ACS Surgery News

Rates of reoperation after breast conservation surgery have declined significantly since 2003, but nearly 25% of women are still undergoing repeat operations, new data suggest.

Researchers analyzed data from a population-based sample of 89,448 women undergoing primary breast conservation surgery for breast cancer in New York State from 2003 to 2013.

According to a study published online Feb.17 in JAMA Surgery, the mean 90-day reoperation rate declined from 39.5% in 2003-2004 to 23.1% in 2011-2013 (P less than .001), with an overall rate of 30.9% for the entire study period.

“We believe that the findings of reduced occurrence of reoperations are encouraging and imply improvements in training and patient selection for BCS,” wrote Abby J. Isaacs of Cornell University, New York, and her coauthors.

Reoperation rates were highest in younger women (37.7%), compared with women aged over 65 years (26.3%).

However, the study also showed that women aged 50-64 years were less likely than were older or younger women to undergo breast conservation surgery, compared with mastectomy as a repeat procedure (JAMA Surg 2016 Feb 17. doi:10.1001/jamasurg.2015.5535).

Breast conservation surgery was more common than was mastectomy as a repeat procedure in women who were white, had commercial insurance, had low comorbidity scores, or had in situ disease.

Researchers observed significant surgeon-level variation in rates of reoperation after breast conservation surgery, which they described as “novel and unprecedented.” The rates of reoperation among surgeons ranged from 0% to nearly 100%.

Overall, the mean rate of reoperation for surgeons was 30.8%, but nearly 20% of surgeons had reoperation rates above 50% and 6.1% had reoperation rates above the 99.8% limits.

Similarly, 6% of surgeons had reoperation rates below the 95% confidence limits and 2.9% were below the 99.8% limits.

Reoperation rates were independently associated with surgical volume; surgeons performing fewer than 14 breast conservation surgery procedures had a mean reoperation rate of 35.2% while those who performed 34 or more procedures had a reoperation rate of 27.5%.

Over the entire study period, the overall rate of breast conservation surgery peaked in 2004 with more than 8,500 cases, then decreased to a mean number of 8,078 for 2011-2013.

The decrease in primary breast conservation surgery was significantly greater in women aged 20-49 years (P less than .001) with 1,416 women in this age group undergoing breast conservation surgery in 2013, compared with 3,644 women aged 65 years or older.

“The reduction in the use of BCS in women younger than 50 years and a corresponding reduction in overall reoperation rates over time implies that surgeons may be selecting more appropriate patients for the procedures,” the authors wrote.

They acknowledged that they did not have access to information on tumor size, grade, and staging, which are variables known to have an important influence on margin rates and reoperation rates. “We believe, however, in the context of physician-level outcomes, that these factors will not bias the results; the recommendation for BCS will be made by surgeons based on their knowledge of the patients’ disease, and we have no reason to believe that unknowable patient characteristics will be unbalanced between surgeons.”

Two authors reported involvement with the Food and Drug Administration–funded MDEpiNet Science and Infrastructure Center; no other conflicts of interest were declared.

Rates of reoperation after breast conservation surgery have declined significantly since 2003, but nearly 25% of women are still undergoing repeat operations, new data suggest.

Researchers analyzed data from a population-based sample of 89,448 women undergoing primary breast conservation surgery for breast cancer in New York State from 2003 to 2013.

According to a study published online Feb.17 in JAMA Surgery, the mean 90-day reoperation rate declined from 39.5% in 2003-2004 to 23.1% in 2011-2013 (P less than .001), with an overall rate of 30.9% for the entire study period.

“We believe that the findings of reduced occurrence of reoperations are encouraging and imply improvements in training and patient selection for BCS,” wrote Abby J. Isaacs of Cornell University, New York, and her coauthors.

Reoperation rates were highest in younger women (37.7%), compared with women aged over 65 years (26.3%).

However, the study also showed that women aged 50-64 years were less likely than were older or younger women to undergo breast conservation surgery, compared with mastectomy as a repeat procedure (JAMA Surg 2016 Feb 17. doi:10.1001/jamasurg.2015.5535).

Breast conservation surgery was more common than was mastectomy as a repeat procedure in women who were white, had commercial insurance, had low comorbidity scores, or had in situ disease.

Researchers observed significant surgeon-level variation in rates of reoperation after breast conservation surgery, which they described as “novel and unprecedented.” The rates of reoperation among surgeons ranged from 0% to nearly 100%.

Overall, the mean rate of reoperation for surgeons was 30.8%, but nearly 20% of surgeons had reoperation rates above 50% and 6.1% had reoperation rates above the 99.8% limits.

Similarly, 6% of surgeons had reoperation rates below the 95% confidence limits and 2.9% were below the 99.8% limits.

Reoperation rates were independently associated with surgical volume; surgeons performing fewer than 14 breast conservation surgery procedures had a mean reoperation rate of 35.2% while those who performed 34 or more procedures had a reoperation rate of 27.5%.

Over the entire study period, the overall rate of breast conservation surgery peaked in 2004 with more than 8,500 cases, then decreased to a mean number of 8,078 for 2011-2013.

The decrease in primary breast conservation surgery was significantly greater in women aged 20-49 years (P less than .001) with 1,416 women in this age group undergoing breast conservation surgery in 2013, compared with 3,644 women aged 65 years or older.

“The reduction in the use of BCS in women younger than 50 years and a corresponding reduction in overall reoperation rates over time implies that surgeons may be selecting more appropriate patients for the procedures,” the authors wrote.

They acknowledged that they did not have access to information on tumor size, grade, and staging, which are variables known to have an important influence on margin rates and reoperation rates. “We believe, however, in the context of physician-level outcomes, that these factors will not bias the results; the recommendation for BCS will be made by surgeons based on their knowledge of the patients’ disease, and we have no reason to believe that unknowable patient characteristics will be unbalanced between surgeons.”

Two authors reported involvement with the Food and Drug Administration–funded MDEpiNet Science and Infrastructure Center; no other conflicts of interest were declared.

Rates of reoperation after breast conservation surgery have declined significantly since 2003, but nearly 25% of women are still undergoing repeat operations, new data suggest.

Researchers analyzed data from a population-based sample of 89,448 women undergoing primary breast conservation surgery for breast cancer in New York State from 2003 to 2013.

According to a study published online Feb.17 in JAMA Surgery, the mean 90-day reoperation rate declined from 39.5% in 2003-2004 to 23.1% in 2011-2013 (P less than .001), with an overall rate of 30.9% for the entire study period.

“We believe that the findings of reduced occurrence of reoperations are encouraging and imply improvements in training and patient selection for BCS,” wrote Abby J. Isaacs of Cornell University, New York, and her coauthors.

Reoperation rates were highest in younger women (37.7%), compared with women aged over 65 years (26.3%).

However, the study also showed that women aged 50-64 years were less likely than were older or younger women to undergo breast conservation surgery, compared with mastectomy as a repeat procedure (JAMA Surg 2016 Feb 17. doi:10.1001/jamasurg.2015.5535).

Breast conservation surgery was more common than was mastectomy as a repeat procedure in women who were white, had commercial insurance, had low comorbidity scores, or had in situ disease.

Researchers observed significant surgeon-level variation in rates of reoperation after breast conservation surgery, which they described as “novel and unprecedented.” The rates of reoperation among surgeons ranged from 0% to nearly 100%.

Overall, the mean rate of reoperation for surgeons was 30.8%, but nearly 20% of surgeons had reoperation rates above 50% and 6.1% had reoperation rates above the 99.8% limits.

Similarly, 6% of surgeons had reoperation rates below the 95% confidence limits and 2.9% were below the 99.8% limits.

Reoperation rates were independently associated with surgical volume; surgeons performing fewer than 14 breast conservation surgery procedures had a mean reoperation rate of 35.2% while those who performed 34 or more procedures had a reoperation rate of 27.5%.

Over the entire study period, the overall rate of breast conservation surgery peaked in 2004 with more than 8,500 cases, then decreased to a mean number of 8,078 for 2011-2013.

The decrease in primary breast conservation surgery was significantly greater in women aged 20-49 years (P less than .001) with 1,416 women in this age group undergoing breast conservation surgery in 2013, compared with 3,644 women aged 65 years or older.

“The reduction in the use of BCS in women younger than 50 years and a corresponding reduction in overall reoperation rates over time implies that surgeons may be selecting more appropriate patients for the procedures,” the authors wrote.

They acknowledged that they did not have access to information on tumor size, grade, and staging, which are variables known to have an important influence on margin rates and reoperation rates. “We believe, however, in the context of physician-level outcomes, that these factors will not bias the results; the recommendation for BCS will be made by surgeons based on their knowledge of the patients’ disease, and we have no reason to believe that unknowable patient characteristics will be unbalanced between surgeons.”

Two authors reported involvement with the Food and Drug Administration–funded MDEpiNet Science and Infrastructure Center; no other conflicts of interest were declared.

JACKSONVILLE, FLA. – About one-third of patients admitted to the hospital for abdominal problems like diverticulitis and small bowel obstruction get discharged without having surgery, but their outcomes are not typically included in quality assessment, leaving this group of patients in a “blind spot” of surgical quality, according to Dr. Michael Wandling.

However, researchers from Northwestern University in Chicago have analyzed data from the Nationwide (National) Inpatient Sample and determined how many cases of diverticulitis, small bowel obstruction (SBO), cholecystitis, and acute appendicitis are managed without surgery and the clinical factors that may influence that, he reported at the Association for Academic Surgery/Society of University Surgeons Academic Surgical Congress.

Richard Mark Kirkner

“Surgeons frequently will admit patients for nonoperative management of diagnoses such as diverticulitis, small bowel obstruction, cholecystitis, and perforated appendicitis,” said Dr. Wandling, a general surgery resident at Northwestern. “Yet nonoperative management does not really factor into current surgical quality assessment. In fact, nonoperative management is not frequently evaluated, and utilization rates have not even really been quantified.”

The researchers’ goal was to evaluate hospital-level variability in nonoperative management practices and identify hospital characteristics associated with high rates of nonoperative management, Dr. Wandling said.

“What we found was that smaller bed size, fewer annual discharges, being a public government-run hospital, being a nonteaching hospital, and being rural or located in the Midwest were all associated with greater use of nonoperative management,” he said.

They extracted a sample from the Nationwide (National) Inpatient Sample that analyzed admission and discharge data on 1.6 million patients admitted for one of the four studied diagnoses from 1998 to 2011. Overall, the four diagnoses accounted for more than 500,000 annual admissions, “and this rate has been increasing over time,” Dr. Wandling said. To calculate rates of nonoperative management for each diagnosis, the researchers concentrated on data from 2010 and 2011. They found the following rates of nonoperative management: 87.1% for diverticulitis, 38.1% for SBO, 11.3% for cholecystitis, and 3.7% for appendicitis. The overall rate of nonoperative management for all four diagnoses was 32.8%, Dr. Wandling said.

They also evaluated the overall rates of nonoperative management for each year from 1998 to 2011 and found they steadily increased from 25.6% to 32.8%, Dr. Wandling said. “Nonoperative management is not uncommon, with approximately 190,000 patients being admitted for nonoperative management each year, and this number has also been increasing,” he said.

Dr. Wandling acknowledged some limitations with the study because it used an administrative dataset with data collected retrospectively and because the data do not track patients after discharge, making it impossible to know if any patients managed nonoperatively were subsequently readmitted for surgery. “Current surgical quality assessment only focuses on patients who have surgery, which can be seen through public reporting programs like Hospital Compare, pay-for-performance initiatives like [Centers for Medicare & Medicaid Services] valued-based purchasing, and clinical data registries,” he said. “As a result, patients who are managed nonoperatively are really left in a blind spot of surgical quality.”

Dr. Wandling said he and his coauthors are working with the American College of Surgeons National Surgical Quality Improvement Program to develop an Emergency General Surgery (EGS) Pilot to evaluate performance in operative and nonoperative care for SBO, cholecystitis, and appendicitis. Fourteen centers have so far collected more than 6 months of data as part of the EGS Pilot, he said, and additional hospitals are currently being recruited to participate.

“Ultimately the goal is to identify optimal nonoperative management strategies in general surgery so that all patients can receive high-quality surgical care, not just those who we operate on,” Dr. Wandling said.

He and his coauthors had no relevant financial disclosures.

JACKSONVILLE, FLA. – About one-third of patients admitted to the hospital for abdominal problems like diverticulitis and small bowel obstruction get discharged without having surgery, but their outcomes are not typically included in quality assessment, leaving this group of patients in a “blind spot” of surgical quality, according to Dr. Michael Wandling.

However, researchers from Northwestern University in Chicago have analyzed data from the Nationwide (National) Inpatient Sample and determined how many cases of diverticulitis, small bowel obstruction (SBO), cholecystitis, and acute appendicitis are managed without surgery and the clinical factors that may influence that, he reported at the Association for Academic Surgery/Society of University Surgeons Academic Surgical Congress.

Richard Mark Kirkner

“Surgeons frequently will admit patients for nonoperative management of diagnoses such as diverticulitis, small bowel obstruction, cholecystitis, and perforated appendicitis,” said Dr. Wandling, a general surgery resident at Northwestern. “Yet nonoperative management does not really factor into current surgical quality assessment. In fact, nonoperative management is not frequently evaluated, and utilization rates have not even really been quantified.”

The researchers’ goal was to evaluate hospital-level variability in nonoperative management practices and identify hospital characteristics associated with high rates of nonoperative management, Dr. Wandling said.

“What we found was that smaller bed size, fewer annual discharges, being a public government-run hospital, being a nonteaching hospital, and being rural or located in the Midwest were all associated with greater use of nonoperative management,” he said.

They extracted a sample from the Nationwide (National) Inpatient Sample that analyzed admission and discharge data on 1.6 million patients admitted for one of the four studied diagnoses from 1998 to 2011. Overall, the four diagnoses accounted for more than 500,000 annual admissions, “and this rate has been increasing over time,” Dr. Wandling said. To calculate rates of nonoperative management for each diagnosis, the researchers concentrated on data from 2010 and 2011. They found the following rates of nonoperative management: 87.1% for diverticulitis, 38.1% for SBO, 11.3% for cholecystitis, and 3.7% for appendicitis. The overall rate of nonoperative management for all four diagnoses was 32.8%, Dr. Wandling said.

They also evaluated the overall rates of nonoperative management for each year from 1998 to 2011 and found they steadily increased from 25.6% to 32.8%, Dr. Wandling said. “Nonoperative management is not uncommon, with approximately 190,000 patients being admitted for nonoperative management each year, and this number has also been increasing,” he said.

Dr. Wandling acknowledged some limitations with the study because it used an administrative dataset with data collected retrospectively and because the data do not track patients after discharge, making it impossible to know if any patients managed nonoperatively were subsequently readmitted for surgery. “Current surgical quality assessment only focuses on patients who have surgery, which can be seen through public reporting programs like Hospital Compare, pay-for-performance initiatives like [Centers for Medicare & Medicaid Services] valued-based purchasing, and clinical data registries,” he said. “As a result, patients who are managed nonoperatively are really left in a blind spot of surgical quality.”

Dr. Wandling said he and his coauthors are working with the American College of Surgeons National Surgical Quality Improvement Program to develop an Emergency General Surgery (EGS) Pilot to evaluate performance in operative and nonoperative care for SBO, cholecystitis, and appendicitis. Fourteen centers have so far collected more than 6 months of data as part of the EGS Pilot, he said, and additional hospitals are currently being recruited to participate.

“Ultimately the goal is to identify optimal nonoperative management strategies in general surgery so that all patients can receive high-quality surgical care, not just those who we operate on,” Dr. Wandling said.

He and his coauthors had no relevant financial disclosures.

JACKSONVILLE, FLA. – About one-third of patients admitted to the hospital for abdominal problems like diverticulitis and small bowel obstruction get discharged without having surgery, but their outcomes are not typically included in quality assessment, leaving this group of patients in a “blind spot” of surgical quality, according to Dr. Michael Wandling.

However, researchers from Northwestern University in Chicago have analyzed data from the Nationwide (National) Inpatient Sample and determined how many cases of diverticulitis, small bowel obstruction (SBO), cholecystitis, and acute appendicitis are managed without surgery and the clinical factors that may influence that, he reported at the Association for Academic Surgery/Society of University Surgeons Academic Surgical Congress.

Richard Mark Kirkner

“Surgeons frequently will admit patients for nonoperative management of diagnoses such as diverticulitis, small bowel obstruction, cholecystitis, and perforated appendicitis,” said Dr. Wandling, a general surgery resident at Northwestern. “Yet nonoperative management does not really factor into current surgical quality assessment. In fact, nonoperative management is not frequently evaluated, and utilization rates have not even really been quantified.”

The researchers’ goal was to evaluate hospital-level variability in nonoperative management practices and identify hospital characteristics associated with high rates of nonoperative management, Dr. Wandling said.

“What we found was that smaller bed size, fewer annual discharges, being a public government-run hospital, being a nonteaching hospital, and being rural or located in the Midwest were all associated with greater use of nonoperative management,” he said.

They extracted a sample from the Nationwide (National) Inpatient Sample that analyzed admission and discharge data on 1.6 million patients admitted for one of the four studied diagnoses from 1998 to 2011. Overall, the four diagnoses accounted for more than 500,000 annual admissions, “and this rate has been increasing over time,” Dr. Wandling said. To calculate rates of nonoperative management for each diagnosis, the researchers concentrated on data from 2010 and 2011. They found the following rates of nonoperative management: 87.1% for diverticulitis, 38.1% for SBO, 11.3% for cholecystitis, and 3.7% for appendicitis. The overall rate of nonoperative management for all four diagnoses was 32.8%, Dr. Wandling said.

They also evaluated the overall rates of nonoperative management for each year from 1998 to 2011 and found they steadily increased from 25.6% to 32.8%, Dr. Wandling said. “Nonoperative management is not uncommon, with approximately 190,000 patients being admitted for nonoperative management each year, and this number has also been increasing,” he said.

Dr. Wandling acknowledged some limitations with the study because it used an administrative dataset with data collected retrospectively and because the data do not track patients after discharge, making it impossible to know if any patients managed nonoperatively were subsequently readmitted for surgery. “Current surgical quality assessment only focuses on patients who have surgery, which can be seen through public reporting programs like Hospital Compare, pay-for-performance initiatives like [Centers for Medicare & Medicaid Services] valued-based purchasing, and clinical data registries,” he said. “As a result, patients who are managed nonoperatively are really left in a blind spot of surgical quality.”

Dr. Wandling said he and his coauthors are working with the American College of Surgeons National Surgical Quality Improvement Program to develop an Emergency General Surgery (EGS) Pilot to evaluate performance in operative and nonoperative care for SBO, cholecystitis, and appendicitis. Fourteen centers have so far collected more than 6 months of data as part of the EGS Pilot, he said, and additional hospitals are currently being recruited to participate.

“Ultimately the goal is to identify optimal nonoperative management strategies in general surgery so that all patients can receive high-quality surgical care, not just those who we operate on,” Dr. Wandling said.

He and his coauthors had no relevant financial disclosures.

JACKSONVILLE, FLA. – Voice quality changes after thyroid surgery are detectable by using both subjective and objective measures, according to investigators at Monash University in Melbourne, Australia.

After thyroid surgery, up to 80% of patients with functional recurrent laryngeal nerves (RLNs) have reported voice changes, so the investigators set out to evaluate the extent of those voice changes and how the extent of the operation and RLN edema may affect them.

“It has been confirmed that thyroid procedures do alter the voice without necessarily causing a measurable recurrent laryngeal nerve palsy,” said lead investigator Dr. James Lee, “and the change of voice is correlated to the extent of surgery and the amount of nerve swelling.” The findings were presented at the Association of Academic Surgery/Society of University Surgeons Academic Surgical Congress.

The study evaluated 62 patients who had total and partial thyroidectomy surgery between 2010 and 2011 at the Monash University Endocrine Surgery Unit. To subjectively measure voice quality after surgery, the researchers used the Voice Disorder Index (VDI), which measures voice quality on a 0-40 scale from best to worst. After surgery, the mean VDI score in this group showed a 5.2 plus or minus 1.2–point deterioration from 4.2 to 9.4 (P less than .001). For objective evaluation, the researchers used the Dysphonia Severity Index (DSI), which scores voice quality on a scale of –5 to 5 from worst to best. After surgery, the mean DSI score showed a 1.1 plus or minus 0.2–point deterioration from 3.9 to 2.8 (P less than .001). Two speech pathologists conducted the voice assessments.

“Subjective scoring of both hemithyroidectomy and total thyroidectomy reported worse voice postoperatively,” Dr. Lee said. “However, when you take a close look at the numbers, those undergoing total thyroidectomy reported a higher measure of deterioration in their voice.”

Patients who had either partial and total thyroidectomy reported significant subjective deterioration of their voice with mean VDI change from 5.4 to 7.9 (P = 0.02) and 3.5 to 10.6 (P less than .001), respectively. However, on objective evaluation, only the total thyroidectomy patients showed significant voice deterioration, with a mean DSI change from 4 to 2.5 (P less than .001).

Dr. Lee noted that study outcomes between partial and total thyroidectomy patients diverged in another respect: the impact RLN swelling had on voice deterioration. To evaluate RLN swelling, the researchers measured the diameter of the nerve with Vernier calipers before and after the lobectomy during each operation. RLN diameter increased 0.58 plus or minus 0.05 mm on average (P less than .001). In patients who had partial thyroidectomy, the greater the RLN swelling, the worse the subjective score (P = .03). This was not the case in the total thyroidectomy patients where involvement of two nerves complicates the interaction, he said.

During follow-up, the investigators came upon a revelatory finding. “With median 8-month follow-up, the self-reported, VDI scores had returned to baseline levels,” Dr. Lee said. “Interestingly, not only did the objective DSI scores show a return to baseline levels, but it exceeded the baseline levels, meaning the voice had scored better after surgery than before.” However, he noted only 13 patients completed the follow-up.

“Voice change post-thyroidectomy without recurrent laryngeal nerve injury is a complex phenomenon and is likely multifactorial, and we only looked at two of those factors: the extent of surgery and the gradient of recurrent laryngeal nerve injury with nerve edema as a surrogate,” Dr. Lee said. Future studies should evaluate other factors, including the role of the external branch of the superior laryngeal nerve and patient factors such as diabetes or smoking, he said.

Dr. Lee and his coauthors had no disclosures.

JACKSONVILLE, FLA. – Voice quality changes after thyroid surgery are detectable by using both subjective and objective measures, according to investigators at Monash University in Melbourne, Australia.

After thyroid surgery, up to 80% of patients with functional recurrent laryngeal nerves (RLNs) have reported voice changes, so the investigators set out to evaluate the extent of those voice changes and how the extent of the operation and RLN edema may affect them.

“It has been confirmed that thyroid procedures do alter the voice without necessarily causing a measurable recurrent laryngeal nerve palsy,” said lead investigator Dr. James Lee, “and the change of voice is correlated to the extent of surgery and the amount of nerve swelling.” The findings were presented at the Association of Academic Surgery/Society of University Surgeons Academic Surgical Congress.

The study evaluated 62 patients who had total and partial thyroidectomy surgery between 2010 and 2011 at the Monash University Endocrine Surgery Unit. To subjectively measure voice quality after surgery, the researchers used the Voice Disorder Index (VDI), which measures voice quality on a 0-40 scale from best to worst. After surgery, the mean VDI score in this group showed a 5.2 plus or minus 1.2–point deterioration from 4.2 to 9.4 (P less than .001). For objective evaluation, the researchers used the Dysphonia Severity Index (DSI), which scores voice quality on a scale of –5 to 5 from worst to best. After surgery, the mean DSI score showed a 1.1 plus or minus 0.2–point deterioration from 3.9 to 2.8 (P less than .001). Two speech pathologists conducted the voice assessments.

“Subjective scoring of both hemithyroidectomy and total thyroidectomy reported worse voice postoperatively,” Dr. Lee said. “However, when you take a close look at the numbers, those undergoing total thyroidectomy reported a higher measure of deterioration in their voice.”

Patients who had either partial and total thyroidectomy reported significant subjective deterioration of their voice with mean VDI change from 5.4 to 7.9 (P = 0.02) and 3.5 to 10.6 (P less than .001), respectively. However, on objective evaluation, only the total thyroidectomy patients showed significant voice deterioration, with a mean DSI change from 4 to 2.5 (P less than .001).

Dr. Lee noted that study outcomes between partial and total thyroidectomy patients diverged in another respect: the impact RLN swelling had on voice deterioration. To evaluate RLN swelling, the researchers measured the diameter of the nerve with Vernier calipers before and after the lobectomy during each operation. RLN diameter increased 0.58 plus or minus 0.05 mm on average (P less than .001). In patients who had partial thyroidectomy, the greater the RLN swelling, the worse the subjective score (P = .03). This was not the case in the total thyroidectomy patients where involvement of two nerves complicates the interaction, he said.

During follow-up, the investigators came upon a revelatory finding. “With median 8-month follow-up, the self-reported, VDI scores had returned to baseline levels,” Dr. Lee said. “Interestingly, not only did the objective DSI scores show a return to baseline levels, but it exceeded the baseline levels, meaning the voice had scored better after surgery than before.” However, he noted only 13 patients completed the follow-up.

“Voice change post-thyroidectomy without recurrent laryngeal nerve injury is a complex phenomenon and is likely multifactorial, and we only looked at two of those factors: the extent of surgery and the gradient of recurrent laryngeal nerve injury with nerve edema as a surrogate,” Dr. Lee said. Future studies should evaluate other factors, including the role of the external branch of the superior laryngeal nerve and patient factors such as diabetes or smoking, he said.

Dr. Lee and his coauthors had no disclosures.

JACKSONVILLE, FLA. – Voice quality changes after thyroid surgery are detectable by using both subjective and objective measures, according to investigators at Monash University in Melbourne, Australia.

After thyroid surgery, up to 80% of patients with functional recurrent laryngeal nerves (RLNs) have reported voice changes, so the investigators set out to evaluate the extent of those voice changes and how the extent of the operation and RLN edema may affect them.

“It has been confirmed that thyroid procedures do alter the voice without necessarily causing a measurable recurrent laryngeal nerve palsy,” said lead investigator Dr. James Lee, “and the change of voice is correlated to the extent of surgery and the amount of nerve swelling.” The findings were presented at the Association of Academic Surgery/Society of University Surgeons Academic Surgical Congress.

The study evaluated 62 patients who had total and partial thyroidectomy surgery between 2010 and 2011 at the Monash University Endocrine Surgery Unit. To subjectively measure voice quality after surgery, the researchers used the Voice Disorder Index (VDI), which measures voice quality on a 0-40 scale from best to worst. After surgery, the mean VDI score in this group showed a 5.2 plus or minus 1.2–point deterioration from 4.2 to 9.4 (P less than .001). For objective evaluation, the researchers used the Dysphonia Severity Index (DSI), which scores voice quality on a scale of –5 to 5 from worst to best. After surgery, the mean DSI score showed a 1.1 plus or minus 0.2–point deterioration from 3.9 to 2.8 (P less than .001). Two speech pathologists conducted the voice assessments.

“Subjective scoring of both hemithyroidectomy and total thyroidectomy reported worse voice postoperatively,” Dr. Lee said. “However, when you take a close look at the numbers, those undergoing total thyroidectomy reported a higher measure of deterioration in their voice.”

Patients who had either partial and total thyroidectomy reported significant subjective deterioration of their voice with mean VDI change from 5.4 to 7.9 (P = 0.02) and 3.5 to 10.6 (P less than .001), respectively. However, on objective evaluation, only the total thyroidectomy patients showed significant voice deterioration, with a mean DSI change from 4 to 2.5 (P less than .001).

Dr. Lee noted that study outcomes between partial and total thyroidectomy patients diverged in another respect: the impact RLN swelling had on voice deterioration. To evaluate RLN swelling, the researchers measured the diameter of the nerve with Vernier calipers before and after the lobectomy during each operation. RLN diameter increased 0.58 plus or minus 0.05 mm on average (P less than .001). In patients who had partial thyroidectomy, the greater the RLN swelling, the worse the subjective score (P = .03). This was not the case in the total thyroidectomy patients where involvement of two nerves complicates the interaction, he said.

During follow-up, the investigators came upon a revelatory finding. “With median 8-month follow-up, the self-reported, VDI scores had returned to baseline levels,” Dr. Lee said. “Interestingly, not only did the objective DSI scores show a return to baseline levels, but it exceeded the baseline levels, meaning the voice had scored better after surgery than before.” However, he noted only 13 patients completed the follow-up.

“Voice change post-thyroidectomy without recurrent laryngeal nerve injury is a complex phenomenon and is likely multifactorial, and we only looked at two of those factors: the extent of surgery and the gradient of recurrent laryngeal nerve injury with nerve edema as a surrogate,” Dr. Lee said. Future studies should evaluate other factors, including the role of the external branch of the superior laryngeal nerve and patient factors such as diabetes or smoking, he said.

Dr. Lee and his coauthors had no disclosures.

Cardiovascular, surgery, and pneumonia patients at hospitals with a fully electronic health record (EHR) system experienced lower rates of in-hospital adverse events, according to a new study published in the Journal of Patient Safety.

A research team led by Dr. Mark L. Metersky, medical director at the UConn Health Center for Bronchiectasis Care in Farmington, Conn., conducted a retrospective analysis of patient discharges using data from the 2012 and 2013 Medicare Patient Safety Monitoring System.

©pandpstock001/ThinkStock.com

The study sample included patients aged 18 years and older that were hospitalized for one of three conditions: acute cardiovascular disease, pneumonia, or conditions requiring surgery. The main outcome measures were in-hospital adverse events, including hospital-acquired infections, adverse drug events (based on selected medications), general events, and post-procedural events.

Among the 45,235 patients who were at risk for 347,281 adverse events in the study sample, the occurrence rate of adverse events was 2.3%, and 13% of patients were exposed to a fully electronic EHR. In multivariate modeling adjusted for patient and hospital characteristics, investigators discovered that patient exposure to a fully electronic EHR was associated with 17%-30% lower odds of any adverse event for cardiovascular, pneumonia, and surgery patients.

“Beyond the direct effects on safety, EHRs can also indirectly reduce overall adverse event rates by enabling quality improvement initiatives,” said Dr. Metersky and his coauthors.

Read the full study in the Journal of Patient Safety (2016 Feb 6. doi: 10.1097/PTS.0000000000000257).

[email protected]

On Twitter @richpizzi

Cardiovascular, surgery, and pneumonia patients at hospitals with a fully electronic health record (EHR) system experienced lower rates of in-hospital adverse events, according to a new study published in the Journal of Patient Safety.

A research team led by Dr. Mark L. Metersky, medical director at the UConn Health Center for Bronchiectasis Care in Farmington, Conn., conducted a retrospective analysis of patient discharges using data from the 2012 and 2013 Medicare Patient Safety Monitoring System.

©pandpstock001/ThinkStock.com

The study sample included patients aged 18 years and older that were hospitalized for one of three conditions: acute cardiovascular disease, pneumonia, or conditions requiring surgery. The main outcome measures were in-hospital adverse events, including hospital-acquired infections, adverse drug events (based on selected medications), general events, and post-procedural events.

Among the 45,235 patients who were at risk for 347,281 adverse events in the study sample, the occurrence rate of adverse events was 2.3%, and 13% of patients were exposed to a fully electronic EHR. In multivariate modeling adjusted for patient and hospital characteristics, investigators discovered that patient exposure to a fully electronic EHR was associated with 17%-30% lower odds of any adverse event for cardiovascular, pneumonia, and surgery patients.

“Beyond the direct effects on safety, EHRs can also indirectly reduce overall adverse event rates by enabling quality improvement initiatives,” said Dr. Metersky and his coauthors.

Read the full study in the Journal of Patient Safety (2016 Feb 6. doi: 10.1097/PTS.0000000000000257).

[email protected]

On Twitter @richpizzi

Cardiovascular, surgery, and pneumonia patients at hospitals with a fully electronic health record (EHR) system experienced lower rates of in-hospital adverse events, according to a new study published in the Journal of Patient Safety.

A research team led by Dr. Mark L. Metersky, medical director at the UConn Health Center for Bronchiectasis Care in Farmington, Conn., conducted a retrospective analysis of patient discharges using data from the 2012 and 2013 Medicare Patient Safety Monitoring System.

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The study sample included patients aged 18 years and older that were hospitalized for one of three conditions: acute cardiovascular disease, pneumonia, or conditions requiring surgery. The main outcome measures were in-hospital adverse events, including hospital-acquired infections, adverse drug events (based on selected medications), general events, and post-procedural events.

Among the 45,235 patients who were at risk for 347,281 adverse events in the study sample, the occurrence rate of adverse events was 2.3%, and 13% of patients were exposed to a fully electronic EHR. In multivariate modeling adjusted for patient and hospital characteristics, investigators discovered that patient exposure to a fully electronic EHR was associated with 17%-30% lower odds of any adverse event for cardiovascular, pneumonia, and surgery patients.

“Beyond the direct effects on safety, EHRs can also indirectly reduce overall adverse event rates by enabling quality improvement initiatives,” said Dr. Metersky and his coauthors.

Read the full study in the Journal of Patient Safety (2016 Feb 6. doi: 10.1097/PTS.0000000000000257).

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On Twitter @richpizzi

With patients indicating that they are regularly ignoring dosing guidelines on over-the-counter pain medications, the American Gastroenterological Association is calling for better patient education, including a more active role for doctors.

In particular, AGA is asking doctors to be more proactive in understanding how their patients are using over-the-counter pain medications after a survey revealed that 43% of respondents who suffer from chronic pain said that they knowingly have taken more than the recommended dose, with 28% saying they have experienced complications due to OTC pain medication overdose.

©Ingram Publishing/thinkstockphotos.com

“Patients are self-medicating and actually ignoring the dosing guidelines,” Dr. Charles Melbern Wilcox, professor at the University of Alabama at Birmingham, said during a Jan. 25 teleconference to talk about the survey results. “Commonly, patients are unaware of overdose symptoms or not connecting their symptoms to over-the-counter pain medicine overdose or overusage. Patients are presenting with nausea, abdominal pain, and stomach ulcers due to over-the-counter pain medicine overdose and overuse. Patients with chronic pain are often taking multiple medications.”

AGA hosted the conference call as part of the “Gut Check: Know Your Medicine” campaign to encourage educating consumers on the proper usage and risks associated with OTC pain medication. The survey of 1,015 adults aged 30 years or older (479 were currently experiencing chronic pain at the time of the survey) and 251 licensed gastroenterologists conducted as part of the campaign occurred in September and October 2015.

Additionally, chronic pain sufferers also are taking multisymptom OTC products for allergy, cold, and flu symptoms that could cause the extra intake of pain medication.

“Our survey findings suggest that providers give more attention to patients with chronic pain since they are likely to take more than the recommended dose and also to take more than one pain medicine,” Dr. Byron Cryer, assistant dean for faculty diversity and development at the University of Texas Southwestern Medical Center, Dallas, said during the call to discuss the survey results and AGA campaign to promote OTC pain medication awareness. “Providers should work with patients to determine the best treatment options that address the patient’s pain while using medicines safely.”

Dr. Cryer noted that health care professionals “must start asking simple direct questions about pain medicine use each time they see a patient and must lead the way to improve the lines of communication.”

He added that having these active conversations about pain medications, both OTC and prescribed, can provide the necessary warnings about the products that “are likely to be remembered by patients” and will allow doctors to provide follow-up timing and instructions if the pain does not subside in a certain amount of time.

Another survey finding that is adding to the call for more patient education is that, according to the survey’s executive summary, most chronic pain sufferers “say they don’t always read the full Drug Facts label on an OTC pain medicine they haven’t taken before (66%) and many say the directions on the labels of OTC pain medicines are really just guidelines – they know what works for them (43%).”

Additionally, the survey found that 27% of chronic pain sufferers “are willing to take more of an OTC pain medicine than directed because they incorrectly believe their symptoms will disappear faster.”

[email protected]

With patients indicating that they are regularly ignoring dosing guidelines on over-the-counter pain medications, the American Gastroenterological Association is calling for better patient education, including a more active role for doctors.

In particular, AGA is asking doctors to be more proactive in understanding how their patients are using over-the-counter pain medications after a survey revealed that 43% of respondents who suffer from chronic pain said that they knowingly have taken more than the recommended dose, with 28% saying they have experienced complications due to OTC pain medication overdose.

©Ingram Publishing/thinkstockphotos.com

“Patients are self-medicating and actually ignoring the dosing guidelines,” Dr. Charles Melbern Wilcox, professor at the University of Alabama at Birmingham, said during a Jan. 25 teleconference to talk about the survey results. “Commonly, patients are unaware of overdose symptoms or not connecting their symptoms to over-the-counter pain medicine overdose or overusage. Patients are presenting with nausea, abdominal pain, and stomach ulcers due to over-the-counter pain medicine overdose and overuse. Patients with chronic pain are often taking multiple medications.”

AGA hosted the conference call as part of the “Gut Check: Know Your Medicine” campaign to encourage educating consumers on the proper usage and risks associated with OTC pain medication. The survey of 1,015 adults aged 30 years or older (479 were currently experiencing chronic pain at the time of the survey) and 251 licensed gastroenterologists conducted as part of the campaign occurred in September and October 2015.

Additionally, chronic pain sufferers also are taking multisymptom OTC products for allergy, cold, and flu symptoms that could cause the extra intake of pain medication.

“Our survey findings suggest that providers give more attention to patients with chronic pain since they are likely to take more than the recommended dose and also to take more than one pain medicine,” Dr. Byron Cryer, assistant dean for faculty diversity and development at the University of Texas Southwestern Medical Center, Dallas, said during the call to discuss the survey results and AGA campaign to promote OTC pain medication awareness. “Providers should work with patients to determine the best treatment options that address the patient’s pain while using medicines safely.”

Dr. Cryer noted that health care professionals “must start asking simple direct questions about pain medicine use each time they see a patient and must lead the way to improve the lines of communication.”

He added that having these active conversations about pain medications, both OTC and prescribed, can provide the necessary warnings about the products that “are likely to be remembered by patients” and will allow doctors to provide follow-up timing and instructions if the pain does not subside in a certain amount of time.

Another survey finding that is adding to the call for more patient education is that, according to the survey’s executive summary, most chronic pain sufferers “say they don’t always read the full Drug Facts label on an OTC pain medicine they haven’t taken before (66%) and many say the directions on the labels of OTC pain medicines are really just guidelines – they know what works for them (43%).”

Additionally, the survey found that 27% of chronic pain sufferers “are willing to take more of an OTC pain medicine than directed because they incorrectly believe their symptoms will disappear faster.”

[email protected]

With patients indicating that they are regularly ignoring dosing guidelines on over-the-counter pain medications, the American Gastroenterological Association is calling for better patient education, including a more active role for doctors.

In particular, AGA is asking doctors to be more proactive in understanding how their patients are using over-the-counter pain medications after a survey revealed that 43% of respondents who suffer from chronic pain said that they knowingly have taken more than the recommended dose, with 28% saying they have experienced complications due to OTC pain medication overdose.

©Ingram Publishing/thinkstockphotos.com

“Patients are self-medicating and actually ignoring the dosing guidelines,” Dr. Charles Melbern Wilcox, professor at the University of Alabama at Birmingham, said during a Jan. 25 teleconference to talk about the survey results. “Commonly, patients are unaware of overdose symptoms or not connecting their symptoms to over-the-counter pain medicine overdose or overusage. Patients are presenting with nausea, abdominal pain, and stomach ulcers due to over-the-counter pain medicine overdose and overuse. Patients with chronic pain are often taking multiple medications.”

AGA hosted the conference call as part of the “Gut Check: Know Your Medicine” campaign to encourage educating consumers on the proper usage and risks associated with OTC pain medication. The survey of 1,015 adults aged 30 years or older (479 were currently experiencing chronic pain at the time of the survey) and 251 licensed gastroenterologists conducted as part of the campaign occurred in September and October 2015.

Additionally, chronic pain sufferers also are taking multisymptom OTC products for allergy, cold, and flu symptoms that could cause the extra intake of pain medication.

“Our survey findings suggest that providers give more attention to patients with chronic pain since they are likely to take more than the recommended dose and also to take more than one pain medicine,” Dr. Byron Cryer, assistant dean for faculty diversity and development at the University of Texas Southwestern Medical Center, Dallas, said during the call to discuss the survey results and AGA campaign to promote OTC pain medication awareness. “Providers should work with patients to determine the best treatment options that address the patient’s pain while using medicines safely.”

Dr. Cryer noted that health care professionals “must start asking simple direct questions about pain medicine use each time they see a patient and must lead the way to improve the lines of communication.”

He added that having these active conversations about pain medications, both OTC and prescribed, can provide the necessary warnings about the products that “are likely to be remembered by patients” and will allow doctors to provide follow-up timing and instructions if the pain does not subside in a certain amount of time.

Another survey finding that is adding to the call for more patient education is that, according to the survey’s executive summary, most chronic pain sufferers “say they don’t always read the full Drug Facts label on an OTC pain medicine they haven’t taken before (66%) and many say the directions on the labels of OTC pain medicines are really just guidelines – they know what works for them (43%).”

Additionally, the survey found that 27% of chronic pain sufferers “are willing to take more of an OTC pain medicine than directed because they incorrectly believe their symptoms will disappear faster.”

[email protected]

PHOENIX – A blood lactate dehydrogenase level of at least 1,150 IU/L may be the best cutoff for identifying pump thrombosis in patients who have received a left ventricular assist device based on findings from a combined series of 502 pump recipients.

Using this cutoff correlated with a positive predictive value of 74% and a negative predictive value of 92%, Dr. Vikram Sood said at the annual meeting of the Society of Thoracic Surgeons.

Mitchel L. Zoler/Frontline Medical News

Results from several prior studies had established an elevated blood level of lactate dehydrogenase (LDH) as perhaps the best early flag of significant thrombus inside of a left ventricular assist device (LVAD), a condition called pump thrombosis. But prior studies had not identified a specific cutoff value to use that could confidently diagnose pump thrombosis. A level of 1,150 IU/L is about five times the upper limit of normal, noted Dr. Francis D. Pagani, professor of surgery and surgical director of adult heart transplantation at the University of Michigan, Ann Arbor, and a senior author on this report.

Dr. Sood and his associates reviewed records for 502 patients who received a HeartMate II LVAD at either the University of Michigan or at the Mayo Clinic in Rochester, Minn., during 2004-2014. During that time, 58 of the patients required a total of 70 LVAD explants. Fifty-two of the explants were for suspected pump thrombosis, 12 for infection, and 6 for lead fracture. The average time from LVAD placement to explant was 12 months.

Among the 52 LVADs explanted for suspected pump thrombosis, 47 actually had thrombosis. In addition, six of the LVADs that were explanted for other reasons also had a significant amount of thrombus, resulting in 53 total explanted LVAD with confirmed pump thrombosis.

The researchers analyzed blood levels of LDH during the 6 months prior to explant. Among the patients with the 53 LVADs explanted with confirmed pump thrombosis, the median of all LDH levels during the period was 1,061 IU/L and the median maximum LDH level for each patient was 1,940 IU/L, reported Dr. Sood, a cardiac surgeon at the University of Michigan. In contrast, among the patients who had a total of 17 LVADs explanted without pump thrombosis, the median value for all LDH measures during the 6 months prior to explant was 533 IU/L, and their medium maximum level was 504 IU/L.

Analysis of LDH levels prior to explant and subsequent confirmation of pump thrombosis identified a cut off of 1,150 IU/L as able to identify pump thrombosis with a sensitivity of 78% and a specificity of 90%, Dr. Sood reported.

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On Twitter @mitchelzoler

PHOENIX – A blood lactate dehydrogenase level of at least 1,150 IU/L may be the best cutoff for identifying pump thrombosis in patients who have received a left ventricular assist device based on findings from a combined series of 502 pump recipients.

Using this cutoff correlated with a positive predictive value of 74% and a negative predictive value of 92%, Dr. Vikram Sood said at the annual meeting of the Society of Thoracic Surgeons.

Mitchel L. Zoler/Frontline Medical News

Results from several prior studies had established an elevated blood level of lactate dehydrogenase (LDH) as perhaps the best early flag of significant thrombus inside of a left ventricular assist device (LVAD), a condition called pump thrombosis. But prior studies had not identified a specific cutoff value to use that could confidently diagnose pump thrombosis. A level of 1,150 IU/L is about five times the upper limit of normal, noted Dr. Francis D. Pagani, professor of surgery and surgical director of adult heart transplantation at the University of Michigan, Ann Arbor, and a senior author on this report.

Dr. Sood and his associates reviewed records for 502 patients who received a HeartMate II LVAD at either the University of Michigan or at the Mayo Clinic in Rochester, Minn., during 2004-2014. During that time, 58 of the patients required a total of 70 LVAD explants. Fifty-two of the explants were for suspected pump thrombosis, 12 for infection, and 6 for lead fracture. The average time from LVAD placement to explant was 12 months.

Among the 52 LVADs explanted for suspected pump thrombosis, 47 actually had thrombosis. In addition, six of the LVADs that were explanted for other reasons also had a significant amount of thrombus, resulting in 53 total explanted LVAD with confirmed pump thrombosis.

The researchers analyzed blood levels of LDH during the 6 months prior to explant. Among the patients with the 53 LVADs explanted with confirmed pump thrombosis, the median of all LDH levels during the period was 1,061 IU/L and the median maximum LDH level for each patient was 1,940 IU/L, reported Dr. Sood, a cardiac surgeon at the University of Michigan. In contrast, among the patients who had a total of 17 LVADs explanted without pump thrombosis, the median value for all LDH measures during the 6 months prior to explant was 533 IU/L, and their medium maximum level was 504 IU/L.

Analysis of LDH levels prior to explant and subsequent confirmation of pump thrombosis identified a cut off of 1,150 IU/L as able to identify pump thrombosis with a sensitivity of 78% and a specificity of 90%, Dr. Sood reported.

[email protected]

On Twitter @mitchelzoler

PHOENIX – A blood lactate dehydrogenase level of at least 1,150 IU/L may be the best cutoff for identifying pump thrombosis in patients who have received a left ventricular assist device based on findings from a combined series of 502 pump recipients.

Using this cutoff correlated with a positive predictive value of 74% and a negative predictive value of 92%, Dr. Vikram Sood said at the annual meeting of the Society of Thoracic Surgeons.

Mitchel L. Zoler/Frontline Medical News

Results from several prior studies had established an elevated blood level of lactate dehydrogenase (LDH) as perhaps the best early flag of significant thrombus inside of a left ventricular assist device (LVAD), a condition called pump thrombosis. But prior studies had not identified a specific cutoff value to use that could confidently diagnose pump thrombosis. A level of 1,150 IU/L is about five times the upper limit of normal, noted Dr. Francis D. Pagani, professor of surgery and surgical director of adult heart transplantation at the University of Michigan, Ann Arbor, and a senior author on this report.

Dr. Sood and his associates reviewed records for 502 patients who received a HeartMate II LVAD at either the University of Michigan or at the Mayo Clinic in Rochester, Minn., during 2004-2014. During that time, 58 of the patients required a total of 70 LVAD explants. Fifty-two of the explants were for suspected pump thrombosis, 12 for infection, and 6 for lead fracture. The average time from LVAD placement to explant was 12 months.

Among the 52 LVADs explanted for suspected pump thrombosis, 47 actually had thrombosis. In addition, six of the LVADs that were explanted for other reasons also had a significant amount of thrombus, resulting in 53 total explanted LVAD with confirmed pump thrombosis.

The researchers analyzed blood levels of LDH during the 6 months prior to explant. Among the patients with the 53 LVADs explanted with confirmed pump thrombosis, the median of all LDH levels during the period was 1,061 IU/L and the median maximum LDH level for each patient was 1,940 IU/L, reported Dr. Sood, a cardiac surgeon at the University of Michigan. In contrast, among the patients who had a total of 17 LVADs explanted without pump thrombosis, the median value for all LDH measures during the 6 months prior to explant was 533 IU/L, and their medium maximum level was 504 IU/L.

Analysis of LDH levels prior to explant and subsequent confirmation of pump thrombosis identified a cut off of 1,150 IU/L as able to identify pump thrombosis with a sensitivity of 78% and a specificity of 90%, Dr. Sood reported.

[email protected]

On Twitter @mitchelzoler