction mechanism. The third chamber is the collection chamber for fluid drainage.

Indications for a chest tube include pneumothorax, hemothorax, or a persistent or large pleural effusion. Pneumothorax and hemothorax usually require immediate chest tube placement. Chest tubes are also commonly placed at the end of thoracic surgeries to allow for appropriate re-expansion of the lung tissue.

A chest X-ray should be obtained after any chest tube insertion to ensure appropriate placement. Chest tubes are equipped with a radiopaque line along the longitudinal axis, which should be visible on X-ray. Respiratory variation in the fluid in the collecting tube, called “tidling,” should also be seen in a correctly placed chest tube, and should be monitored at the bedside to reassure continued appropriate location. The interventional radiologist or surgeon who placed the tube should determine the subsequent frequency of serial chest X-rays required to monitor the location of the chest tube.

If the patient has a pneumothorax, air bubbles will be visible in the water chamber; called an air leak, these are often more apparent when the patient coughs. The chest tube should initially be set to continuous suction at -20 mmHg to evacuate the air. Once the air leak has stopped, the chest tube should be placed on water seal to confirm resolution of the pneumothorax (water seal mimics normal physiology). If, after the transition from suction to water seal, resumption of the air leak is noted, it may indicate recurrence of the patient’s pneumothorax. A stat chest X-ray should be obtained, and the chest tube should be placed back on continuous suction. In general, a chest X-ray should be obtained any time the chest tube is changed from suction to water seal or vice versa.

If the patient experiences ongoing or worsening pain, fever, or inadequate drainage, a chest computed tomographic (CT) scan may be warranted to identify inappropriate positioning or other complications, such as occlusion or effusion of the tube. Blood or other debris might clog chest tubes; the surgical team may be able to evacuate the tube with suction tubing at the bedside. If unsuccessful, the tube may need to be removed and reinserted.

The team that placed the tube should help the hospitalist determine the timing of the chest tube removal. If the patient has a pleural effusion, the chest tube can usually be removed when the output is less than 100-200 mL per day and the lung is expanded. The tube should usually be taken off suction and placed on water seal to rule out pneumothorax prior to tube removal.

Penrose drains. Penrose drains are often used to drain fluid or to keep a space open for drainage. Surgeons may use sutures to anchor Penrose drains to skin. Common indications include:

• Ventral hernia repair;
• Debridement of infected pancreatitis; and
• Drainage of superficial abscess cavities.

Penrose drains are simple, flexible tubes that are open at both ends; in contrast to closed drains, they permit ingress as well as egress, facilitating colonization.

Closed suction drains. Closed suction drains with a plastic bulb attachment (i.e., Jackson-Pratt, Blake, Hemovac) are used to collect fluid from a postoperative cavity. Common indications include:

• Post-mastectomy to drain subcutaneous fluid;
• Abdominal surgery;
• Plastic surgery to prevent seroma formation and promote tissue apposition;
• Cholecystectomy if there is concern for damage to ducts of Luschka or other source of bile leak;
• Inadvertent postoperative leakage following a difficult rectal anastomosis; and
• Post-pancreatic surgery.

The quality and quantity of fluid drained should always be carefully noted and recorded. Changes in the fluid can imply development of bleed, leak, or other complications. The surgical team should be contacted immediately if changes are noted.

Typically, closed suction drains will be left in place until the drainage is less than 20 mL per day. These drains can be left in for weeks if necessary and will often be removed during the patient’s scheduled surgical follow-up. Rare complications include erosion into surrounding tissues and inadvertent suturing of the drain in place, such that reexploration is required to remove it. If a closed suction drain becomes occluded, contact the team that placed the drain for further recommendations on adjustment, replacement, or removal.

Nasogastric and duodenal tubes. Nasogastric tubes (NGTs) are often used in the nonoperative management of small bowel obstruction or ileus. They should be placed in the most dependent portion of the gastric lumen and confirmed by chest or abdominal X-ray. NGTs are sump pumps and have a double lumen, which includes an air port to assure flow. The air port should be patent for optimal functioning. The tube may be connected to continuous wall suction or intermittent suction, set to low (less than 60 mmHg) to avoid mucosal avulsion.

NGT output should decrease during the resolution of obstruction or ileus, and symptoms of nausea, vomiting, and abdominal distention should concomitantly improve. Persistently high output in a patient with other indicators of bowel function (flatus, for example) may suggest postpyloric placement (and placement should be checked by X-ray). The timing of NGT removal depends on resumption of bowel function.

Gastrostomy and jejunostomy tubes. Gastrostomy tubes are most commonly used for feeding but may also be used for decompression of functional or anatomic gastric outlet obstruction. They are indicated when patients need prolonged enteral access, such as those with prolonged mechanical ventilation or head and neck pathology that prohibits oral feeding. They are also rarely used for gastropexy to tack an atonic or patulous stomach to the abdominal wall or to prevent recurrence of paraesophageal hernias. These tubes can be placed percutaneously by interventional radiologists, endoscopically by surgeons and gastroenterologists, or laparoscopically or laparotomally by surgeons. This last option is often reserved for patients with difficult anatomy or those who are having laparotomy for another reason.

Because of the stomach’s generous lumen, gastrostomy tubes rarely clog. In the event that they do get clogged, carbonated liquids, meat tenderizer, or enzymes can help dissolve the obstruction. If a gastrostomy tube is left to drain, the patient may experience significant fluid and electrolyte losses, so these need to be carefully monitored.

Jejunostomy tubes are used exclusively for feeding and are usually placed 10-20 cm distal to the ligament of Treitz. These tubes are indicated in patients who require distal feedings due to gastric dysfunction or in those who have undergone a surgery in which a proximal anastomosis requires time to heal. These tubes are more apt to clog and can be more difficult to manage because the lumen of the small bowel is smaller than the stomach. Some prefer not to put pills down the tube to mitigate this risk. Routine flushes with water or saline (30 mL every four to six hours) are also helpful in mitigating the risk of clogging. In the event that they do get clogged, they may be treated like gastrostomy tubes, using carbonated liquids, meat tenderizer, or enzymes to help dissolve the obstruction.

Percutaneous tube sites should be examined frequently for signs of infection. Though gastrostomy and jejunostomy tubes are typically well secured intraabdominally, they can become dislodged. If a gastrostomy or jejunostomy tube has been in place for more than two weeks, it can easily be replaced at the bedside with a tube of comparable caliber by a member of the surgical team or by an experienced hospitalist. If the tube has been in place less than two weeks, it requires replacement with radiographic guidance, as the risk of creating a false lumen is high. Over time, tubes can become loose and fall out. If they need replacement, the preceding guidelines apply.

Back to the Case

A potential major complication of cholecystectomy is severance of the common bile duct, which necessitates significant further surgery. Less severe complications include injuries to the cholecystohepatic ducts (otherwise known as the ducts of Luschka), which can result in leakage of bile into the peritoneal cavity. A bile leak can lead to abscess and systemic infection if left undrained.

Surgeons who are concerned for such a complication intraoperatively may opt to leave a closed suction drain in the gallbladder fossa, such as a Blake drain, for monitoring and subsequent drainage. The drain will remain in place at least until the patient’s diet has been advanced fully, because digestion promotes the secretion of bile and may elucidate a leak. Bilious fluid in the Blake drain is suspicious for a leak.

The surgeon should be notified, and imaging should be obtained to find the nature of the injury to the biliary tree (CT scan with IV contrast, hepatobiliary iminodiacetic acid scan, or endoscopic retrograde cholangiopancreatography). If injury to major biliary structures (the cystic duct stump, the hepatic ducts, or the common bile duct) is diagnosed, a stent may be placed in order to restore ductile continuity.

Minor leaks, with damage to the cystic duct stump, hepatic ducts, and common bile duct ruled out, more often resolve on their own over time, and thus the patient’s closed suction drain will be left in place until biliary drainage ceases, without further initial intervention.

Bottom Line

Surgical tubes and drains have several placement indications. Alterations in quality and quantity of output can indicate changes in clinical status, and hospitalists should be able to handle initial troubleshooting. TH

Dr. Columbus is a general surgery resident at Brigham and Women’s Hospital in Boston. Dr. Havens is an instructor for the department of surgery at Brigham and Women’s Hospital. Dr. Peetz is an instructor for the department of surgery at University Hospital Case Medical Center in Cleveland.